Failure to Monitor and Respond to Critical Potassium Levels
Penalty
Summary
A resident with multiple complex medical diagnoses, including chronic obstructive pulmonary disease, hypertension, heart disease, and aortic aneurysms, was admitted to the facility and was being treated for hypokalemia (low potassium). The resident's potassium levels were monitored through laboratory testing, which revealed several critically low values. Orders were given for potassium supplementation, but there was inconsistent documentation regarding the administration of these supplements and a lack of timely repeat laboratory monitoring to assess the effectiveness of the interventions. Despite ongoing potassium supplementation, there was no evidence that the facility ensured ongoing and timely laboratory monitoring of potassium levels in accordance with professional standards of practice. Subsequently, a laboratory result indicated a critically high potassium level of 8.4 mEq/L, which was flagged as critical and verified by repeat testing. The nurse who reviewed this result documented that the lab was relayed to the nurse practitioner via phone and that they were awaiting a response. However, there was no further documentation of any actions taken, no confirmation that the provider was made aware of the critical value, and no evidence of nursing assessment or clinical intervention. The nurse did not initiate emergent medical care or escalate the situation as required by facility policy, and the critical lab result was cleared in the electronic medical record, preventing further follow-up by subsequent staff. Interviews with facility staff revealed that the nurse failed to follow established protocols for reporting and acting upon critical laboratory values, including contacting the provider, medical director, or telehealth services when a response was not received. The facility's policy required that critical lab results be communicated to a licensed practitioner within one hour and that escalation procedures be followed if the provider could not be reached. The lack of timely intervention and failure to act upon the critically abnormal potassium level resulted in the resident not receiving necessary medical intervention. Four days after the critical lab result, the resident was found unresponsive and subsequently expired in the facility.
Removal Plan
- The DON checked and verified all residents with time sensitive critical medication, recognizing therapeutic laboratory level, conducting routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly.
- All Nurses staff were provided with education by the DON/Designee. The training included ensuring time sensitive critical medication have therapeutic laboratory level, have routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly.
- The Medical Director, Administrator and DON reviewed the facility's policies which include Policy of Critical Lab Result Reporting, Critical Medications Requiring Laboratory Monitoring.
- New hires will be in-serviced by the DON, ADON or Designee. All staff members who are currently on vacation, or are not available, will also receive the same education upon their return to work. The staff members will also be provided with the same educational materials.
- The facility will utilize the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift. The Administrator/DON will send the same training materials to the staffing agency. Additionally, the agency staff will be provided with the same training as mentioned above. An agency staff will not start the shift without finishing the training first.
- The DON/ADON/designee will conduct audits to identify any potential concerns related to this plan of removal.
- The DON/ADON/Designee will also conduct staff (nurses and agency) interview, with at least five employees, to gauge knowledge retention and determine if additional training is required.
- During the weekends, the assigned Nursing Supervisor/Designee will conduct the audit, ensuring time sensitive critical medication, recognizing therapeutic laboratory level, conduct routine labs per doctor's order, following facility protocols for reporting results, and escalating life-threatening findings promptly. Any identified concern will be addressed immediately.
- To ensure compliance, the results of the audit will be reviewed during the meeting which is attended by the clinical leadership which includes the DON, ADON, MDS, IP, Restorative, and the Administrator/Designee.
- Any identified concern will be addressed immediately and will also be discussed during the weekly Adhoc QAPI.
- All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance.
- The Administrator, DON and Designee will monitor completion of this plan of removal.