HospitalInspections.org

Based on staff interview and record review, the facility failed to ensure nursing staff identified/evaluated/addressed discrepancies in patients' weights including weight loss/weight gains (A0395). The cumulative effects of these systemic practices resulted in the facility's inability to ensure patients received correct doses of medications which are weight specific (mg/kg) and failed to ensure patients received diet/nutritional adjustments to avoid weight loss/gain. This had the potential to affect the facility's 71 patients.

Based on record review and staff interview, the facility failed to ensure nursing staff identified/evaluated/addressed discrepancies in patients' weights including weight loss/gains for four (Patient #1, #3, #5, and #6) of ten medical records reviewed for weight assessments. This had the potential to affect all the facility's 31 active patients.

Findings include:

The facility's Documentation Standards policy (Number: D05-G, Revised Date: 07/01/20) stated:
Purpose:
To provide clinical personnel with requirements for documentation that will:
1. Provide a current, complete and concise description of the patient's status with minimal duplication of information.
2. Reflect interdisciplinary team process and integrate the patient's goals.
3. Provide useful information in a retrievable format.
4. Assist in protecting the legal interest of the patient, the hospital, the physician, and department personnel.

1. Patient #1 was admitted to the facility on 03/02/20 with a Stage 4 sacral decubitus ulcer and was on enteral feedings. Patient #1 was ventilator dependent. Patient #1 was ordered Vancomycin 20 mg/kg on 05/06/20 at 2:51 PM. The medical record for Patient #1 contained the following documented weights:
03/02/20 166 lb.
03/03/20 165 lb.
03/09/20 165 lb.
03/17/20 167 lb.
03/18/20 159 lb.
03/18/20 160 lb.
03/19/20 160 lb.
03/20/20 162 lb.
03/21/20 164 lb.
03/22/20 160 lb.
03/22/20 155 lb.
03/25/20 182 lb.
03/26/20 181 lb.
03/26/20 185 lb.
03/27/20 183 lb.
03/28/20 187 lb.
03/31/20 132 lb.

04/01/20 119 lb.
04/02/20 146 lb.
04/02/20 148 lb.
04/04/20 152 lb.
04/04/20 169 lb.
04/06/20 167 lb.
04/07/20 173 lb.
04/11/20 163 lb.
04/11/20 163 lb.
04/13/20 164 lb.
04/15/20 110 lb.
04/16/20 109 lb.
04/17/20 110 lb.
04/18/20 141 lb.
04/22/20 138 lb.
04/25/20 140 lb.
04/28/20 138 lb.
04/30/20 136 lb.

05/01/20 136 lb.
05/02/20 138 lb.
05/03/20 126 lb.
05/04/20 126 lb.
05/07/20 124 lb.
05/09/20 120 lb.
05/10/20 122 lb.
05/11/20 123 lb.
05/12/20 115 lb.
05/13/20 122 lb.
05/14/20 122 lb.
05/15/20 120 lb.
05/16/20 119 lb.
05/18/20 121 lb.
05/21/20 121 lb.
05/22/20 112 lb.

Per the weights documented in the medical record, Patient #1 had weight loss of 54 pounds from 03/02/20 through 05/22/20.

2. Patient #3 was admitted to the facility on 06/14/20 for continued IV (intravenous) antibiotics and wound care. The patient's weights and related notes documented in the medical record stated:
06/14/20 170 lb.
06/20/20 174 lb.
06/21/20 179 lb.
06/22/20 194 lb.
06/23/20 192 lb.
06/26/20 191 lb.
Progress Notes by Staff GA on 06/29/20 at 2:00 PM stated:
Latest Weight: (unable to weigh-scale needs zeroed.)
A Team Conference note by Staff HA on 07/02/20 at 12:12 PM stated:
07/02/20 Current Weight: (bed needs zeroed)

Per the weights documented in the medical record, Patient #3 had weight gain of 21 pounds from 06/14/20 through 06/26/20.

3. Patient #5 was admitted to the facility on 06/18/20. The patient's weights and related notes documented in the medical record stated:
06/18/20 Weight 219 lb.
06/19/20 Weight Comment: weight per bed scale today is 211 lbs.-weight at host hospital was 159 lbs. Patient reports usual weight is closer to 150-160 lbs. and 211 lb. weight is erroneous. Will need to recalibrate bed scale when patient out of bed and attempt to obtain more accurate weight.
06/21/20 204 lb.
06/22/20 188 lb.
06/23/20 190 lb.
Progress Notes by Staff GA on 06/25/20 at 9:11 AM stated:
Admit Weight: 219 lb.
Latest Weight: 190 lb. (06/23/20 5:54 AM)
Weight Comment: Uncertain if weight on admission is accurate. If so, may need insulin adjusted to accommodate for weight loss.
06/26/20 Weight: 192 lb.
06/30/20 Weight: (unable to weigh-bed needs to be zeroed)
07/01/20 Latest Weight: (bed needs zeroed)
07/02/20 Current Weight: (bed needs zeroed)
07/09/20 180 lb.
07/15/20 170 lb.
07/16/20 171 lb.
Progress Notes by Staff GA on 07/22/20 at 9:44 AM stated:
Latest Weight: 173 lb. 8 oz (78.7 kg) (07/21/20 6:01 AM)
Weight Comment: weight may be inaccurate-some loss may be d/t fixator removal
07/23/20 161 lb.
07/28/20 157 lb.
Progress Notes by Staff GA on 08/04/30 at 8:55 AM stated:
Latest Weight: 160 lb. (08/04/20 5:00 AM)
Weight Comment: will discuss weight discrepancy with staff and work to obtain more accurate, reliable weights
08/06/20 165 lb.
08/11/20 171 lb.
08/17/20 168 lb.
08/24/20 171 lb.

Per the weights documented in the medical record, Patient #5 had weight loss of 48 pounds from 06/18/20 through 05/22/20.

The findings were shared with Staff AZ on 09/02/20 at 2:59 PM and confirmed.

4. Patient #6 was admitted to the facility on 08/04/20 due to a history of needed a NGT (nasogstric tube) placement and SBO (small bowel obstruction). Patient #6 then developed respiratory distress and needed to be placed on vent. The medical record for Patient #6 contained the following documented weights:
Admit Weight: 159 lb. (08/04/20 5:10 PM)
08/05/20 164 lb.
08/06/20 155 lb. after bed zeroed
08/10/20 143 lb.
08/11/20 144 lb.
08/14/20 weight not done
08/16/20 146 lb.
08/17/20 147 lb.
08/18/20 140 lb.
08/19/20 148 lb.
08/20/20 149 lb.
08/21/20 Weight: probably inaccurate, recorded as 131 lb., 149 lb. yesterday.
08/24/20 119 lb.
Progress Notes by Staff GA, on 08/25/20 at 8:49 AM:
Latest Weight: 118 lb. (08/25/20 6:00 AM)
Weight Comment: 159 lb. weight was most likely erroneous
08/25/20 118 lb.
08/26/20 116 lb.
08/27/20 115 lb.
08/31/20 114 lb.
08/31/20 110 lb.

Per the weights documented in the medical record, Patient #6 had weight loss of 49 pounds from 08/04/20 through 08/31/20.

The findings were shared with Staff AZ on 09/02/20 at 1:33 PM and confirmed.