Failure to Obtain and Document Consultant Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist’s monthly medication regimen review (MRR) for one resident was complete and that the pharmacist’s recommendations were received and available to staff. For this resident, the MRR dated 7/14/25 stated, “Please take the following action described below,” but the actual actions and/or recommendations were missing from the document. When the surveyor inquired on 7/30/25 about the pharmacist’s recommendations that were referenced but not included, the DON (V2) reported that the pharmacist had checked off a recommendation for a medication change for the resident but had not sent the facility the actual recommendation. The facility’s written policy dated 10/25/14 on documentation and communication of consultant pharmacist recommendations requires that the consultant pharmacist work with the facility to establish a system to ensure that observations and recommendations regarding residents’ medication therapy are communicated to those with authority to implement them and that these are documented and made available in an easily retrievable form to nurses, physicians, and the care planning team. The policy further states that the consultant pharmacist documents potential or actual medication-related problems, irregularities, and other MRR findings appropriate for prescriber and/or nursing review, and that comments and recommendations concerning medication therapy are communicated in a timely fashion. In this case, the pharmacist’s recommendation for a medication change for the resident was not present in the MRR and was not available to facility staff in accordance with the policy.
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