Health inspection·January 8, 2024

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to promptly notify the ordering physician or NP of laboratory results that fell outside the clinical ranges in accordance with facility policies and procedures for notification for 1 of 4 residents reviewed for labs. The facility received lab results for Resident #1's labs on 12/14/23 which indicated his potassium was low. The requesting physician and the NP were not notified. This failure could place residents at risk of delayed treatment/intervention and decline in health. Findings Included: Record review of Resident #1's face sheet dated 1/4/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, high blood pressure, dementia, and mixed high cholesterol. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated he was moderately cognitively impaired. The MDS indicated he was independent with all ADLs. Record review of Resident #1's Labs dated 12/9/23 indicated his potassium was 3.2 (normal range 3.54.9) Record Review of Resident #1's physician's order from an outside provider (in the facility computer system) dated 12/7/23 indicated repeat BMP on 12/14/23 for a diagnosis of Hypokalemia (low potassium). Please fax the results to number provided. Record review of a nursing note dated 12/11/23 indicated the family member wanted a copy of Labs drawn at the hospital to be sent to the facility NP for review. There were no new orders at this time. The BMP (Basic Metabolic Panel) was due to be rechecked on 12/14/23 per orders from the hospital. Record review of labs dated 12/14/23 indicated Resident #1's potassium was low at 3.3 (range 3.5 to 4.9) there was no indication they were received or signed off on until 12/21/23. Record review of Resident #1's nursing notes from 12/14/23 to 12/19/23 revealed there was no mention in the nursing notes of the 12/14/23 labs being sent to NP or faxed to the physician requesting the redrawn lab. Page 1 of 2 676311 676311 01/08/2024 Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility root cause analysis dated 1/3/24 (received on 1/4/24 at 2:40 p.m.) indicated Resident #1 had a TURP (surgery used to treat urinary problems that are caused by an enlarged prostate.) surgery scheduled for 12/20/23. The Resident attended a pre-surgery appointment on 12/7/23, and pre-surgical baseline labs were drawn. At that time the surgeon did not order a potassium supplement for this current level of 3.2 potassium level. However, he did request that the potassium level be redrawn on 12/4/23. On 12/11/23 Resident #1's labs were reviewed by the NP. There were no new orders but to continue with the redraw for labs on 12/14/23. On 12/14/23 Resident #1's labs were drawn, and his potassium was 3.3. The lessons learned was all abnormal lab values are to be reported to the NP by phone and documented. The Nurse supervisor will monitor resident with labs pending and if the resident becomes symptomatic. Nursing staff would be educated on the lessons learned. During an interview on 1/4/23 at 12:30 p.m. the Administrator and DON said they could not provide any information that the NP was notified of Resident #1's lab on 12/14/23 with low potassium. During an interview on 1/4/24 at 1:30 p.m. LVN A said that she did not know the Resident #1 had low potassium. She said no one informed her and she did not know anything about Resident #1's labs. During an interview on 1/4/24 At 1:58 p.m. an interview with NP said that she looked at the original labs from the neurologist from 12/9/23. She said she remembered Resident #1's potassium level was 3.2. She said he was scheduled for repeat labs on 12/14/23 and she was fine with that recommendation. The NP said could not confirm that she received the labs for 12/14/23. She did not remember seeing the follow up labs before the resident was discharged . She said the potassium levels are not critical until they are under 3.0. She said if she had seen the labs, she would likely have ordered a repeat, as she did not want to put residents on a supplement until a pattern was established of low potassium labs or the labs were critical. During an interview on 1/4/24 at 3:55 p.m. RN B said she was not aware Resident #1 had low potassium and she was not aware of any labs. Record review of the facility Laboratory Services policy last revised in October 2012 indicated Laboratory services will be performed as ordered by the physician. Record review of the facility Change in Condition Notification policy indicated the Resident's attending physician and representative would be notified of change in resident condition. Situations which would require a change in medication or treatment regimen such as abnormal lab values. 676311 Page 2 of 2