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Based on observation, interview and record review the facility failed to supervise the nursing care needs of patients to ensure weights ordered by the physician are done as ordered. This failed practice had the potential to adversely affect patient recovery outcomes.

Findings:

Review of nursing assessment records for (Patient # 1) revealed the patient was admitted to the facility on 8/4/2014 with diagnoses that include severe malnutrition, deconditioning, stage 4 pressure ulcer and inability to eat solid foods due to aphasia.

Review of physicians orders dated 8/4/2014 revealed the patient had orders for total parenteral nutrition and daily weights.

Review of treatment sheets dated 8/4/2014 when the patient was admitted through 8/27/2014 when he was discharged revealed daily weights were documented 8/4/2014, 8/17/2014 and 8/24/2014. The patient was not weighed for a total of twenty (21) days.

Review of medical records for three current patient's with physician orders for weights revealed the following information:

(Patient #2) was admitted to the facility on 1/19/2015 with diagnosis of Chronic Renal Failure. Physician orders dated 2/7/2015 revealed orders for weights to be done Mondays, Wednesdays and Fridays (MWF). Review of patient care records revealed weights were not documented as done for 2/9, 2/11, 2/13, 2/16, and 2/25/2015 a total of six(6) out of nine (9) required weights.

(Patient #3) was admitted to the facility on 1/29/2015 with diagnosis of Chronic Renal Failure and Congestive Heart Failure Physician orders dated 1/29/2015 revealed orders for weekly weights Review of patient care records revealed weights were only documented as done for 1/29/2015 2/1/2015 a total of two (2) weeks out of five (5) weeks.

(Patient #4) was admitted to the facility on 1/20/2015 with diagnosis of Chronic Kidney Disease and Coronary Artery .

Physician orders dated 1/20/2015 revealed orders for daily weights Review of patient care records revealed weights were not documented as done for five ( 5) days in January 2015.
Review of recorded weights for February 2015 revealed weights were not recorded as done on 2/13, 2/15, 2/16, 2/17, 2/19, 2/21 and 2/22, a total of Seven(7) days in February.

During an interview on 2/27/2015 at 12:30 pm with Staff (21) Chief Nursing Officer she stated the facility identified there was a problem in getting staff to weigh patients as ordered, she stated some strategies were implemented but it is not working.