HospitalInspections.org

Based on interviews and document review, it was determined the hospital failed to ensure that all staff received adequate supervision, that all staff received adequate orientation to the Emergency Department (ED) prior to providing patient care, that staff was assigned nursing care that they were qualified and competent to perform, and that staff administered medications safely and as ordered by physician.

Due to the lack of sufficient staff orientation to ED and nursing supervision, the facility staff failed to correctly and safely administer i.v. medication and monitor patient as required by the facility policy.(A-0405, A-0410)

In addtion, the facility staff providing nursing care did not receive the required orientation, training to ED and clinical skill evaluation for specific procedures that can be delegated to staff.(A-0397)

Review of medical records revealed that Registered nurses failed to perform and/or document patient assessments and administer medications as ordered.(A-0398)

Please refer to A0397, A0398, A0405 and A0410 for further information.

Based on document review and interviews the hospital's registered nurses failed to assign nursing care of one (1) of seven (7) patient included in the sample to staff specialized by qualification and competence.

The findings included:

Patient #3 presented to the ED at 5:12 AM on 8/11/22 as a walk-in patient. Principal complaint was documented as nausea and vomiting. Patient #3 was triaged as a level 3 and placed in room 07, where a nursing assessment was completed. Staff #8 documented an exam of Patient #3, review of vital signs and nursing notes, review of an EKG and placed orders for a complete blood count, comprehensive metabolic panel, urinalysis, lipase, magnesium level, Covid, troponin and a urine drug screen.

After receipt of critical result for Potassium of 2.7 mmol/L (desired range is 3.4 - 5.0), Staff #10 entered orders for Potassium Chloride 40 mEq (Klor-Con M20 (microencapsulated) Extended Release Tablet 40 mEq orally once) and Potassium Chloride 10 mEq intravenously once (administer over 2 hours) at 8:24 AM.

Oral Potassium administration was documented at 8:58 AM and IV Potassium at 9:04 AM by Staff #6. Review of the medication administration record (MAR) found documentation with start (8:30 AM) and stop (10:36 AM) times for IV potassium which conflicts with the documented administration time of 9:04 AM. The IV potassium was listed on the MAR as "Potassium Chl 10MEQ K-Ryder [10 MEQ] Piggyback 100ml/hr intravenous one time dose [1 x 100 ml [10 MEQ] per dose] CPOE COMMENT: ADMINISTER OVER 2 HRS" and "Infuse over: 1 HOURS".

Staff #6 is a NRP (Nationally Registered Paramedic) and has worked in the hospital as a telemetry tech prior to working in the ED as a paramedic. During a phone interview on 10/12/22 Staff #6 was asked about the training and orientation they received to ED. Staff #6 stated never receiving an orientation packet despite their multiple requests and only 2 days with someone and then "they turned me loose". Staff #6 informed the surveyor they started helping out in ED in January 2022. Staff #6 was asked about experience administering piggyback medications, specifically potassium and replied not having a lot of experience. Staff #6 stated that prior to this event, they did not know a cardiac monitoring and i.v. piggyback was needed during administration of this medication. Staff #6 was asked what if anything, they are not allowed to do it the ED; Staff #6 replied "I cannot verify blood products, do full assessments or triage".

The surveyor requested to review training and personnel file for Staff #6. Human Resources provided the official transfer date of Staff #6 from the Telemetry unit to ED as 7/17/22. Surveyor review of documented training for Staff #6 and found the following: New Employee Orientation Competency to the Telemetry Department completed 6/18/20 with hire date of 5/25/20. No documented orientation to the ED was provided to the surveyor. Review of HealthStream (computer-based learning) found Staff #6 was up to date with assigned tasks. Surveyor review of time worked (per Human Resource documentation) found for the period of 1-1-2022 until 10-13/2022, 2.25 hours of education documented on 3/18/22. The surveyor found no orientation time documented and found 13 occasions documenting Staff #6 working in the ED prior to being transferred to the service line on 7/17/22.

The surveyor was informed that unit manager(s) are responsible for developing the orientation to their units and the documentation of such. Unit managers are also responsible for ensuring staff have completed HealthStream learning/training. Unit managers and the employees who have not completed assigned training, would receive email notification. Staff #2 provided the surveyor with a blank orientation and evaluation packet. The surveyor found under "3. Medication/Blood Administration" the following "Patient Care Skills: Use of IV infusion pumps, Administer intravenous continuous medication, Identify medications requiring infusion pump, Identity medications requiring cardiac monitoring, Administer & document IV piggybacks."

