Failure to Administer STAT-Ordered Lokelma for Elevated Potassium
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s STAT medication order for a resident with an elevated potassium level. The resident was admitted with a diagnosis of a right lower leg fracture and had a BIMS score of 13, indicating intact cognition. A STAT order for Lokelma, a medication used to treat high blood potassium levels, was placed on 8/1/25. According to the facility’s Risk Management report and a Progress Note dated 8/3/25, the facility did not administer the ordered STAT dose of Lokelma. As a result of the missed medication, the on-call provider was notified and the resident was sent to the emergency room on 8/3/25. During interviews, a hospital social worker stated the facility failed to administer the physician-ordered medication for the resident’s elevated potassium level and confirmed the resident was sent to the hospital related to the missed dose. An LPN reported that a medication error occurred involving the Lokelma dose and stated that an incident report should have been written, though they could not recall if one was completed. An RN/Resident Care Manager also recalled a medication error involving the Lokelma but could not remember details of the findings. Administrative and nursing leadership staff acknowledged that the resident should have received the STAT Lokelma dose as ordered.
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