Failure to Implement Pharmacist Medication Regimen Review Recommendation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a consultant pharmacist’s medication regimen review (MRR) recommendation was implemented and appropriately followed up for one resident. Facility policy titled "Medication Regimen Review and Reporting" required the consultant pharmacist to review each resident’s medication regimen and medical chart at least monthly and for the facility to follow up on recommendations in a timely manner, including obtaining physician acceptance or rejection with documented rationale. Resident #37, admitted with diagnoses including Alzheimer’s disease and cerebral atherosclerosis and assessed as having severe cognitive impairment (BIMS score of 3), had an active order for lactobacillus capsules, two capsules by mouth once daily, related to cerebral atherosclerosis. The pharmacy MRR dated 09/02/2025 contained a recommendation to add a strength to the lactobacillus order because the existing order lacked a specified strength. Despite this recommendation, the order for lactobacillus was not corrected to include a strength, and there was no evidence that the physician had reviewed or responded to the pharmacist’s recommendation. The LPN Unit Manager was unable to locate an MRR with the physician’s signature for this resident, and the consultant pharmacist confirmed that the recommendation had not been acted upon and reiterated that every medication order must include a strength. The resident’s primary physician stated that if he had seen the recommendation, he would have signed it and agreed that lactobacillus is available in different strengths and the dosage should be specified. The DON stated she expected staff to maintain a copy of the signed MRR for each resident and that physicians should respond to pharmacist recommendations within a day or two, and the Administrator stated MRRs should be completed and followed up on in a timely manner, confirming that the pharmacist’s recommendation for this resident’s lactobacillus order was not followed up as required.
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