HospitalInspections.org

Based on clinical record review and interview, it was determined a Registered Nurse failed to supervise and evaluate the nursing care for two of two (Patient #3 and #5) Patients in that nursing staff failed to obtain and record daily weights. Failure to obtain and record daily weights did not ensure the Physician had information needed to make decisions regarding patient care and had the potential to prolong the patient's hospitalization. The failed practice affected Patient #3 and #5 on 01/04/18. Findings follow:

A. Review of Patient #3's clinical record showed orders authored by Physician #1 at 5:51 PM on 12/23/17 for daily weights at 6:00 AM. Review of the clinical record showed a weight of 100 pounds (lbs) documented on 12/23/17. Review of the clinical record showed no weights documented from 12/24/17 through 01/04/18. During an interview with the Regulatory Compliance Officer at 10:20 AM on 01/04/17, she verified the above findings.

B. Review of Patient #5's clinical record showed orders authored by Physician #2 at 2:44 PM on 12/26/17 for daily weights at 6:00 AM. Review of the clinical record showed a weight of 175 lbs on 12/16/17. Review of the clinical record showed no weights documented from 12/26/17 through 01/04/18. During an interview with the Regulatory Compliance Officer at 12:20 PM on 01/04/18, she verified the above findings.