Incomplete Medication Regimen Review Policy Lacking Time Frames and Urgent Action Steps
Penalty
Summary
The facility failed to ensure that its monthly drug regimen review (MRR) policy contained required elements, specifically time frames for the different steps in the MRR process and directions for actions the pharmacist must take when an irregularity requiring urgent action is identified. Review of the facility document titled “Medication Regimen Review,” revised on multiple dates, showed that while it stated medications are reviewed in multiple ways, including the MRR conducted by the consultant pharmacist, it lacked evidence of defined time frames for each step of the process and did not specify the steps the pharmacist must take when an irregularity is identified. During an interview, the DON confirmed that the policy does not include time frames for the different steps in the medication review process. These findings were discussed with the NHA, DON, and ADON during the exit conference. No specific residents, medical histories, or clinical conditions were identified in the report in relation to this deficiency.
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