Failure to Provide Timely Intervention and Monitoring for Critically Low Potassium
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for a resident with a critically low potassium level. After the laboratory notified the facility of a critical potassium result of 2.7 mEq/L, the nurse who received the result did not notify the physician, did not assess the resident, and did not initiate a Change in Condition Evaluation Form (CIC). There was no documentation of any assessment or communication regarding the abnormal lab result until several hours later, when another nurse became aware of the situation and contacted the physician. Following the physician's orders for urgent potassium replacement and IV hydration, there was a significant delay in administering the ordered potassium, as it was not given until approximately five hours after the order was placed and after a reminder from the supervising nurse. Additionally, the ordered IV fluids for hydration were not administered because staff were unable to establish IV access, and the physician was not notified of this delay. Documentation did not show that the resident was monitored for complications of hypokalemia, such as cardiac symptoms, as required by the care plan. The resident had a complex medical history, including diabetes, acute kidney failure, hypertension, and cognitive impairment, and was dependent on staff for all activities of daily living. Despite the critical nature of the lab results and the resident's vulnerability, the facility did not ensure timely notification, intervention, or monitoring. The resident was later found unresponsive and expired despite resuscitation efforts. Interviews with staff confirmed lapses in communication, assessment, and timely intervention in response to the critical lab findings.