HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 8 patients' (Pt. #2 and Pt. #3) clinical records reviewed, the Hospital failed to document patients' weight and intake and output, to ensure that the registered nurse supervised the implementation or evaluation of the patients' care.

Findings include:

1. On 9/1/2020, at approximately 11:30 AM, the Hospital's Job Description for Staff Nurses (undated) was reviewed and included, "... Essential Functions... implements and evaluates the care of patients based upon current nursing standards and practices... Implements nursing plan of care... Anticipates and evaluates patient outcomes..."

2. On 9/1/2020, at approximately 1:30 PM, the Hospital's policy titled, "Meditech Computerized Clinical Data: Documentation & Review" (reviewed by the Hospital on 9/17) included, "1. Members of the healthcare team document clinical nursing interventions using the electronic health record... 6. Healthcare team documents vital signs, I & O (intake and output)..."

3. On 9/1/2020, at approximately 2:00 PM, the Hospital's policy titled, "Weighing Patient: Criteria and Frequency" (revised 9/19) included, "... Weight loss in adults is one of six accepted characteristics that provide criteria for the assessment of malnutrition... Procedure... 9. Document weight..."

4. On 9/1/2020, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted on 8/30/2020 with a diagnosis of abdominal pain. Pt. #2's clinical record indicated that on 8/30/2020, two units of fresh frozen plasma (FFP/blood products) with a total volume of 600 ml (milliliters) was administered to Pt. #2. However, the electronic health record indicated that the volume of FFP infused was not documented in Pt. #2's intake and output.

5. On 9/1/2020, the clinical record of Pt. #3 was reviewed. Pt. #3 was admitted on 8/18/2020 with a diagnoses of abdominal pain and cholecystitis (inflammation of the gallbladder). Pt. #3's clinical record included a physician's order, dated 8/27/2020, for daily monitoring of the patient's weight. However, the electronic health record indicated that Pt. #3's weight was not obtained on 8/28/2020.

6. On 9/1/2020 at approximately 2:00 PM, findings were discussed with E #4 (5 East Unit Manager). E #4 stated that the volume of FFP infused was not documented on Pt. #2's intake and output record. E #4 said that appropriate evaluation of the patient's fluid volume includes documentation and monitoring of the intake and output. E #4 added that Pt. #3's weight on 8/28/2020 was not documented.