HAMILTON, NJ - A dialysis patient at Atrium Post Acute Care of Hamilton consistently missed critical medications for more than two months because facility staff failed to adjust administration times to account for the resident's three-times-weekly dialysis schedule, according to a February 2025 state inspection.
Medication Timing Failures for Dialysis Patient
A resident receiving hemodialysis treatments on Tuesdays, Thursdays, and Saturdays regularly missed noon medications because staff scheduled doses during the hours the patient was away from the facility. The resident departed for dialysis appointments around 10 AM and returned approximately 4 PM, yet the facility continued administering medications at times when the patient was physically absent.
The resident reported to inspectors in early February that staff "frequently run out of their medications," specifically noting they did not receive Sevelamer (brand name Renvela), a critical phosphorus-binding medication essential for dialysis patients. The resident had been at the facility since late November 2024, with a brief hospital stay in January.
Medical records revealed the facility's care plan, dated January 30, 2025, specifically noted the need to "ensure medication schedule is adjusted to administer medications when I am in the facility." Despite this documented requirement, medication administration records from December 2024 through February 2025 showed repeated failures to implement the necessary schedule changes.
Critical Medications Affected by Scheduling Problems
Sevelamer represents a particularly important medication for patients with end-stage renal disease. This phosphorus binder works by preventing the intestines from absorbing phosphorus from food. When kidneys fail, they cannot remove excess phosphorus from the blood. Elevated phosphorus levels can lead to serious complications including cardiovascular disease, bone disorders, and calcification of soft tissues throughout the body. Dialysis patients must take phosphorus binders with meals to effectively control phosphorus levels.
The facility's electronic medication administration records documented extensive missed doses throughout December and January. On 13 separate dates in December alone, the noon dose of Sevelamer was not administered. Documentation indicated the resident was either "absent from home without meds" or "at dialysis" during scheduled medication times.
The pattern continued into January and February 2025. Records showed missed doses on January 2, 4, 6, 7, 8, 13, 14, 15, 25, 28, and 30. Electronic progress notes for several of these dates indicated the medication was "not available, awaiting from pharmacy or on order," suggesting compound failures in both medication supply management and schedule coordination.
Beyond Sevelamer, other essential medications were affected by the scheduling conflict. Heparin sodium injections, prescribed every eight hours for blood clot prevention, were missed on 11 dates in December at the 2 PM administration time. Calcium carbonate (TUMS), prescribed with meals for dialysis patients, was not administered on three dates in January during the noon time slot. Even Calcitriol, a vitamin D medication used to treat low calcium levels caused by kidney disease, was missed on two dates in December during morning administration times when the resident was in the facility.
Lack of Physician Communication and Order Modifications
Despite clear documentation that the resident attended dialysis three times weekly at consistent times, physician orders were not modified to reflect appropriate medication timing. The facility had a physician's order dated January 21, 2025, confirming the dialysis schedule with pickup at 10 AM and chair time at 11 AM on Tuesdays, Thursdays, and Saturdays. However, medication orders maintained a standard three-times-daily schedule including a noon administration time—precisely when the resident was unavailable.
Standard medical practice for dialysis patients requires coordination between the dialysis schedule and medication administration. Medications prescribed multiple times daily should be adjusted on dialysis days to times when the patient is present. For a medication ordered three times daily, this typically means reducing to two daily doses on dialysis days, scheduled around the treatment time.
The facility's consultant pharmacist confirmed this standard during an interview, stating that "a resident that goes out to dialysis had to have their medications scheduled to accommodate them being out of the facility." The pharmacist explained that physicians should be contacted for specific timing orders in these situations.
When medication administration records showed code "9"—indicating medication not given—for multiple doses, corresponding progress notes often lacked proper explanation. The facility's own policy required that when medications are unavailable, staff must contact the physician to obtain instructions about alternative arrangements, rather than simply documenting the medication was not available.
Documentation and Communication Breakdowns
The inspection revealed significant gaps in communication among nursing staff, pharmacy services, and medical providers. When inspectors interviewed the unit manager on February 5, she stated she was "unaware that there was an issue with Renvela or any medications" for the resident, despite the documented pattern of missed doses spanning more than two months.
The unit manager acknowledged during the inspection that "there should not be a time of 12 NOON for the Renvela on Tuesdays, Thursdays and Saturdays because the resident was out to dialysis." This statement confirmed staff awareness of the scheduling conflict, yet no corrective action had been taken to modify the medication orders or administration times.
Electronic progress notes frequently contained insufficient information. Multiple entries showed only that medication was not administered "pending pharm delivery" or stated "pharmacy contacted awaiting from pharmacy," without documentation of follow-up actions or physician notifications as required by facility policy.
The facility's own policies outlined appropriate standards. One policy specified that medications should be administered within one hour of prescribed time unless otherwise specified. Another policy on end-stage renal disease care specifically addressed the need for staff education and training on "timing and administration of medications, particularly those before and after dialysis."
Medical Implications of Missed Medications
The health consequences of inconsistent medication administration for dialysis patients can be severe and potentially life-threatening. Phosphorus binders like Sevelamer must be taken with meals to effectively bind dietary phosphorus before absorption. Missing doses allows phosphorus levels to rise unchecked, increasing cardiovascular disease risk—already the leading cause of death among dialysis patients.
Calcium carbonate serves dual purposes for dialysis patients: neutralizing stomach acid and binding phosphorus while providing calcium supplementation. Irregular dosing can result in electrolyte imbalances affecting heart rhythm, muscle function, and bone health.
Heparin injections prevent blood clots, a significant risk for patients with end-stage renal disease who often have vascular access devices and altered blood flow patterns. Missing scheduled anticoagulation doses increases the risk of deep vein thrombosis, pulmonary embolism, and clotting of dialysis access sites.
Calcitriol, the active form of vitamin D, regulates calcium absorption and bone metabolism. Dialysis patients cannot produce adequate amounts naturally due to kidney failure. Inconsistent dosing contributes to renal bone disease, a condition that weakens bones and increases fracture risk.
The cumulative effect of missing multiple medication classes over an extended period compounds these individual risks. Laboratory values can fluctuate, making it difficult for nephrologists to adjust treatment regimens appropriately when medication adherence is unreliable.
Additional Issues Identified
The inspection documented that electronic medication administration records showed inconsistent use of reason codes when medications were not given. Several dates had code "9" entered without corresponding explanatory progress notes, violating documentation standards.
Staff interviews revealed knowledge gaps about proper procedures when medications are unavailable. While the consultant pharmacist explained that physicians must be contacted for alternative instructions, actual practice did not consistently reflect this requirement.
The resident's care plan, though it correctly identified the need to adjust medication schedules, was not implemented effectively until inspectors raised concerns in February 2025—more than two months after the resident's admission and weeks after the care plan specifically documented the scheduling requirement.
The Director of Nursing, when interviewed on February 7, 2025, acknowledged that medications must be scheduled to accommodate residents being out for dialysis, confirming organizational awareness of the standard but failure to implement it consistently.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Atrium Post Acute Care of Hamilton from 2025-02-14 including all violations, facility responses, and corrective action plans.
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