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.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
676311
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676311
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Watkins-Logan-Garrison Texas State Veteran's Home
11466 Honor Lane
Tyler, TX 75708
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676311
If continuation sheet
Page 2 of 2
