BRENHAM, TX - Federal inspectors declared an immediate threat to resident safety at Focused Care at Brenham, a nursing facility at 1303 Hwy 290 East, after discovering staff waited 20 days to collect a physician-ordered blood specimen from a resident with chronic heart and respiratory failure. The resident was subsequently hospitalized with septic shock. The complaint survey, completed February 1, 2025, resulted in immediate jeopardy citations under two federal deficiency tags.
Blood Work Ordered November 12, Drawn December 2
The inspection centered on the care of an elderly male resident with combined systolic and diastolic heart failure and chronic respiratory failure with hypoxia. The resident also had dementia and moderate cognitive impairment, meaning he could not effectively advocate for his own medical needs.
On November 12, 2024, a physician assistant ordered a comprehensive panel of blood tests including a CBC (complete blood count), CMP (comprehensive metabolic panel), TSH (thyroid function), digoxin level, thiamine, and folic acid. These tests are standard monitoring tools for a patient with heart failure - they help clinicians track organ function, medication levels, and metabolic balance.
The orders were faxed to the facility on November 13, 2024. When the PA returned the following week and found no results, she personally handed a copy of the orders to the Director of Nursing. According to the inspection report, the PA told investigators she verbally reminded the DON and the facility administrator every week that the lab work was needed.
Despite these repeated requests, the blood specimen was not collected until December 2, 2024 - twenty days after the original order.
Incomplete Results and a Critical Gap
When results finally came back, they revealed significant abnormalities. Of the 22 panels measured in the CBC, 13 fell outside normal range. Key findings included:
- Platelet count of 80, roughly half the minimum normal value of 163, indicating potential issues with blood clotting or bone marrow function - Hemoglobin at 12.0, below the normal range of 13.7-17.5, suggesting anemia - Neutrophils at 82.2%, well above the normal upper limit of 67.9%, a pattern commonly associated with bacterial infection - Lymphocyte count of 0.49, far below the normal minimum of 1.32, indicating a compromised immune response
Perhaps most critically, the CMP - the test that measures calcium, kidney function, liver enzymes, and electrolyte balance - was never completed at all. The DON was reportedly aware it still needed to be added, but it remained undone.
For a patient on digoxin for heart failure, CMP results are not optional. Calcium levels directly affect how digoxin works in the body, and electrolyte imbalances can make the medication dangerous rather than therapeutic. Kidney function indicators determine whether drug dosages need adjustment. Without this information, clinicians were essentially managing a complex cardiac patient without critical data.
Resident Hospitalized With Septic Shock
The day after the partial lab results were received, the situation reached a crisis. On December 3, 2024, the resident was working with a therapist when he became short of breath. Staff measured his oxygen saturation at 88-90% - below the threshold that typically triggers clinical intervention. He displayed altered mental status and had difficulty keeping his eyes open.
EMS transported the resident to the hospital at 11:52 AM. Upon arrival, he presented with hypotension (dangerously low blood pressure), hypoxia (inadequate oxygen), and hypothermia (abnormally low body temperature). A CT scan revealed bilateral pleural effusion - fluid buildup around both lungs - along with volume overload and a bladder infection.
The resident's condition was serious enough that he was transferred to a second hospital, where he was intubated due to concerns about his ability to protect his own airway. His principal diagnosis: septic shock.
The Calcium Connection
The PA told investigators that had the facility processed the lab work in a timely manner, they might have been able to identify and address the resident's declining condition before it reached the point of septic shock. The missing CMP results - particularly calcium levels - could have provided early warning signs. Abnormal calcium levels can contribute to cardiac instability and, in combination with fluid overload, can accelerate a patient's deterioration.
In patients with heart failure, routine lab monitoring serves as an early warning system. Shifts in electrolytes, kidney markers, or blood counts can signal that a treatment plan needs adjustment days or weeks before symptoms become emergent. A 20-day delay in obtaining this information effectively eliminated that window of intervention.
Physician: "I Had to Beg for Labs"
The resident's attending physician provided investigators with a candid assessment of the facility's laboratory operations. He told inspectors he did not know whether the resident's complete labs were ever received. He stated that monitoring chronic conditions without lab work is extremely difficult and that the missing results "could have contributed to Resident #1's death."
The physician described a pattern of dysfunction that extended beyond this single case. He told inspectors he "repeatedly had to ask for lab work" and had waited up to three weeks for stat lab orders - orders that by definition require immediate processing. He characterized the facility as "a very disorganized facility" and said he "had to beg for labs to be done."
An RN at the facility corroborated these concerns, telling investigators that without proper lab processing, residents "could be hospitalized or die if lab work is not handled properly."
No Tracking System in Place
The investigation revealed a systemic failure in laboratory management, not merely an isolated oversight. An RN told inspectors there was "no system for labs" at the facility. The lab tracking binder - a basic organizational tool required by the facility's own policy - had gone missing approximately two weeks before the survey.
The administrator told investigators she believed the former Director of Nursing may have taken the lab tracking binder when she left the facility on January 18, 2025, though she had no proof. When inspectors asked the administrator to produce lab orders for the affected resident and other residents, she was unable to do so.
The facility's own written policy, dated August 2021, explicitly requires daily lab tracking documentation, timely communication of results to physicians and families, and monitoring by the designated clinical officer. According to the inspection findings, none of these procedures were being followed.
The RN described the breakdown in direct terms: "The problem was the labs were not put in a system and that is why labs were missed... there was absolutely no follow up or follow through with the DON."
Administrator Acknowledges Failures
The facility administrator acknowledged the severity of the situation during multiple interviews with inspectors. She stated the former DON had assured her that systems were in place but "hindsight is 20/20 and she now found out that this was not the case at all."
The administrator told investigators that failing to follow through with labs "could have potentially caused harm" to the resident and described it as "embarrassing that an MD had to come to the facility and ask for the labs." She acknowledged that as the person responsible for overseeing the DON's performance, the DON's failures were "a detriment to the residents."
Additional Citations: Weight Monitoring Failures
Beyond the lab failures, inspectors also cited the facility under F-tag 684 for failing to weigh the resident daily as ordered. For a patient with congestive heart failure and fluid restrictions, daily weights are a primary tool for detecting fluid retention. A weight gain of just a few pounds over a short period can signal worsening heart failure and the need for medication adjustments.
Records showed the resident had gained 4 pounds in a single week before his hospitalization - a finding documented by the PA on December 3, the same day the resident was transported by EMS.
Immediate Jeopardy Declared and Removed
Inspectors identified the immediate jeopardy on January 29, 2025, and provided the facility with formal notification. The facility implemented a corrective plan that included a 100% audit of all pending lab orders, creation of new lab tracking binders at each nurses' station, staff re-education on laboratory monitoring procedures, and establishment of a quality assurance plan.
After verifying staff training and reviewing the corrective measures, inspectors removed the immediate jeopardy designation on February 1, 2025. However, the facility remained out of compliance at a severity level of actual harm with a scope of pattern, pending evaluation of whether the corrective systems would prove effective over time.
The full inspection report is available through the Centers for Medicare & Medicaid Services and provides additional details on the deficiency findings and the facility's plan of correction.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Focused Care At Brenham from 2025-02-01 including all violations, facility responses, and corrective action plans.
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