**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach, to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status, when: 1. The facility failed to ensure a Registered Dietitian (RD) evaluated or reassessed Resident 31's nutritional status timely, in order to recommend nutritional interventions, after an unplanned severe and continuous weight loss of 23.9% (percent) over eight months. The facility failed to intervene timely when Resident 31's weight loss began despite documented meetings acknowledging weight loss. There was no evidence demonstrating recommended interventions were implemented from 2/21 to 7/21. The was no plan of care to address the weight loss and prevent further weight loss. During the weight loss, Resident 31 also acquired a pressure ulcer to the coccyx. 2. The facility's Registered Dietitian failed to identify an unplanned severe weight loss in a timely manner or to recommend nutritional interventions for Resident 5, during which time the weight loss had continued. Resident 5 had a severe weight loss of 10 pounds (5.1%) in one week and 20 pounds (9.7%) in one month. As a result, the facility's system was not effective at ensuring the Registered Dietitian evaluated unplanned severe weight loss. The facility failed to consistently ensure that nutrition interventions to address identified nutritional concerns were implemented. These failures resulted in Resident 31 experiencing an unplanned severe weight loss of 29 pounds in eight months, which put the resident at risk for further decline in health and for Resident 5 at risk for undesirable weight loss. Findings: During a review of the facility's policy and procedure titled Weight Monitoring dated 12/31/16, indicated in order to monitor nutrition and hydration, height and weight would be obtained. It indicated weight is recorded by the nursing department upon admission, monthly and often if risk is identified. It indicated all weights will be reviewed by the Interdisciplinary team (IDT). The IDT will determine all referrals to other healthcare professionals. It indicated when weight change is significant or severe, the licensed nurse will notify the resident's physician and notify the resident's family member. It indicated the facility will have a Nutrition Risk Committee and this committee should meet regularly to determine possible reasons for weight loss and make recommendations to prevent further unplanned changes. It indicated suggested parameters for evaluating significant of unplanned and undesired weight loss: One month - 5% significant loss, greater than 5% severe loss Three month - 7.5% significant loss, greater than 7.5% severe loss Six months - 10% significant loss, greater than 10% severe loss According to the American Academy of Family Physician journal, indicated Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. (American Family Physician, February 15, 2002/Volume 65, Number 4) According to the American Academy of Family Physician journal, indicated 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. In another study, 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 one year. (February 15, 2002/Volume 65, Number 4 www.aafp.org/afp American Family Physician) According to the 2009 National Pressure Ulcer Advisory Panel [NAME] Paper, indicated Compromised nutritional status such as unintentional weight loss, undernutrition, protein energy malnutrition (PEM), and dehydration deficits are known risk factors for pressure ulcer development. (The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel [NAME] Paper, 2009) 1. During a review of Resident 31's admission Face Sheet, indicated Resident 31 was admitted to the facility on [DATE]. Resident 31's diagnoses included Type 2 Diabetes Mellitus [adult onset diabetes, when the pancreas (a large gland behind the stomach) does not produce enough insulin - a hormone that regulates the movement of sugar into your cells - and cells respond poorly to insulin and take in less sugar], Gastro-esophageal reflux disease (a condition in which acidic gastric fluid flows backward into the esophagus - connects the throat to the stomach, resulting in heartburn), generalized anxiety disorder, major depressive disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), recurrent chronic pain and unspecified dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) without behavioral disturbance to name a few. During a review of Resident 31's Minimum Data Set (MDS), a standardized assessment and care-planning tool, dated 5/28/2021, the MDS indicated Resident 31 had a BIMS (Brief Interview for Mental Status) score of 14 which indicates cognitively (thought process) intact. The MDS indicated Resident 31's Mood regarding poor appetite was present. The MDS indicated Resident 31 was not on a physician-prescribed weight loss regimen. During a review of the physician's orders dated, showed the following: 2/11/20, a regular diet; 2/11/20 Mitazapine (Remeron - medication for depression and may cause weight gain) 15 milligrams (mg) for depression 2/22/20 Remeron 15 mg for appetite 7/15/20 Remeron 7.5 mg until discontinued 7/9/21 6/14/21, a Controlled Carbohydrate Diet (CCHO - a diet for people with diabetes (disorder in which the body does not produce enough or respond normally to insulin [hormone that regulates the amount of glucose in the blood], causing blood sugar (glucose) levels to be abnormally high) to help stabilize blood glucose levels [sugar in the blood]); 6/28/21, an order to admit resident to hospice (providing care for the sick or terminally ill) with terminal diagnosis (disease which can not be cured and likely to dead to death) Alzheimer's disease (progressive mental deterioration, due to generalized degeneration of the brain); 7/8/21, showed a regular diet; and 7/15/21 showed regular diet, puree texture, honey thickened liquids (slightly thicker, less pourable and drizzle from a cup). During a review of Resident 31's weights and vitals summary showed: 10/1/20 - 119 pounds (lbs.) 11/2/20 - 121 lbs. 12/1/20 - 119 lbs. 1/4/21 - 115 lbs. 2/1/21 - 112 lbs. 3/2/21 - 109 lbs. 4/2/21 - 105 lbs. 5/1/21 - 104 lbs. 6/2/21 - 100 lbs. 7/1/21 - 92 lbs. Based on the weight history from 11/20-1/21 it was noted Resident 31 lost 6 pounds (4.9%), while it did not reach the threshold of significant or severe weight loss in accordance with the Weight Monitoring policy it demonstrated a pattern for concern. There was no indication the facility recognized or evaluated this weight loss pattern. Beginning in January 2021 Resident 31 consistently demonstrated significant and severe weight loss, in accordance with the Weight Monitoring policy, through multiple timeframes. A loss of 9 pounds (7.4%) from 11/20-2/1/21, 7.5% is considered significant. A weight loss of 14 pounds (11.76%) from 10/20-4/21 is considered severe. Resident 31 lost a total of Resident 31 lost a total of 29 pounds (23.9%) from 11/20-7/21. According to the Journal of the American Dietetic Association (currently called the Academy of Nutrition and Dietetics), indicated Unintended weight loss is defined as a gradual, unplanned weight loss that may occur slowly over time or have a rapid onset. 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. (Journal of the American Dietetic Association, October 2010/Volume 110, Number 10). During a review of the facility's nutrient analysis for the menu, indicated on average the regular diet provided 2220 calories, 97 grams of protein per day. During a review of Resident 31's meal intake record from 11/20 to 12/20, Resident 31's oral intake had an average range from 43% to 49%. Resident 31's meal intake provided approximately on average 1021 calories and 44 grams of protein when compared to the facility menu's nutrient analysis. Resident 31's meal intake record from 1/21 to 2/21, had an average range from 48% to 51%. Resident 31's meal intake provided approximately on average 1100 calories and 48 grams of protein when compared to the facility menu's nutrient analysis. Resident 31's meal intake record from 3/21 to 4/21, average range from 54% to 61%. Resident 31's meal intake provided approximately on average 1275 calories and 56 grams of protein when compared to the facility menu's nutrient analysis. Resident 31's meal intake record from 6/21 to 7/21, average range from 21% to 39%. Resident 31's meal intake provided approximately on average 660 calories and 29 grams of protein when compared to the facility menu's nutrient analysis. During a review of Resident 31's Nutrition Note dated 2/11/21, Registered Dietitian (RD) 2 notes indicated resident expressed difficulty chewing meat, she refused alterations to the texture of the meat and requested partials for missing teeth. RD 2 indicated Resident 31's request was discussed with interdisciplinary team (IDT). There was no mention of the weight loss. There was no documentation of nutritional interventions. During a review of Resident 31's Nutrition Data note dated 2/25/21, completed by the Dietetic Service Supervisor (DSS 2), indicated Resident 31's oral intake was 65% and her weight was down by 2.6% in one (1) month, following a 5% loss in six (6) months. DSS 2 indicated she offered Resident 31 a supplement (oral nutrition supplement) due to decreased intake and that resident remains in room for all meals due to protocol for COVID-19 (a highly contagious viral lung infection) pandemic and that they will continue to monitor monthly weights and intake. While there was recognition of decreased oral intake it was not possible to determine if and when the supplement was initiated. During a review of Resident 31's Nutrition assessment dated [DATE], completed by RD 2, indicated Resident 31 estimated needs were 1300 calories and 50 grams protein, and that her intake was meeting her estimated needs. It indicated there was no significant nutrition issues, current nutrition interventions