HospitalInspections.org

Based on staff interviews, review of one (1) of one (1) medical record and a review of facility policy and procedure, it was determined that the facility failed to ensure that all patients are weighed in accordance with the facility's policy and procedure and the physician's order.

Findings include:

Reference: Facility policy titled, "Interdisciplinary Admission Assessment" states, "... Procedure ... The following time frames will be followed for completion of initial assessments: ... Actual weights taken by nursing and documented within 24 hours ..."

1. On 10/21/2021 at 1:15 PM, a review of Patient #1's medical record was conducted with Staff #6 and Staff #7 and the following was revealed:

a. The patient was admitted to the facility on 8/25/2021. At 10:55 PM, the nursing flowsheet indicated that the patient's weight was 141 lb. (pounds). Staff #6 and Staff #7 confirmed that based on the documentation, this was a stated weight by the patient, and not an actual weight.

b. Review of the nursing flowsheets indicated that the first actual patient weight was taken on 8/27/2021 at 5:13 PM. This was not within the 24-hour time frame as specified in the facility policy.

2. On 8/25/2021 at 11:40 PM, a physician order was placed to weigh the patient daily. There was no evidence in the medical record that the patient was weighed on the following dates:
8/28/2021, 8/29/2021, 9/8/2021, 9/10/2021.

a. This was not in accordance with the physician order.

3. The above findings were confirmed on 10/21/2021 by Staff #6 and Staff #7 at the time of discovery.