Failure to Promptly Notify Physician of Abnormal Potassium Level
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify a physician of an abnormal laboratory result for a resident. The resident, who had a history of hypertension, chronic kidney disease, and diabetes, had a blood potassium level of 5.6 mEq/L, which was flagged as high. The laboratory result was available at 11:26 PM, but the physician was not notified until the following day at 5:50 PM. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that abnormal lab results should be reported to the physician as soon as they are received, in accordance with facility policy. The resident was cognitively intact and required substantial to maximal assistance with activities of daily living. The facility's policy required licensed nurses to promptly notify the attending physician of abnormal laboratory findings by telephone or fax, with the date and time noted. Despite this, there was a significant delay in notifying the physician about the resident's hyperkalemia, as documented in the records and confirmed during staff interviews.