HospitalInspections.org

Based on review of hospital policy, medical record review, and interview, the hospital failed to ensure a Registered Nurse supervised and evaluated the weight and oral intake for each patient for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's policy "Evidenced Based Clinical Documentation: Documenting Standard of Care" revealed, "...ASSESSMENT AND REASSESSMENT...Registered Nurses [RN] perform and document assessments...RNs are responsible for reviewing and analyzing the data, drawing conclusions and taking appropriate actions...CARE ACTIVITIES...Vital signs/ht [height] & [and] wt [weight]/measurements..."

Review of the hospital's policy "Appendix A Clinical Assessment, Reassessment, and Plan of Care," revealed, "...Area...[named psychiatric unit]...Weight...Upon admission, every Sunday, and Per Provider Order..."

2. Medical record review for Patient #1 revealed an admission date of 10/19/20 with diagnoses which included Senile Dementia of the Alzheimer's Type, Complicated by Behavioral Disturbance and Psychosis, Hypertension, and Urinary Tract Infection.

The "CLINICAL DOCUMENTATION RECORD" dated 10/19/20 at 6:28 PM revealed Patient #1's weight was documented as 44 kilograms (kg) (96.8 lbs) per bed scale.

The "CLINICAL DOCUMENTATION RECORD" dated 10/22/20 at 6:19 AM revealed Patient #1's weight was documented as 44 kg.

The "CLINICAL DOCUMENTATION RECORD" dated 10/25/20 at 5:06 PM revealed Patient #1's weight was documented as 43.7 kg (96.14 lbs) per bed scale.

The "CLINICAL DOCUMENTATION RECORD" dated 10/27/20 at 6:31 AM revealed Patient #1's weight was documented as 43.7 kg (96.14 lbs).

The "CLINICAL DOCUMENTATION RECORD" dated 10/29/20 at 6:11 AM revealed Patient #1's weight was documented as 43.7 kg (96.14 lbs).

The "CLINICAL DOCUMENTATION RECORD" dated 11/1/20 at 6:27 PM revealed Patient #1's weight was documented as 31.4 kg (69.08 lbs) per bed scale. There was a 12.6 kg (27.72 lbs) difference between this weight and the weights documented on 10/19/20 and 10/22/20. There was a 12.3 kg (27.06 lbs) difference in this weight and the weights documented on 10/25/20, 10/27/20 and 10/29/20.

The "CLINICAL DOCUMENTATION RECORD" dated 11/3/20 at 7:00 AM revealed Patient #1's weight was documented as 31.4 kg (69.08 lbs).

The "CLINICAL DOCUMENTATION RECORD" dated 11/5/20 at 6:24 AM revealed Patient #1's weight was documented as 31.4 kg (69.08 lbs).

There was no documentation Patient #1 was weighed on 11/8/20 (Sunday) as indicated per policy.

There was no documentation the weights (31.4 kg/69.08 lbs) documented on 11/1/20, 11/3/20 and 11/5/20 were addressed as aberrant weights or actual weight loss.

The "CLINICAL DOCUMENTATION RECORD" dated 11/10/20 through 11/12/20 revealed Patient #1 ate 25% of lunch on 11/10/20. Patient #1 consumed less than 10% of all meals from 11/10/20 through 11/12/20 except for lunch on 11/10/20. There was no documentation nursing staff addressed or notified the physician of the decreased oral intake.

3. Medical record review from Hospital #2 revealed Patient #1's weight was documented on 11/13/20 at 12:54 AM as 37.1818 kg (81.8 lbs) per bed scale. This weight was 6.8182 kg (15 lbs) less than Patient #1's weight documented on 10/19/20 and 10/22/20 and 6.5182 kg (14.34 lbs) less than Patient #1's weight documented on 10/25/20, 10/27/20 and 10/29/20.

4. In a phone interview on 11/24/20 at 12:35 PM, Nurse Practitioner #1 stated the providers were dependent on nursing staff to inform them of any weight loss or if a patient was not eating adequately. Nurse Practitioner #1 stated no one communicated to her that there was a problem with Patient #1's weight or her oral intake.

In a phone interview on 11/24/20 at 12:34 PM, the Manager of the Memory Care Unit stated the Patient Care Technicians were supposed to weigh each patient every Sunday. The Manager of the Memory Care Unit stated if there was a significant weight loss or an aberrant weight, the system would send the Pharmacist a message. The Pharmacist could ask staff to reweigh the patient if concerned about the weight being an error. If there was an actual weight loss, there should be a nutritional consult. We did not have a concrete process to review weights and make sure all the weights were done.