Failure to Develop and Implement Resident-Centered Care Plan for DVT
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for a resident with a diagnosis of left upper extremity (LUE) deep vein thrombosis (DVT). The responsible party (RP) for the resident had specifically requested that signage be placed above the resident's bed instructing nursing staff to avoid taking blood pressures in the affected left arm, but this request was not honored or implemented. Additionally, the care plan did not include the location of the DVT or provide specific instructions for staff on how to assess for complications related to the DVT, such as monitoring for pain, swelling, warmth, discoloration in the affected extremity, or signs of pulmonary embolism (PE) like difficulty breathing, cough, and chest pain. Record review showed that the resident had a history of atrial fibrillation, acute embolism, and thrombosis of the left upper extremity deep veins, with severely impaired cognitive skills for daily decision making. Despite these significant medical issues, the care plan lacked necessary interventions and details. Observations confirmed that no sign was present above the resident's bed, and interviews with staff revealed they were unaware of the DVT location or the RP's request. The MDS nurse and DON both acknowledged that the care plan was generic and did not provide adequate information for staff to deliver appropriate care or assessments. The facility's own policies require the interdisciplinary team to develop a comprehensive, person-centered care plan with measurable objectives and timeframes, and to involve the resident or their representative in the process. However, the failure to include the RP's request and to specify interventions for the resident's DVT resulted in staff not being properly informed or able to assess for complications, as confirmed by staff interviews and record review.