Failure to Monitor and Respond to Potassium Supplementation
Penalty
Summary
A resident with multiple significant medical diagnoses, including chronic obstructive pulmonary disease, hypertension, and heart disease, was admitted to the facility and treated for hypokalemia (low potassium). The resident initially had a potassium level of 3.0 mEq/L, which was flagged as abnormal, and was prescribed a one-time dose of potassium. However, there was no documentation that this dose was administered, nor was there any evidence of follow-up laboratory orders or monitoring after this intervention. Subsequent labs showed a critically low potassium level of 2.0 mEq/L, prompting a new order for potassium supplementation over three days and a repeat basic metabolic panel (BMP) the following morning. Despite these interventions, there was a lack of consistent documentation and follow-up regarding the administration of potassium and the monitoring of potassium levels. The resident continued to receive potassium supplementation, with orders entered incorrectly, resulting in the resident receiving potassium for a longer duration than intended. The medication administration record showed that the resident received 34 doses of potassium over an extended period, rather than the intended three days. During this time, there was no evidence that the facility ensured ongoing and timely laboratory monitoring of potassium levels, nor was there ongoing assessment for the continued need for potassium supplementation. Repeat potassium levels were not obtained until 13 days after the initial critical low value, at which point the resident was found to have a critically high potassium level of 8.4 mEq/L. Upon discovery of the critically elevated potassium level, there was no documentation of nursing assessment, clinical intervention, or initiation of emergent medical care. The nurse who reviewed the lab result documented relaying the information to the nurse practitioner but did not document any further actions or confirmation that the provider was made aware of the critical value. The resident was found unresponsive in the facility four days after the critically high potassium result was obtained, and the death certificate listed cardiopulmonary arrest as the cause of death, with other comorbidities. Facility policy required ongoing laboratory monitoring and prompt reporting of critical values for medications like potassium, but these procedures were not followed in this case.