HospitalInspections.org

Based on record review and interview it was determined the facility failed to ensure physician orders were followed for one [#1] of four patients sampled.

Findings included:

A review of Patient #1's medical record revealed the patient was admitted to the facility on 06/12/2019 at 9:27 a.m. for a planned surgical procedure to both knees. A review of the physician's post-operative orders documented the following:
- Bedrest-do not roll to operative side.
- Notify Physician neurological symptoms.

A review of the nursing documentation revealed Patient #1 was rolled from side to side to place on a bedpan. The documentation also showed that the patient was turned and repositioned from left and right sides.
The nursing post-operative assessment noted bilateral 3+ to 4+ edema [swelling] to feet bilaterally. The nursing notes on 06/12/2019 at 8:00 a.m. documented left and right sensation decreased with tingling and at 20:00 (8:00 p.m.) nursing documented left and right sensation decreased with numbness. No documentation was found of physician notification of the swelling and numbness.
No documentation was found to indicate why the physician orders were not followed.

An interview with the Quality Manager, during record review on 08/07/2019, confirmed the above findings.