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Based on review of medical records and interviews it was determined that the facility failed to provide patient care as ordered for the patient by the physician. Review of 7 (seven) medical records, 2 (two) of the medical records did not follow patient care Physician's Orders.

Findings included:

Review of patient #3 medical record on 10/19/15 revealed, Physician's Orders dated 10/16/15 stated, "Activity- ambulate as tolerated, three times a day" and "compression stockings continuous." The medical record revealed that on 10/18/15 there was no documentation showing patient was ambulated, no documentation showing that the physician's orders were followed, no documented evidence that the patient was wearing the compression stockings and no documenntation to the patient's response to treatment.


Review of patient #4 medical record on 10/19/15 revealed, Physician's Orders dated 10/13/15 read, "OOB (out of bed) 4 hours post-op (post-operation) then every 3 hours, as tolerated and compression device sequential." In the medical record on 10-14-15 there was no evidence that the physician's orders were followed or that the patient was assessed for response to the above orders .

Facility Policy titled, "Nursing Assessment and Reassessment" states in part, "II Reassessment:
A. A comprehensive assessment as defined by the nursing flow sheet must be completed and documented minimally at the beginning of each shift by the assigned RN and with each change in RN. Additional reassessments will be done and documented according to the following:
3. Determine the patient's response to treatment and services for the patient (i.e. post procedure)."

In interviews on 10/19/15 with the Director of Quality and Patient Safety the above was confirmed.

Based on medical record review, policy review, and staff interview the facility failed to ensure 2 (two) out of 7 (seven) patients were counseled or prepared for post-hospital care.

Findings included:

Facility Policy titled "Discharge Process" stated in part "It is the policy of Lakeway Regional Medical Center that a patient will be discharged in an orderly fashion after discharge teaching with written information regarding diagnosis, follow up appointments, dietary needs, and medications to continue, start, or stop."

Review of medical record for patient #5 on 10-19-15 revealed no discharge instructions documented.
Review of medical record for patient #7 on 10-19-15 revealed no discharge instructions documented.
In an interview with staff #1 and #2 on 10-19-15, both acknowledged no discharge instructions were documented or found on each patient.