and nutrition goals were not applicable (n/a). It indicated Resident 31 had gained 7 lbs. per year, her intake averaged >25% this past week on the regular diet and no physical signs of malnutrition. It stated Resident 31 refuses a texture change and stated, I need partials. RD 2 indicated that Resident 31 was at risk for weight loss. There was no mention of the 9 lbs. (7.4%) weight loss that occurred in the previous three (3) months or the monthly 3 lbs. (2.6%) weight loss. There was no timely follow up. During a concurrent interview and review of Resident 31's clinical record with RD 1 on 7/15/21 at 11:06 AM, she stated for weights they monitor significant changes which are 5% in one month, 7.5% in three (3) months or 10% in six months for either a gain or loss but focus is on weight loss. When asked about if a resident is at 7.4% in 3 months, RD 1 stated yes we want to look at that but we aren't there yet with this group and the goal is to look at those so they do not flip over to a significant weight loss. RD 1 stated it looked like at their report that Resident 31 triggered for weight loss in April. When reviewing RD 2's Nutrition assessment dated [DATE], RD 1 acknowledged RD 2 was looking at the annual weights not what was going on currently. During a review of Resident 31's Nutrition Data note dated 5/28/21, completed by DSS 2, indicated Resident 31's weight was 104 lbs., had weight loss of 10% or more in the last six (6) months (11/20-5/21) and was not on a prescribed weight-loss regimen. It indicated Resident 31's average oral intake was 75% per day. DSS 2 indicated a supplement was offered due to decreased intake and there was noted a pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin on coccyx (base of the spinal column). DSS 2 indicated will continue to monitor monthly weights and intake. Despite a recognized severe weight loss indicated on the Weight and Vitals Summary, there was no indication Resident 31 was referred to the RD. While the note documented offering a supplement, there was no indication when and if the supplement was implemented. Review of Resident 31's weight note dated 5/28/21, completed by the Director of Nurses (DON), indicated Resident 31 had lost 17 lbs. in six (6) months (11/20-5/21) and had been staying in her room since the pandemic. It indicated prior to pandemic resident was up and about eating snacks often, has acquired a pressure ulcer and her current intake fluctuates. It indicated will have staff encourage resident to get up in wheelchair and will add protein to her diet. While the note identified a change in eating patterns, there was no indication the facility attempted to reinstate Resident 31's snack pattern. Similarly, the DON recommended the addition of extra protein to facilitate wound healing, there was no indication of implementation. During an interview with DSS on 7/15/21 3:08 PM, while looking at computer with Resident 31's profile card to see if resident on any supplements or added protein. DSS stated the House Supplement (oral liquid supplement) three times a day (TID) changed to honey thick liquids today. DSS stated she is notified by nursing of supplement orders and nursing will write that on a paper then she would shred it. When asked how we would see if there is more protein added on the meal ticket for Resident 31, the DSS stated we would see the profile card show more protein at each meal, but she does not see anything like that. DSS stated she was not sure if it ever came by a paper document from nursing since she shreds them. DSS stated she cannot tell when house supplement was added in her computer system but getting it three times a day. There was no evidence that the recommendations from 5/28/21 were implemented. It is unclear what date the supplements were started to know how long they were in place. During a review of Resident 31's general note completed by Social Services Director (SSD) dated 5/28/21, indicated they asked Resident 31 if she was interested in being referred to the dentist for dentures. Resident 31 wanted the referral since she only had eight (8) teeth then later came back and said she did not want dentures. This was three (3) months after Resident 31 requested partial dentures to RD 2 and RD 2 stated she would request to the IDT in the Nutrition Note dated 2/11/21. During a review of Resident 31's weight note dated 6/16/21, indicated Resident 31 had an additional nine pound (7.5%) weight loss since March, on Mitazapine (Remeron - medication for depression and may cause weight gain) 7.5 milligrams and she is on a CCHO diet with an intake of 48%. It indicated to ask the Physician if they can increase Remeron, sugar free house supplements (liquid nutrition supplement) twice a day, and a multivitamin with mineral daily. It indicated to continue weekly weights. RD 1, DON, DSS present for the weight meeting. There was no evidence provided to show this recommendation was communicated