HospitalInspections.org

Based on facility policy review, medical record review, and interview, the facility failed to follow facility policy for one patient (#4) of five patients reviewed.

The findings included:

Review of facility policy, Admission of a Patient, last revised on 10/2013 revealed "...Responsibilities...the licensed practical nurse...Registered Nurse may be responsible for...obtaining weight..."

Medical record review revealed Patient #4 was admitted to the Senior Care Unit at the facility on 1/20/15 with diagnoses including Alzheimer's, Dementia, Dysphagia, Periodontal Disease, Abnormal Finding of Lung, Hypopotassemia, and Constipation.

Medical record review revealed the patient's first documented weight was on 2/1/15 (twelve days after admission).

Interview with the Chief Nursing Officer on 9/22/15 at 8:34 AM, in the conference room, revealed "...February 1st is the first date I see a weight...should've been one on admission... or documentation of why a weight was not taken..." Further interview confirmed the facility did not follow facility policy.