HospitalInspections.org

Based on record review and staff interview, it was determined that the facility's nursing staff failed to address all patient needs in the nursing plan of care for 1(#3) 3 sampled patients. This practice may result in failure to achieve patient goals.


Findings include:


Patient #3 was admitted to the facility on 10/17/10 with the diagnosis of chronic obstructive pulmonary disease, diabetes, dyspnea and morbid obesity. The physician documented the patient also had a history of congestive heart failure. The patient was on diuretic and antihypertensive therapy. The physician wrote an order on 10/18/10 for the daily weights to be recorded due to the patient's history of congestive heart failure. Review of the medical record revealed no evidence that the patient's weight had been measured or recorded in the record. The Director of Nursing was interviewed on 10/25/20 at approximately 2:00 p.m. She confirmed that there was no recording of the patient's weight after the order was written.