to the physician. During a clinical record review of Resident 31 and concurrent interview with RD 1 on 7/15/21 at 11:06 AM, RD 1 stated we need to see if there is documentation in other binder to see if Resident 31 was put on weekly weights in May or June. During an interview with DON on 7/15/21 at 3:38 PM, DON confirmed there was no weekly weights ever taken on Resident 31 for that time. Review of Resident 31's weight note dated 7/8/21, indicated Resident 31 was admitted to hospice on 6/28/21 and she had a pressure ulcer to the coccyx. It indicated Resident 31 is down eight (8) lbs. over the last month and the oral intake has been 26% over the last week. It indicated Resident 31's weight is down 23 pounds over the last six months (1/21-7/21). The IDT recommended health shakes (oral nutrition supplement) twice a day, multivitamin with minerals once a day, discontinue CCHO diet and to increase Remeron. DON, DSS, RD 1 and SSD present for the weight meeting. During a review of Resident 31's Care Plans, there were only two care plans that mentioned appetite. Care Plan with focus indicated the resident felt sad and had no appetite dated 2/18/20, showed an intervention to offer me food and beverages I like initiated 2/18/20. It further showed all the interventions/tasks were initiated 2/18/20 and 2/28/20. There were no updated interventions after 2/28/20. Care Plan with focus indicated had behaviors which include episodes of depression m/b poor appetite of eating less than 50% dated 2/21/20, showed an intervention to offer me food and beverages I like initiated 5/27/20. There were no updated interventions since 5/27/20. There were no Care Plans specific to Nutrition or weight loss in the clinical record. Review of Resident 31's clinical record, indicated Resident 31 expired on 7/16/21. During an interview and concurrent review of Resident 31's clinical record with DON 7/15/21 at 4:11 PM, DON confirmed she could not find any orders for any of the recommendations made by the IDT in the clinical record. DON stated there should be an order for the house supplement in the clinical record. DON stated Resident 31 used to come to buy snacks of Cheetos and Pepsi before Covid-19 pandemic and get 5 bags of the chips at a time. DON stated prior to Covid-19 the family would also buy and bring in Cheetos, but they offered these snacks during Covid-19 but Resident 31 did not want that anymore. During a review of the facility's document titled DTH Nutrition Intervention Flow Sheet revised 1/2018, indicated if there was severe/significant weight loss or need for increased calories due to wound healing or other causes gave examples of 32 different types of interventions such as: monitoring weights weekly, involving speech therapy (evaluation of swallowing), to changing diet orders to include fortified foods (adding additional calories and/or protein to foods) and using foods first approach, adding supplements, meal time assistance, adding snacks, adding a med pass 2.0 supplement protocol (oral nutrition supplement), request psych referral and med review for depression and consider appetite stimulants. The document also indicated IDT considerations/areas to evaluate when determining root cause for weight loss or poor intake. The document listed approximately five to 10 things under each group ranging from suggestions for family, checklist for nurse, labs, food considerations, environmental considerations and a list of changes in taste/sensory, dental, feeding ability, motor agitation. 2. According to the Nutrition in Clinical Practice journal, indicated Adequate nutrients from oral intake should be demonstrated prior to discontinuing tube feeding. (Nutrition in Clinical Practice, August 2014, Volume 29, Number 4) During a review of Resident 5's admission Face Sheet, the Face Sheet indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included Gastrostomy (G-tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food) and Gastrointestinal hemorrhage (Gastrointestinal (GI) bleeding is a symptom of a disorder in your digestive tract), to name a few. admission weight was 195 pounds. admission diet order was tube feeding of Jevity 1.2 (liquid nutrition) 100 milliliters (ml) for a total 1500 ml and 1800 calories. During a review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care-planning tool, dated 4/8/21, the MDS indicated Resident 5 had a BIMS (Brief Interview for Mental Status) of 13 to indicate cognitively intact (no evidence for dementia or cognitive impairment). The MDS indicated Resident 5 was not on a physician-prescribed weight loss regimen. During a review of the physician's orders for Resident 5, dated 4/1/21 the diet was changed to a regular mechanical soft diet (soft and easy to chew). During a review of Resident 5's Weights and Vitals Summary, showed: 3/26/21: 195 lbs. 4/2/21: 185 lbs. 4/12/21: 179 lbs. 4/19/21: 180 lbs. 4/26/21: 176 lbs. Based on the weight history, Resident 