Failure to Complete and Act on Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MMRs) were completed and acted upon as required by policy. For one resident, there was no evidence that the MMR was completed for the month of March 2025, and the Director of Nursing (DON) confirmed that she could not produce the required documentation. This indicates that the process for ensuring regular pharmacist reviews and documentation was not followed for this resident. Additionally, for another resident, the pharmacist identified the need for a one-time digoxin level test during the MMR, which was subsequently ordered by the physician. However, there was no evidence that the facility acted on this order, as the required digoxin level was not obtained or documented in the resident's record in a timely manner. The pharmacist repeatedly noted the absence of the test result in subsequent monthly reviews, and the DON was unable to provide evidence that the order was carried out as directed.