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Based on review of the clinical record of patient #1 and interview with staff, the hospital failed to provide care in a safe setting for this patient as the patient was transported on 2/24/11, to a Cardiologist appointment and left there alone.

Findings were;

During a review of the clinical record of patient #1 this patient was documented by nursing staff as "confused" and by the physician as "has the impulsiveness of a 3 year old". This patient was dropped off for the cardiology appointment alone. There was no one to advocate for the patient at the appointment. There was no assurance of the patient's safety while alone. In addition The patient had on a T-shirt, two hospital gowns and sweatpants with a blanket on his lap. There was no mention of shoes or socks in the record. In February the weather is quite cold in the panhandle of Texas,
The above findings were confirmed in inter view with the Nursing Director and administrator in the conference room on 3/28/11.

Based on review of the clinical record of patient #1, the restraint log and interview with staff, the hospital failed to ensure this patient had physician orders for physical restraints.

Findings were;

Patient #1 was was documented in the Restraint log 2/15 through 2/16 as being restrained by his bilateral wrists, the rationale was that the patient was climbing out of bed pulling off clothes and pulling on tube feeding portable machine. There was not a physician order for this restraint.

On 2/19 the patient was documented as restrained with bilateral wrist and ankle restraints,and a posey vest . There was not a physician order nor rationale for this restraint.
The above findings were confirmed in interview with the Nursing Director and administrator in the conference room on 3/28/11.

Based on review of the clinical record of patient #1 and interview with staff, the hospital failed to ensure that a registered nurse evaluated the care of patient #1 on the morning of 2/24/11 before he left the hospital..

Findings were;

Clinical record review for patient #1 revealed that on 2/24/11 between 0700 and the time the patient was sent for the Cardiology appointment at 0915, there was not a nursing assessment completed for this patient. While waiting for the appointment the patient suffered a syncopal episode. The patient was admitted to the hospital that afternoon.
The above findings were confirmed in inter view with the Nursing Director and administrator in the conference room on 3/28/11.

Based on review of the clinical record of patient #1 and interview with staff, the hospital failed to ensure that the nurse assigned care of this patient was competent in their duties.

FIndings were;

Clinical record review of patient #1 revealed this patient was documented by nursing staff as "confused" and by the physician as "has the impulsiveness of a 3 year old". This patient was dropped off for the cardiology appointment alone. There was no one to advocate for the patient at the appointment. There was no assurance of the patient's safety while alone. In addition The patient had on a T-shirt, two hospital gowns and sweatpants with a blanket on his lap. There was no mention of shoes or socks in the record. In February the weather is quite cold in the panhandle of Texas,

The above findings wer confirmed in inter view with the Nursing Director and administrator in the conference room on 3/28/11.

Based on review of the clinical record of patient #1 and interview with staff, the hospital failed to ensure that verbal and/or telephone orders were used infrequently.

Findings were;

A review of the clinical record for patient #1 revealed that of 21 physician orders, 19 of 21 orders were telephone and/or verbal orders. Only two orders were written by the physician. Therefore 19 of 21 orders does not reflect that verbal and/or telephone orders were used infrequently.
The above findings were confirmed in inter view with the Nursing Director and administrator in the conference room on 3/28/11.

Based on review of the clinical record of patient #1 and interview with staff, the hospital failed to ensure that all telephone and/or verbal orders were signed by the physician within 48 hours.

Findings were;

Based on review of the medical record for patient #1, there were 19 verbal/telephone orders; of these 12 of 19 failed to be signed within 48 hours of the order. No reason for the delay was offered.
The above findings were confirmed in inter view with the Nursing Director and administrator in the conference room on 3/28/11.