Failure to Ensure Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist performed and documented a monthly drug regimen review (MRR) for a resident, as required by facility policy and federal regulations. The facility’s policy, “Monitoring Medication Regimen Review,” dated 12/17, states that the AlixaRx Clinical Pharmacist (ACP) is to perform a comprehensive review of each resident’s medical record at least monthly, with the MRR defined as a thorough evaluation of the resident’s medical regimen. During the survey, one of five residents reviewed under the unnecessary drug pathway (Resident #4) was found to be missing documentation of required monthly MRRs in the electronic medical record for multiple months. Record review showed no documented MRRs for Resident #4 for January 2025 through January 2026 at the time of the initial request on 02/09/25. After the surveyors requested the missing reports, Medical Records Employee #46 later provided completed MRRs for April 2025 through January 2026, but was initially unable to provide documentation for January, February, or March 2025. Upon a second request on 02/10/25, the medical records employee produced the March 2025 MRR but reported that the January 2025 and February 2025 MRRs could not be located. No further documentation was provided before the end of the survey, resulting in a finding that the facility failed to perform or document monthly pharmacist drug regimen reviews for at least two months for this resident, in a facility with a census of 90 residents.
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