**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement an effective process to ensure the maintenance of acceptable parameters of nutritional status and hydration for one of three sampled residents (Residents 1) when staff did not weigh Resident 1 weekly in accordance with facility policy and procedure, the recommendations and instructions provided by the Registered Dietician (RD) after identifying a risk for weight loss during the admission assessment, and again after weight loss had occurred, were not implemented by nursing staff. Staff did not notify the physician of Resident 1's decreased intake of food and fluids and weight loss until Resident 1 had experienced severe weight loss and was dehydrated. Staff did not consistently provide Resident 1 with assistance with eating and drinking. Resident 1 was on a Controlled Carbohydrate diet (CCHO- a diet ordered for diabetics) from 6/17/22 to 7/7/22 and did not have a diagnosis of diabetes. These failures resulted in Resident 1 experiencing an avoidable severe weight loss of 24% from an admission weight of 146.7 pounds (lbs.) on 6/17/22 to 111.2 lbs. on 6/28/22, contributed to dehydration and the development of two pressure-induced Deep Tissue Injuries (DTI) and a decline in health. Resident 1 was transferred to the hospital Emergency Department (ED) on 7/3/22 when Resident 1 became difficult to arouse and again on 7/9/22 due respiratory distress and was admitted to the hospital. Resident 1 was discharged from the hospital to hospice on 7/12/22 where he expired on 7/14/22. Findings: During a review Resident 1 ' s medical record, the document titled, admission Record (AR) dated 6/17/22, indicated, Resident 1 was admitted on [DATE] from an acute care hospital (Hospital A) following hip replacement surgery. The AR indicated Resident 1 was a [AGE] year old male with diagnoses of muscle weakness, difficulty walking, retention of urine after surgery, placement of a indwelling urinary catheter, facial weakness, and a history of chronic kidney disease, hearing loss, unspecified dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function) without behavioral disturbance, enlargement of prostate without urinary tract symptoms, presence of a cardiac pacemaker (a small electronic device, implanted in the chest to help the heart beat at a normal rate and rhythm), and prior cardiac surgery. The AR indicated Resident 1 had been discharged from the facility to an acute care hospital (Hospital B) on 7/9/22. During an interview on 2/16/23 at 10:10 a.m., with a close friend (CF) of Resident 1, CF stated she had been close friends with Resident 1 for 20 years, saw him frequently before his fall and surgery, and visited him several times while he was at the facility. CF stated Resident 1 had stooped posture and had difficulty sitting up enough to be able to feed or hydrate himself. CF stated Resident 1 was weak and unable to reach and pick up a glass of water and bring it to his mouth to drink. CF stated when she visited Resident 1 on more than one occasion there was a cup of water with a straw, a carton of milk or juice with a straw in it on the bedside table but Resident 1 could not drink from them unless someone was there to pick up the drink and put the straw up to his mouth. CF stated she was very concerned Resident 1 would become dehydrated. CF stated Resident 1 lost so much weight while at the facility he was just skin and bones. During a review of Resident 1 ' s admission orders, dated 6/17/2022, the orders indicated Resident 1 had the ability to make his own decisions and wanted Cardiopulmonary Resuscitation (CPR- a lifesaving procedure performed when the heart stops beating) performed if needed. The record included orders for physical therapy and an order for a CCHO mechanical soft diet with thin liquids. During a review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool used to identify resident cognitive and physical function), dated 6/23/22, the MDS assessment indicated Resident 1 ' s Brief Interview for Mental Status (BIMS, an assessment used to identify a resident ' s current cognition) score was 7 out of 15, which indicated at the time of the assessment Resident 1 had severe cognitive impairment. The MDS also indicated Resident 1 required one-person physical assist with Eating/Drinking, and two or more-person physical assist with Bed Mobility (how resident moves to and from lying position, or turns side to side, and positions self in