Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed monthly Medication Regimen Reviews (MRR) for a resident with diagnoses including depression, migraines, and paraplegia. According to facility policy, a pharmacist is required to review each resident's drug regimen at least once a month and report any irregularities to the attending physician and the Director of Nursing. However, clinical record review revealed that the facility was unable to provide completed MRRs for this resident for several months, specifically December 2024, April 2025, May 2025, and June 2025. Interviews with the Director of Nursing confirmed that although the facility received encrypted emails from the pharmacy containing recommendations, the process of having these recommendations reviewed and completed by the physician was not followed. This lapse resulted in the failure to complete the required MRRs for the resident, as documented in the clinical records and confirmed by staff interviews.