**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, document review, and interviews, the facility failed to comprehensively assess and implement nutritional interventions for one resident (Resident 59), who lost a total of 39.6 pounds over a period of 28 weeks. The facility failed to follow the weight loss policy and procedure including providing recommended nutritional interventions, having interdisciplinary committee meetings to provide an analysis of identified weight loss, and calculating adequate estimated nutritional needs by the registered dietitian. This failure had the potential to result in unintended weight loss which is strongly correlated with increased morbidity (the condition of suffering from a disease or medical condition) and mortality (death) in the older adult for one resident (Resident 59) out of a facility census of 65. Findings: Review of a Practice Paper published by the American Dietetic Association, dated 2010, indicated In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost.that may trigger sarcopenia [a condition characterized by loss of skeletal muscle mass and function] and functional decline [a loss of independence in self-care capabilities and deterioration in mobility and in activities of daily living]. (American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities, October 2010 Journal of the American Dietetic Association). Involuntary weight loss can lead to muscle wasting depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician) A publication titled Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated the goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight. During a review of the Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines (2007-2009), indicated the Registered Dietitian (RD) should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT). According to international research the prevalence of malnutrition (lack of proper nutrition) is higher in older adults with PI. Decreased intake of calories (a unit of energy), protein, vitamins, and minerals is commonly seen in individuals with malnutrition, which is often associated with undernutrition. This results in unplanned and undesired weight loss, protein-calorie malnutrition, decreased BMI (Body Mass Index, a weight to height ratio), reduced muscle mass, and dehydration, all of which are linked to PIs (Pressure Injuries, injury to skin and underlying tissue resulting from prolonged pressure on the skin. Pressure injuries which are classified as unstageable when the wound is covered by a layer of dead tissue referred to as slough or eschar. Unstageable PIs are a stage 3 or 4 when revealed because slough/eschar does not form on stage 1 and 2 ulcers. The term PI and pressure ulcer are often used interchangeably). Unplanned or involuntary weight loss is considered a major risk factor for both malnutrition and PI development. The EPUAP (European Pressure Ulcer Advisory Panel)/NPIAP (National Pressure Injury Advisory Panel)/PPPIA CPG (Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guidelines) recommendation is to provide 30-35 kcal per kg (kilocalorie and kilogram - metric units of measure) of body weight per day for adults with PI who are malnourished or at risk for malnutrition. The recommendation for protein is 1.25 to 1.5 g (gram a metric unit of weight) per kg or body weight per day (Munoz N, Posthauer M E, Cereda E, Schols J, Haesler E. (2020). The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations. Advances in Skin and Wound Care Journal, March 2020, 123-136.) The Centers for Medicare-Medicaid Services, State Operations Manual (SOM) revised 2/3/23 provides these parameters for significant/severe weight loss: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% Review of facility the Policy and Procedure titled Weight Assessment and Intervention dated 2001 and revised March 2022, showed residents weights are monitored for undesirable or unintended weight loss. Residents are weighed at intervals established by the interdisciplinary team (IDT) and recorded in the individual's medical record. If the weight change is desirable, this is documented. For the evaluation, undesirable weight change is evaluated by the treatment team to assess if the criteria for significant weight change is met. This evaluation includes: an evaluation of the resident's target weight range, and evaluation of the resident's calorie, protein, and other nutrient needs which are compared with the resident's current intake, an evaluation of the relationship between the resident's current medical condition and recent weight change, and an evaluation of whether and to what extent weight stabilization or improvement can be anticipated. The evaluation also includes the physician and IDT to identify conditions and medications that may be causing weight loss or increasing the risk of weight loss. Review of the facility protocol titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol dated 2001 and revised September 2017, showed staff will report to the physician significant weight gains or losses. Review of the facility Policy and Procedure titled Nutrition Assessment dated 2001 and revised October 2017, showed the dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. The nutrition assessment will be conducted by IDT and shall identify things including but not limited to, usual body weight, fluid and nutrient loss that may increase nutritional requirements. The dietitian is to complete an estimate of calorie, protein, nutrient and fluid needs, whether the resident's current intake is adequate to meet his/her nutritional needs. Review of the facility policy and procedure titled Food and Nutrition Services dated 2001, showed each resident is provided with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs. The multidisciplinary team staff, including nursing staff, the attending physician, and the dietitian will assess each resident's nutritional needs. Resident 59 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses including but not limited to unspecified protein-calorie malnutrition, an unstageable pressure ulcer of the left heel, a non-pressure chronic ulcer of the other part of left foot with unspecified severity, and congestive heart failure (CHF, a chronic condition in which the heart does not pump blood as well as it should). admission diet order was a cardiac (low-fat low cholesterol), 2-gram, pureed diet. Review of the Minimum Data Set (MDS) - Version 3.0 Resident Assessment and Care Screening Nursing Home Quarterly (NQ) Item Set dated 2/20/23 and 5/19/23 showed Resident 59 had a BIMS score (Brief Interview for Mental Status, a structured evaluation aimed at evaluating aspects of the cognition in elderly patients. A BIMS of 0-7 indicates severe cognitive impact) of 1 and 4 respectively. The MDS dated [DATE] showed Resident 59 currently had one unstageable pressure ulcer which was present since admission. The MDS dated [DATE] showed Resident 59 currently had state 4 pressure ulcer present since admission. Review of the document titled Weights and Vitals Summary from 11/19/2022 to 6/1/2023 for Resident 59, showed the following: 11/19/2022 165.6 pounds (lbs); 12/3/2022 154 lbs - a decrease of 11.6 lbs or 7% in 2 weeks; 1/3/2023 137.6 lbs - a decrease of an additional 16.4 lbs or 10.6% in one month and a total loss of 28 lbs or 16% in 2 months both of which are considered severe. 2/1/2023 130.4 lbs - a further decrease of 7 lbs or 5% in 1 month; a total loss of 23.6 lbs in 2 months or 15%; a total loss of 35 lbs or 21.5% in 3 months - all of which are considered severe. 5/1/23 129.2 lbs - a decrease of 24.8 lbs or 16% in 5 months which is considered severe. 6/1/23 126 lbs - a decrease of 28 lbs in 6 months or 18%, and overall weight loss of 39 lbs or 23% in 6-1/2 both of which are considered severe. Review of the document titled Nutritional Breakdown dated Spring 2023 and provided by the facility as the nutitional analyisis of the current menu, showed the combination Lowfat/Cholesterol, 2-gram sodium diet provided between 1850-2100 kcals per day. Percentage of intake calculations of the Lowfat/Cholesterol, 2-gram sodium diet show this diet would provide the following kcals on a daily basis: 0%-25% = 0-525 kcals 26%-50% = [PHONE NUMBER] kcals 51%-75% = [PHONE NUMBER] kcals 76%-100% = 1406-2100 kcals The facility's Documentation Survey Report v2 from 11/20/22-3/31/23 for Resident 59 were reviewed. Calculation of the facility's documented meal intakes show: The average meal intake for 30 documented meals (one refusal was not included) from 11/20/22-11/30/22 was 18%, this equates to an average daily intake of 333-378 kcals. The average meal intake for 86 documented meals from 12/1/22 -12/31/22 was 15% (this calculation does not include 3 meal refusals), this equates to an average daily intake of 278-315 kcals. The average meal intake for 82 documented meals from 1/1-1/31/23 was 14% this equates to an average daily intake of 259-294 kcals. The average meal intake for 77 documented meals from 2/1/23 - 2/28/23, was 35% which equates to an average daily caloric intake of 648-735 kcals. There was no documentation of meal intake on this form from 3/1/23-3/26/23. The average meal intake for 15 documented meals from 3/27-3/3 was 71%, this equates to an average daily intake of 1314-1491 kcals. A Nutrition admission Note completed by Registered Dietitian (RD) 3 on 12/6/22 (2-1/2 weeks after admission) showed Resident 59 was on a low fat, low cholesterol, 2-gram sodium, pureed diet. RD3 noted current body weight as 154 lbs and admission weight as 165.6 lbs. She showed this was an 11.6 lb weight loss which was a 7% decrease since admission. RD3 documented there was an unstageable pressure injury at left heel and wounds present since admission. RD 3 estimated Resident 59's energy needs as 1400 - 1750 kcal (kilocalories). Additionally, RD3 noted Resident 59's meal intake was documented as 0-75% (the time frame was not included in the note). RD3 noted the weight loss was likely due to poor intake, Lasix (a medication that can reduce fluid retention which is known as a diuretic), and wounds. RD3 recommend Sugar Free Health Shake three times a day (TID) and Pro-Stat (a protein supplement) 30 ml twice a day (BID) for weight stabilization and wound healing (In an interview on 6/9/23 at 2:14 p.m., DSD stated no nutrition supplements