HospitalInspections.org

Based on interview and document review, the nursing staff failed to ensure DVT (deep venous thrombosis) prophylaxis was in place as ordered for one (1) of five (5) patients included in the survey sample. Patient #5

The findings include:

Surveyor review of medical records on 1/3/24 at 11:00 AM found the following in part:

Patient #5 was admitted to the hospital after undergoing a right colectomy with ileocolostomy on 6/5/23. SCDs (sequential compression device) used for DVT prophylaxis was ordered for the patient. An anticoagulant was not ordered for Patient #5.

The surveyor determined nursing staff had implemented bilateral SCD's on 6/5/23 at 3:32 PM. SCDs are documented as none or "refused" after 6/8/23 at 8:45 AM. The medical record did not provide documentation the provider was notified of the patient's refusal to wear SCDs.

Patient #5 was transferred to ICU on 6/13/23 due to severe abdominal pain and respiratory distress. A CTA chest was completed and showed a PE (pulmonary embolism, PE is a sudden blockage in a lung artery. It usually happens when a blood clot breaks loose and travels through the bloodstream to the lungs) Retrieved from Medlineplus.gov on 1/11/24.

In an interview on 1/4/23, Staff Member (SM) #7 stated they would expect nursing staff to notify them if a patient refuses to wear ordered SCDs. SM #7 stated if made aware that a patient was not using SCDs as ordered they would look at alternate methods of DVT prophylaxis such as an anticoagulant and counsel the patient on the risks of refusal.