Failure to Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the Clinical Consultant Pharmacist during the monthly Medication Regimen Review (MRR) were reviewed and acted upon by the residents' providers for three of six residents reviewed. For one resident, the pharmacist recommended decreasing the Lantus insulin dose and evaluating the Sitagliptin dose, as it exceeded the manufacturer's maximum recommended amount. For another resident, the pharmacist recommended evaluating the continued need for lorazepam, reviewing the diagnosis and usage pattern, and either discontinuing the order or specifying the duration for the PRN order. For a third resident, the pharmacist identified duplicate PRN orders for phenazopyridine, recommended clarifying acetaminophen dosing to not exceed 3 grams daily, and suggested specifying the amount of fluid to mix with Miralax. Record review did not reveal evidence that these recommendations were reviewed or acted upon by the residents' providers. During an interview, facility leadership was unable to provide documentation that the pharmacy consultation reports were reviewed and addressed as required by facility policy and procedure.