Failure to Complete Required Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly medication regimen reviews (MRR) for two out of five sampled residents, as required by facility policy and state regulations. The policy, last reviewed in April 2025, mandates that the consultant pharmacist conduct a thorough monthly review of each resident's medical record to identify, report, and resolve medication-related problems, errors, and irregularities. However, a review of clinical records for two residents revealed no evidence that the pharmacist had conducted these reviews for the months of February and March 2025. One resident had diagnoses including dementia and anxiety, while the other had post-traumatic stress disorder (PTSD) and dementia. The absence of documented monthly MRRs for these residents was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the required reviews had not been completed as stipulated by facility policy and regulatory requirements.