The resident's potassium dropped to a critical 2.7 mEq/L, requiring immediate intervention. A physician ordered the treatment at 5:11 pm, but the resident didn't receive it until 10:32 pm.
"It would be considered a delay in care that the potassium was ordered at 5:11 pm and given at 10:32 pm," LVN 2 told inspectors during their November investigation.
The physician who assessed the resident described finding them "debilitated, unresponsive, and edematous" — swollen with abnormal fluid accumulation. The doctor ordered lab work after discovering the resident's severely weakened condition.
Multiple system failures compounded the delay. RN 2 couldn't establish an IV line and contacted a third-party IV provider at 6:00 pm. No IV nurse was available until 7:00 am the following day.
RN 2 never notified the physician about this critical delay.
Instead, she passed the information to RN 3, who also failed to attempt IV placement. The Director of Nursing later told inspectors that RN 3 "should have attempted to establish an IV for Resident 1 at least two to three times to start the D5W IV fluids."
The facility's own nursing supervisor job description requires RNs to "make sound independent decisions when circumstances warrant such action."
RN 4 reviewed the resident's progress notes and found no documentation that licensed nurses monitored for abnormal heartbeat — a critical requirement for patients with dangerously low potassium.
"A resident with a CIC for low potassium should be monitored for abnormal heartbeat by palpating the resident's pulse and auscultating cardiac sounds with a stethoscope," RN 4 explained to inspectors.
The progress notes showed no such monitoring occurred.
The resident also had elevated sodium levels of 158. "High sodium levels have the potential to cause seizures, dehydration, and kidney issues if left untreated," the Director of Nursing told inspectors.
The DON acknowledged multiple failures in the resident's care. Licensed nurses are expected to notify physicians and initiate critical incident communications for abnormal lab results, she said.
"It was a delay in care when LVN 1 failed to act right away on Resident 1's low potassium," the DON stated. "Residents with low potassium can experience cardiac complications."
She emphasized that nurses "should have notified the doctor promptly for low potassium and other abnormal labs to provide interventions as soon as possible."
When IV access couldn't be established, proper protocol required the RN supervisor to contact the physician for alternative orders, including potential hospitalization for unstable patients or placement of a PICC line.
None of this happened.
The DON reviewed progress notes from the critical period and confirmed that RN 3 failed to document any attempts to start an IV. "RN 3 did not document that she tried to start an IV for Resident 1 when she should have instead of waiting for the IV Nurse to come in the morning."
Federal inspectors found the facility failed to ensure residents received necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
The inspection classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The facility's registered nurses are specifically tasked with medication administration "when needed" according to their job descriptions.
The resident's condition — described by the physician as debilitated and unresponsive with dangerous electrolyte imbalances — required immediate medical intervention that was delayed by over five hours due to multiple nursing failures and communication breakdowns.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glendale Post Acute Center from 2025-11-13 including all violations, facility responses, and corrective action plans.