Lack of Documented Monthly Medication Regimen Reviews by Pharmacist
Penalty
Summary
The facility failed to provide documentation of monthly medication regimen reviews (MRR) by a licensed pharmacist for three sampled residents. According to the facility's policy, a licensed pharmacist is required to conduct a thorough monthly review of each resident's medication regimen, including a review of the medical chart. For each of the three residents reviewed, their care plans indicated that pharmacy reviews were to occur monthly as per protocol. However, for the month of April 2025, there was no documentation in the clinical progress notes or medication regimen review records to show that these reviews had been completed. The residents involved had complex medical histories, including diagnoses such as dementia, heart disease, diabetes, chronic kidney disease, hyperlipidemia, emphysema, hypertension, and cirrhosis of the liver. Despite these conditions and the facility's stated policy, there was no evidence that a licensed pharmacist had performed or documented the required monthly medication reviews for these residents during the specified period. The Director of Nursing confirmed the absence of this documentation during an interview.