Failure to Document Monthly Medication Regimen Reviews by Pharmacist
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed and documented monthly medication regimen reviews (MRRs) for nine residents over a 12-month period, as required by facility policy and federal regulations. Surveyors found that for each of the nine residents reviewed, there was no documentation of MRRs in the electronic medical record, despite these residents having complex medical histories and being prescribed multiple daily medications, including psychotropics, antipsychotics, antiseizure medications, opioids, and insulin. The absence of MRR documentation was confirmed through record reviews and interviews with facility staff. Specific examples included residents with diagnoses such as schizophrenia, bipolar disorder, depression, dementia, diabetes, and heart disease, all of whom were receiving multiple medications daily. For instance, one resident with anxiety, depression, diabetes, and stroke was administered 13 medications daily, including antiseizure and antipsychotic drugs, with no MRRs documented for the past year. Another resident with schizoaffective disorder, bipolar disorder, and hypertension was also found to have no MRRs documented, despite being on 12 daily medications, including antipsychotics and antihypertensives. When surveyors requested the missing MRRs from staff, including the infection control preventionist and corporate consultant, staff indicated that the reviews may not have been scanned into the medical record and would investigate further. However, no MRRs were provided or uploaded into the electronic medical record before the survey concluded. The facility's policy required pharmaceutical services to meet each resident's needs and comply with state and federal requirements, but the lack of MRR documentation demonstrated a failure to follow these procedures.