bed). During an interview on 7/29/2022 at 3 p.m. with the Director of Nurses (DON), the DON stated Resident 1 was no longer a resident at the facility. The DON stated Resident 1 was sent from the facility to the hospital (Hospital B) on 7/9/22 and did not return to the facility. The DON stated she was aware that Resident 1 had passed away several days after he was sent to Hospital B. During an interview on 7/29/2022 at 3:15 p.m. with the Social Services Assistant (SSA), the SSA stated she met with Resident 1 shortly after he was admitted , and Resident 1 was alert, aware of his name and where he was, and did not seem confused. The SSA stated Resident 1 was independent prior to having hip surgery and lived at home with his girlfriend and her caregiver. The SSA stated Resident 1 ' s goal was to be discharged back to his home. During a review of Resident 1 ' s admission Nutrition Assessment, dated 6/20/22 at 4:43 p.m., the assessment completed by RD 2 indicated Resident 1 was 5 feet 10 inches tall and weighed 146.7 pounds on admission to the facility with a Body Mass Index (BMI - measure of body fat based on height and weight. A normal BMI is 18.5 to 24.9) of 21. RD 2 indicated Resident 1 ' s usual weight was unknown, and his ideal body weight was 166 lbs. RD 2 ' s assessment indicated Resident 1 was alert and was not confused. RD 2 indicated Resident 1's estimated daily calorie requirements were between 1340 and 1675 kilocalories (kcals- a unit of measurement, used interchangeably with calories) estimated daily protein requirements were between 54 and 67 grams (gms- a unit of measurement), and estimated daily fluid requirements were between 1340 and 1675 milliliters (mls- a unit of measurement). RD 2 indicated Resident 1's current CCHO diet provided 1961 calories and 93 gms of protein per day. RD 2 reviewed the three days of oral intake since admission and noted Resident 1 consumed approximately 36% of his meals (706 calories and 33 gms of protein per day) which met 53% of Resident 1 ' s estimated nutritional needs. RD 2's assessment indicated Resident 1 was at risk for weight loss and required a therapeutic diet. RD 2 ' s recommendations included a fortified diet (addition of protein, fat, and/or carbohydrate to foods), nutritional supplement shakes twice a day, weekly weights, monitor oral intake and skin. During a review of Resident 1's report of meal percentage (%) consumed, the report showed the % eaten by Resident 1 for each meal (breakfast, lunch, and dinner) during his stay at the facility from 6/17/22 through 7/9/22. Of the 65 meals scheduled, three meals were not served due to Resident 1 being away from the facility or fasting for lab work. The report showed for 45 of the 62 meals (72.5%) served, Resident 1 ate 50% or less of the meal. The report showed Resident 1 ate 75% or more for eight of the meals served (13%) and refused six meals (9.6%). The report indicated there was no documentation of how much Resident 1 ate for three of the meals (4.8%). During a review of the Interdisciplinary Care Conference (meeting with staff from different disciplines involved in the resident's care) Summary dated 6/30/22, the Dietary section completed on 6/28/22 by the Dietary Manager indicated, .Percentage of Meal Consumption 38% and fluid intake of 631 mls per day [estimated daily fluid requirement- 1340-1675 mls]. Last recorded weight of 111.2 lbs. on 6/28/2022. Weight loss of 35.5 lbs./24.2% since admission weight on 6/17/2022. admission weight suspected to be inaccurate. Dietary Goal: Continue to tolerate current diet per MD [medical doctor] orders with increased PO (oral) meal and fluid intake and no significant weight changes . During a review of Resident 1 ' s Dietician Note, dated 6/29/22 at 10:52 a.m., the note written by RD 2 indicated Resident 1 had significant weight loss of 35.5 lbs. in two weeks. RD 2 ' s note indicated Resident 1's current daily diet provided 2214 kcal (calories) with 97 gms protein, and Resident 1 consumed approximately 37% of meals (819 calories, 36 gms protein) and approximately 689 ml of fluid per day for the past seven days [approximately 51% of estimated daily fluid need of 1340-1675mls per day]. The note indicated, .RD [RD 2] recommended to fortify diet and provide [nutritional supplement shakes] twice a day upon admission assessment, recommendations not yet carried out. Weight loss r/t [related to] inadequate intake of nutrient needs, 54% of estimated kcal