F0757

E

Failure to Ensure Medications Match Current Diagnoses and Indications

Roswell, New Mexico Survey Completed on 12-18-2025

Penalty

No penalty information released

Summary

The facility failed to ensure that residents’ drug regimens were free from unnecessary medications by not aligning indications for use with residents’ current diagnoses for three residents. One resident was admitted with diagnoses of insomnia, major depressive disorder, and psychotic disorder. Physician orders showed this resident was prescribed cetirizine for seasonal allergies, acetaminophen for pain, and tramadol as needed for pain. The MAR documented that cetirizine and acetaminophen were administered routinely over multiple days and tramadol was administered on several specific dates and times. During interview, the DON confirmed this resident did not have diagnoses of seasonal allergies or pain and stated the indications for cetirizine, acetaminophen, and tramadol did not reflect the resident’s current diagnoses or treatment of symptoms related to those diagnoses.

Another resident was admitted with schizophrenia, dementia, parkinsonism, major depressive disorder, and anxiety disorder. This resident had a physician order for methotrexate sodium 15 mg weekly for rheumatoid arthritis, and the MAR showed the medication was administered on two dates in December. The DON confirmed this resident did not have a diagnosis of rheumatoid arthritis and stated the indication for methotrexate did not reflect the resident’s current diagnoses or treatment of related symptoms. A third resident was admitted with major depressive disorder, insomnia, anxiety disorder, hyperlipidemia, and heart failure. This resident had a physician order for Zyrtec 10 mg daily via G-tube for allergies, and the MAR showed daily administration over multiple days. The DON confirmed this resident did not have a diagnosis of allergies and stated the indication for Zyrtec did not reflect the resident’s current diagnoses or treatment of related symptoms.