Failure to Complete and Act Upon Medication Regimen Reviews
Penalty
Summary
Facility staff failed to ensure that monthly medication regimen reviews (MRRs) were completed by a licensed pharmacist and that recommendations from these reviews were reported to and acted upon by medical providers in a timely manner for multiple residents. For one resident with multiple complex diagnoses, including progressive multifocal leukoencephalopathy and chronic kidney disease, the MRR completed by the pharmacist was not acknowledged or signed by a medical provider until well after the recommendation was made. The recommendation involved evaluating the use of multiple antidepressants and considering a dose reduction, but documentation of timely provider review and action was lacking. Another resident with severe cognitive impairment and multiple chronic conditions did not have evidence of MRRs being completed for several consecutive months. When MRRs were completed, the reports and recommendations were not promptly available in the clinical record, and provider responses were delayed. Recommendations included monitoring thyroid therapy and clarifying medication stop dates, but provider acknowledgment and action were not documented until weeks after the pharmacist's recommendations. A third resident with severe cognitive impairment had a pharmacist's recommendation for a dose reduction of Depakote that was not addressed by the medical provider for several months. The facility's policy required that MRR irregularities be reported and acted upon, but documentation showed significant delays in provider response and action. These deficiencies were confirmed through staff interviews, clinical record reviews, and facility policy review, with no additional information provided to the survey team prior to exit.