needs met via diet .Malnutrition r/t inadequate intake of meals AEB [as evidenced by] underweight BMI 16, significant weight loss 24.4%/35 lbs. x 2 weeks. Fortify diet, shakes with lunch and dinner, MD- add malnutrition as diagnosis. During a concurrent interview and record review on 12/30/22 at 9:35 a.m. with the Registered Dietician (RD 1), RD 1 stated she did not take care of Resident 1, but she had reviewed the record. RD 1 stated weights are supposed to be done on admission and once a week for the first four weeks and then at least once a month unless they need to be done more frequently. Review of Resident 1 ' s Weight and Vitals Summary indicated: 6/17/22 146.7 lbs. (pounds) 6/26/22 106.9 lbs. 6/28/22 111.2 lbs. RD 1 stated she did not know why Resident 1 was not weighed again after 6/28/22 given there was such a significant change. RD 1 stated it may be that the nursing staff thought things were improving when the weight was 111.2 lbs. on 6/28/22. RD 1 stated 106.9 lbs. is quite a drop. RD 1 stated if someone gets a weight which seems wrong, they should re-weigh the resident to make sure they are getting an accurate weight. RD 1 stated the staff can contact the RD if they have a concern about weight loss and should also notify the physician. During a concurrent interview and record review on 12/30/22 at 12:30 p.m. with the Director of Nurses (DON), Resident 1's weight summary record was reviewed. The DON confirmed the weight summary indicated Resident 1 had experienced a weight loss of 35.5 lbs. from admission on [DATE] to 6/28/22 and that no more weights were obtained after 6/28/22. The DON stated she does not know why Resident 1 was not weighed again after 6/28/22 since weights were supposed to be done weekly The DON stated she thought the resident had refused to be weighed but could not remember specifically when Resident 1 refused. The DON stated the record indicated staff did not document any unsuccessful attempts to weigh Resident 1 or any occasions when Resident 1 refused to be weighed. The DON also stated there was no documentation in Resident 1 ' s medical record indicating the physician was notified about a refusal, if it had occurred. The DON stated if there is a question about a weight being correct, it should be rechecked. During a review of Resident 1's record, the intake record from 6/18/22 through 7/8/22 was reviewed. The record indicated the date, time, and amount of oral fluid intake, and the total amount for each day which included the amount of fluid served with the meal trays. The record indicated Resident 1's daily oral fluid intake between 6/18/22 and 7/8/2022 ranged from 240 ml (one cup) to 1090 ml per day. The record indicated the majority of the time (13 of 20 days [6/17/22 and 7/3/22 excluded]), Resident 1's fluid intake was 720 ml or less per day. The record indicated there were no days that Resident 1's fluid intake met the estimated daily fluid requirement of between 1340 ml and 1675 ml per day. During a concurrent interview and record review on 12/30/22 at 12:40 p.m. with the Director of Nurses (DON), Resident 1 ' s fluid intake records were reviewed. The DON stated Resident 1 refused fluids frequently. Review of the record of fluid intake from admission on [DATE] until 7/9/22, indicated out of the 119 times Resident 1 was offered fluids, the record indicated he refused six times. The DON stated the staff need to document any time the resident refuses. A review of the care plan dated 6/17/22 through 7/9/22 did not indicate refusal of food and fluids had been identified as a problem. During an interview on 12/30/22 at 1 pm with the Director of Staff Development (DSD), the DSD stated in order to ensure weights are accurate and not missed, there needs to be a consistent process. The weights need to be done in the same way, on the same day of the week, and by the same core group of certified nursing assistant (CNA) staff. The DSD stated they used to do it this way but that stopped this last year when they did not have enough staff to dedicate to that task which meant each CNA was responsible for doing the weights of the residents on their assigned team. The DSD stated this method of taking weights led to missed weights, inaccurate weights, and the need to reweigh residents. The DSD stated all of the staff were trained before, it is just that some staff are better than others at weighing residents. The DSD stated the facility just restarted the process that