Failure to Complete and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRRs) were consistently completed and documented for several residents, as required by both facility policy and regulatory guidelines. For one resident, a pharmacist's recommendation to order a new Basic Metabolic Panel due to persistently high Blood Urea Nitrogen levels was not completed by the physician, and the corresponding form was not finalized or scanned into the resident's electronic health record (EHR). Staff interviews confirmed that the expected process for handling pharmacist recommendations was not followed, resulting in incomplete documentation and lack of physician response. Additionally, two other residents did not have documented MRRs for multiple months, with no records found in either the facility's MRR binder or the residents' EHRs for the specified periods. Despite written requests for additional documentation, staff were unable to provide evidence that the required monthly reviews had been performed. Both the administrator and the director of nursing acknowledged that MRRs should be completed monthly and available in the EHR, but the documentation was missing for the residents in question.