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F0755
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Failure to Notify Pharmacy Consultant for Immediate Medication Review After Resident Weight Loss

Susanville, California Survey Completed on 09-12-2025

Penalty

No penalty information released
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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 notify the Pharmacy Consultant (PC) to conduct immediate medication regimen reviews (MRR) for three residents who experienced significant weight loss. Facility policies required that the PC be alerted for an immediate MRR when a resident experienced a change in condition, such as weight loss, to evaluate whether medications could be contributing factors. However, interviews and record reviews confirmed that the Director of Nursing (DON) did not notify the PC, and there was no documentation of immediate MRRs being performed for these residents. The three residents involved had complex medical histories, including diagnoses such as major depression, Alzheimer's disease, dementia, adult failure to thrive, and type 2 diabetes with neuropathy. Each resident experienced severe weight loss over a 180-day period, as documented in their weight summaries. Despite facility policies and procedures outlining the need for prompt pharmacy review in such cases, the required notifications and reviews were not completed, and the PC confirmed no pharmacy review had been conducted regarding the weight loss for these residents.

See complete original report
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