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Based on medical record review and interview, facility staff failed to weigh PI (Patient Identifier) # 1, a patient identified at risk for weight loss on admission, daily as ordered by the physician. This affected one of ten sampled patients and had the potential to affect all patients served by the facility.

Findings include:

PI # 1 was admitted on 9/18/15 with diagnoses to include: Self-care mobility deficits after a large MCA (Middle Cerebral Artery) Stroke in an elderly male patient with a pre-existing stroke and Speech and Swallowing Deficits.

Physician's Orders:
9/18/15: Mechanical soft heart healthy diet with honey thick liquids.
9/22/15: Daily weights using a standing scale please and record.

Weights:
9/18/15: 140.5 pounds
9/22/15: 135.9 pounds
9/25/15: 128.1 pounds
9/29/15: 122.4 pounds
10/2/15: 125.3 pounds
10/6/15: 128.7 pounds
10/9/15: 126 pounds

During an interview on 2/11/16 at 10:00 AM with Employee Identifier (EI # 1), the CNO (Chief Nursing Officer) stated patients are weighed weekly unless otherwise ordered by the physician. The CNO confirmed PI # 1 was not weighed daily as ordered by the physician on 9/22/15.

As a result of the failure of staff to follow the physician's order and weigh PI # 1 daily, staff was unaware of PI # 1's weight loss of 9.9 pounds over 17 days.