Failure to Adjust Potassium Supplementation and Ensure Informed Refusal of Lab Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to discontinue or adjust potassium chloride ER dosing and to ensure a resident was informed of the risks of refusing laboratory monitoring, resulting in unmonitored treatment for hypokalemia in a resident with chronic kidney disease. The resident had diagnoses including chronic kidney disease, diabetes, and hypertension, and was cognitively intact per an admission BIMS score of 13. Laboratory results showed hypokalemia with a potassium level of 2.8, along with elevated BUN and creatinine and a reduced eGFR, indicating impaired renal function. In response, the physician ordered potassium chloride ER 20 mEq tablets, 40 mEq three times daily, without an end date. A repeat lab two days later showed a normal potassium level of 4.5, but BUN and creatinine remained elevated and eGFR remained low. No labs were ordered for the next two days. A lab was ordered for a subsequent date to recheck potassium, but the resident refused two attempts to obtain the specimen, and there was no documentation that the resident was made aware of the risks of declining the lab test. When the physician was notified of the refusal, the lab was simply reordered for a later date, and the facility continued administering potassium chloride ER 40 mEq three times daily over several days without any potassium level monitoring. The resident was later sent to the hospital for altered mental status, where admission labs revealed hyperkalemia with a potassium level of 7.1, along with further elevated BUN and creatinine and a lower eGFR. The hyperkalemia was treated in the emergency department, and the resident was admitted for continued monitoring and evaluation of altered mental status and possible infection. The deficiency was cited under 28 Pa. Code 211.2(d)(3)(9) Medical Director, 28 Pa. Code 211.10(c) Resident Care Policies, and 28 Pa. Code 211.12(c) Nursing Services.
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