Failure to Administer Potassium as Ordered Due to MAR Display Error
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including hypertension and respiratory failure, did not receive potassium supplementation as ordered by the physician for a period of 13 days. The physician's order specified an initial dose of two tablets of Potassium Chloride ER 20 mEq, followed by one tablet twice daily. However, the medication administration record (MAR) displayed incomplete instructions unless an additional link was clicked, leading to confusion among staff. As a result, the medication aide administered two packets of Potassium 20 mEq powder (totaling 40 mEq) daily, rather than the intended regimen. The medication aide stated she was unaware of the full instructions due to the MAR's display limitations and had been following what was visible on the screen. The Director of Nursing (DON) confirmed the discrepancy between the physician's order and the MAR, noting that the facility had recently transitioned to a new electronic charting system. The DON also acknowledged that nurse managers were responsible for ensuring medication orders matched the MARs. A stat potassium level was ordered by the physician after the error was discovered, and the resident's potassium level was found to be within the normal range at that time.