Failure to Act on Elevated Ammonia Level Resulting in Hospitalization
Penalty
Summary
Facility staff failed to ensure that a resident’s abnormal laboratory result was appropriately evaluated and addressed by the practitioner. The resident had diagnoses including pancreatic cancer and cirrhosis of the liver with ascites and esophageal varices. A progress note indicated that a cancer center appointment was cancelled and that the NP’s order for labs, including an ammonia level, should be followed. The resident’s ammonia level, drawn the following day, was 76 (reference range 9–35) and marked as high. The result was circled, annotated “NNO” (no new orders), and noted to have no previous ammonia level for comparison, and was signed by PA #1. There were no new treatment orders, no monitoring orders, and no corresponding progress note documenting assessment or clinical reasoning in the medical record related to this abnormal result. Subsequently, the resident experienced a change in mental status and abdominal pain. A progress note documented that the resident was sent to the ED for further evaluation after the resident’s family insisted on transfer. In the ED, the resident was found to have an ammonia level of 180 (reference range 9–35) and was diagnosed with hepatic encephalopathy. The resident was treated with lactulose and remained hospitalized for six days before discharge. The attending physician/Medical Director later stated that the resident had an elevated ammonia level that PA #1 had missed and acknowledged that the family was not happy with the situation. During interview, PA #1 confirmed that she had reviewed the elevated ammonia level and had not written any orders. She stated that because the resident did not have a history of hepatic encephalopathy and nursing staff had not reported a change in mental status, she decided not to treat the resident and did not write monitoring orders, believing such monitoring to be part of routine nursing care. She also reported that she had intended to recheck the ammonia level in a couple of days but failed to enter the order into the medical record. This failure to order treatment or monitoring, and the omission of the planned repeat ammonia level, occurred despite the clearly abnormal lab value and contributed to the resident’s subsequent hospitalization for hepatic encephalopathy.
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