HospitalInspections.org

Based on medical record review, policy and procedure review and interviews, the Registered Dietitian failed to acknowledge the discrepancy in Patient Identifier (PI) # 1's weight on admission of 170 pounds (lbs), the weight of 142.8 lbs on 9/26/17 and the weight of 152 pounds on 9/28/17. As a result, the patient's actual weight was not accurately determined by hospital staff. This affected PI # 1, but has the potential to affect all patients admitted to the hospital.

Findings include:

PI # 1 was admitted to the hospital on 9/20/17 with diagnoses to include COPD (Chronic Obstructive Pulmonary Disease) Exacerbation and Respiratory Distress.

PI # 1's weight on admission was documented as 170 lbs. (pounds) per bed scales.

On 9/26/17, PI # 1 was admitted to Swing Bed Status. PI # 1's weight was documented as 142 lbs. and 8 ounces per bed scales.

On 9/28/17 PI # 1's weight was documented as 151 lbs and 8 ounces per bed scales.

A review of PI # 1's Nutrition Assessment / Plan / Education Form dated 9/28/17 revealed
the patient's weight was 152 lbs. There was no acknowledgement and/or explanation regarding the weight gain of 9.8 lbs. by the Registered Dietitian and/or the admission weight of 170 lbs.

A copy of the weight policy was requested. The following policy, written 10/24/79 and revised 6/13/07, provided by the Chief Executive Officer, revealed:
"Policy: 1. Upon admission each patient is to be weighed and height taken, unless patient's condition warrants otherwise.
2. When patient's weight is ordered daily, always weigh him before breakfast on same scales.
3. Patients may be weighed and their height measure by trained individuals...

Chart:
1. Time
2. Weight and Height."

During an interview on 10/12/17 at 10:45 AM, the Swing Bed Coordinator, Employee Identifier (EI) # 1, stated patient weights vary greatly. According to EI #1, education for nursing assistant staff has been provided and the bed scales have been calibrated by maintenance staff, but the cause for the discrepancies has not been determined by the hospital.

During an interview on 10/12/17 at 2:15 PM, the Chief Executive Officer, EI # 2, verified Patient Identifier's (PI#1) ten pound weight gain (142 lbs. on 9/26/17 and 152 lbs. as documented by the Registered Dietitian on 9/28/17). EI # 2 stated the Dietician was not onsite for an interview. The CEO was notified that the Registered Dietitian could contact the surveyor by noon on 10/13/17 for an interview. However, there was no contact from the Dietitian.