except for Pros-tat/Proheal (a protein supplement) were ordered for Resident 59 while Resident 59 was at the facility.) The Nutrition admission Noted written by RD3 on 12/6/22 shows she did not use current standard recommendations for calculating estimated energy needs and protein needs for wound healing. RD3 showed she used 20-25 kcals/kg (kilogram) for energy needs and 1.0 - 1.2 gm/kg for protein needs in her Nutrition admission Note dated 12/26/22. Using the current recommended standards of 30-35 kcals/kg (energy needs for PI), Resident 59's energy needs are estimated as 2100-2450 kcals per day. A calculation of Resident 59's documented meal intake using the facility's Documentation Survey Report v2 from 11/20/22-12/5/22 includes 42 documented meals (did not include 2 refusals) and reveals Resident 59's had an average intake was 15% which equates to an intake of 278-315 kcals per day. The Pro-Stat adds an additional 200 calories per day. The calculation of estimated needs using the current recommended standard energy needs (30-35 kcals/kg/day for PI), compared to Resident 59's calculated estimated intake shows Resident 59's intake was significantly less than estimated needs. In addition, the comparison of RD3's estimation of needs for resident 59 (calculated in her 12/26/22 Nutrition admission Note as 1400-1750 kcals/kg/day), also shows Resident 59's intake was significantly less than the needs calculated by RD3. A follow up RD progress note titled Weight Change Note dated 2/3/2023 (2 months after the last RD note tiled Nutrition admission Note dated 12/6/22), completed by RD2 showed Resident 59 was on a low-fat low cholesterol, 2-gram sodium, pureed diet. RD2 documented resident 59 was not receiving supplements at this time. The assessment showed Resident 59 had a significant weight loss. RD2 failed to recognize the weight loss since admission as severe and noted Resident 59 had significant weight loss related to poor intake. RD2 maintained Resident 59's energy needs as 1400-1750 using 20 -25 kcal/kg/day. RD 2 recommended health shakes TID, (In an interview on 6/9/23 at 2:14 p.m., DSD stated no nutrition supplements except for Pros-tat/Proheal were ordered for Resident 59 while the Resident was at the facility). RD2 also recommended a swallow evaluation and one to one feeding assistance. There were no other nutrition interventions to support increased caloric intake. A follow up RD progress note titled RD note re: need RD eval dated 2/17/2023 completed by RD2 showed resident current intake by mouth is about 68% average in the past week. RD2 recommended to add a health shake (sugar free) TID with meals for weight maintenance and to prevent further weight loss. A calculation of Resident 59's documented meal intake using the facility's Documentation Survey Report v2 from 2/10/23-2/16/23 (the 7 days prior to RD2's note on 2/17/23) includes 18 documented meals and reveals Resident 59 had an average intake of 42% which equates to an intake of 777-882 kcals per day. An average intake of 68% (which RD2 showed for Resident 59 in her note on 2/17/23), equates to an intake of 1258-1428 kcals per day. A calorie intake of 1258-1428 barely meets the low end of RD3's estimated needs for Resident 59 of 1400-1750 kcals per day based on 20-25 kcal/kg/day (from RD2's note on 2/3/23). There was no follow up or assessment by an RD until 5/26/23 (over 3 months after the last RD note). Review of the Nutritional Risk Review (Quarterly) dated 5/26/23 and signed by RD1, showed Resident 59 was on a low-fat low cholesterol, 2-gram sodium diet, soft and bite size texture. The document also showed, Resident 59 was not receiving nutritional supplements/nourishment. RD 1 showed the percent meal intake was 75-100% (no time frame indicated). RD1 documented Resident 59 had a Stage 4 pressure injury on the left heel. RD1 documented Resident 59 had increased nutrition needs related to wound healing and had significant weight loss of 24.8 lbs in six months. Caloric interventions recommended by RD1 included diet liberalization and adding health shakes TID. There was no documentation of estimated nutritional needs. Resident 59's Nutrition Care Plan initiated on 12/1/2022 and last updated on 5/26/23 showed two significant rather than severe, weight losses of 16.1% on 5/1 and 20.3% on 4/1. Also mentioned was a Stage 4 pressure injury on left heel and significant weight loss. The Interventions which supported increased caloric intake included Recommend adding health shakes TID which was added to the care plant on 5/26/23. Review of the Order Summary Report dated 6/9/23, showed a physician order for Soft and Bite Sized texture, No added salt diet was ordered for Resident 59 on 6/6/23. A dining observation and interview with Certified Nursing Aide (CNA) 2 on 6/8/23 at 12:03 p.m., showed a lunch tray was delivered to Resident 59 in her room. The tray tag showed Resident 59 was on a Soft and Bite-Sized NAS (no added salt) diet. According to the menu, gravy was missing on the rice, there was no pureed bread with margarine, and no milk. CNA 2 stated resident 59 ate solid foods okay and really liked her fluids. Resident 59 sat upright in bed and fed