week (the last week of December 2022) of having a core group of CNAs doing the weights on a designated day of the week. The DSD stated this process was not in place when Resident 1 was at the facility (6/17/22- 7/9/22). During a concurrent interview and record review on 12/30/22 at 2 p.m. with the DON, a report of the documented level of eating/drinking support provided by staff for breakfast, lunch, and dinner was reviewed. The DON stated staff assisted Resident 1 with eating and drinking. The report indicated from 6/17/22 to 7/9/22 set up help only was provided with eating and drinking for 31 of 62 meals served (50%) meals, one-person physical assist was provided for 24 meals (38.7%), and the level of assistance provided was not documented for seven meals (11.3%) Review of the Care Plan dated 6/21/22, indicated a Focus of Risk for Weight Fluctuations however, the only interventions were to provide supplements as ordered and to weigh resident weekly and did not include providing staff assistance with eating and drinking. During a review of Resident 1 ' s Skin/Wound Note, dated 7/2/22 at 8:33 p.m., the note indicated Resident 1 had developed deep tissue injuries (DTI) on both of his heels, the left one measuring four centimeters by four centimeters in size, and the right one measuring six centimeters by six centimeters in size. During a review of Resident 1 ' s record, the Physical Therapy notes dated 7/3/22 at 9:48 a.m., indicated, Resident 1 experienced a syncopal episode (passed out) while sitting in his wheelchair and was unresponsive for 1-2 minutes. During a review of the Physician's Assistant's (PA - a licensed health care professional trained to provide medical care under physician supervision) progress note dated 7/3/22, untimed, the progress note indicated, . Staff reporting decreased oral intake. BMI 16, weight 111.2 lbs. [6/28/22], height 70 inches .oral mucosa dry .Foley [urinary catheter] cloudy .discussed with Dr. [name of MD] .Plan: Lab- Complete Blood Count [CBC- test to evaluate the different types of blood cells and can be used to help diagnose health conditions such as anemia and infection], basic metabolic panel [BMP s a blood test that includes eight different measurements and may be used to evaluate kidney function, fluid and electrolyte balance, blood sugar, and acid-base balance], clamp foley for urinalysis [UA] and urine culture and sensitivity [C&S- a test to identify what bacteria is present in the urine and which antibiotics will be most effective in treating the infection] . Start Intravenous line [IV-into a vein)] D5NS [IV fluid containing dextrose and sodium chloride] infuse at 100 ml/hour .Intake and Output [I&O]- Record hourly urine output . During a review of Resident 1 ' s record, the SBAR (Situation, Background, Assessment, and Recommendation-a communication tool used by staff for assessing and recording change in resident status) note dated 7/3/22 at 4:42 p.m., indicated, .At 3:40 p.m . noticed a change in condition in pt [patient] from prior days. Pt had been sleeping throughout the day and hard to arouse awake and was drinking and eating very little .This is new as previous days pt would be awake and able to answer questions .PA to send pt to ER . The record indicated Resident 1 was sent to the Emergency Department (ED) at Hospital B at 4:02 p.m. During of review Hospital B ' s ED physician ' s note dated 7/3/22 at 4:27 p.m., the note indicated Resident 1 was brought to ED by ambulance due to staff concern that Resident 1 has not been eating and does not want to get out of bed and is not at his baseline mentation. The note indicated Resident 1 was at baseline with no neuro deficits (abnormal function caused by injury to the brain, spinal cord, nerves), was alert and oriented and had no complaints except being tired. Lab work including blood cultures, imaging, and an electrocardiogram were done. A urinalysis was ordered but not done. ED MD indicated Resident 1 was dehydrated and IV fluids were given. The note indicated at 7:07 p.m. Resident 1 was feeling better and the ED MD gave a discharge order and diagnoses of dehydration, acute renal failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), and generalized weakness. Resident 1 was transferred back to the facility at approximately 10:30 p.m. During a interview on 12/30/22 at 2:10 p.m. with the DON, the DON was asked if a urinalysis (UA) was obtained by the facility per the PA ' s note on 7/3/22. The