Failure to Document and Follow Up on Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure consistent follow-up and documentation of monthly medication regimen reviews (MRRs) for two residents. For both residents, the electronic medical record (EMR) indicated that pharmacy recommendations were made on specific dates, but there was no documentation or pharmacy report available in the EMR detailing what those recommendations were. This lack of documentation meant that the recommendations from the pharmacist were not accessible for review or follow-up by the care team. When questioned, the DON stated that recommendations from the pharmacy are typically received via email and that nursing staff are responsible for auditing charts to ensure follow-up on pharmacy recommendations. However, the DON was unable to provide the missing pharmacy recommendations for the two residents in question. The facility's policy requires that consultant pharmacist findings and recommendations be documented and filed in the resident's chart in an easily retrievable format, but this was not done for the affected residents.