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Based on record review and interview, RN nursing staff failed to evaluate the care for 2 sampled patients. Physician orders for daily weights were not fully implemented for 2 of 5 current sampled patients ( Patient ID 5, 6)

Findings included:

Record review of professional guidelines established by the American Nurses Association (ANA) titled :" Principals of Nursing Documentation: Guidance for Registered Nurses," 2010, showed:

-Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice;

-The uses of Nursing Documentation include: Communication within the healthcare team. Timely documentation of the following types of information should be maintained in the patient's health record: assessments; order acknowledgement, implementation, and management [*not all inclusive ].

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Record review on 4/26/2024 of five (5) current patient clinical records with Staff -C, RN on Unit 2-South showed the following :

Patient # 5 :

Patient # 5 was a 63 year-old male, admitted on 4/21/2024 for "congestive heart failure exacerbation with shortness of breath and likely fluid over load." Physician admission orders, dated 4/21/2024 included: fluid restriction of 1.2 Liters daily; Lasix 40 mg IV twice daily; intake and output monitoring; and daily weights.

Staff-C, RN was unable to locate documentation of daily weights on 2 of 5 days reviewed: April 24 and 26, 2024.

Patient # 6 :

Patient # 6 was a 87 year-old male, admitted on 4/19/2024 ( to 2 South Unit) for "symptomatic bradycardia, lower leg edema, reports chest tightness and shortness of breath; dizziness."

Physician admission orders included: cardiology consult, lower extremity Doppler; bedrest; and fluid restriction of 1500 ml. Staff-C reported all patients on fluid restriction had I & O and daily weight recorded.

Staff-C, RN was unable to locate documentation of a daily weight for 1 of 13 days reviewed: April 22, 2024

During an interview at the time of the record review, Staff-C, RN said the expectation was the daily weight for Patient # 5, 6 would have been measured and recorded by nursing staff.