Failure to Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that medication regimen review (MRR) recommendations made by the consulting pharmacist were addressed by the provider for several residents. In one case, a resident was prescribed multiple psychotropic medications, including Alprazolam, Gabapentin, and Quetiapine. The pharmacist recommended a gradual dose reduction (GDR) for these medications, but there was no evidence that the resident was re-evaluated by psychiatry after the recommendation. Additionally, the medical director increased the resident's Seroquel dosage without documenting the rationale or addressing the pharmacist's GDR recommendation. Interviews with the DON and medical director confirmed that no documentation was available to support the clinical decisions or to show that the pharmacist's recommendations were considered. For another resident, the facility's records showed that the pharmacist identified irregularities in the MRRs on two separate occasions. However, there was no documentation in the medical record indicating that these irregularities were addressed by the provider. The DON acknowledged the concern when interviewed and confirmed that the provider did not respond to the pharmacist's recommendations. A third resident's records revealed that the pharmacist recommended a GDR for several psychotropic medications, but the provider did not respond to these recommendations or make adjustments to the medications until several months later. There was also no documentation from the physician indicating agreement or disagreement with the pharmacist's recommendations, nor evidence of non-pharmacological interventions being provided. The DON was unable to provide documentation of such interventions when asked.