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 monthly Medication Regimen Reviews (MRR) were acted upon for four residents. According to facility policy, recommendations from the pharmacist are to be addressed and documented by staff or the prescriber, with the prescriber either accepting and acting upon the suggestion or providing an explanation for disagreement. For each of the four residents reviewed, there was no evidence that pharmacy recommendations were reviewed or acted upon by the provider or facility staff, as required by policy. Specifically, for residents with diagnoses such as dementia, major depressive disorder, anxiety, PTSD, delusional disorder, and bipolar disorder, pharmacy recommendations regarding medication adjustments or discontinuations following incidents such as falls were not documented as reviewed or addressed. Interviews with the Director of Nursing Services confirmed the absence of documentation or evidence that these recommendations were considered or acted upon for the residents in question.