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Based on interview, clinical document and record review, the hospital failed to ensure a Registered Nurse (RN) evaluated patient care on an ongoing basis for 4 of 20 Patients (patients 4, 9, 11, and 17) when patient weights were found to have significant variances from day to day and were not verified or validated by nursing staff.

This failure had the potential to compromise the nutritional and medical status of patients.

Findings:

a. On 5/5/15 starting at 4:48 p.m., Patient 4's record was reviewed. She was admitted on 5/2/15 with diagnoses that included diabetes, and not eating for the last three days. Her admission weight was recorded at 11:01 a.m. at 140 pounds, and at 17:29 p.m. at 131.5 pounds. There was no indication in the record as to possible reasons for the 8.5 pound weight loss in six hours. Her weight was recorded on 5/4/15 at 150.75 pounds and on 5/5/15 at 149 pounds. There was no indication in the record as to why there was a 10 pound weight increase in two days, and the physician was not notified of the change. There was no indication that attempts were made to determine why there was such a large variance in recorded weights.

b. On 5/5/15 Patient 9's record was reviewed. He was admitted from the Emergency Department on 4/24/15 with diagnoses that included sepsis, hypotension, pneumonia, and acute kidney injury. His initial weight on 4/24/15 indicated 165 pounds. On 4/26/15 his weight was recorded at 181 pounds. There was no documentation in the record as to possible reasons for the 16 pound weight increase in two days.

A review of Patient 9's nutritional intake indicated between 4/29/15 to 5/5/15 he ate nothing for five days and his intake for the three days he did eat ranged from 20 to 100 percent (average of about 50 percent). Registered Dietitian 1 (RD 1) noted in a nutrition assessment dated 5/4/15 that the patient was refusing to eat and recommended TPN (total parenteral nutrition, complete nutrition provided directly into the blood through a vein) which was started on 5/5/15.

c. On 5/5/15 Patient 11's record was reviewed. She was admitted from the Emergency Department on 4/17/15 with diagnoses that included hypoxia, bronchiostasis, and chronic obstructive pulmonary disease. Her initial weight was recorded on 4/17/15 at 153 pounds and at 194 pounds on 4/19/15. On 4/20/15 her weight was recorded at 91 pounds. There was no documentation in the record as to why there was such a huge variance/discrepancy in the documented weights.

Weights documented in the record were:
4/17/15 153 pounds
4/19/15 194 pounds
4/20/15 91 pounds
4/21/15 92 pounds
4/22/15 90 pounds
4/25/15 90 pounds
4/28/15 83 pounds
4/29/15 83 pounds
4/30/15 115 pounds
5/1/15 118 pounds
5/2/15 123 pounds
5/3/15 124 pounds
5/4/15 116 pounds

There was no documentation in the record to indicate an attempt to re-weigh the patient or possible explanations for weight variances.

A review of Patient 11's Nutrition Assessment dated 5/2/15 indicated under the comments section, "Weights documented range from 74-194 pounds. Spoke with patient and husband. Patient's arms and chest were visible. Patient appears underweight. Difficulty eating at times due to what sounded like some sort of esophageal spasming causing stricture which occurs sporadically. Lunch tray was observed. Pt (patient) ate a few bites of a tuna sandwich, but most of the bread was not eaten. Pt also had an Ensure (nutritional supplement) and pudding that had not been eaten yet."

A review of Patient 11's meal intakes indicated they ranged from 25-100 percent.

d. On 5/6/15 Patient 17's record was reviewed. He was admitted on 4/23/15 with diagnoses that included dehydration and non-compliance of taking antibiotics for an infection from 4/18/15. On 4/24/15 the record indicated his weight was 220 pounds. On 4/25/15 his documented weight indicated 203 pounds, On 4/26/15 his documented weight indicated 220 pounds. There was no explanation in the record to indicate why this weight variance occurred.

A review of the data entry screens for these dates indicated on 4/24/15 no source for how the weight was obtained, on 4/25/15 it indicated a bed scale was used, on 4/26/15 no source for how the weight was obtained was documented.

During a concurrent interview Registered Nurse 1 (RN 1) stated nurses were not supposed to over-ride the source for obtaining weights when recording weights. She further stated that if a nurse entered a weight that was significantly different from the previous entry, a note appears on the screen indicating the discrepancy and prompting the nurse to review the entry for accuracy.

During an interview with RD 1 on 5/5/15 at 2:05 p.m., she stated she used the initial weight and subsequent weights to conduct patient nutritional assessments. She further stated it was important for documented weights to be accurate in order to develop an appropriate care plan for each patient who was at nutritional risk.

A review of the hospital policy dated 4/14 entitled "Clinical Housewide Manual, Patient Care Standards" indicated under Section II Guidelines: ...Standards for clinical practice are modeled after a. Clinical Nursing Skills: Basic to Advanced Skills... was the standard used by the hospital to weigh patients.

A review of the hospital policy "Clinical Nursing Skills, Chapter 4 Admission, Transfer, Discharge, Measuring Height and Weight" did not indicate what nurses should do if there was a significant weight variance from the previous measurement.