HospitalInspections.org
Bringing transparency to federal inspections
VIBRA HOSPITAL OF CLEAR LAKE
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on review of clinical records, hospital policy, and staff interviews, the hospital failed to ensure that an RN properly supervised and evaluated the nursing care for each patient, as there was no documented evidence that patients were consistently weighed per physician order, 2 of 11 patients ( patient #s 2 and 11).
Findings include:
Patient #2
Review of medical record for patient #2 on 2/8/13 revealed patient was admitted to the above facikity on 1/22/13. There was admission order that read "weigh on admission/ weekly". Patient's weight on 1/22/13 on admission was 258 pounds. Patient's weight on 2/2/13 was 259 pounds. There was no documentation of any other weight between 1/22/13 and 2/2/13. Patient #2 was on dialysis three times a week. Review of physician order dated 2/7/13 on 2/8/13 revealed "Daily wts". Patient #11 was on dialysis three times a week and order for weight was determined by the physician.
Patient #11
Review of medical record for patient #11 on 2/8/13 revealed patient was admitted to the above facikity on 12/20/12. There was admission order that read "weigh on admission/weekly". Patient's weight on 12/20/12 on admission was 304 pounds. Patient's weight on 12/21/12 was 287 pounds, patient's weight on 1/9/13 was 278 pounds. There was no consistent documentation of weekly weight on this patient's medical record as per admission order. Patient #11 was on dialysis three times a week and order for weight was determined by the physician.
Review of facility admission police dated 12/12 on 2/8/13 revealed #5. "Weight and height is obtained and recorded and documented on admission".
Interview with facility staff #57 on 2/8/12 at 12:30pm in one of the offices revealed "all patients are weighed on admission and weekly if ordered by the physician". This staff also confirmed that three of the sampled patients' reviewed did not weights checked on admission orders. Further interview with this same staff revealed that the dialysis patient's weight was determined by the physician per information given to her by the dialysis nurse and that the two patients were inpatients.