DON stated no UA was done at the facility; once the resident goes to the ED, that negates any orders given by the PA. The DON stated she was not sure if the hospital did a UA. During a review of the Nursing Progress Note, dated 7/6/22 at 9:52 a.m., the progress note indicated Resident 1 tested positive for COVID-19. During a review of Resident 1 ' s Dietician Note, dated 7/7/22 at 6 p.m., the note written by RD 3 indicated Resident 1 was on a CCHO diet. The note indicated Resident 1 had developed pressure induced DTI and had a recent ED visit because of a change in condition. Average intake for the last six days of approximately 31% of meals (686 calories, 30 gms protein per day) with a fluid intake of 658 ml per day (approximately 44% of estimated daily fluid requirements of 1500-1750 mls). RD 3 noted Resident 1 did not have a diagnosis of diabetes and recommended liberalizing the diet, discontinuing the CCHO diet and starting him on a regular fortified diet, nutritional supplement shakes, and adding a concentrated form of liquid protein to promote wound healing and meet Resident 1 ' s estimated needs. During a review of the document Clinical Physician Orders, dated 1/6/23, the document indicated on 7/7/22 the CCHO mechanical soft diet was discontinued, and a Fortified Regular mechanical soft diet was ordered. During a review of Resident 1 ' s Dietician Note, dated 7/8/22 at 11:58 a.m., the note written by RD 2 indicated Resident 1 was being seen due to a change in condition and that Resident 1 had not been weighed since 6/28/22. The note indicated Malnutrition r/t inadequate nutrient intake AEB [as evidenced by] significant weight loss, emergence of DTI to bilateral heels . The note indicated the recommendation to add malnutrition to diagnosis [BMI 16], provide assistance with oral intake as needed .monitor weight, skin, PO [oral] intake . During a concurrent interview and record review at 1/5/23 at 10:57 a.m. with the DON and the Administrator (ADM), Resident 1 ' s Nutrition Assessments were reviewed. The DON indicated when the RD has completed her note and recommendations, an email goes out to the DON, the ADON, the MDS Coordinator, and the dietary manager so everyone knows. The DON stated the MDS coordinator then faxes the recommendations to the physician who is supposed to review the recommendations and send back orders. The DON and ADM agree the orders and the Medication Administration Record (MAR) from 6/17/22 through 7/6/22 did not indicate Resident 1 was receiving nutritional supplement shakes, and the RD notes on 6/29/22 and 7/7/22 indicate Resident 1 was not receiving nutritional supplements. However, the ADM stated the dietary list of what is included on the meal tray indicated Resident 1 was receiving shakes twice a day beginning on 6/21/22. The DON stated they have standing orders for supplements so as soon as the RD writes her notes the dietary manager gets alerted so the supplement can get added to the meal tray. Unfortunately, for some reason the supplements didn ' t get added to the orders, so they were not part of the medical record. The ADM stated they need to communicate better, and a consistent process has to be followed. The ADM stated the addition of supplements needs to get onto the orders, not just onto the meal tray list so that information is available for the dieticians and others to review. As far as the fortified diet, the DON stated she does not know why the RD ' s recommendation on 6/20/22 and 6/29/22 for a fortified diet was not implemented until 7/7/22 or why Malnutrition was never added as a diagnosis as the RD recommended on 6/29/22 and 7/8/22. During a concurrent interview and record review on 2/16/23 at 11:55 a.m. with RD 2, the Dietician Note dated 6/20/22 and 6/29/22 were reviewed. RD 2 stated when she documents her nutrition assessment and recommendations, the recommendations are sent to nursing to carry out and to send to the doctor for orders. RD 2 stated it is her expectation that the nursing staff implement the recommendations of the RD. RD 2 stated if she sees that a recommendation was not implemented, she follows up by notifying the DON. RD 2 stated in this case, on 6/29/22 when she checked on Resident 1 for the second time, she noticed the recommendations from 6/20/22 were not carried out and notified the DON. As far as the weights, RD 2 stated she does not know why staff did not weigh Resident 1 again after 6/28/22. RD 2 was asked why