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Based on interview and record review, the hospital failed to ensure the nursing staff weighed one of four sampled patients (Patient 1) as per the physician's order. This failure posed the potential for an increased risk of poor health outcomes to this patient.

Findings:

Review of the hospital's P&P titled Core: Weight Measurement dated June 2021 showed the purpose of the policy is to establish guidelines for measuring weight. Weight is an anthropometric measurement used in conjunction with other information to calculate estimated energy, protein, and fluid needs, body mass index and the patients' ideal/desired weight range. Weight change overtime is an indicator of nutritional status and fluid status. The policy includes to ensure proper measurement of patient weights scheduled within 24 hours of admission and weekly thereafter. Timing of weight assessment maybe individualized based on physician's order, nutrition assessment, or interdisciplinary team recommendations.

Review of Patient 1's medical record was initiated on 10/10/24 at 0730 hours.

Patient 1's medical record showed the patient was admitted to the hospital on 2/12/24.

Review of the RN Admission Assessment dated 2/12/24, showed the RN had assessed the patient's weight.

* Review of the physician's order dated 5/27/24 at 0600 hours, showed an order to weigh the patient once a week (Mondays at 0600 hours) and stop after 90 days.

Review of the RN notes showed Patient 1's weights were taken on 6/3, 6/17, and 6/24/24.

However, review of Patient 1's weight flowsheets showed on 6/10/24, the patient's weight was not taken due to the bed not being calibrated.

Further review Patient 1's weight flowsheets dated 7/1, 7/8, 7/15, and 7/29/24, showed the order was scheduled and not carried out.

Review of Patient 1's medical record failed to show documented evidence the patient's weights were taken once a week as ordered by the physician.

* Review of the physician's order dated 7/16/24 at 0937 hours, showed an order to weigh once; the patient needed a new weight as there were no new weights for three weeks.

However, review of Patient 1's medical record failed to show documented evidence Patient 1's weight was taken on 7/16/24, as ordered by the physician.

* Review of the physician's order dated 8/27/24 at 1459 hours, showed an order to weigh the patient once.

Review of Patient 1's weight flowsheet dated 8/27/24, showed the order was scheduled and not carrried out.

On 10/11/24 at 1326 hours, an interview and concurrent medical record review was conducted with the Director of Quality Management. The Director of Quality Management was asked if there was a weight taken on 7/16/24, as ordered. The Director of Quality Management stated no, the weight was taken on 7/22/24 instead of 7/16/24. The Director of Quality Management was also asked if the weight was taken on the week of 8/27/24, as ordered. The Director of Quality Management stated no, the order was not followed. The Director of Quality Management was asked if the weekly weight was taken for the patient. The Director of Quality Management stated no. The Director of Quality Management was informed and acknowledged the findings.

On 10/11/24 at 1540 hours, the findings were shared with the CEO, CCO, and Director of Quality Management.