**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#17) of three residents reviewed for nutritional status out of 20 sample residents maintained acceptable parameters of nutritional status such as usual body weight or desirable body weight. Specifically, the facility failed to implement interventions to prevent a significant weight loss for Resident #17 with nutritional risks including poor nutritional intake and requiring staff assistance for cueing at meals, and was not outlined on her comprehensive care plan. The resident had a weight loss of nine pounds over a period of one month, which was 5%, considered significant weight loss. The weight loss was not addressed timely with her family since the resident had cognitive impairments. The resident was not assessed by the registered dietitian (RD), until she lost an additional four pounds in the next 10 days (total of 14 pounds, 8% of her total body weight over a period of 42days). Lack of timely interventions in aiding in maintaining Resident #17's nutritional status led to her sustaining a significant weight loss of 8% over 42 days. Findings include: I. Facility policy and procedure The Weight Assessment and Intervention policy, with no revision date, was provided by the director of nursing (DON) on 8/24/2021 at 10:30 a.m. It read, in pertinent part: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The nursing staff will measure resident weights on admission, then weekly for three weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Any weight changes of 5% or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Dietitian. The DON/designee will review the unit Weight Record in skin/weight meetings to follow individual weight trends over time by the skin/weight team. Negative trends will be evaluated by the treatment team whether or not the criteria for ' significant ' weight change has been met. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the resident's target weight range, approximate calorie, protein, and other nutrient needs compared with the resident's current intake. Individualized care plans shall address the identified cause of weight loss, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. The DON/designee will discuss undesired weight gain/loss with the resident and /or family. II. Resident status Resident #17, age [AGE], admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), diagnoses included displaced fracture of the right femur, hypertension, and dementia without behavioral disturbance. The 7/15/21 minimum data set (MDS) assessment revealed the resident's cognition was moderately impaired with a brief interview for mental status (BIMS) score eight out of 15. She required extensive assistance of one person with most activities of daily living (ADLs), and cueing with meals. She did not exhibit any chewing or swallowing problems, she did not have a weight loss and was not on a prescribed physician weight loss regimen. Resident #17 did not exhibit any behaviors and did not resist the care. III. Family interview On 8/23/21 at 1:30 p.m. the resident's family member was interviewed. She stated she had a hard time getting any information from the facility about her mom's health. She said she was not aware of her mom's current health status, or if she was participating in therapy or not. She said the last message she received from the facility's social worker was regarding payment status and bills. Today she received a call from the physical therapist (PT) who was asking her if she will be willing to pay a co-payment for speech therapy evaluation that her mom needs. She said PT did not say why her mom needed that evaluation and stated she would ask DON to call her back. She did not receive any calls from DON. She said she did not recall any care conferences and was not contacted by nurses or DON with updates or changes until today (8/23/21). She said she visited her mom in the evenings after work and all managers were not on duty at that time. She believed staff were not encouraging or helping her mom to get better and she observed that in the evenings that her mom was put to bed right at the dinner time instead of being taken for dinner. She said she was not satisfied with the care facility provided and was looking for other places. She said she was not contacted by a physician who followed her mom and did not even know who her physician was. She was not aware if her mom had any changes in her health. IV. Record review A care plan was initiated on 7/9/21, with no revisions. It read the resident was at nutritional risk and risk for dehydration due to poor intake, eating about 25 percent of her meals, and dementia. Pertinent interventions included: Provide and serve diet as ordered. Honor resident's food choices. Offer alternatives with meals. Provide snacks and fluids between meals. Monitor intake and record every meal; and registered dietician (RD) to evaluate and make diet change recommendations