F0756

E

Failure to Ensure Monthly Pharmacist Medication Regimen Reviews for Multiple Residents

Prescott, Arizona Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly medication regimen reviews (MRRs) for multiple residents, as required by facility policy. The facility’s written Drug Regimen Review policy, revised in January 2025, states that the pharmacist will review each resident’s medication regimen at least monthly to detect irregularities and clinically significant risks, and will document in the resident’s medical record that the review has been completed. Surveyors’ review of pharmacy review documents, closed records, and staff interviews showed that these monthly reviews were missing for several residents over multiple months.

For one resident with aftercare following joint replacement surgery, dysphagia, cognitive communication deficit, and acute kidney failure, who was cognitively intact and receiving antidepressant, opioid, and anticonvulsant medications, there were no documented pharmacy reviews for October and November 2025, and January and February 2026; only a December 2025 review was present with no recommendations. Another resident with Alzheimer’s disease, dysphagia, dementia, and cognitive communication deficit, who had severe cognitive impairment and was receiving antipsychotic, antianxiety, antidepressant, antibiotic, diuretic, and hypoglycemic medications, had no documented pharmacy reviews for September, October, and November 2025, and January and February 2026, with only a December 2025 review available showing no recommendations. A third resident with traumatic ischemia of muscle, opioid dependence with opioid-induced sleep disorder, chronic respiratory failure with hypoxia, and left knee pain, who was cognitively intact and receiving antidepressant and opioid medications, had no documented pharmacy reviews for August, September, October, and November 2025, and January and February 2026.

A fourth resident with type 2 diabetes, dysphagia, unspecified dementia, acute kidney failure, and cognitive communication deficit, who was cognitively intact and receiving antidepressant and opioid medications, had no documented pharmacy reviews for September, October, November, and December 2025, and January and February 2026. During interviews, the ADON stated that medication reviews are conducted upon admission with the facility provider and that the facility receives a monthly packet from the pharmacist, which he and the provider review, sometimes with pharmacist suggestions that may or may not be accepted, and then sent to medical records. However, he confirmed that he could not locate the pharmacy review records for the missing months for the identified residents and acknowledged that not having monthly pharmacy reviews was not acceptable. The interim DON reported that the pharmacist is in the facility monthly but believed pharmacy reviews only needed to be conducted quarterly, which conflicted with the facility’s written policy requiring at least monthly reviews and documentation in the medical record.