herself. She consumed 100% of the fluids on her tray and approximately 80% of her solid food. The menu spreadsheet titled Noon Meal Therapeutic Spreadsheets dated Week 2 Thursday Cycle 2 2023, showed a soft bite-sized diet included but not limited to rice with gravy, pureed bread with margarine, and 8 ounces of whole milk. In an interview on 6/8/23 at 10:44 AM, Registered Nurse (RN) 1 indicated RD recommendations were placed in a binder for nursing staff to act upon. In a phone interview on 6/8/23 at 3:25 p.m., RD 1 said if milk or a comparable substitute was not provided on a regular basis, then residents would not receive enough protein or calories according to the planned menu. RD1 stated she typed recommendations and handed a copy to nursing staff. She said these typed recommendations went into a binder kept by nursing staff. RD1 stated nursing staff called the Medical Doctor to approve or not approve a recommendation. In an interview on 6/9/23 at 9:02 a.m., RD1 stated she was aware that Resident 59 was losing weight and had a recent significant weight loss over three months RD 1 stated she wanted to focus on Resident 59's wound before addressing the weight loss. RD 1 stated she did not use severe weight loss parameters and still documented significant weight loss even if the weight loss was severe. She said she was aware Resident 59 was not receiving health shakes and would check her next monthly weight before recommending a supplement to address the Resident's weight loss. RD1 stated she did not calculate Resident 59's calorie or protein needs on her quarterly assessment because calculating needs for a quarterly assessment was not required. RD1 stated Resident 59 should have been weighed weekly. RD1 confirmed it was not appropriate for Resident 59 to only be weighed one time per month when Resident 59 exhibited continual weight losses. RD1 confirmed Resident 59 was continuing to lose weight and stated, but not as much. When RD 1 was asked if weight loss was beneficial when a wound was healing, RD 1 stated no. In an interview on 6/9/23 at 9:02 a.m., RD1 stated she did not talk to the resident's doctor about weight loss for Resident 59. RD1 said she was responsible for the nutrition care plan for the residents at the facility. She stated there was not a care plan for planned weight loss for Resident 59. RD1 stated when assessing resident weight loss, she assessed if the resident met nutritional needs. She stated interventions included therapeutic diets and additional snacks. She stated if the snacks she recommended did not help, then she changed the intervention. RD1 said she should have recommended weekly weights to assess Resident 59's weight on June 6, 2023. RD1 stated IDT meetings were conducted every Tuesday and the team included herself and the Assistant Director of Nursing (ADON). She said in the meetings she talked about resident weight loss and her recommendations. RD1 stated there was not an IDT meeting done for Resident 59. Review of the undated, untitled document RD1 provided as a reference to show estimated nutritional needs for a variety of medical diagnoses, showed for pressure ulcers at stages 2-5, the estimated energy needs were 30-35 kcals/kg/day. In an interview on 6/9/23 at 12:07 p.m., Licensed Vocational Nurse 6 (LVN 6) stated she started treating Resident 59's Stage 4 pressure ulcer wound about 2 months ago LVN 6 stated she has not seen any signs of edema or fluid retention. In an interview on 6/9/23 at 12:58 p.m., the Director of Staff Development (DSD) stated she was also the acting Assistant Director of Nursing (ADON) since there was not a current ADON or DON (Director of Nursing). She stated when a resident had a significant weight loss, the weight assessment and intervention policy should be followed. She stated this included notification to the physician and family member, and a meeting with IDT to come up with a plan of treatment to promote weight stabilization or weight gain. In a phone interview on 6/9/23 at 1:50 p.m., Nurse Practitioner 1 (NP1) stated she was familiar with Resident 59. She stated Resident 59 was ordered diuretics for CHF. She stated Resident 59's CHF was stable and did not see any problems. NP1 stated there would be initial fluid loss with a diuretic, however she would not expect to see continuous severe weight loss over months. She stated weight stabilization and wound healing was desired. NP1 stated the resident needed enough protein and calories to heal the wound and stabilize weight. She stated with severe weight loss, the resident would benefit from calorie supplements. In an interview on 6/9/23 at 2:14 p.m., the DSD stated the weight assessment and intervention policy would be followed if a resident had a severe weight loss. She stated this would require a nutritional assessment by the RD to calculate the resident's nutritional needs. DSD stated no nutrition supplements except for Pros-tat/Proheal were ordered for Resident 59 while Resident 59 was at the facility. The DSD also said the physician and family were not notified for Resident 59's severe weight loss and there were no documentation of IDT meetings for Resident 59 while the resident was at the facility.