Failure to Administer and Accurately Document Potassium Chloride as Ordered
Penalty
Summary
The facility failed to ensure that Potassium Chloride (KCL) was administered to a resident as ordered by the physician and in accordance with facility policy. The resident, who had a history of seizure and paraplegia, was readmitted with a low potassium level and had a physician's order for daily KCL administration. The Medication Administration Record (MAR) indicated that KCL was given daily over a five-day period, but a physical count of the medication packets revealed that three doses were not administered as documented. Interviews with nursing staff and review of the medication cart confirmed that there were more KCL packets remaining than should have been if the medication had been administered as recorded. The resident and a family member both reported that the resident did not receive KCL on certain days, with the family member observing and questioning the lack of administration. The charge nurse initially stated that KCL was not available, but later administered a dose after repeated inquiries from the family. Further review by the pharmacist and the Director of Nursing corroborated the discrepancy between the number of KCL packets delivered, the number remaining, and the MAR documentation. The facility's policy required accurate documentation and timely administration of medications, but the nurses documented administration of KCL even when it was not given, resulting in a failure to meet the resident's pharmaceutical needs as ordered.