Failure to Obtain Physician Response to Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the consultant pharmacist were reviewed and acted upon by the attending physician or prescriber, as required by facility policy. The policy titled "Medication Regimen Review (Monthly Report)" stated that recommendations are to be acted upon and documented by facility staff and/or the prescriber. For three residents, documentation showed that nursing staff acknowledged and implemented pharmacist recommendations, but there was no evidence that a physician had reviewed or addressed the identified irregularities. For one resident with heart failure and respiratory failure, the consultant pharmacist recommended on December 10, 2025, that additional monitoring be added for an anticonvulsant medication; a nurse signed the recommendation and documented "added to order," but there was no physician signature or documentation of physician review. For a second resident with heart failure and respiratory failure, the pharmacist recommended on October 17, 2025, that a PRN antianxiety medication either be limited to 14 days or have a documented rationale and duration; a nurse signed and documented "14-day added to order" without any physician signature or evidence of physician review. For a third resident with a fracture of the first thoracic vertebra and respiratory failure, the pharmacist recommended on December 10, 2025, additional monitoring for an antipsychotic medication; a nurse signed and documented "AIMS" without a physician signature or documentation that the physician reviewed or acted on the irregularity. In an interview, the DON stated they would expect the regulation to be followed.
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