The medication error at Cascade Terrace Post Acute involved temozolomide, a cancer drug that was supposed to stop after five days in April 2025. Instead, the resident continued receiving 390mg doses daily well past the April 26 cutoff date.
Staff 24, the facility's medical director, told inspectors the resident "was supposed to receive temozolomide for five days in April 2025 but received the medication longer than ordered." He said the incident "resulted in Resident 2 going back-and-forth to the hospital."
The confusion began April 21, when the resident returned from a neuro-oncology clinic appointment. Staff 22, a licensed nurse, entered the medication into the resident's clinical record based on a consultation note that listed temozolomide as part of the current medication regimen.
But there was no actual prescription order.
Staff 2, another licensed nurse, told inspectors she "completed a lengthy investigation of this medication error and was never able to find a paper order from the resident's neuro-oncology clinic for the temozolomide." She said she "denied ever visualizing a paper order for the medication."
The consultation note from the neuro-oncology clinic specified that temozolomide should be "taken once daily at bedtime on days one to five of a 28-day treatment cycle." Staff 2 acknowledged this note "did not constitute an order for the medication."
The error went undetected for weeks. It wasn't until May that Staff 23 received a phone call from Witness 3, alerting the facility that "the resident was not supposed to receive temozolomide past April 26, 2025."
By then, the damage was done. The resident had been receiving a cancer drug daily when they should have stopped after five days. The medical director said he expected nurses to contact prescribers "to get clarification with any order that was ambiguous," noting that the April 21 order "was unclear."
Staff 2 said Staff 22 "should have contacted Witness 2 on April 21, 2024 and requested clarification for the temozolomide order in writing." She also admitted she never checked Staff 22's entry into the resident's clinical record regarding the medication.
Temozolomide is used to treat certain types of brain tumors and is typically given in carefully controlled cycles with specific rest periods between treatments. Extending treatment beyond the prescribed duration can increase the risk of serious side effects.
The facility identified the problem as "past noncompliance" on May 20, 2025, and implemented corrective measures. Licensed nurses received education on obtaining paper copies for all prescriptions from outside medical providers. The facility also required two licensed nurse signatures for accuracy on all prescriptions entered into medical records.
Staff 2 completed an audit of medication administration records for all residents to ensure paper copies existed for prescriptions from outside providers. She also conducted weekly medication prescription audits for four weeks.
But the resident had already endured weeks of unnecessary medication and multiple hospitalizations. Inspectors found the facility failed to ensure drugs were administered in accordance with physician orders, resulting in actual harm to the resident.
The investigation revealed a breakdown in the facility's medication management system. Staff 22 entered a medication based on a consultation note rather than a proper prescription order. Staff 2 failed to verify the entry or ensure proper documentation existed. The medical director acknowledged the order was ambiguous but nurses didn't seek clarification.
Attempts to reach Witness 3 on November 4 and 5 were unsuccessful, leaving questions about how long the facility knew about the error before taking action.
The resident's prolonged exposure to chemotherapy medication and subsequent hospital visits illustrate the serious consequences when nursing homes fail to properly manage prescription drugs for vulnerable patients receiving complex cancer treatments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cascade Terrace Post Acute from 2025-11-06 including all violations, facility responses, and corrective action plans.