Hospital policy "Potassium Administration" revised 9/22 read in part "A licensed nurse or paramedic, in accordance with the following procedure, who is competent in IV therapy may administer pre-mixed Potassium Chloride" and "Maximum concentration should not exceed 40 mEq per liter for peripheral lines...Infusion rate should not exceed 10 mEq/hour....". (Patient #3 received 10 mEq of Potassium in approximately 30 minutes.)

The above findings were reviewed with Staff #1 and Staff #2 during the survey and prior to exit on 10/14/22.

Based on document review and interview the hospital nursing staff failed to ensure all staff received adequate supervision and orientation to the Emergency Department (ED) prior to providing patient care.

The findings included:

During the review on medical record for Patient #3 who presented to the ED at 5:12 AM on 8/11/22 with complaints of nausea and vomiting, the surveyor reviewed administration of order from Staff #10 (physician), " Potassium Chloride 40 mEq (Klor-Con M20 (microencapsulated) Extended Release Tablet 40 mEq orally once) and Potassium Chloride 10 mEq intravenously once (administer over 2 hours). " Oral Potassium administration was documented at 8:58 AM and IV Potassium at 9:04 AM by Staff #6. The record did not provide documentation of the location and an assessment of the IV site.

Review of the medication administration record (MAR) found documentation with start (8:30 AM) and stop (10:36 AM) times for IV potassium which conflicts with the documented administration time of 9:04 AM. The IV potassium was listed on the MAR as "Potassium Chl 10MEQ K-Ryder [10 MEQ] Piggyback 100ml/hr intravenous one time dose [1 x 100 ml [10 MEQ] per dose] CPOE COMMENT: ADMINISTER OVER 2 HRS" and "Infuse over: 1 HOURS".

A second order for Lactated Ringers 1000 ml IV was entered at 9:40 AM by Staff #3 (RN); there was no documentation of administration. The clinical record did not contain any documentation of issues with the i.v. medication administration and/or concerns reported by patient or family present during the treatment. Patient #3's clinical record failed to provide evidence of cardiac monitoring before, during or after the event (other than an EKG). No nursing assessment was documented after or during the administration of i.v. potassium.

Telephone interview was conducted on 10/12/22 with Staff #3 about the above noted event. Staff #3 recalled Staff #6 informed them that a patient's mother wanted to speak with the charge nurse. Staff #3 went to the room and when entering the patient's mother pointed at the bag of potassium and asked if it was okay for it to run like that, without additional fluid. Staff #3 stated they looked at the bag to see it was potassium, checked the pump to ensure it was programmed for KCL (potassium) and said it could be run like that as long as it's not burning or irritating the vein. Staff #3 stated they asked the patient if it was bothering them, and the patient (Patient #3) had no complaints. Staff #3 told the patient's mother they would get a bag of fluid started to dilute the mixture further and place the patient on a monitor. Staff #3 (an experienced nurse) stated knowing patients receiving electrolytes should be on a monitor.

During a phone interview on 10/12/22 Staff #6 was asked about the supervision, training and orientation they received to ED, specifically i.v. medications requiring administration with piggyback fluids. Staff #6 informed the surveyor they started helping out in ED in Jan. 2022 and never received an orientation packet despite their multiple requests. Staff #6 was asked about experience administering piggyback medications specifically potassium and replied not having a lot of experience. Staff #6 stated that prior to this event they did not know a cardiac monitoring and i.v. piggyback was needed during administration of this. Staff #6 added that Staff #10 talked to them after this event and explained the proper administration and monitoring requirement during administration of i.v. potassium.

Surveyor review of training and orientation records for staff assigned to the ED found eight (8) of eight (8) RN Staff completed general orientation to the hospital but no orientation to the ED was documented (new staff were excluded from count). Four (4) of eight (8) RN Staff have past due HealthStream learning including but not limited to courses in Sedation Compliance, Violent Restraints, Suicide Risk Assessment, Drug Diversion, ESI Triage Annual Training, Pain Management, EMTALA and Rapid Response. The review did not include Staff who are not dedicated ED staff. The review focused on the role of the Registered Nurse in ED but all disciplines in ED were reviewed.

