HospitalInspections.org

A. Based on review of documents and interview of staff, it was determined the facility failed to ensure nursing staff obtained daily weights as ordered and per policy, for two (2) of three (3) patients for whom daily weights were ordered (Patients # 2 and # 8). This can lead to changes in a patient's condition remaining undetected and untreated, with possible negative outcomes.

Findings include:

1. Facility policy entitled "Documentation" last approval date 3/15, was reviewed on 4/6/16 and states, in part, "Personnel from various health care disciplines, who provide direct/indirect patient care are responsible for documentation of care activities to meet patients' initial needs as well as his/her needs as they change in response to care". It further states, in part, "Reassessments and evaluations of patients' response to both nursing care... and medical care, provide the direction and continuation of (the nursing process)...The nursing process is not complete unless documented and, therefore, communicated to other nurses...and physicians."

2. Patient #2's medical record was reviewed on 4/5/16. It revealed, in part, a physician's order for "daily weights" dated 3/28/16 at 11:09 a.m. Further review of the record revealed weights were obtained on 4/2, 4/3, and 4/4. The above documentation was reviewed with the Nurse Manager 4N unit on 4/6/16 at 11:30 a.m., at which time she agreed the weights had not been obtained daily as ordered.

3. Patient # 8's medical record was reviewed on 4/6/16. It revealed, in part, a physician's order for "daily weights" dated 3/29/16. Further review of the record revealed no weight documented for 4/2/16. The above documentation was reviewed with the Nurse Manager 4N unit on 4/6/16 at 11:30 a.m., at which time she stated daily weights are assigned to Patient Care Technicians, who are supervised by unit nurses. She agreed the weights had not been obtained daily, as ordered.

B. Based on review of documents and interview of staff, it was determined the facility failed to ensure nursing staff completed neurological assessments (neuro checks) as ordered and per facility policy, for one (1) of one (1) patient for whom neuro checks were ordered (Patient # 9). This can lead to changes in a patient's condition remaining undetected and untreated, with possible negative outcomes.

1. Facility policy entitled "Documentation" last approval date 3/15, was reviewed on 4/6/16 and states, in part, "Personnel from various health care disciplines, who provide direct/indirect patient care are responsible for documentation of care activities to meet patients' initial needs as well as his/her needs as they change in response to care". It further states, in part, "Reassessments and evaluations of patients' response to both nursing care... and medical care, provide the direction and continuation of (the nursing process)...The nursing process is not complete unless documented and, therefore, communicated to other nurses...and physicians."

2. Patient # 9's medical record was reviewed on 4/6/16, and revealed a physician's order for "neuro checks Q 4 hours (every four hours)" dated 4/2/16 at 12:13 a.m. Further review of the record revealed neuro checks documented by nursing on 4/2/16 at 2:38 a.m. and 9:30 p.m., on 4/3/16 at 8:30 a.m. and 9:30 p.m., on 4/4/16 at 9:20 p.m., and 4/5/16 at 9:50 p.m. The above documentation was reviewed with the Nurse Manager 4N unit on 4/6/16 at 11:30 a.m., at which time she agreed the neuro checks had not been completed every four hours as ordered.