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Based on review of medical records, policies and procedures, staff and physician interviews, it was determined that the facility staff failed to follow the patient's plan of care for one of two (#1) sampled patients.

Findings were:

Review of patient #1's medical record revealed that the physician's orders specified that the patient was to be on bedrest with bathroom privileges.


During an interview on 1/26/11 at 3:30 p.m. in the conference room, the nurse who took care of the patient, stated that he/she helped to transfer the patient from the patient's room to another room on the floor. The nurse explained that the patient wanted another room that had a window and that the physician wrote an order for the patient to be transferred to room 315. The nurse stated that the patient had gotten up when the patient saw him/her getting the patient's belongings for the transfer. The nurse further stated that he/she had some of the patient's belonging and was planning to take the belongings in the new room and then come back and get the patient but that the patient wanted to go and was ready to go. The nurse stated that he/she felt that because the patient had been up walking to the bathroom earlier without complications that he/she felt that the patient could walk to the new room. The patient allowed to walked to the new room although the order was for bedrest with bathroom privileges.

During a tour on 1/26/11 on the ante-partum area with the nurse manager, it was noted that the room the patient was transferred from to the distance of the room the patient was transferring to was three (3) times the distance that the patient walked going to and from the bathroom in his/her room.