Failure to Complete and Implement Monthly Medication Regimen Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist completed and the facility acted upon monthly drug regimen reviews (MRRs) as required, including timely reporting and implementation of identified irregularities. For one resident with chronic kidney disease, hypertension, diabetes mellitus, hyperlipidemia, osteoarthritis, dementia with psychotic disturbance, paranoid schizophrenia, depression, and anxiety, the pharmacist documented multiple MRRs over several months and recorded three irregularities. The prescriber’s responses were documented only as “I agree,” without specifying what actions would be taken to address the irregularities, and there was no evidence that the pharmacist’s drug regimen review was conducted every month. During an interview, the DON acknowledged both the lack of monthly reviews and the incomplete responses to the pharmacist’s documented irregularities. Another resident with dementia with psychotic disturbance, seizure disorder, and a colostomy was receiving memantine, quetiapine, and divalproex sodium for dementia with behavioral disturbances and agitation. The care plan included monitoring for side effects and effectiveness of psychotropic medications and communicating with the physician and family about ongoing need and potential adverse reactions. However, review of the medical record showed no documented evidence that monthly drug regimen reviews were completed for several specific months, despite the resident’s use of multiple psychotropic medications and the care plan’s emphasis on monitoring and review. A third resident with schizophrenia and psychotic disorder was prescribed aripiprazole and had care plans addressing psychotropic medication use and polypharmacy, including monitoring for adverse reactions and reviewing pharmacy consult recommendations. The record review revealed that monthly drug regimen reviews were missing for two identified months. The DON stated that MRR reports are received through a portal and distributed to unit managers for physician review and implementation, and that once providers agree with recommendations, they should be implemented and uploaded within about one week; however, the missing documentation showed this process was not consistently followed. For another resident with hemiplegia, type 2 diabetes mellitus, protein energy malnutrition, major depressive disorder, atrial fibrillation, hydronephrosis, urinary retention, urinary calculus, impaired cognition, wheelchair use, an indwelling urinary catheter, and a diabetic toe wound, the consultant pharmacist made specific recommendations in two separate MRRs to define the dose and dosing limits for diclofenac (Voltaren) gel. These recommendations included suggested gram amounts per application and maximum daily doses for upper and lower extremities and total body use. The MRRs were signed by the consultant pharmacist and the unit manager RN, but the medication administration record showed the gel was administered twice daily without the dosing parameters specified, and the initial physician order entered later also lacked the recommended dosing limits. The DON acknowledged that the pharmacy recommendations had not been uploaded into the electronic medical record as expected, and the nurse practitioner stated he inadvertently missed the pharmacist’s recommendations when prescribing the medication. These findings demonstrate that pharmacist-identified medication regimen irregularities were not consistently reported, acted upon, or implemented in a timely manner for multiple residents.
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