Resident 1 was on a CCHO diet from admission on [DATE] until the diet was changed by RD 3 on 7/7/22 since Resident 1 did not have a diagnosis of diabetes. RD 2 stated she was not sure but stated usually a resident will be put on whatever they were on at the hospital. RD 2 was asked what the benefit of continuing the CCHO diet was for Resident 1 who had poor intake and significant weight loss. RD 2 stated, Good question. During a concurrent interview and record review on 2/16/23 at 12:35 p.m. with the DON and the ADM, the DON was asked when the nursing staff first notified the MD or a PA about Resident 1's ongoing inadequate oral intake of food and fluid and severe weight loss. The DON stated she wasn't sure and needed to review the record. The DON reviewed the nurses ' notes for Resident 1 from 6/17/22 through 7/9/22 and stated the nursing staff notified the PA on 7/3/22, when Resident 1 was sent to the ED. The DON confirmed there were no nurses' notes other than on 7/3/22 indicating the MD or PA were notified about weight loss, or poor oral intake of food or fluids. The DON was asked under what circumstances would she notify the MD or PA about a resident's ongoing inadequate oral intake of fluids over a period of a week or more. The DON stated if a resident did not drink anything for a day, she would notify the physician. During an interview on 2/17/23 at 10:40 a.m. with CNA 1, CNA 1 stated she does not recall Resident 1 specifically but stated she had worked with residents who did not want to eat or drink much. CNA 1 stated she cannot recall ever being told a resident was dehydrated or that there was a certain amount of fluid the resident should be drinking. CNA 1 stated if a resident is not eating or drinking very much or is refusing to eat or drink, CNA 1 would always inform the nurse. During an interview on 2/17/23 at 11:25 a.m. with CNA 2, CNA 2 stated he recalled taking care of Resident 1 on several days during Resident 1 ' s stay. CNA 2 was asked what set up only and one-person physical assist meant in terms of CNA support provided to a resident for eating or drinking. CNA 2 stated set up only means the meal tray is placed on the table within reach of the resident and the lid removed. CNA 2 stated one-person physical assist means the resident needs staff to stay with him to assist him with eating and drinking. CNA 2 stated if a resident is unable to reach for a cup and lift it to his mouth the resident would need to be offered assistance with drinking fluids every two hours. CNA 2 stated Resident 1 required total assistance with eating and drinking. CNA 2 stated he was not told by anyone that Resident 1 required feeding but found out after taking care of him. CNA 2 stated on one of the first days he took care of Resident 1, he set the meal tray and drink on the bed table in front of him and left the room. Later when CNA 2 returned he saw the food and drink was still sitting there untouched. From then on when CNA 2 took care of Resident 1 he stayed with the resident and fed him and helped him to drink fluids. CNA 2 recalled Resident 1 did not want to eat or drink very much and required a lot of encouragement and assistance. CNA 2 stated Resident 1 did not communicate when he was hungry or thirsty and was quiet most of the time. CNA 2 stated he recalled there were times when Resident 1 ate less than 25% of his food. CNA 2 stated he always notifies the nurse if a resident is refusing to eat or drink or does not eat or drink very much. CNA 2 stated he was not told Resident 1 had lost weight or was getting dehydrated and had not been told Resident 1 should try to drink a certain volume of fluid. During an interview on 2/17/23 at 11:50 a.m. with Restorative Nursing Assistant (RNA 1), RNA 1 stated she was recently assigned along with a CNA to do all the residents' weights. RNA 1 stated this process started at the beginning of the year. RNA 1 stated all residents on the short-term unit of the facility get weighed every Sunday. Residents on the long-term unit are weighed at least once a month, on Sunday during the first week of the month. Weights are done either with a Hoyer lift or a chair scale depending on the ability of the resident. Standing weights are not done. RNA 1 stated she has a list of all the residents and what each resident's weight was the last time they were weighed. After she weighs a resident, she compares that weight to what they weighed the last time and if the weight