F0756

E

Failure to Complete Monthly Medication Regimen Reviews and Address Pharmacist Recommendations

Hanover, Pennsylvania Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that each resident’s drug regimen was reviewed at least monthly by a licensed pharmacist and that identified irregularities were addressed in a timely manner by the attending physician or prescriber. Facility policy on Medication Regimen Review required a comprehensive monthly medication regimen review (MRR) by the consultant pharmacist, with recommendations acted upon and documented by staff and/or the prescriber. For two residents with diagnoses including GERD, hyperlipidemia, dementia, repeated falls, and other conditions, the clinical records did not show that required monthly MRRs were completed for a specified month. In addition, multiple MRRs contained recommendations that lacked any documented response or evidence of implementation.

For one resident with GERD and dementia, there was no MRR documented for April, and later MRRs in June and August included recommendations to administer omeprazole on an empty stomach before meals and to obtain routine lab values, with no documented response or implementation; the same omeprazole administration recommendation reappeared in a December MRR. For another resident with repeated falls and dementia, there was no MRR documented for April, and a September MRR recommendation to specify the gram amount for diclofenac gel application had no documented response or implementation and was repeated in December. For a third resident with Down syndrome and dementia receiving pantoprazole, an October MRR recommendation to administer the medication on an empty stomach 30–60 minutes before a meal was not addressed until several months later. In interviews, the DON stated an expectation that monthly MRRs be completed and available, and that physicians review and respond to MRR recommendations in a timely manner.