|§483.45(c) Drug Regimen Review. |
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.
§483.45(c)(2) This review must include a review of the resident's medical chart.
§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.
§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to respond to recommendations made by the consultant pharmacist for three of five residents reviewed. (Residents 12, 21, and 22)
Review of facility policy and procedure titled Pharmacy Services, last revised on August 28, 2018, revealed a licensed pharmacist will review the drug regimen of each residents at least once a month. The pharmacist will report any irregularities to the attending physician, the director of nursing, and the medical director. These reports will be acted upon.
Review of Resident 12's clinical record revealed there were pharmacy reviews completed on August 2, 2021, June 12, 2021, May 6, 2021, April 18, 2021, March 21, 2021, February 16, 2021, January 3, 2021 and December 3, 2021 in which the pharmacist identified irregularities to be addressed by the facility.
Review of Resident 21's clinical record revealed there were pharmacy reviews completed on July 4, 2021, June 11, 2021, April 18, 2021, March 21, 2021, February 16, 2021, November 5, 2021 in which the pharmacist identified irregularities to be addressed by the facility.
Review of Resident 22's clinical record revealed there were pharmacy reviews completed on May 6, 2020, July 6, 2020, September 11, 2020, December 3, 2020, January 3, 2021, February 16, 2021, and April 18, 2021 in which the pharmacist identified irregularities to be addressed by the facility.
Interview with the Director of Nursing and the Nursing Home administrator on December 9, 2021 at 10 a.m. confirmed the facility could not provide evidence that the irregularities were acted upon by the facility when reported by the pharmacist for Residents 12, 21, and 22.
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
| ||Plan of Correction - To be completed: 02/01/2022|
1. Pharmacy recommendations for resident 12, 21 and 22 have been addressed.
2. A baseline pharmacy recommendation audit was completed. Pending pharmacy recommendations were addressed.
3. The DON will be re-educated on the Drug Regime Review Policy and Procedure. Pharmacy recommendations will be reviewed as part of the morning meeting process.
4. The NHA or designee will perform audits on a monthly basis x 3 months to ensure that pharmacy reviews and recommendations have been completed. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.