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Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by failing to perform weekly weights as ordered by the physician for 5 of 5 sampled patients (Patient #1, 2, 3, 4, 5).
Findings:

Review of the hospital policy titled, Weight Policy, revealed that patients will be weighed weekly on admit and then all patients will then be weighed on a weekly basis.

Patient #1
Review of the closed medical record for Patient #1 revealed an admit date of 10/02/20, with diagnoses including CHF, gastrointestinal bleed and status post PEG placement, and a discharge date of 12/04/20. Review of admit physician orders revealed an order to weigh upon admit and then weekly. Review of the medical record revealed the only weight documented was on admit. There were no weekly weights documented. Further review of the record revealed that S2RD documented weekly reviews of the patient's dietary status, but did not address the missing weekly weights.

Patient #2
Review of the closed medical record for Patient #2 revealed an admit date of 04/08/21, with diagnoses including quadriplegia and decubitus ulcer, and a discharge date of 05/01/21. Review of admit physician orders revealed an order to weigh upon admit and then weekly. Review of the medical record revealed the only weight documented was on admit. There were no weekly weights documented. Further review of the record revealed that S2RD documented weekly reviews of the patient's dietary status, but did not address the missing weekly weights.

Patient #3
Review of the medical record for Patient #3 revealed an admit date of 03/11/21, with diagnoses including diabetes, UTI and decubitus ulcer. Review of admit physician orders revealed an order to weigh upon admit and then weekly. Review of the medical record revealed the only weight documented was on admit. There were no weekly weights documented. Further review of the record revealed that S2RD documented weekly reviews of the patient's dietary status, but did not address the missing weekly weights.

Patient #4
Review of the medical record for Patient #4 revealed an admit date of 04/21/21, with diagnoses including UTI, malnutrition and infected decubitus ulcer. Review of admit physician orders revealed an order to weigh upon admit and then weekly. Review of the medical record revealed the only weight documented was on admit. There were no weekly weights documented. Further review of the record revealed that S2RD documented weekly reviews of the patient's dietary status, but did not address the missing weekly weights

Patient #5
Review of the medical record for Patient #5 revealed an admit date of 04/27/21, with diagnoses including diabetes, decubitus ulcer and PEG tube. Review of admit physician orders revealed an order to weigh upon admit and then weekly. Review of the medical record revealed the only weight documented was on admit. There were no weekly weights documented. Further review of the record revealed that S2RD documented weekly reviews of the patient's dietary status, but did not address the missing weekly weights

On 05/11/21 at 10:40 a.m., interview with S2RD revealed that all patients should have a minimum of weekly weights performed. S2RD stated that she performs weekly dietary assessments for the patients in the hospital. S2RD further stated that she was aware that weekly weights were not being performed for the patients. When asked how she conducted weekly dietary assessments without current weights, including weekly weights, she stated "It's hard to do."

On 05/11/21 at 11:30 a.m., S1DON revealed that he had reviewed the medical records for the above patients and was unable to find documented weekly weights as ordered by their physicians.