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F0756
D

Failure to Ensure Consistent Monthly Pharmacist Drug Regimen Reviews

Jefferson, Wisconsin Survey Completed on 06-23-2025

Penalty

10 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review, including a review of the medical chart, for one of five residents reviewed. According to the facility's policy, the consultant pharmacist is required to review each resident's medication regimen monthly and provide a report to the director of nursing, with nursing staff responsible for following up with the prescribing physician as needed. For the resident in question, who had multiple complex diagnoses including pulmonary embolism, paraplegia, Parkinson's disease, Alzheimer's disease, dementia, mood disturbance, and anxiety, the electronic medical record showed that monthly medication reviews were not documented for two specific months. The surveyor found that the resident's medical record lacked evidence of pharmacist reviews for January and April, despite documentation of reviews in other months. When questioned, facility leadership acknowledged the missing reviews and explained that the resident's hospitalization in April may have contributed to the oversight, as the resident did not trigger for pharmacist review upon return. No documentation was provided to account for the missing reviews, confirming that the required monthly pharmacist review was not consistently performed for this resident.

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