Missing and Inconsistently Filed Pharmacist Medication Review Recommendations
Penalty
Summary
Facility staff failed to maintain a consistent and accessible location for the consultant pharmacist’s monthly medication review recommendations (MMRs) in the resident’s medical record. For Resident #8, who had intact cognition with a BIMS score of 15 and diagnoses including Type 2 DM, epilepsy, HTN, bipolar disorder, schizoaffective disorder, hepatitis C, and generalized muscle weakness, the surveyor reviewed both paper and electronic records. The resident’s orders included multiple psychotropic and other high‑risk medications, such as Haldol Decanoate given intramuscularly on two separate monthly dates for schizoaffective disorder, Depakote for bipolar disorder with scheduled valproic acid level monitoring, Lantus and Novolog insulins with specific parameters and sliding scale instructions, and ammonia level monitoring. Despite this complex regimen, the surveyor found only three MMR documents in the paper chart: two dated the same day in early January 2025 (one noting an ammonia level of 62 and one stating no irregularities) and one dated in early May 2025 noting a valproic acid level of 41. Further review of the resident’s paper and electronic records showed no documented evidence of the pharmacist’s monthly medication review recommendations for extended periods, specifically from early January 2025 to early May 2025 and from early May 2025 through the end of December 2025. During an interview, the South Unit RN Manager stated that the MMRs should be in each resident’s paper chart, explaining that the DON receives them via email from the pharmacist and then distributes them to unit supervisors to be placed in the charts for physician review and signature. When asked to locate the pharmacist’s recommendations for the missing months in 2025, the RN Manager was only able to produce the three MMRs already identified by the surveyor and made no further comment regarding the absence of the remaining monthly reviews, confirming that the facility had not ensured a consistent location or complete set of pharmacist recommendations for this resident.
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