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Based on record review and interview, the facility failed to ensure physician and nutrition orders for plan of care were implemented for 3 of 5 patients reviewed (#'s 1, 3, and 6) as evidenced by:

-Patient #1's Physician's Orders for getting out of bed was not documented as being done as ordered and Nutrition Orders for receiving nutritional supplement were not documented as being done as ordered.

-Patient #3's Physician's Orders for daily weights, strict I&O (Intake and Output) and getting out of bed twice a day were not documented as being done as ordered. The patient's physician had to write multiple orders for the same things before they were carried out.

-Patient #6's Physician's Order for daily standing weights was not documented as being done as ordered.


Findings include:

Patient #1

Record review of Patient #1's closed medical record revealed he was admitted on 5/6/14 with diagnoses of cholecystitis and Ecoli sepsis. The patient was admitted to the hospital for continued IV antibiotic therapy and rehabilitation before he was able to have surgery to remove gallbladder.

Record review of Patient #1's Thrombosis (Blood clot) Risk Factor Assessment dated 5/7/14 revealed a score of 7. A score of 5+ was the highest level which equaled 40 to 80 percent of patients with calf DVT (deep vein thrombus).

Record review of Patient #1's Physician's Orders revealed the following:

5/8/14 - Out of bed to wheelchair twice a day with safety belt.
5/14/14 - Out of bed for meals
5/18/14 - Venous Doppler ultrasound of both legs to rule out DVT.

Record review of Patient #1's Critical Value Report dated 5/19/14 revealed extensive bilateral DVT by ultrasound.

Record review of Patient #1's Physical Therapy treatments and Nurses' Notes revealed Patient #1 was out of bed only once a day on the following days in May 2014:
12, 14, 15, 16, 22, 23, 27, 28, 29, 30, and 6/3/14. There was a Physician's Order to hold PT for 5/19, 20, and 21/2014 secondary to DVT treatments.

Record review of Patient #1's Medical Record revealed no Treatment Administration Record (TAR).

Record review of Patient #1's MAR (Medication Administration Record) revealed no documentation of getting the patient out of bed twice a day to his wheelchair or out of bed for meals.

Further record review of Patient #1's Physician's Orders revealed a Nutrition Order dated 5/7/14 for one carton of nutritional supplement three times a day between meals. On 5/16/14 there was a Nutrition Order to please make sure patient receives three times a day between meals nutritional supplement.

Record review of the patient's MAR revealed no documentation the patient received the ordered nutritional supplement as follows:
May 15, 16, 17, 18, 19, 21, 23, 28, and 6/2/14.
There was no documentation on the MAR that the patient was refusing the supplement. The first nutritional supplement was documented as being given on 5/11/14.

The patient was discharged for surgery on 6/4/14.

Interview on 8/14/14 at 2:30 p.m. with Therapy Director #54, she said most of the patients that came to the facility were at an acute level of care and so the therapists only did therapy once a day. You could say it was twice a day, because physical therapy (PT) worked with the patient at one time and then occupational therapy (OT) worked with them at another time. Physical therapy was responsible for walking and transferring patients. Therapy Director #54 was shown Patient #1's orders. She said the order to get the patient out of bed twice a day and for meals was written by the Therapy Physician. She said the order was not just for the therapy department, but also for nursing.

Record review of an on-line information sheet from University of Michigan Health System revised on 7/24/13 revealed walking was one of the best things to be done to help reduce chance of getting a blood clot and to be out of bed as much as possible.

Record review of an on-line information sheet from Encyclopedia of Surgery for Venous Thrombosis Prevention revealed "Sitting for long periods or being confined to bed after surgery or during a long illness can slow blood flow, allowing clots to form. As soon as possible after surgery, the patient should move the legs, stand, and begin taking short walks."


Patient #3

Record review of Patient #3's medical record revealed she was admitted on 8/5/14 with diagnoses of gastrointestinal (GI) bleeding and volume depletion.

Record review of Patient #3's History and Physical dated 8/6/14 revealed diagnoses that included diverticulosis, congestive heart failure, pleural effusion, chronic obstructive pulmonary disease, and chronic restrictive lung disease.

Record review of Patient #3's Physician's Orders revealed the following:

8/5/14 - weight on admission and weekly
8/6/14 - strict I&O (intake and output), weigh daily
8/8/14 - out of bed to wheelchair twice a day
8/8/14 - strict I&O night and day shift, second order
8/13/14 - weigh patient daily, second order
strict I&O, third order. House supervisor/Charge nurse to verify I&O complete prior to every shift change.
8/14/14 - 1.5 liter per day fluid restriction

Record review of Patient #3's vital sign sheets revealed the following:

Weights not taken on 8/6, 8/8, and 8/13/14.

I & O's not complete for multiple days.

Record review of the patient's nurses' notes and therapy notes revealed she was only documented out of bed once a day on the following days: 8/7, 8/9, 8/12, 8/13, and 8/14//14.

Further review of Patient #3's medical record revealed no TAR.

Record review of the patient's MAR revealed nothing about getting the patient out of bed twice a day.

Interview on 8/15/14 at 10:30 a.m. with LVN (Licensed Vocational Nurse) #57, she was asked about getting patients out of bed twice a day as ordered by a physician. She said it depended on if the patient was willing to get out of bed. When she was asked if therapy was the one to get them up twice a day, she said she did not know about that. She said on the weekends, the staff got the patients up or the patient would ask to be gotten up. She said if the physician wanted the patient up for meals, then staff would need to do that.

Interview on 8/15/14 at 3:35 p.m. with CNO (Chief Nursing Officer) #50, he was asked for a policy and procedure for getting patients out of bed. He said getting patients out of bed was a practice, not a policy.

Patient #6

Record review of Patient #6's medical record revealed she was admitted on 7/24/14 with diagnoses that included respiratory insufficiency, hypoxia and carbon dioxide retention.

Record review of the patient's History and Physical dated 7/25/14 revealed diagnoses that included chronic obstructive pulmonary disease, congestive heart failure and anasarca. Anasarca is a generalized infiltration of edema fluid into subcutaneous connective tissue.

Record review of Patient #6's Physician's Orders revealed the following:

7/24/14 - Weigh patient on admission and weekly.

7/25/14 - Daily standing weight. 1.5 liter fluid restriction.

Record review of Patient #6's vital sign records revealed she was not weighed daily on the following dates: 7/30, 8/3, 8/4, 8/5, 8/6, or 8/7/14.



Record review of the above patients' charts revealed 24 hour chart checks were documented on the Physician's Orders.

Interview on 8/15/14 at 1:45 p.m. with CNO #50, he was asked what a 24 hour chart check entailed. He said the night shift RN (Registered Nurse) verified that all orders for that day were transcribed, carried out and put in the computer.