F0580

D

Failure to Notify Physician of Omitted Potassium Doses After Admission

Thief River Falls, Minnesota Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify the resident’s physician of omitted potassium doses following admission, despite existing orders and documented hypokalemia. The resident was admitted from an acute hospital with a recent CVA and multiple comorbidities, including hypokalemia attributed to Lasix use. Hospital records showed a potassium level of 3.1 mEq/L on the morning of discharge and discharge instructions that the resident was to receive potassium chloride 10 mEq by mouth twice daily for approximately one month, with the possibility of discontinuation if levels normalized. An e-prescription for potassium chloride 10 mEq CR twice daily was sent to the pharmacy and receipt was confirmed, and the pharmacy delivered a card of potassium tablets to the facility on the day of admission.

On admission, the facility’s care plan directed staff to administer medications as ordered and report abnormal labs or vital signs to the primary care provider. However, the potassium order was not entered onto the facility’s EMAR at the time of admission, and the resident did not receive the ordered potassium doses from the evening of admission through several subsequent medication passes. The facility’s own Medication Error document later identified that the resident potentially missed three doses on the evening of admission and four additional doses over the next two days, with potassium therapy not started until several days after admission. During this period, there is no documentation that the resident’s physician or on-call provider was notified of the missed doses or of the resident’s low potassium level on admission.

Staff interviews confirmed that the potassium medication was delivered and recognized as not appearing on the EMAR, but the issue was not escalated to a provider. The TMA who accepted the delivery noted that the potassium was not on the EMAR and placed the medication with a note in the medication room, consistent with what she stated she had done in similar situations in the past, but she did not administer the medication or contact a nurse or provider before going off work. A night-shift RN later discovered the untouched potassium card in the cart, identified this as a red flag, and located the hospital order in the hospital record, but did not notify a provider at that time because it was the middle of the night. The DON and the primary provider both stated in interviews that nursing staff would have been expected to notify the prescribing provider or on-call provider about the missed potassium doses and the low potassium level, and the facility’s policy on Notification of physician and family required timely notification of physicians when treatment or medications are altered significantly, including when existing medications are discontinued or not given as ordered. Despite this, there was no evidence that the physician was notified of the omissions, constituting the cited deficiency.

The resident’s subsequent clinical course included an ED visit after an unwitnessed fall with a right ankle fracture, during which her potassium level was within normal limits, and a later ED visit for hyperkalemia, hypernatremia, acute renal failure, and severe dehydration, with a potassium level of 7.2 mEq/L. At both ED encounters, the outpatient medication list still reflected potassium chloride 10 mEq twice daily. The primary provider reported she was not aware of the missed potassium doses prior to her initial visit several days after admission and that she had not initiated provider coverage until that visit. The facility’s Medication Error document related to the missed potassium doses contained no documentation of any notifications to agencies or people, and sections for such notifications were left blank. This sequence of events demonstrates that the facility did not follow its own policy requiring timely physician notification when treatment is altered by missed medication doses, specifically failing to notify the physician of the potassium omissions for this resident with documented hypokalemia.