HospitalInspections.org

Based on staff interview and document review, it was determined the hospital failed to ensure medications were administered according to the provider's order and patient's plan of care in one (1) of six (6) medical records reviewed in the survey sample. Medical record #5. Specifically, hospital staff did not implement a potassium replacement protocol according to the physician order.

Findings:

The medical record for patient #5 contained documentation that the patient had a potassium level of 3.4 mmol/L (normal value 3.5-5.3 mmol/L) at 8:30 AM on 05/10/24 and was administered oral potassium per physician order at 10:00 AM. According to the physician order, the potassium level should be rechecked four (4) hours after potassium was given, then every 4 hours until within normal limits, then daily. The potassium level should have been rechecked at 2:00 PM on 05/10/24 but was not rechecked until 05/12/24 at 1:11 AM (over 35 hours late). The result of the potassium level drawn at 1:11 AM on 05/12/24 was 3.4 mmol/L. The patient was not repleted with oral potassium until 10:57 AM. (Over nine (9) hours later). The potassium level should have been rechecked around 2:57 PM on 05/12/24, but was not rechecked until 05/13/24 at 1:27 AM (10.5 hours late).

An interview was conducted with Staff Member #3 on 06/10/24 who confirmed the potassium level should be rechecked four (4) hours after oral administration per the potassium protocol and physician order.