F0756

D

Failure to Timely Address Pharmacist Medication Regimen Review Recommendations

Silver Spring, Maryland Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely completion and follow-up of monthly Medication Regimen Reviews (MRRs) by a provider, and failure to respond to consulting pharmacist recommendations as required by facility policy. For one resident reviewed for unnecessary medications, the medical record showed MRR entries for two consecutive months documented only as “See [pharmacist’s] report,” without the actual reports initially available. The ADON described the facility’s MRR process, stating that the pharmacist emails the MRRs, she prints the recommendations, and then gives them to the NP to address, with the expectation that the provider will check agree/disagree/other, sign, and date the form. She further stated that some recommendations are implemented in the EMR by the NP, while others are passed to unit managers to enter, and that MRRs are to be completed before the next month’s review.

When the surveyor requested the resident’s MRRs, the 1/8 MRR was not provided until the following day, and the 2/9 MRR was initially unavailable. Review of the 1/8 MRR showed a pharmacist recommendation to discontinue melatonin, with the provider marking “agree” and signing on 3/3, nearly two months after the recommendation. The 2/9 MRR, when later produced, contained the same recommendation to discontinue melatonin, but had no provider signature, date, or box checked, and the ADON acknowledged that both MRRs had been missed, noting she had been on vacation. The facility’s policy states that MRR irregularities must be reported to the attending physician, medical director, and DON, must be acted upon, and that non-urgent recommendations must be addressed and documented prior to the next scheduled review, which did not occur in this case.