Failure to Obtain Timely TPN Order and Ensure Consistent Administration
Penalty
Summary
A deficiency occurred when the facility failed to obtain a physician's order to ensure the consistent provision of a customized Total Parenteral Nutrition (TPN) for a resident with complex medical needs, including dysphagia, malnutrition, and metastatic cancer. The resident was dependent on TPN for nutrition and hydration, which included critical electrolytes such as potassium. The TPN order expired, and there was a lapse in obtaining a new order from the metabolic physician, resulting in the resident missing multiple doses of customized TPN containing potassium over several days. During this period, the resident also experienced an interruption in hydration for more than 12 hours. Documentation revealed that nursing staff and supervisors were aware that an updated TPN order was required, but failed to follow up with the metabolic physician or ensure the pharmacy received the necessary prescription. The medication administration record showed missed TPN administrations, and nursing progress notes lacked adequate documentation for the missed doses. There was also confusion regarding the type of TPN administered, as the medical record system did not accurately reflect the TPN formula received and administered, leading to further discrepancies in care. As a result of these failures, the resident developed severe hypokalemia, metabolic alkalosis, and acute kidney injury, which required hospitalization. Laboratory results confirmed critically low potassium levels, and the resident exhibited symptoms such as fatigue and headache. The facility's own investigation confirmed the interruption in TPN and hydration, as well as the lack of appropriate follow-up to secure the necessary physician orders.