HospitalInspections.org

Based on observation, record review, and interview, the facility failed to ensure 2 of 6 patients reviewed (#9 and #10) received daily weights as ordered by their physicians.


Findings include:


Patient #9


Observation on 12/15/15 at 3:00 p.m. with DM (Director Quality Management) C revealed Patient 9 lying in bed unresponsive to verbal stimuli with a tracheostomy. The Patient was obese and her hands were swollen with pitting edema. She also had a gastric tube and an indwelling urinary catheter.


Record review on 12/15/15 of Patient #9 ' s admission orders revealed she was admitted on 11/20/15 with diagnoses of respiratory failure and anoxic brain injury.


Record review of the Physician ' s Orders revealed an order dated 11/29/15 to give Lasix 40 mg now and to do daily weights.


During an interview on 12/15/15 at 3:40 p.m. with Interim DQM B, she was asked where daily weights were recorded. She said there were two places the weights could be recorded, in a weight book and in the computer.


Record review of the weight book revealed a weight of 262 pounds (#) on 11/29/15. The next weight of 268.5 # was recorded a week later on 12/7/15. There were no other weights recorded.


Further interview at this time with DQM B and Regional CNO (Chief Nursing Officer) D revealed they were going to check in the computer to see if the weights were recorded there. At 3:50 p.m. Interim DQM B said the weights were not recorded, so were not done as ordered by the physician.


Interview on 12/16/15 at 10:55 p.m. with Interim DQM B, she said the procedure for getting patient weights was to always get an admission weight. All patients were to be weighted weekly. If there was an order different from that it was to be put on a Cardex in the patient ' s soft chart. It was also to be put in the weight book. She said they used a color system to identify who was to get the patient ' s weight. One color was for the patient to be weighed on days and the other color to be weighed at night. Interim DQM B said she stayed over yesterday to in-service the staff on how weights were to be done. She said she decided all weights need to be done on days and were to only be put in the computer. She was doing away with having two choices for where to enter weights.


Patient #10


Observation on 12/15/15 at 3:10 p.m. of Patient #10 revealed she was alert to person, place and time and had a tracheostomy that was capped so she was able to talk. The patient was extremely obese on a bariatric bed. The patient could not say how long she had been at the facility. She said she came to the hospital in a daze.


Record review on 12/16/15 of Patient #10 ' s admission orders revealed she was admitted on 11/17/15 with diagnoses of respiratory failure and ventilator weaning. There was an order for daily weights.


Record review of the Patient ' s nursing assessment sheet revealed the patient ' s admission weight was 569 pounds (#).


Record review of the weight book revealed the following 2015 weights for Patient #10:
11/22 - 573#
11/24 - 574#
11/25 - 588#
11/28 - 584#
11/29- 578#
12/3- 563#
12/5 - 565#
There were no other documented weights after the last date.


Interview on 12/16/15 at 1:55 p.m. with Interim DQM B, she said she was not able to show the weights were done daily. She said she interviewed two CNA (Certified Nurse Aides) P and Q who said they did the weights but did not enter them in the book or on the computer. She said she told them if it was not documented then it was not done.


Interview at this time with CNAs P and Q, they said they did the daily weights, but did not put the weights in the weight book and did not know how to put the weights in the computer.


Record review of the facility ' s Policy & Procedure titled Guidelines and Protocols issued 5/1/03 and revised on 10/1/15 revealed the following:

" Nutrition and Fluids
Weighs (on same scale)
Every week or per physician order "