F0756

D

Failure to Ensure Provider Response to Monthly Medication Regimen Review Recommendations

Towson, Maryland Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that providers consistently responded to and acted upon monthly Medication Regimen Review (MRR) recommendations made by the consultant pharmacist. The facility’s policy requires that, upon receiving the MRR report, the attending physician review and respond to the pharmacist’s recommendations, document in the medical record that the recommendations were reviewed, and indicate what actions, if any, were taken. The DON stated that the pharmacist typically visits during the third week of the month, emails the MRRs to regional staff, the DON, and Unit Managers, and that the printed MRRs are physically handed to the provider, who is expected to check agree/disagree/other, provide rationale if disagreeing, and sign and date the form within 7–10 days. Despite this described process and policy, multiple MRRs for two residents were either not fully addressed, not acted upon, or not completed by the provider.

For one resident reviewed for unnecessary medications, the pharmacist made several recommendations over multiple months. An MRR dated 8/22/25 recommended co-prescribing naloxone for a resident on routine oxycodone for lower extremity pain; the provider checked agree and signed and dated the MRR, but the resident did not have an active naloxone order in the medical record. An MRR dated 9/21/25 recommended a gradual dose reduction (GDR) of Uzedy for schizophreniform disorder and instructed that, if the recommendation was declined, the provider should select a rationale option and provide a brief clinical rationale note; the provider checked disagree and signed and dated the MRR but did not select any of the rationale options or document a brief clinical rationale on the MRR. An MRR dated 11/16/25 recommended adding a stop date for cefepime and adding a probiotic while on antibiotic therapy; the provider checked other and documented that the patient had a stop date of 12/3/25, thereby addressing the stop-date portion, but did not respond to or act on the probiotic recommendation on the MRR form.

Further review for the same resident showed that the facility did not provide a complete set of MRRs for the requested six-month period. Initially, only August, September, and November 2025 MRRs were produced. The DON later stated there were no recommendations for December 2025 and that the resident was hospitalized during the January 2026 review, so no MRR was conducted then. However, the DON acknowledged that an October 2025 MRR existed and had been missed. When the October 10/26/25 MRR was produced, it was found that the provider had not completed it at all: there was no indication of agree, disagree, or other, no signature or date, and no documented action taken to address the pharmacist’s recommendation. The DON confirmed that this MRR had not been addressed and that, several months later, it still remained incomplete.

For a second resident, the pharmacist’s MRRs also contained recommendations that were not fully reconciled by the provider. An MRR dated 10/26/25 included a psychiatry recommendation for a GDR of olanzapine 10 mg at bedtime for paranoid schizophrenia, stating the resident was due for a dose reduction to find the lowest effective dose. The MRR form for this recommendation was left entirely blank, with no box checked for agree, disagree, or other, and no provider signature or date, and there was no indication that the recommendation had been completed. Another MRR dated 1/19/26 contained a physician recommendation regarding trazodone 50 mg at bedtime for depression/insomnia, stating that if an antidepressant is used for sleep or to manage behavior, mood, or a psychiatric disorder, it must be reviewed for possible GDR and, if a reduction is clinically contraindicated, the rationale and risk–benefit should be documented. The provider checked disagree and signed and dated the form but did not write any brief clinical rationale note on the MRR. Review of the physician’s progress notes for this resident also failed to show any documented reason for disagreeing with the trazodone GDR recommendation, and there was no documentation that the olanzapine GDR recommendation had been addressed, demonstrating that the facility did not ensure provider response and action on the pharmacist’s MRR recommendations.