Delayed Review and Implementation of Pharmacist Medication Regimen Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were reviewed and acted upon in a timely manner for five out of six months reviewed. According to facility policy, MRR reports should be received within three days of the pharmacist's review and the provider should review and respond within fourteen days. However, the policy did not specify the timeframe for the facility to note and implement the provider's recommendations. Review of records showed significant delays between the pharmacist's review, the provider's review, and the facility's implementation of recommendations for multiple months. For example, MRRs completed in January were not reviewed by the provider until February, and recommendations were not implemented until April. Similar delays occurred in subsequent months, with some recommendations not implemented until several weeks after provider review. During an interview, the Director of Nursing Services acknowledged the delays and attributed them to a recent change in pharmacy providers, which altered the timing and process for receiving MRR reports. The reports are now sent by email, printed upon arrival, and given to the provider, but the facility has not yet adjusted to the new process. The Director confirmed that not all reviews are being addressed in a timely manner, as required by policy and regulatory standards.