HospitalInspections.org

Based on document review and interview, a registered nurse (RN) failed to ensure that nursing staff reassessed patients related to daily and weekly weight checks for 1 of 6 patients with open records, patient #6 and 1 of 4 closed medical records reviewed, patient #1.

Findings Include:
1. Review of the policy: Nursing Assessment and Reassessment, policy number 477518, last reviewed/revised 7/2013, indicated on page two, Reassessment: The purpose of reassessment is to identify the ongoing status of the patient and response to the current plan of care...The Patient Plan of Care is reviewed daily based on assessing the patient's problems and or nursing care needs.

2. Review of the closed medical record for patient #1 (admitted 7/9/15 and discharged 9/2/15) indicated daily weights were noted on the "Weight Log" document, and underlined three times. The following dates lacked documentation on the weight log form of daily weights being noted: 7/11/15; 7/12/15; 7/15/15; 7/16/15; 7/28/15; 8/7/15; 8/18/15 and 9/1/15.

3. Review of the open medical record for patient #6 indicated that weekly weights were required after admission on 11/4/15 and none had been documented since 12/3/16.

4. At 3:50 PM on 1/14/16, interview with staff member #54, the 2 South nursing manager, confirmed that pt. #6 had:
A. Documentation that weekly weights were to be obtained.
B. No weekly weights had been documented since 12/3/16.
C. The Nursing Assessment and Reassessment policy was not followed in regard to the requirement for reassessment of weekly weights for patient #6.