HospitalInspections.org

Based on document review and interview, the facility failed to ensure documentation of patient's weight on admission in 4 out of 10 patients (patient 3, 4, 5, and 6) and weekly weights in 2 out 10 patients (patient 6 and 8) medical records.

1. Review of policy titled, "Vital Signs and Weight", PolicyStat ID 12386461, last approved 09/2022, indicated all patients will have their weights taken on admission, a minimum of once a week, and recorded in the patient's medical record.

2. Review of patients 3, 4, 5, and 6's medical record lacked documentation of admission weight.

3. Review of the the following medical records lacked documentation of weekly weights:
a. Patient 6's medical record lacked documentation of weekly weights on 05/24/2023, 06/07/2023, 06/21/2023, 06/28/2023, 07/12/2023, and 07/26/2023.
b. Patient 8's medical record lacked documentation of weekly weight on 09/06/2023.

4. Interview with A3, (Director of Nursing), on 11/29/2023, at approximately 6:00 pm, confirmed patients 3, 4, 5, 6's medical record lacked documentation of admission weight and and patients 6 and 8's medical records lacked documentation of weekly weights.