Failure to Monitor Resident Following DVT Diagnosis
Penalty
Summary
The facility failed to assess and monitor a resident for signs and symptoms of circulatory insufficiency in the right lower leg after the resident tested positive for deep vein thrombosis (DVT). The resident, who had a history of diabetes, end stage renal disease, and was on hemodialysis, was admitted with a diagnosis of DVT in the right popliteal vein. The care plan included interventions to monitor for swelling, pain, discoloration, and changes in the ability to move the lower extremity. However, there was no documentation that these assessments or monitoring were performed following the DVT diagnosis. Interviews with nursing staff and the DON confirmed that standard care and facility protocol required monitoring for pain, swelling, temperature changes, skin discoloration, and checking pedal pulses after a DVT diagnosis. Despite this, there was no evidence in the resident's records that such monitoring occurred. The lack of assessment and documentation was identified after the resident developed necrosis of the right foot, leading to hospital admission with a diagnosis of gangrene affecting multiple toes. The DON acknowledged the absence of a specific DVT management policy but stated that monitoring was an expected standard of practice.