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Based on document review and interview, the facility failed to ensure nursing staff followed policy/procedure for vital signs and weight being completed on 9 (nine) (P1, P2, P3, P4, P5, P6, P7, P8, and P9) of 10 (ten) medical records (MR) reviewed, and policy/procedure for Incident reports for 1 of 10 (P6).

Findings include:


1. Review of the policy titled: "Vital Signs and Weight", revised 09/2022, PolicyStat ID: 12386461: indicated all patients will have their vital signs, weight, and height taken on admission. Weights will be taken a minimum of once (1) a week unless diagnosis deems need for increased frequency weighing and the provider orders a more frequent schedule.

2. Review of the policy titled "Incident Reports", revised 01/2023, PolicyStat ID: 13033981: indicated a policy of the hospital to support a culture of shared accountability for the identification, reporting and management if patients events that impact the quality of care provided. Any hospital staff member who witnesses, discovers or has direct involvement in and/or knowledge of an event must complete an incident report.

3. Review of medical records (MR) indicated:

a. P1 admitted on 05/17/2023 and discharged on 05/24/2023 lacked the MR documentation of weekly weights for 05/24/2023.

b. P2 admitted on 05/10/2023 and is a current patient. The MR lacked documentation of weekly weights for 05/17/2023, 05/24/2023, 05/31/2023, 06/07/2023, 06/14/2023, 06/21/2023, 06/28/2023, 07/05/2023, 07/12/2023, 07/19/2023, 07/26/2023, and 08/02/2023.

c. P3 admitted on 05/20/2023 and discharged on 05/31/2023. The MR lacked documentation of an admission weight for 05/20/2023 and weekly weight for 05/27/2023.

d. P4 admitted on 05/12/2023 and discharged on 06/01/2023. The MR lacked documentation of weekly weights for 05/19/2023 and 05/26/2023. .

e. P5 admitted on 05/11/2023 and discharged on 06/06/2023. The MR lacked documentation of weekly weights for 05/18/2023, 05/25/2023, and 06/01/2023.

f. P6 was admitted on 05/12/2023 and discharged on 06/09/2023. The MR lacked documentation of weekly weights for 05/19/2023 and 05/26/2023. The MR lacked documentation of meal consumption for P6. Psychiatric progress noted dated 5/30/23 indicated patient fell into the wall and staff reported several bruises to his/her face.

g. P7 admitted on 05/12/2023 and discharged on 05/25/2023. The MR lacked documentation of weekly weight for 05/19/2023.

h. P8 admitted on 05/12/2023 and discharged on 06/09/2023. The MR lacked documentation of weekly weights for 05/19/2023, 05/26/2023, 06/02/2023 and 06/09/2023.

i. P9 admitted on 05/12/2026 and discharged on 06/09/2023. The MR lacked documentation of weekly weights for 05/19/2023, 05/26/2023, 06/02/2023 and 06/09/2023.

4. Reviewed Incident reports dated 01/01/2023 through 08/07/2023. The incident reports lacked an incident report dated 05/24/2023 filed for P6 reported fall (hitting into the wall) and discovery of multiple bruises and small scabs to the upper and lower extremities.

5. On 08/07/2023 at approximately 1500 hours, staff A2 (Director of Nursing) was interviewed and confirmed the above MR's provided for review were complete patient records as presented. Staff A2 confirmed nursing staff should have followed policy/procedure for Vital Sign and Weight and Incident Reports.