Failure to Document and Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were consistently added to resident records and that the pharmacist's recommendations were reviewed and acted upon in a timely manner. For one resident, who was receiving multiple medications including antipsychotics, antidepressants, anticoagulants, antiplatelets, blood sugar control, and antiseizure medications, the pharmacist recommended routine blood work related to a cancer treatment medication. This recommendation was not acknowledged, not included in the resident's record, and not acted upon or discussed with the physician for over five months. Additionally, other MRRs for this resident were missing from the record, with only a few months' reports present. For another resident, who was also on several medications such as antianxiety, antidepressants, water pills, and antiplatelets, the pharmacist made recommendations to consider reducing certain medications based on blood test results. These recommendations were not documented as reviewed or addressed by staff, and were not included in the resident's record. The recommendations were not acted upon until more than two months after they were made. Staff interviews confirmed that the MRRs were not followed up on, not implemented, and not included in the residents' records as required by facility policy.