HospitalInspections.org

Based on record review and interview nursing staff failed to properly assesss and evaluate the care of patients as evidenced by not obtaining daily weights as ordered in 1 of 1 patient records reviewed (Patient #1) and not documenting hourly nursing rounds per policy in 5 of 10 patients reviewed (Patients #1,2,3,4,5) in a total sample of 10 records reviewed.

Findings include:

Pt. (Patient) #1 was admitted to the facility on 12/22/2022 with a diagnosis of hyponatremia (low sodium) and weakness. Review of the medical record revealed admission orders written on 12/22/2022 that included weight on admission and daily.

Review of Pt. #1's medical record did not find any documentation of a weight on admission or performed daily.

On 8/23/2023 at 12:30 PM in an interview with Nurse Manager G, Manager G confirmed that no weights were recorded and stated, "They should have been."

Review of the facility policy titled, "Documentation/Charting" #13351067 dated 6/10/2022 revealed, "D. Ongoing Patient Assessment and Interventions: 1. All care given to a patient, by any member of the interdisciplinary team, must be documented in the patient's EMR (electronic medical record) as care is being delivered."

Review of the facility policy titled, "Patient Rounding" #13404757 dated 2/20/2023 revealed, "Purpose: To proactively take care of patient's needs by visiting their room on a regular basis. Meaningful patient rounding requires specific actions and words to help the nurse anticipate patient needs, rather than reacting to the needs, when a patient uses their call light...Practice: ...6. Document everything done for the patient while rounding such as medication given, toileting, etc."

Review of the Electronic Medical Record revealed the following as an expectation for rounding, "Items checked to ensure a safe environment may include (but not limited to) Appropriate call light within reach, Belongings in reach, Bed/cart in lowest position, bed/cart/chair wheels locked, non-skid footwear on if up in chair or ambulating, Remove clutter, unnecessary equipment and organize equipment, Whiteboard reflects alarms, activity, assistance/equipment, Orient to the surrounds and educate on the function and use of the call light."

Review of Pts #1,2,3,4 and 5 medical records did not reveal any documentation of hourly rounding being performed.

On 8/23/2023 at 1:27 PM in an interview with Manager G the above list of "Items to be checked for a safe environment" was reviewed. Manager G agreed that those items are part of hourly rounding. The facility policy titled, "Documentation/Charting" was reviewed with Manager G and when asked if she felt that the items in the safe environment list constituted "care given to a patient" Manager G stated, "Yes, I guess it does. I agree with the policy and it appears that hourly rounding should be documented. It wasn't in any of those medical records."