Resident 86 arrived at the facility with acute bone infection, sepsis caused by antibiotic-resistant staph bacteria, surgical amputation recovery, diabetes, heart failure, dementia and an open foot wound. The 84-bed Columbus facility discharged the resident on September 3, 2025, after a stay that began earlier in the summer.
Laboratory results from August 27 showed the resident's potassium at 4.0 milliequivalents per liter, within the normal range of 3.5 to 5.3. But by September 2, the level had plummeted to 2.6 — critically low and potentially life-threatening.
A physician immediately ordered a STAT basic metabolic panel. The emergency blood test confirmed the resident's potassium remained dangerously low at 2.7.
Licensed Practical Nurse 209 documented the critical result in a note at 10:43 that evening. The physician called the nursing supervisor directly and ordered potassium supplements.
Registered Nurse 208 received detailed instructions just after midnight on September 3. The physician ordered potassium chloride 40 milliequivalents to be given orally thirty minutes after anti-nausea medication, then repeated at 3:00 a.m. and 7:00 a.m. If the resident couldn't tolerate the medication, staff were to notify the physician immediately. The resident might need hospitalization.
The physician also ordered a comprehensive metabolic panel and magnesium level to be drawn that same day.
RN 208 relayed the orders to LPN 209, instructing her to place the orders and arrange the lab work. LPN 209 said she understood.
The potassium treatment worked. A basic metabolic panel completed September 3 showed the resident's potassium had returned to 4.5, back within normal range.
But the comprehensive metabolic panel and magnesium test were never completed.
When state inspectors interviewed Director of Nursing staff on October 20, she confirmed the blood work orders were never carried out. The registered nurse and licensed practical nurse had failed to enter the physician's orders into the medical record system.
LPN 209 told inspectors she could not recall information about the resident's potassium levels or the ordered blood work.
RN 208 acknowledged she had been notified of the critical lab results and confirmed she relayed the new medication and blood work orders to LPN 209 for the practical nurse to handle.
The facility's physician orders policy requires nurses who receive telephone orders from doctors to transcribe them into the electronic medical record. The nurse receiving the order must execute it or safely hand it off to the next nurse, including contacting laboratory services as required.
The laboratory services policy states the facility is responsible for providing or obtaining lab services to meet residents' needs and ensuring timeliness of those services.
Potassium levels below 2.5 can cause dangerous heart rhythm abnormalities, muscle weakness and paralysis. For a resident already battling sepsis, heart failure and recovering from amputation, the missed follow-up testing represented a significant gap in monitoring a potentially deadly condition.
The inspection was conducted in response to a complaint filed with state regulators. State inspectors classified the violation as causing minimal harm or potential for actual harm to residents.
The resident was among three reviewed for condition changes during the inspection. Only one case revealed problems with laboratory testing compliance.
Resident 86's complex medical conditions required careful monitoring throughout the stay. The acute bone infection, MRSA sepsis and open wound created multiple risks for complications. Severe cognitive impairment meant the resident could not advocate for proper care or report symptoms of worsening condition.
The communication breakdown occurred between experienced nursing staff during a critical period when the resident's potassium had dropped to levels requiring emergency intervention. Despite the physician's direct involvement and specific instructions, the follow-up testing ordered to ensure the resident's safety never happened.
The missed laboratory work represented exactly the kind of monitoring gap that can prove fatal for medically complex nursing home residents, particularly those unable to speak for themselves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wexner Heritage House from 2025-10-23 including all violations, facility responses, and corrective action plans.