HospitalInspections.org

Based on interview and record review, the facility failed to ensure the right to care in a safe setting was met for Patient #1 regarding the lack of monitoring of weight and nutritional intake. The sample size was eight patients with a census of 282 patients.

Findings include:

1. The medical record review for Patient #1 was completed on 07/06/17. The review revealed the 35 year old patient was admitted to the facility on 04/07/17 with schizophrenia and unspecified dementia.

The review revealed a history and physical exam dated 4/21/17 that stated: "Weight loss of 42 pounds in almost 2 years. She was 130 pounds on 04/07/14 and 88 pounds on 2/24/2016 .... She is 5 feet 3 inches tall. She has gained weight since. Her weight was 96 pounds a year ago on 07/28/16 with BMI of 17. Today, she weighs 102 pounds with BMI of 18.1, still in underweight range."

The medical record review revealed a nutrition assessment dated 05/11/17 that listed her height as two inches taller at 5 ft, 5 inches, and stated Patient #1 is on a diet of 2200 kcal.

The medical record review did not reveal any care plan to address the patient's weight loss, nor could a weight/nutrition related goal statement be found.

The medical record review did not reveal any information about how much Patient #1 ate during meal times.

On 07/06/17 at 9:45 AM in an interview, Staff F explained they weighed Patient #1 during her weekly bath. Staff F explained that since the patient will physically resist any bathing or hygiene interventions, the patient requires sedation for staff to provide the bath for her. The history and physical revealed Patient #1 requires emergency medications in preparation for her weekly bath, specifically 20 mg of Geodon and 4 mg of Ativan given as an injection.

Staff F could not locate any of those weekly weights or any other weights noted in the medical record.

On 07/06/17 at 9:45 AM Staff F then went on to explain staff attempted to weigh the patient at weekly vital signs, but the patient refuses.

Review of the medical record revealed no evidence on how much the patient eats and when, and had no recorded weight since 04/21/17 (which was then assessed as underweight).

On 07/06/17 at 9:45 AM in an interview, Staff G explained the patient's weight was not a problem and that the patient doesn't have a problem eating. Staff G also explained the patient would take her tray to her room and eat behind closed doors.






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