as needed. Review of Resident #17's weights revealed the resident lost 13.6 pounds between July 2021 and August 2021 losing weight from 170 pounds on 7/8/21 to 156.4 pounds on 8/19/21, which was 8% between a two month period. Meal intake records for the last 30 days revealed out of 90 documented meals, the resident consumed less than 50% for 35 of those meals, 28 meals of 25% or less. The resident was marked as independent/no assistance needed with 58 meals, received physical assistance at two meals, and refused seven meals. -The interdisciplinary team did not address the resident's poor intake identified in August 2021 until 8/16/21 when a supplement was added for the resident's weight loss and poor intake (see below). On 7/9/21 a nutrition note on admission by a registered dietitian (RD) #1 revealed the resident's current weight was 170 pounds. The resident had a good appetite, usually consumed above 50% with most meals. Nursing staff helping to monitor meals and help resident with alternative meals. On 7/14/21 a nurse practitioner (NP) noted that the resident had low albumin (protein level) and was started on the Prostat, a protein supplement. On 7/19/21 a primary care physician (PCP) #1 documented that the resident has a diagnosis of protein calorie malnutrition and she was receiving a protein supplement daily. On 7/27/21 a nutritional note by RD #2 documented a late entry note for 7/12/21. The note read resident's current weight was 165.8 pounds (7/12/21) with no significant weight changes. Resident continues rehab services. Good overall intake of food/beverage reported on records. Currently able to meet needs with intake of meals and snacks. Continue with the current nutritional plan of care. -The note indicated that the resident had a weight loss of 4.2 pounds. On 8/6/21 a primary care physician (PCP) #1's note documented that the resident was seen on 8/6/21 with complaints of abdominal pain and low appetite. The x-ray revealed no significant changes and resident was started on the medication for potential constipation. Same day nurses note documented that nurse practitioner (NP) who worked with PCP #1 contacted the facility and left a recommendation to stay with the resident at meal times, to encourage the resident to increase intake and fluids. -The above recommendations were not updated in the resident's care plan or CNA [NAME] (a care directive). The facility did not initiate one-on-one eating assistance to the resident at meal times as it was recommended by NP. On 8/12/21 a nutrition note revealed the resident's current weight was 161 pounds which indicated a significant weight loss of nine pounds or 5% in 30 days. -The note indicated that the weight loss was not desirable, therefore additional interventions should have been implemented. Instead, RD #2 documented Will start following the resident at next week's weight and skin review. On 8/13/21 resident was started on house supplement twice a day, four days later it was discontinued (on 8/16/21). On 8/16/21 the resident started to receive an additional (Ensure) supplement twice a day for weight loss. -There was no supporting nurses note or RD notes to clarify the orders. There was no RD assessment. On 8/19/21 a weight and skin note documented the most recent weight was 161 pounds (8/8/21) and it was compared to the previous weight of 162 pounds on 8/3/21. No weight trend fields were completed, meal intakes were marked 0-25% daily, supplement Prostat and Ensure intake was 50-75% twice a day. The resident was marked on the assessment as independent, with no need for assistance with meals. New interventions were implemented to educate caregivers/resident/family with no updates to the care plan. The participants of the meeting were RD #2 and the DON. On 8/20/21 a nutrition note revealed the resident's current weight was 156.4 pounds which indicated a severe weight loss of 13.6 pounds or 8% in less than 90 days. -RD #2 documented weight loss was due to decreased oral intake and referred to weight and skin note for details. There were no further weight and skin notes after the note on 8/19/21. There were no further RD evaluations. A physician note dated 8/20/21 by PCP #1 revealed the resident continued to lose a significant percentage of body weight possibly due to dysphagia (swallowing difficulty). Speech therapy evaluation was ordered and staff to assist patient when eating meals. Continue supplements and monitoring by RD. -Review of the resident's progress notes, care plans, nutritional assessments and meal intake records revealed no additional interventions or actions, other than adding supplements, were implemented or considered by facility staff to prevent further weight loss. There were no orders or interventions written for the resident to consistently receive assistance or cueing at meals and not indicated on her comprehensive care plan. Additionally, there was no evidence of discussion with the