HospitalInspections.org

Based on record review and staff interview it was determined that the Registered Nurse failed to supervise nursing care related to physician orders for daily weights for two (#8, #9) of 10 sampled patients. This practice does not ensure needed information is obtained to develop a plan of care.

Findings include:


1. Patient #8 was admitted on 4/12/11 with the diagnosis of renal insuffiencey, upper gastrointestinal bleed and history of stroke. The physician ordered daily weights at 6 a.m. to be recorded. Review of nursing documentation revealed the weight was not recorded on 4/13/11.

2. Patient #9 was admitted on 4/12/11 with the diagnosis of renal failure. Review of the physician admitting orders revealed daily weights were to be documented each day at 6:00 a.m. due to the diagnosis of renal failure. Review of nursing documentation revealed that the weight was not documented on 4/13/11.

The nursing director who was in attendance during the record review on 4/14/11 confirmed the above findings.