Lack of Documented Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
Facility staff failed to ensure that a licensed pharmacist completed and documented monthly drug regimen reviews, including review of the medical chart, for all sampled residents as required by facility policy dated 06/20/22. The policy stated that each resident’s drug regimen must be reviewed at least once a month by a licensed pharmacist and that this review must include the resident’s medical chart. For five sampled residents, their medical records contained no documentation that a pharmacist had conducted these monthly reviews or reported any medication irregularities to the attending physician, medical director, or DON. This lack of documentation occurred despite residents having multiple diagnoses and receiving various high‑risk medications. One resident assessed as cognitively intact had diagnoses including diabetes, UTI, and paraplegia and was receiving opioids, anticoagulants, antibiotics, anti‑anxiety medications, and insulin injections, yet there was no record of a pharmacist’s monthly review. Another cognitively intact resident with diabetes, coronary artery disease, peripheral vascular disease, renal failure, stroke, anxiety, and depression was receiving anti‑anxiety, antidepressant, diuretic, opioid, and antiplatelet medications, also without documented pharmacist review. A cognitively impaired, delusional resident with heart disease, malnutrition, stroke, dementia, depression, arthritis, and hemiplegia, who was receiving PRN pain medication, antipsychotic, antidepressant, and antiplatelet medications, had a care plan directing monthly pharmacy review, but no such documentation was found. Two additional residents with severe cognitive impairment, non‑traumatic brain dysfunction, heart disease or atrial fibrillation, Alzheimer’s disease, anxiety, and depression, who were receiving antipsychotic, antidepressant, and anti‑anxiety medications, likewise had no documented monthly pharmacist review. In interviews, the facility director stated the pharmacist chooses a day each month to review charts and leaves a sheet only if changes are recommended, and acknowledged there is no documentation when no changes are made, while the Administrator confirmed the available documentation did not indicate that required reviews were completed.
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