The surveyor requested to review training and personnel file for Staff #6. Human Resources provided the official transfer date of Staff #6 from the Telemetry unit to ED as 7/17/22. Surveyor review of documented training for Staff #6 found the following: New Employee Orientation Competency to the Telemetry Department completed 6/18/20 with hire date of 5/25/20. No documented orientation to the ED was provided to the surveyor. Review of HealthStream (computer-based learning) found Staff #6 was up to date with assigned tasks. Surveyor review of time worked (per Human Resource documentation) found for the period of 1-1-2022 until 10-13/2022, 2.25 hours of education documented on 3/18/22. The surveyor found no orientation time documented and found 13 occasions documenting Staff #6 working in the ED prior to being transferred to the service line on 7/17/22.

Concerns related to training and staffing were shared with Staff #1 and Staff #2 throughout the course of the investigation. Staff #1 and #2 stated the lack of documented orientation and the failure to ensure education is completed by ED staff before providing patient care may be attributed to the absence of an ED director for at least the last 6 months. An interim Director was appointed but was overseeing the ICU as well. Staff #2 provided for the surveyor ' s review the Healthcare Compliance Committee (HCC) Meeting Minutes for the past year. HCC meeting Minutes for 9/21/22 read in part as follows "Training Requirements---New hire training within 30 days of hire--Code of Conduct is 80.96% and IT Security and Awareness is 80.96%." ... " As of 9/21/22, the following completion rates for annual required in-services include but are not limited to: Information Security --72.99%; Rapid Regulations Clinical 1- 65.71%; Rapid Regulations Clinical 2- 62.38%; Rapid Regulations Non-Clinical 1-69.33%; Rapid Regulations Non-Clinical 2-66.67%." Staff #1 and Staff #2 confirmed that staffing continues to be an issue in the area of nursing. Review of "Emergency Steering Committee" minutes for 7/18/22 read in part "Nurse staffing still a challenge HR is having sevral (sic) recruiting events to help improve staffing. "The hospital is utilizing Paramedics and LPNs (Licensed Practical Nurse) in the ED and currently has two RN Interns working part-time. A Director for the ED has been hired and is in orientation. A 2 day nursing "Boot Camp" is held monthly for new hires (if any)."

The above findings were reviewed with Staff #1 and Staff #2 during the survey and prior to exit on 10/14/22.

Based on interviews, document review and review of clinical records, hospital staff failed to administer medication as ordered by the physician. For 1 (one) of 7 (seven) patient's selected for review. (Patient #3)

The findings include:

Patient #3 presented to the ED at 5:12 AM on 8/11/22 as a walk-in patient. Principal complaint was documented as "nausea, vomiting (gender), adult." Triage documented by Staff #10 at 6:22 AM read as follows "Patient reports that (they) has had vomiting since July 31st. States that they have been on vacation as (sic) was seen at Urgent care was tested for Covid but was negative. Had diarrhea a few days ago. Has a pacemaker. Denies any Covid exposure." Vital signs at 6:15 AM were, "temperature 97.1 F, blood pressure 116/71, pulse 83, respirations 18 and oxygen saturation 96% on room air." Patient #3 was triaged as a level 3. The ED uses the Emergency Severity Index (ESI) 5 tier triage system. Per policy "Nur-ED 141 Guidelines for Triage, Vital Signs and Assessments (Adult/Pediatric), 9305 Effective 03/2022", ESI level 3 is defined as "Urgent (Two or more resources required)". Per policy ESI level 3 requires prompt care with a goal to see the patient within 2 hours of presentation. Patient #3 was placed in room 07. A nursing assessment was completed by Staff #10 and documented beginning at 7:37 AM.

Staff #8 documented an exam of Patient #3, review of vital signs and nursing notes, and review of an EKG as completed at 7:58 AM. Orders were placed for a complete blood count, comprehensive metabolic panel, urinalysis, lipase, magnesium level, Covid, troponin and a urine drug screen.

Critical result for Potassium of 2.7 mmol/L (desired range is 3.4 - 5.0) was called to Staff #3 at 8:11 AM. Staff #10 entered orders for Potassium Chloride 40 mEq (Klor-Con M20 (microencapsulated) Extended Release Tablet 40 mEq orally once) and Potassium Chloride 10 mEq intravenously once (administer over 2 hours) at 8:24 AM. Oral Potassium administration was documented at 8:58 AM and IV Potassium at 9:04 AM by Staff #6.

