Failure to Ensure Timely Follow-Up and Communication of Potassium Lab Results for Dialysis Resident
Penalty
Summary
Nursing staff failed to ensure appropriate follow-up and communication regarding a resident's potassium (K) laboratory order and results. After the resident, who had a history of end stage renal disease and hyperkalemia, was reported by the dialysis center to have a critically high potassium level, the medical director ordered Kayexalate and a repeat potassium level. The medication was administered, and a lab requisition was completed for a repeat potassium test. However, the requisition was incorrectly filled out, resulting in a Keppra (Levetiracetam) level being drawn instead of the required potassium level. The error in the lab requisition was not identified or corrected by the nursing staff. There was no documentation that the potassium result was received, nor was there evidence that the medical director was notified of the missing or incorrect lab result. The facility's policy required nurses to follow up on lab orders, notify the physician of abnormal results, and ensure that lab reports were received and acted upon. In this case, the lack of follow-up and communication led to a delay in identifying and addressing the resident's ongoing hyperkalemia. Interviews with nursing staff, the director of nursing, the medical director, and the laboratory director confirmed that the potassium test was not properly ordered or followed up on. The laboratory director indicated that the requisition was unclear, and the error was not clarified with the facility. The nursing staff acknowledged that the potassium box on the requisition was not checked, and the error was not discovered until days later. This series of actions and inactions resulted in the resident not receiving timely and appropriate monitoring for a potentially life-threatening condition.