Failure to Administer Ordered Sevelamer for Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring dialysis received Sevelamer as ordered to manage hyperphosphatemia, consistent with professional standards of practice. The resident, who was readmitted with end stage renal disease and dependence on hemodialysis three times a week, was cognitively intact with a BIMS score of 15 and dependent on staff for all ADLs. The care plan included coordinating medications with dialysis days. A physician’s order dated 10/1/2025 prescribed Sevelamer 3200 mg three times daily with meals for elevated phosphorus levels. Review of the MARs for November and December 2025 and January 2026 showed that the resident did not receive 27 scheduled doses of Sevelamer across multiple dates and times. Laboratory results from the hemodialysis center showed the resident’s phosphorus level was elevated at 5.5 on 12/19/2025 and had further increased to 7.5 by 1/12/2026. During interviews, an RN at the facility stated that Sevelamer had not been available for a while and had been placed on hold due to unavailability, and that the medication was only recently received from the dialysis center. The dialysis center RN reported that Sevelamer was ordered three times daily with meals and that the center was unaware the resident had run out of the medication, as the facility had not communicated this, even though the dialysis center supplied it. The NP stated that the increased phosphorus levels were due to the resident not receiving Sevelamer. The DNS reported she was initially unaware that the resident’s Sevelamer supply came from the dialysis center and could not provide evidence that the medication had been administered as ordered.
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