Dyer Nursing Center: Blood Clot Treatment Delayed - IN
Federal inspectors found that Dyer Nursing and Rehabilitation Center received Doppler ultrasound results on July 30 showing a partial blood clot in the resident's leg vein but didn't communicate the findings until August 5, when the patient finally received a prescription for blood thinners.
The resident, identified in inspection records as Resident D, suffered from stroke, aphasia, paralysis on one side of the body, difficulty swallowing and weakness. A May assessment indicated severe impairment for daily decision making and the need for substantial assistance with bathing, dressing and personal hygiene.
On July 29, the resident developed new swelling and pain in the right lower leg and foot. A nurse practitioner ordered a Doppler ultrasound to examine blood flow in the affected limb. Staff documented that a technician would arrive within 24 hours to perform the test.
The next morning, nursing notes indicated the resident's leg remained swollen. The Doppler technician completed the scan and told staff the report would be ready within an hour. A nurse wrote that the nurse practitioner had been made aware of the situation.
The ultrasound results, interpreted at 12:25 p.m. on July 30, revealed a serious finding: partial clotting in the superficial femoral vein that was restricting blood flow through the vessel. Such clots can break loose and travel to the lungs, causing potentially fatal pulmonary embolisms.
But nursing home records contain no documentation that staff communicated these abnormal results to the ordering physician or nurse practitioner upon receipt. For the next six days, there was no follow-up on the Doppler procedure despite the concerning findings.
The treatment delay ended August 5, when a physician's order appeared for Eliquis, a blood thinner prescribed at 5 milligrams twice daily. A nursing note from that morning indicated staff had received the new medication order.
During an August 11 interview with federal inspectors, the Director of Nursing acknowledged the facility had ordered the Doppler on July 29 and completed it July 30. She said she had contacted the company that interpreted the results, and they confirmed reporting the findings on July 30.
However, the nursing director could not determine when the results were actually reported to the physician. She told inspectors she understood their concern about the treatment delay.
The inspection was conducted in response to a complaint filed against the facility. Federal regulations require nursing homes to promptly notify ordering practitioners of test results, particularly abnormal findings that could affect patient care.
Blood clots in leg veins pose serious risks for nursing home residents, who often have limited mobility and other conditions that increase clotting risks. Prompt treatment with anticoagulants like Eliquis can prevent clots from growing larger or breaking off to cause life-threatening complications.
The resident's underlying conditions made the delayed treatment particularly concerning. Stroke patients already face elevated risks for additional blood clots, and the resident's severe cognitive impairment meant they could not advocate for themselves or communicate worsening symptoms.
The six-day gap between test results and treatment represents a significant breakdown in the facility's communication systems. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, but noted it affected the resident's access to timely medical intervention.
This case illustrates how administrative failures can directly impact patient care in nursing homes. While the Doppler ultrasound was ordered promptly and completed within the expected timeframe, the critical step of communicating results to the treating physician fell through the facility's processes.
The resident ultimately received appropriate treatment with blood thinners, but the delay could have allowed the clot to worsen or cause complications during those six days of inaction.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dyer Nursing and Rehabilitation Center from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
DYER NURSING AND REHABILITATION CENTER in DYER, IN was cited for violations during a health inspection on August 11, 2025.
A May assessment indicated severe impairment for daily decision making and the need for substantial assistance with bathing, dressing and personal hygiene.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.