Failure to Care Plan for Resident With History of DVT and Embolism
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a documented personal history of other venous thrombosis and embolism. The resident’s face sheet showed admission with diagnoses including diabetes mellitus and a personal history of venous thrombosis and embolism, and the history and physical documented that the resident’s cognitive functioning was intact. Despite this information being available in the admission records, there was no care plan initiated to address the resident’s diagnosis and history of deep vein thrombosis (DVT) and embolism. During an interview and concurrent record review with the DON, it was confirmed that licensed staff or the MDS Coordinator were responsible for initiating the care plan upon admission and that this had not been done for the resident’s DVT condition. The DON acknowledged that the care plan should have addressed the resident’s DVT diagnosis and risk for developing DVT, and that the care plan serves as a guide for necessary interventions. The facility’s own policy on comprehensive, person-centered care plans required development of a care plan with measurable objectives and timetables to meet each resident’s medical, physical, mental, and psychosocial needs, and to reflect recognized standards of practice for identified problem areas and conditions, which was not followed in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.