HospitalInspections.org

Based on record review and interview the facility failed to develop and implement a plan of care for prevention of Deep Vein Thrombosis (DVT) ( a blood clot in a deep vein in the leg) for 1 out of 1 (#1) records reviewed. These finding have the potential to cause harm to all patients who are high risk for DVT which could result in clots in the lungs.

Review of patient # 1 medical record on 04/07/2011, in the conference room of the facility, the patients medical record contained an assessment form for patients who may be at risk for DVT. The form was completed and the assessment indicated this patient was at risk for developing a DVT. This patient was admitted on 07/19/2011 at 0030 a.m. The form for the DVT prevention was signed by the physician on 07/20/2011 and the record indicated the prevention plan was not implemented until the next day on 07/21/2011. There was no indication the nurse notified the physician at the completion of the assessment when the patient was determined to be at risk so that the DVT protocol could be implemented to prevent DVT's on the day of admission. In addition there is also no indicating in the medical record the protocol was implemented on the day the physician became aware that this patient was at risk of DVT's and that the prevention protocol should be implemented.

Interview with staff # 1 on 04/07/2011 at 04:00 p.m. confirmed the protocol was no implemented when the patient was determined to be at risk for DVTs. In addition she stated the DVT assessment is to be completed with the admission assessment and the plan should be implemented as soon as the patient is determined to be at risk.