HospitalInspections.org

Based on document review and interview, the Registered Nurse failed to follow the P&P (Policy & Procedure) related to patient weights, for obtaining weight before and after dialysis, and document in the patient's EMR (Electronic Medical Record), for 1 of 6 closed MR's (Medical Records) reviewed (Patient # 5 - A & 5 - B).

Findings include:

1. Review of established hospital policy titled: "Weight, Patient", indicated on page 1, General Information, 1.0, "All patients will be weighed in the following instances"; 2nd point, "Before and after dialysis". Policy effective date 11/2021.

2. Review of Patient # 5 - A & 5 - B MR's, indicated the following:
A. Patient with two hospital stays/visits. First visit 4/30/2022 to 6/7/2022 and second visit 6/11/2022 to 6/28/2022.
B. Patient weight on 4/30/2022 = 270 lbs. (pounds); on 5/4/2022 = 258 lbs.; on 5/16/2022 = 249 lbs.; on 5/22/2022 = 236 lbs.; on 6/7/2022 = 206 lbs.; on 6/26/2022 = 174 lbs. Weights noted from progress notes and dietary notes.
C. Patient on hemodialysis on Monday, Wednesday & Fridays. MR documentation on nurse flowsheets lacked weights on days of dialysis runs.
D. MD (Doctor Of Medicine) # 33 (Renal) progress note on 5/2/2022 and on 6/16/2022, reflected under Plan: continue to monitor daily weights. MR lacked order for daily weights.

3. In interview on 7/27/2022 at approximately 4:02 pm, with administrative hospital staff member A # 1 (Administrative Director - PCS {Patient Care Services}), confirmed the following:
A. Patients to be weighed before and after dialysis; per policy.
B. No weights documented in MR; for before and after dialysis runs. Contractual dialysis nurse(s) document in EMR (electronic medical record); would be able to document the patient's weight.

4. In interview on 7/27/2022 at approximately 2:56 pm, and at approximately 4:00 pm, with administrative hospital staff member A # 2 (Quality Care Program Coordinator), confirmed the following:
A. Weights to be documented before and after dialysis runs. No weights documented on flowsheets on days with dialysis.
B. Weights in MR varied; not consistent throughout hospital stays.