HospitalInspections.org

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to ensure that a registered nurse supervise and evaluate the nursing care provided to patients with regard to the measurement, monitoring and evaluating of patients' weights for 4 of 6 patients (Pt #s 3, 5, 6 and 7), which poses a risk of delayed identification of patients' failing health and nutritional status.

Findings include:

Review of hospital policy/procedure titled Vital Signs, Last approved: 07/2015, revealed: "...Weights will be taken upon admission and then weekly unless ordered more frequently...."

The Director of Nursing (DON) confirmed, during interview conducted on 3/2/16, that nursing staff are to weigh patients at the time of admission, weekly (on Wednesdays), unless the physician orders weights more frequently, and at discharge. Nursing records the weights on the Daily Graphic Sheet. Discharge weights are recorded on the Discharge /Aftercare Instructions form.

Review of Pt # 3's medical record revealed that nursing weighed Pt # 3 on the day of admission (Friday, 7/24/15). Nursing did not weigh Pt # 3 again on Wednesday, 8/5/15. The weight at discharge was not recorded.

Review of Pt # 5's medical record revealed that nursing recorded Pt# 5's admission weight on 2/8/16, weekly weights on 2/10 and 2/17, but not on 2/24. No discharge weight was recorded.

Review of Pt # 6's medical record revealed that nursing recorded Pt# 6 admission weight. The weekly weight, required on 2/10, was not recorded.

Review of Pt # 7's medical record revealed that nursing recorded Pt#7 admission weight. The weekly weight required on 2/10 was not recorded.

The DON confirmed, during interview conducted on 3/2/16, that nursing did not weigh the above listed patients and record their weights as required.