F0756

E

Failure to Timely Implement Pharmacist Recommendation for Medication Indication

Alamogordo, New Mexico Survey Completed on 11-21-2025

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s process for ensuring that consultant pharmacist recommendations are reviewed and acted upon by the physician. A resident with diagnoses of unspecified dementia without behavioral, psychotic, mood disturbance, or anxiety, and unspecified schizophrenia was admitted on an unspecified date. The physician’s order dated 08/11/25 for donepezil 10 mg at bedtime listed the indication as schizophrenia, unspecified. During the monthly Medication Regimen Review dated 09/05/25, the consultant pharmacist recommended clarification of the donepezil indication, specifying that it should be changed from schizophrenia to dementia.

Record review showed that the physician’s order for donepezil was not updated to reflect dementia as the indication until 10/28/25, indicating that the pharmacist’s recommendation was not implemented in a timely manner and no documented rationale for not following the recommendation was provided. During an interview on 11/21/25 at 10:19 AM, the DON confirmed that the diagnosis for donepezil was not updated until 10/28/25 and stated that the diagnosis should have been updated within the month of the recommendation. This sequence of events demonstrated the facility’s failure to ensure that the consultant pharmacist’s recommendation regarding the medication indication was reviewed and implemented by the physician or that a rationale was documented for not following it.