F0760

D

Missed Potassium Therapy Due to Pending Order and Lack of Timely Notification

Emporia, Kansas Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident remained free from significant medication errors when ordered potassium for hypokalemia was not administered. The resident had diagnoses including fluid overload, hypokalemia, hypertension, dementia with severely impaired cognition, unsteadiness on feet, muscle weakness, and repeated falls, and was receiving a diuretic. A care area assessment documented the resident was at risk for dehydration related to diuretic use, impaired mobility, a wound, dementia, and constipation, and the care plan identified risk for adverse reactions related to polypharmacy and use of medications with Black Box Warnings. A nurse received an order from a nurse practitioner for potassium 40 mEq by mouth three times a day for three days due to low potassium levels, with instructions to recheck a CMP and magnesium level.

The electronic medical record showed the potassium order under discontinued orders and the MAR documented the potassium as “pending confirmation” with a start date and discontinue date, but the clinical record lacked evidence that the potassium doses were administered or rescheduled, and there was no documentation that the physician was notified when the medication was not given as ordered. The order was placed in a pending status by the nurse on duty, and because it remained in pending, it did not appear on the MAR and the medical records nurse’s second check did not identify the issue. The facility’s medication error policy required that residents be free of significant medication errors, that such errors be immediately reported to the physician and DON or designee, documented on an incident tracking report, and tracked for quality assurance purposes, but the documentation showed the potassium doses were missed and not reported at the time they were omitted.