is five pounds or more over or five pounds or more under what their last weight was then she does not record the weight. RNA 1 stated she notes this on the list and those residents will be reweighed the next day. RNA 1 stated she gives the list with all the residents' weights and the residents that need to be reweighed to the DSD. During a review of Resident 1 ' s record, the SBAR note, dated 7/9/22 at 10:25 a.m., the note indicated Resident 1 ' s oxygen saturation (the amount of oxygen carried by the red blood cells- Normal values are 95-100%) dropped to 80% and he became difficult to arouse. The physician was notified, and Resident 1 was transferred to Hospital B. During a review of Hospital B ' s ED record dated 7/9/22 at 11:15 a.m., the record indicated Resident 1 was brought by ambulance to Hospital B with shortness of breath due to possible aspiration (the accidental breathing in of food or fluid into the lungs) arriving to ED with altered mental status and was hypoxic. COVID+ since 7/6/22. Oxygen saturation of 88% on 15 liters of oxygen. Temperature 38.5 degrees Celsius, respirations 34 breaths per minute, gurgling respirations. Diagnoses included aspiration syndrome, urinary tract infection, sepsis (the body's overwhelming and life-threatening response to infection), pneumonia, acute kidney injury. admitted to ICU. Review of the Discharge summary dated [DATE], indicated Resident 1 was receiving end of life care and was discharged to hospice on 7/12/22. During a review of the facility ' s policy and procedure (P&P) titled Weights, dated 11/24/17, the P&P indicated, .All residents are to be weighed upon admission to the facility. The resident is to be weighed by the CNAs and/or licensed nurse as soon as possible after arrival to the facility .New residents are to be weighed weekly for the first four weeks in the facility . Physician orders should be obtained for residents who require daily weights. Daily weights may be indicated for residents with specific medical conditions that require close monitoring of weight fluctuations. Gross weight gains or losses should trigger an immediate reweighing of the resident to be completed the day after the original weight. Reweighs are to be done on any resident who has a five (5) pound weight difference, whether it is a gain or loss .Weight Variance: Calculate weight loss or gain every time a resident is weighed . Significant weight variances [5% or more in 30 days; 10% or more in 180 days] are to be reported to the Registered Dietitian for review . Dietitian or designee is to review weight changes and discuss recommended interventions with the resident and/or their authorized representative. Recommendations and discussions are to be documented in the resident's medical record .The physician is to be notified of significant weight changes by the licensed nurse. All dietitian recommendations are to be communicated to the physician and orders carried out as indicated . The resident's care plan is to be updated with recommendations made by the dietitian and IDT [Interdisciplinary Team- a healthcare approach that integrates multiple disciplines through collaboration] upon review. Residents should be weighed by the same type of scales on a consistent basis, when possible. The type of scale used should be documented and considered when a significant weight variance is found . During a review of a professional reference, retrieved from https://www.aafp.org/dam/brand/aafp/pubs/afp/issues/2002/0215/p640.pdf titled, Evaluating and treating unintentional weight loss in the elderly, dated 2/15/02, the reference indicated, . Elderly patients with unintentional weight loss are at higher risk for infection, depression and death .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 .One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death . Another study showed institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within a year . During a review of a professional reference titled, Prognostic Significance of Monthly Weight Fluctuations Among Older Nursing Home Residents, dated 6/01/04, the reference indicated, .a weight loss of =10% in any 3-month interval was associated with an 8-fold increased risk for death after controlling for age and other health status variables .A 1-month weight loss of 5% or more was a powerful predictor of death . During a review of the professional reference Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidel[TRUNCATED]