Failure to Timely Communicate and Act on Diagnostic Results for DVT
Penalty
Summary
The facility failed to follow its own policies and procedures regarding timely diagnostic testing, follow-up on diagnostic results, and physician notification for a resident experiencing a change in condition. The resident, who had a history of obesity, cellulitis, peripheral vascular disease, and prior pulmonary embolism, presented with unilateral leg swelling, warmth, and increased pain. Despite these symptoms, there was a delay in scheduling and performing the ordered venous and arterial doppler studies, with the tests being conducted three days after the initial order. After the diagnostic tests were completed, the results of the venous duplex scan, which confirmed deep vein thrombosis (DVT), were not promptly communicated to the physician. The physician was not notified of the abnormal findings or the resident's escalating pain, which increased to a rating of 8/10. The physician only became aware of the positive DVT result during a subsequent visit, seven days after the initial symptoms were noted, and initiated appropriate anticoagulant therapy at that time. Interviews with facility staff revealed that required documentation, such as the SBAR communication form, was missing for the period in question, and there was no record of the change in condition being communicated via the facility's established communication systems. Staff acknowledged that the expected process for reporting and following up on diagnostic results was not followed, and the physician confirmed that he was not informed of the abnormal results or the resident's increased pain until several days later.