Failure to Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that medication regimen review (MRR) recommendations made by the consultant pharmacist were reviewed and addressed by the attending physician or prescriber for one resident. Facility policy titled "Medication Regimen Review and Reporting," revised January 2024, stated that for recommendations not requiring physician intervention, the DON or licensed designee would address the recommendations, implying that recommendations requiring physician intervention should be addressed by the physician. For Resident 4, who had diagnoses including major depressive disorder and dementia, the consultant pharmacist made specific recommendations related to the resident’s PRN pain medication regimen. Review of Resident 4’s medical record showed that on one occasion the consultant pharmacist recommended adding parameters for the resident’s PRN pain medication, and on another occasion recommended adding an appropriate dose for the resident’s pain medication. In both instances, further review of the record failed to show that the physician had reviewed or taken any action to address these identified irregularities. During an interview, the DON stated an expectation that the regulation would be followed and that the physician would review the irregularities, document any action taken, and document the rationale in the resident’s medical record, which had not occurred for these recommendations.
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