HospitalInspections.org

Based on record review and interview, the hospital failed to ensure:

1. Patient assessment for two (Patients #1 and #4) of four patient records reviewed.
2. Nursing intervention for one (Patient #1) of four patient records reviewed.


PATIENT ASSESSMENT

Review of the medical record showed an order for daily weight and did not show the patient was weighed daily. Specifically:

Patient #1

1. A physician order dated 03/25/25 at 12:05 AM read in part, "Obtain Weight ...Frequency: Routine Daily 03/25/25 0600 [6:00 AM] - Until Specified."
2. No documented weight for the following dates for 11 missed days:
03/28/25 03/29/25
04/03/25 04/04/25 04/05/25
04/06/25 04/07/25 04/09/25
04/10/25 04/11/25 04/12/25

Patient #4

1. A physician order dated 04/08/25 at 5:39 AM read in part, "Obtain Weight ...Frequency: Routine Daily 04/08/25 0600 [6:00 AM] - Until Specified."
2. No documented weight for the following dates for two missed days:
04/11/25 04/12/25

On 06/04/25 at 1:38 PM, Staff A reviewed the medical records for Patients #1 and #4 and stated:

1. The patients were not weighed daily per the order.
2. Obtaining the daily weight was important for assessing fluid, renal and cardiovascular status.



NURSING INTERVENTION

Patient #1

Review of the medical record showed the patient had no bowel movement for eight days and did not show physician notification by nursing. Specifically:

1. A medical progress note dated 04/09/25 at 11:21 AM showed an assessment and plan for constipation.
2. A nursing assessment entry dated 04/12/25 at 2:01 PM read in part, "Last BM Date 04/11/25"
3. Stool occurrence entries from 04/12/25 to 04/19/25 read in part, "0."
4. A nursing assessment entry dated 04/21/25 at 1:49 PM read in part, "Last BM Date 04/20/25."

On 06/04/25 at 2:18 PM, Staff A reviewed the medical record and stated:

1. The nurses were expected to communicate with the physician for an adjustment in the patient's medication regimen for constipation and did not.
2. Nurses used end of shift notes to communicate to physicians, but physicians were not obligated to read them.