The resident was supposed to receive Sevelamer HCl, a drug that removes excess phosphate from the blood of dialysis patients. Instead, nurses marked doses as "administered" on medication records even though the facility never had the drug in stock.
The patient's family discovered the deception on November 27 when facility staff finally told them their loved one hadn't received "a single dose" since admission earlier that month.
Medication administration records showed a pattern of false documentation. On November 22 and 23, staff marked two of three daily doses as "OS" — meaning "see nurses' note" — while recording the evening dose as given. The nurses' notes consistently stated "Medication not available."
By November 24, all three doses were marked as unavailable. The pattern continued through November 26, with staff alternating between marking doses as unavailable and falsely recording them as administered.
On November 27, records showed the morning and noon doses were given, while the evening dose was marked unavailable. The next day, two doses were recorded as administered before the patient was transferred to a local hospital that afternoon due to a change in condition.
None of those "administered" doses were real.
The former Director of Nursing told the family the medication couldn't be delivered by the pharmacy. But a single phone call revealed the drug was sitting at a local pharmacy, available for pickup the same day.
During the December inspection, current Director of Nursing B confirmed the falsified records. He stated he had personally verified the medication was never in the facility at any point during the resident's stay.
"The doses of Sevelamer marked as administered on the MAR were not accurate, as the medication was never available in the facility," he told inspectors.
The facility launched an investigation into the falsification and provided staff education, according to the director.
Missing doses of Sevelamer can worsen metabolic balance in dialysis patients, particularly when combined with poor nutrition. This can contribute to increased confusion and lethargy, according to federal health authorities.
The resident had end-stage renal disease and required dialysis three times weekly. Her physician had ordered 2,400 milligrams of Sevelamer daily — three 800-milligram tablets with each meal — to control phosphorus levels that build up between dialysis sessions.
The patient scored 13 out of 15 on a cognitive screening test, indicating she was mentally intact and likely aware something was wrong with her care.
Federal inspectors reviewed the case after receiving a complaint. They found the facility failed to maintain accurate medical records, violating federal standards for nursing home documentation.
The inspection report doesn't indicate how long the resident had been in the facility before the medication issue was discovered, or whether her hospitalization was related to the missed doses.
Staff involved in the false documentation received additional training, but the report doesn't specify what disciplinary actions, if any, were taken.
The case highlights how medication errors can compound in nursing homes when staff prioritize paperwork compliance over patient safety. Rather than immediately addressing the unavailable medication, staff chose to falsify records that could have masked a serious medical problem for days longer.
The resident no longer lives at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cascade Senior Care Center from 2025-12-30 including all violations, facility responses, and corrective action plans.