Review of the medication administration record (MAR) found documentation with start (8:30 AM) and stop (10:36 AM) times for IV potassium which conflicts with the documented administration time of 9:04 AM. The IV potassium was listed on the MAR as "Potassium Chl 10MEQ K-Ryder [10 MEQ] Piggyback 100ml/hr intravenous one time dose [1 x 100 ml [10 MEQ] per dose] CPOE COMMENT: ADMINISTER OVER 2 HRS" and "Infuse over: 1 HOURS"

At 10:32 on 8/11/22, Staff #6 (a paramedic) documented the patient's discharge. Vital signs at discharge were temp 98.1 F, HR 96, oxygen saturation 96%, blood pressure 110/62 and respirations 16.

On 10/12/22 at 9:25 AM an interview was conducted with Staff #3, who was working as charge nurse on 8/11/22. Staff #3 stated Staff #6 (a Paramedic) was one of the nurses working and informed them that a patient's mother wanted to speak with the charge nurse. Staff #3 went to the room and when entering, the patient's mother pointed at the bag of potassium and asked if it was okay for it to run like that, without any additional fluid. Staff #3 stated they looked at the bag to see it was potassium, checked the pump to ensure it was programmed for KCL (potassium) and said it could be run like that as long as it's not burning or irritating the vein. Staff #3 stated they asked the patient if it was bothering them and the patient (Patient #3) had no complaints. Staff #3 told the patient's mother they would get a bag of fluid started to dilute the mixture further and place the patient on a monitor. Staff #3 (an experienced nurse) stated knowing, patients receiving electrolytes should be on a monitor. Patient #3's clinical record failed to provide evidence of cardiac monitoring before, during or after the event (other than an EKG).

A telephone interview was conducted on 10/22/22 with Staff #6. Staff #6's recalled the events related to this patient. Staff #6 stated there was an order for iv potassium for the patient. Staff #6 obtained the medication from the automated dispensing unit and a pump. Staff #6 selected KCL from the pump menu but stated "I didn't double check, I should have double checked" referring to the order and pump settings. After Staff #6 finished setting up the medication, the patient's mother asked if is it was okay and they confirmed that's not how it is usually done. The medication was set to administer without piggyback fluids (An IV piggyback is a small bag of solution attached to a primary infusion line or intermittent venous access device to deliver medication over a specified period of time.) Staff #6 recalled going on break and returning to find the medication had completed. Staff #6 was told to make sure the patient was on a cardiac monitor and to watch them for problems. Staff #6 stated they did not know a monitor would be needed and confirmed the medication ran too fast.

The surveyor was unable to speak with Staff #8 personally due to scheduling conflicts but was provided with a statement given to the Risk Manager, which read in part: " I do remember the case vaguely, not the details. I think the patient and (their) mom were in Room 7. Pretty sure (patient) was low K and had to give (them) oral and IV to get (them) back to normal levels although I think (patient) was here for something else. K is usually done through IV at 10 meq/hr because it burns super bad and can also cause dysrhythmia if done too quickly. I think he got 10 but it was pushed quickly although I don ' t know rate. I spoke to the paramedic afterwards and used it as a very teachable moment. The paramedic who pushed it is very competent and I enjoy working with (them) and feel comfortable with (their) skills. I spoke about dangers of not following protocols because this could result in a bad outcome if a larger amount was used (typically you cap out at 40 meq in a 4 hour infusion through a peripheral IV). I think this case may be a good opportunity to get back to basics and do continuing education. There are a lot of things we do a thousand times a day that can be life saving but if done wrong can cause harm. Potassium replacement is one of those things. "

In an interview with Staff #1 and Staff #2, the surveyor learned the hospital received a complaint related to Patient #3's administration of iv potassium infusion. Staff #2 stated being surprised a complaint was made as they had spoken with the complainant and thought the matter was settled. Staff #1 shared the details of the investigation with the surveyor. It was discovered when investigating the event that there were bags of potassium 10 mEq in 50 mL in stock. Normally the pharmacy stocks 10 mEq in 100 mL bags. The hospital uses a type of infusion pump that has a menu or library of medications for IV infusion. The rates of delivery, volume and concentration of the drug is programmed into the pump. Staff #2 assisted the surveyor with a review of how the pump works; the drug name is selected (in this case KCL), then the line type (central or peripheral), the drug concentration is confirmed, primary or secondary line is selected, the volume is confirmed (in this case 100mL, even though a 50 mL bag was given) and then okay is pressed to finish setting the pump. There are multiple opportunities to confirm the correct drug, concentration, volume and rate are selected. (There was no option for a 50mL bag pre-programmed). The pump also has the option to enter the information manually instead of using the programmed information. (Note, the physician order stated to administer over 2 hours). Staff #1 and Staff #2 confirmed the medication was not administered according to physician orders and hospital policy.

