Failure to Complete and Document Monthly Medication Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed and documented monthly medication regimen reviews (MMRs) for two of five sampled residents. For one resident with hypertension, depression, and a history of stroke, the medical record lacked MMRs for three separate months. This resident had moderate cognitive impairment and an activated Power of Attorney for Healthcare (POAHC). For another resident with Alzheimer's disease, dementia with behavioral disturbance, anxiety, insomnia, and depression, the MMR for one month was missing. This resident had severe cognitive impairment and was also under an activated POAHC. Surveyors reviewed the medical records for both residents and confirmed the absence of the required MMR documentation for the specified months. The Director of Nursing (DON) verified that the facility could not locate the missing MMRs or any pharmacist recommendations for these residents. The DON also confirmed that the facility's process involves the pharmacist emailing all recommendations to the DON for physician follow-up, but the documentation for the months in question was not available.