Failure to Implement Physician Order for Potassium Supplementation
Penalty
Summary
The facility failed to implement a physician order for potassium chloride 10 mEq daily following a low potassium lab result for a resident diagnosed with colon cancer, arthritis, and aphasia, who was cognitively intact and required varying levels of staff assistance for daily activities. The nurse practitioner documented a low potassium result and ordered potassium chloride supplementation and a repeat basic metabolic panel in one week. However, review of the electronic medical record and medication administration record showed no evidence that the potassium chloride order was entered, processed, or administered, nor was the repeat lab completed. Interviews with nursing staff and the nurse practitioner revealed that new orders are typically left with the floor nurse or unit manager, who are responsible for processing and transcribing them into the system and notifying the pharmacy. The nurse practitioner expected the order to be carried out within 24 hours, and the director of nursing confirmed that the order should have been processed and transcribed to the MAR within that timeframe. Facility policy requires prompt entry and follow-through of provider orders, but in this case, the order was not implemented, resulting in a failure to follow physician instructions after an abnormal lab result.