Failure to Follow Physician Orders and Complete Required Assessments Leads to Delayed DVT Diagnosis
Penalty
Summary
A deficiency occurred when nursing staff failed to provide treatment and care in accordance with physician orders and professional standards for a resident who exhibited changes in her lower extremities, including discoloration and swelling. Despite the nurse's assessment and subsequent notification to the physician, which resulted in an order for a vascular consult and elevation of the resident's legs, the vascular consult was never scheduled. There was also no documentation of any attempts to obtain the consult, and the required weekly head-to-toe assessment was not completed as scheduled. Additionally, when changes in the resident's condition were observed, the required Change in Condition (CIC) documentation was not completed on multiple occasions. The resident involved had a medical history that included acute respiratory failure with hypoxia, COPD, hypertension, difficulty in walking, and abnormal posture. She was cognitively intact and able to communicate her needs. The initial change was noted when her legs became discolored and one leg was more swollen than the other. The physician was contacted and ordered a duplex scan, but the scan performed was an arterial ultrasound rather than a venous study, which would have been necessary to diagnose a DVT. The results indicated severe bilateral arterial disease and a possible occlusion, prompting the physician to order a vascular consult and leg elevation. However, the consult was not arranged, and the resident did not receive the ordered follow-up care. As a result of these failures, there was a delay in addressing the resident's symptoms, which led to an acute change in her condition, including increased pain and swelling. The resident was ultimately sent to the hospital, where she was diagnosed with a deep vein thrombosis (DVT) in her left leg and underwent a surgical thrombectomy. The lack of timely assessments, failure to complete required documentation, and not following physician orders contributed to the delay in treatment and escalation of the resident's condition.