In an interview with the Pharmacy Director, the surveyor learned that all of the 50 mL products were removed and sequestered. The reorder sticker was removed from the storage area to prevent reorder. Per Pharmacy Director, should a shortage of the product occur and the 50 mL bags would be utilized, a memo will be sent out and the pumps will be programmed for the use of 50 mL bags. The use of the 50 mL bag with programming for a 100 mL bag resulted in the medication being infused in 30 minutes. This confirmed the allegation by the complainant.

Review of document titled "Medication/Fluid Event Volumes by Specific Event Type" for timeframe 4/1/22 -10/12/22 found no other adverse events involving potassium or use of preprogrammed information in the pump. Hospital policy "Potassium Administration" revised 9/22 read in part "A licensed nurse or paramedic, in accordance with the following procedure, who is competent in IV therapy may administer pre-mixed Potassium Chloride" ... "Maximum concentration should not exceed 40 mEq per liter for peripheral lines...Infusion rate should not exceed 10 mEq/hour....". (Patient #3 received 10 mEq of Potassium in approximately 30 minutes.)

The above findings were reviewed with Staff #1 and Staff #2 during the survey and prior to exit on 10/14/22.

Based on interview, document review and review of clinical records, hospital staff failed to administer an iv (intravenous) medication safely and according to hospital policy. For 1 (one) of 7 (seven) patient's selected for review. (Patient #3)

The findings include:

Patient #3 presented to the ED at 5:12 AM on 8/11/22 as a walk-in patient. Principal complaint documented as "nausea, vomiting (gender), adult". Triage documented by Staff #10 at 6:22 AM read as follows "Patient reports that (they) has had vomiting since July 31st. States that they have been on vacation as (sic) was seen at Urgent care was tested for Covid but was negative. Had diarrhea a few days ago. Has a pacemaker. Denies any Covid exposure." Vital signs at 6:15 AM were, "temperature 97.1 F, blood pressure 116/71, pulse 83, respirations 18 and oxygen saturation 96% on room air." Patient #3 was triaged as a level 3. The ED uses the Emergency Severity Index (ESI) 5 tier triage system. Per policy "Nur-ED 141 Guidelines for Triage, Vital Signs and Assessments (Adult/Pediatric), 9305 Effective 03/2022", ESI level 3 is defined as "Urgent (Two or more resources required)". Per policy ESI level 3 requires prompt care with a goal to see the patient within 2 hours of presentation. Patient #3 was placed in room 07. A nursing assessment was completed by Staff #10 and documented beginning at 7:37 AM. Staff #8 documented an exam of Patient #3, review of vital signs and nursing notes, and review of an EKG completed at 7:58 AM. Orders were placed for a complete blood count, comprehensive metabolic panel, urinalysis, lipase, magnesium level, Covid, troponin and a urine drug screen.

Staff #10 documented receiving order from Staff #8 for Lactated Ringers 1000 ml IV at maximum infusion rate and Ondansetron (for nausea) 4 mg IV. Staff #3 documented administering Ondansetron 4 mg at 7:50 AM and Lactated Ringers at 8:17 AM.

Critical result for Potassium of 2.7 mmol/L (desired range is 3.4 - 5.0) was called to Staff #3 at 8:11 AM. Staff #10 entered orders for Potassium Chloride 40 mEq (Klor-Con M20 (microencapsulated) Extended Release Tablet 40 mEq orally once) and Potassium Chloride 10 mEq intravenously once (administer over 2 hours) at 8:24 AM. Oral Potassium administration was documented at 8:58 AM and IV Potassium at 9:04 AM by Staff #6.