5 had 10 lbs. (5%) severe weight loss in the first week and 19 lbs. (9.74%) severe weight loss in the month (one month). During an interview with Resident 5 on 7/15/21 at 9:28 AM, Resident 5 stated he got the Gastrostomy tube (G-tube) placed at hospital since he had a GI bleed. Resident 5 stated he was told he lost weight and quite a bit of it a while back. Resident 5 stated he did not want to lose weight. He stated the SSD told him he had lost weight but no one else did. He stated his appetite is good and he doesn't have any problems with chewing or swallowing. He stated he will eat sometimes snacks at night if he wants them. When asked, Resident 5 stated no one talked to him about slowing down the Tube feeding from the tube slowly while he was starting to eat by mouth. Resident 5 stated no one talked to him about losing weight slowly/gradually. Resident 5 stated he doesn't remember the dietitian (RD) or anyone from the kitchen ever coming in to talk to him about his weight or adding anything to his meals to slow his weight loss. During a review of Resident 5's Nutrition Data dated 4/7/21, completed by DSS 2, at the time of admission indicated Resident 5 was a readmission to the facility. Resident 5 was noted to have a G-tube and receiving Jevity 1.2 100 ml which was on hold since 3/30/21. It indicated Resident 5 had swallowing and dental problems and with an average oral intake of 52%. DSS 2 indicated Resident 5's weight was 196 lbs. on 9/2/20, and when Resident 5 returned to the facility on 3/26/21 the resident was 195 lbs. and was 185 lbs at the time the note was written. The note also indicated a 10 lbs. weight loss (5.1%), which is considered severe in accordance with the Weight Monitoring policy. It indicated Resident 5 was not on a prescribed weight loss regimen. DSS 2 indicated will monitor. No interventions were done at this time. During a review of Resident 5's Nutrition Note dated 4/13/21, RD 2 indicated Resident 5 lost six (6) lbs. in one week (4/2/21-4/12/21). RD 2 indicated Resident 5 expressed difficulty eating toast, requesting softer foods like pancakes and French toast, fruit and peanut butter. RD 2 indicated food preferences were updated. RD 2 did not mention Resident 5 had lost 16 lbs. (8.2%) since admission (18 days). During a review of Resident 5's meal intake record dated 4/1/21 to 4/30/21, indicated Resident 5 on average was eating 59% of his meals. During a review of the facility's nutrient analysis for the menu, indicated on average the regular diet provided 2220 calories, 97 grams of protein per day. Resident 5's meal intake provided approximately on average 1300 calories and 57 grams of protein when compared to the facility menu's nutrient analysis. During a review of Resident 5's Nutrition assessment dated [DATE], RD 2 indicated Resident 5's estimated nutrition needs were 2100 calories and 80 grams protein. RD 2 indicated the total nutrition intake meets estimated nutrition needs and a Nutrition Diagnosis of Swallowing difficulty related to medical diagnosis as evidence by need for mechanically soft diet and history of G-tube. RD 2 indicated the current interventions were the mechanical soft diet and a nutrition goal to consume greater than 75% of meals. RD 2 indicated his intake fluctuated this past week and diet was appropriate. RD 2 indicated Resident 5 was at risk for weight loss, pressure injury, dehydration and nutrition needs were met. RD 2 did not acknowledge Resident 5 had 15 lbs. (7.6%) weight loss since admission (3/26-4/26/21, 27 days prior). There were no interventions at this time for his weight loss. During a concurrent interview and review of Resident 5's admission Face Sheet, Nutrition Note, Nutrition Assessment, IDT note, physician orders with RD 1 on 7/15/21 starting at 10:24 AM, RD 1 stated she would expect RD 2 would acknowledge the weight loss in that time frame and that did not happen. During an interview with RD 1 on 7/15/21 at 10:43 AM, she stated the facility may have weight meetings and could be somewhere else other than the electronic medical record. RD 1 stated the facility should schedule a weight meeting within two weeks after the weight loss occurs. RD 1 stated two weeks would be the longest window before meeting about the weight loss. RD 1 acknowledged that she could not find anything in clinical record to see that happened and she would expect interventions should be done during that window when weight loss was occurring. During an interview with DON on 7/15/21 at 4:17 PM, the DON confirmed that she could not find any interventions or other weight notes for the resident during the one-month weight loss (3/26-4/26/21). During an interview with on 7/16/21 at 11:25 AM, RD 1 stated in general the gradual slowing of the tube feeding formula (liquid nutrition), would include continuing the tube feeding in conjunction with oral intake. Once the oral intake was adequate, the tube feeding would be discontinued.