Failure to Complete Monthly Pharmacist Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted monthly medication regimen reviews, including a review of the medical chart, for at least two residents. For one resident with diagnoses such as senile degeneration of the brain, major depressive disorder, anxiety disorder, hypertension, hyperlipidemia, hypothyroidism, and sleep apnea, there was no documentation of a pharmacist's review of the medication regimen for the month of February 2025. This resident was receiving antipsychotic, antidepressant, antianxiety, and opioid medications, yet pharmacy records and consultant pharmacist recommendations did not reflect a monthly review or any recommendations for that period. The DON confirmed that no additional documentation was available to indicate the review had occurred. Another resident, admitted with conditions including intracerebral hemorrhage, schizoaffective disorder, anxiety, and hypertension, and who was severely cognitively impaired, also did not have documented pharmacist reviews for June 2024 and February 2025. This resident was receiving daily antipsychotic and antidepressant medications. Review of pharmacy progress notes and consultant pharmacist reports did not show evidence of the required monthly reviews or recommendations for the specified months. The DON confirmed the absence of documentation for these reviews. Facility policy requires that each resident's drug regimen be reviewed at least monthly by a licensed pharmacist, including a review of the medical chart.