Review of the medication administration record (MAR) found documentation with start (8:30 AM) and stop (10:36 AM) times for IV potassium which conflicts with the documented administration time of 9:04 AM. The IV potassium was listed on the MAR as "Potassium Chl 10MEQ K-Ryder [10 MEQ] Piggyback 100 ml/hr intravenous one time dose [1 x 100 ml [10 MEQ] per dose] CPOE COMMENT: ADMINISTER OVER 2 HRS" and "Infuse over: 1 HOURS"

The clinical record did not provide documentation of Patient #3 complaining of burning/pain at the iv site during the infusion or conversation between the mother and nursing staff. The clinical record did not provide documentation of the location of the IV site or an assessment of the site. A second order for Lactated Ringers 1000 ml IV was entered at 9:40 AM; there was no documentation of administration.

Provider progress note at 0945 documented in part "CBC is grossly unremarkable, chemistry with hypokalemia otherwise unremarkable, lipase magnesium troponin UA are unremarkable. There is a small amount of keytones (sic) in urine which is suggestive of dehydration, urine drug screen is positive for marijuana. This may be a factor to patient's symptoms. Patient was tolerating p.o at time of discharge and was asymptomatic and had not vomited throughout entire time in the emergency department." Interventions included: 2 L IV fluid, potassium 10 mEq IV, 40 mEq orally, prescription for Zofran.

At 10:32, Staff #6 (a paramedic) documented the patient's discharge. Vital signs at discharge were temp 98.1F, HR 96, oxygen saturation 96%, blood pressure 110/62 and respirations 16.

A telephone interview was conducted with Staff #3 on 10/12/22. Staff #3, who was working as charge nurse on 8/11/22, stated Staff #6 (a Paramedic) was one of the nurses working that day and informed them that a patient's mother wanted to speak with the charge nurse. Staff #3 went to the patient's room and when entering, the patient's mother pointed at the bag of potassium and asked if it was okay for it to run like that, without additional fluid. Staff #3 stated they looked at the bag to see it was potassium, checked the pump to ensure it was programmed for KCL (potassium) and said it could be run like that as long as it's not burning or irritating the vein. Staff #6 stated they asked the patient if it was bothering them and the patient (Patient #3) had no complaints. Staff #3 told the patient's mother they would get a bag of fluid started to dilute the mixture further and place the patient on a monitor. Staff #3 (an experienced nurse) stated knowing patient's receiving electrolytes should be on a monitor. Patient #3's clinical record failed to provide evidence of cardiac monitoring before, during or after the event.

In a telephone interview on 10/22/22 Staff #6 recalled the events. Staff #6 stated there was an order for iv potassium for the patient and they obtained the medication from the automated dispensing unit and a pump. Staff #6 recalled selecting KCL from the pump menu but stated "I didn't double check, I should have double checked" referring to the order and pump settings. Staff #6 stated that after they finished setting up the medication, the patient's mother asked if it was okay and they confirmed that's not how it is usually done. The medication was set to administer without piggyback fluids. (An IV piggyback is a small bag of solution attached to a primary infusion line or intermittent venous access device to deliver medication over a specified period of time.) Staff #6 recalled going on break and returning to find the medication had completed. Staff #6 was told to make sure the patient was on a cardiac monitor and to watch them for problems. Staff #6 stated they did not know a monitor would be needed and confirmed the medication ran too fast.

The surveyor learned that the facility received a complaint about this event and during their investigation discovered that 50 mL bag of potassium 10 mEq were being used with a pump programmed for a 100mL bag of potassium 10 mEq which resulted in the medication being infused in 30 minutes.There are multiple opportunities to confirm the correct drug, concentration, volume and rate are selected. There option for a 50 mL bag was not pre-programmed. The pump also has the option to enter the information manually instead of using the programmed information. Staff #1 and Staff #2 confirmed in the interview the medication was not administered according to physician orders and hospital policy.

Hospital policy "Potassium Administration" revised 9/22 read in part "A licensed nurse or paramedic, in accordance with the following procedure, who is competent in IV therapy may administer pre-mixed Potassium Chloride" ... "Maximum concentration should not exceed 40 mEq per liter for peripheral lines...Infusion rate should not exceed 10 mEq/hour....". (Patient #3 received 10 mEq of Potassium in approximately 30 minutes.)

The above finding was discussed multiple times with Staff #1 and Staff #2 during the survey and again prior to exit on 10/14/22.