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Based on clinical record review and interview, it was determined the nursing staff implemented placement of Thrombo-Embolic Deterrent (TED) hose without a physician's order for 2 (Patient #1 and #4) of 16 (Patient #1-#16) records reviewed and implemented placement of Plexi-Pulse Foot Pumps for 1 (Patient #4) of 16 (Patient #1-#16) records reviewed. The failed practice placed the patients at risk for skin breakdown which affected one (#1) patient and had the potential to affect all patients on which TED Hose and Plexi-Pulse Foot Pumps were used. The findings follow:

A. Review of Patient #1's clinical record on 08/04/16 revealed the following:
1) Patient had TED Hose in place on 06/14/16, 06/16/16, 06/20/16, 06/21/16, 06/23/16, 06/24/16, 06/25/16, 06/28/16, 06/29/16, 06/30/16, 07/01/16, 07/02/16, 07/07/16, 07/08/16 and 07/10/16. There was no evidence of a physician's order to place TED Hose on Patient #1.

B. The findings of A were confirmed in an interview with Chief Nursing Officer and the Clinical Systems Manager on 08/04/16 at 1040.

C. Review of Patient #4's clinical record on 08/05/16 revealed the patient had TED Hose in place on 08/03/16 and Plexi-Pulse Foot Pumps in place on 08/03/16 and 08/04/16. There was no evidence of a physician's order for TED Hose or Plexi-Pulse Foot Pumps.

D. The findings of C were confirmed in an interview with the Clinical Systems Manager on 08/05/16 at 1045.