Failure to Follow Up on Critically Low Potassium Level Prior to Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate follow-up for a critically low potassium laboratory result for a resident with multiple diagnoses, including bacterial pneumonia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and obesity. The resident was admitted and later discharged without appropriate re-evaluation of a critical potassium level. Medical record review showed that the resident's potassium was critically low at 2.5 mEq/L, and although medication adjustments were made, there was no evidence that the potassium level was re-checked prior to discharge. The discharge paperwork did not include instructions for follow-up laboratory testing. Interviews with facility staff and the nurse practitioner revealed that the nurse practitioner had ordered a repeat metabolic panel to monitor the potassium level, but was not informed of the resident's impending discharge. The resident and family were only notified of the critical potassium level on the day of discharge, at which point they were instructed to go to the hospital. Hospital records confirmed the resident was admitted for hypokalemia with a persistently low potassium level. The facility's policy required a discharge summary and post-discharge plan, but these were not adequately implemented in this case.