Missing Monthly Medication Regimen Review Documentation
Penalty
Summary
A deficiency occurred when the facility failed to have documentation of a monthly medication regimen review (MRR) by a licensed pharmacist for one resident. The resident, who had a history of hypertension, hyperlipidemia, stroke, peripheral vascular disease, chronic kidney disease, depression, and insomnia, was readmitted to the facility and did not have an MRR available for the month of October 2025. During the survey, staff and pharmacist interviews confirmed that the required documentation for the MRR could not be located for this resident. Pharmacist #1 reported that Pharmacist #2, who was responsible for the review, claimed to have paper notes for the October MRR, but these could not be found. The DON stated that she typically received monthly MRRs and recommendations from the pharmacist, with residents not requiring recommendations listed generally and specific recommendations documented separately. However, the resident in question was not included in the October MRR list provided to the DON. The administrator also confirmed that the MRR should have been completed in a timely manner by the pharmacy representative.