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Based on interview, record review, the Assessment/Reassessment of Patients Policy and the Interdisciplinary Patient Care Planning and Documention Policy, it was determined the facility failed to follow current standards of practice for one (1) patient (Patient #1) of the 10 sampled residents related to assessing the patients weight and updating the careplan.

The findings include:

1. Record Review of the Assessment/Reassessment Policy, revised 2/2010, revealed the purpose was to determine care through assessment of each patients' needs. All patients' physical, psychological and social status are assessed and reassessed to provide ongoing information and data for which patient care and treatment is provided. Policy section five (5) stated the reassessment is done at specified times based on the patients course of treatment, and when there is a significant change in the patient's condition or diagnosis. The scope and intensity of reassessments are based on the patient's diagnosis, the setting, the patient's desire for care, treatment and services; and the patient's response to previous care, treatment, and services.

Record Review of Patient #1's chart, revealed the facility admitted the patient on 03/28/11 with a chief complaint of Mental Status Change, Frequent Falls, Possible Normal Pressure Hydrocephalus. Current weight upon admission was 127 pounds in which it was documented "stated", no other weights were documented the entire stay of Patient #1. Interview with the four (4) N Charge Nurse, on 11/16/11 at 1:55 PM, revealed "stated" meant the staff asked the patient/family what the patients' weight was. Record review of the A/P of the Physician Progress Notes on 04/02/11, revealed fever related to a Urinary Tract Infection (UTI), Congestive Heart Failure (CHF) with an order to start low dose Lasix, Atrial Valve Replacement, and Hypertension.

Interview with a family member, on 11/16/11 at 8:54 AM, revealed Patient #1 had a 13 pound weight loss from 03/28/11 through 04/12/11.

Interview with the Certified Nursing Assistant (CNA) #2, on 11/16/11 at 4:07 PM, revealed weights were obtained upon admission. CHF patients were weighed daily and third shift obtained all weights by six (6) AM.

Interview with CNA #4, on 11/17/11 at 1:10 PM, revealed weightsare obtained on all CHF patients daily.

Interview with Registered Nurse (RN) #5, on 11/17/11 at 1:20 PM, revealed it was common knowledge to obtain daily weights on CHF patients. She further stated she would weigh a patient who was on Lasix.

Interview with RN #4, on 11/17/11 at 1:30 PM, revealed it was their protocol to obtain weights on CHF patients daily. RN #4 stated, since Patient #1 was not admitted with CHF, therefore, he/she was not placed on the weight board to have his/her weight obtained. RN #4 further stated, Patient #1 should of been weighed, especially since he/she was on Lasix. The nurse would not need an order to obtain weights on a patient. You would hope the nurse would use critical thinking and nursing judgement to get daily weights for a patient and getting weights would be appropriate for Patient #1. 4 North Charge Nurse further stated that she did not know why weights were not obtained.


2. Record review of the Interdisciplinary Patient Care Planning and Documentation Policy, revised 09/2011, revealed an initial assessment will be completed by a Registered Nurse using the database on all inpatients. Based on the assessment, a list of patients problems including psychosocial concerns and discharge goals will be identified and documented. The plan of care will be revised based on the changing needs of the patient identified by the respective clinician. All problems and goals will continually be evaluated throughout the patients hospitalization.

Record review of Patient #1's care plan, revealed Cardio, Neuro and Falls were addressed. The interventions for cardio stated to assess cardio per shift, to call MD with any changes, Troponin as ordered, cardiac medications as ordered and EKG. The interventions for neuro stated to assess neuro every shift, to call MD with any changes and CT of head. The interventions for falls stated assess for falls, bed alarm and adequate lighting. All interventions were written on the day of admission 03/28/11. The intervention to assist feeding patient was written on 04/06/11. No other care problems were addressed or revised.

Interview with the RN #4, on 11/17/11 at 3:10 PM, revealed there should have been a revision of the care plan for Patient #1 with all of the changes in the patients care noted. Interview with the 4 North Charge Nurse, on 11/16/11 at 4:35 PM, revealed RN #4 should have care planned changes in Patient #1's care. RN #4 further stated she did not know why she did not update the care plan for Patient #1 to reflect CHF.

Interview with the Director of Nursing for the Critical Care and Step Down Units, on 11/16/11 at 2:07 PM, revealed that nurses were taught to update the care plan.