resident's responsible party related to the resident's significant weight loss. V. Resident interview and observations Resident #17 was observed and interviewed on 8/23/21 -At 12:10 p.m., the resident's meal tray was delivered to her room and set in front of her on the table. -At 1:08 p.m. the resident was in bed with the head of the bed elevated to 45 degrees, sleeping. RN #3 approached resident with noon medications. She woke up resident on the second attempt and offered medications. A cup of untouched soup, a piece of cake covered in plastic, and a covered plate were observed on the table in front of the resident. Nurse removed a cover that revealed a fresh salad with beets and bacon shreds, and asked the resident if she would eat. The resident did not answer, after the question was repeated a second time, the resident lifted the spoon, and filled it with soup. RN #3 then left the room. The resident was asked if she liked her meals. She said yes. She appeared sleepy and low energy. She ate a few spoons of soup and put the spoon back on the table. She said she liked all kinds of foods, but the dressing on the salad was making her cough. She closed her eyes and fell asleep. -At 1:22 p.m. CNA #2 approached the resident and asked her if she wanted anything, or if she wanted coffee, the resident said no. CNA #2 removed the uneaten salad plate from the resident. No assistance was offered to the resident, and no other meal substitutes were offered to her. -At 1:53 p.m. resident observed sleeping in bed, less than a half eaten cake observed in front of the resident, open full supplement carton (237 milliliters, chocolate flavor) observed behind the cake. The resident was asleep. -At 3:03 p.m. the resident was asleep in bed, full carton of chocolate supplement and the Styrofoam cup with water marked 8/23 11:00 p.m. on the table. The table positioned away from the resident, not within the reach. -At 4:30 p.m. the dinner tray was delivered to the resident's room. The resident was asleep and the meal tray was set at the table away from her reach. The tray contained mashed sweet potatoes, shepards pie and peach pie. The resident was not woken up for the meal by staff. -At 5:00 p.m. the meal tray was still on the same table away from her reach. The resident was asleep. -At 5:30 p.m. the family member of the resident observed at the bedside assisting her with the meal. The family member said the resident looked worse since she saw her last time, she appeared weak and sleepy. V. Staff interviews PCP #1 was interviewed on 8/23/21 at 3:30 p.m. She said she was aware that the resident was losing weight, she said she was on her list to visit her today. She said the resident was receiving two supplements and it did not matter that one of them was prescribed for different reasons (low albumin). She said the facility was in charge of communicating with the family to minimize the number of calls that family might receive. She said RD was in charge of monitoring weight and completing an assessment regarding this resident's nutrition. CNA #2 was interviewed on 8/24/21 at 11:32 a.m. She stated the resident required assistance from one person with all ADLs and needed cueing to remember to eat. She stated the resident had good and bad days and some days she had more energy than others. She said she asked the resident if she needed help eating, but the resident usually refused. -However, there was no documentation the resident refused eating assistance and she was not offered eating assistance in observations (see above). RN #2 was interviewed on 8/24/21 at 11:42 a.m. She stated the resident fed herself, though required cueing and prompting often. She said the resident was able to drink from the cup independently, but when it came to the supplement it had to be held in front of the resident otherwise she would not drink it. She stated the resident always ate in her room and refused to get up into the chair for meals. The speech therapist (ST) was interviewed on 8/24/21 at 11:50 a.m. She said she was here today to evaluate the resident as it was reported to her that the resident had a cough when she was eating. She said she evaluated the resident and did not find any physical limitations such as dysphagia. She said the resident required one-on-one assistance with meals and she would be recommending that. RD #1 was interviewed on 8/24/21 at 2:10 p.m. She stated this position on 7/23/21. She said her responsibilities were to review the weights and conduct a nutritional assessment on admission and later quarterly. She said nutritional assessments were conducted also when resident had a weight loss. She said when Resident #17 had a weight loss, she put her on supplements, but she forgot to do the assessment as she was too busy at that time. She said she did not observe resident eating and she talked to nurses and CNAs about resident's meal intake. She said after the computer triggered weight loss of 5%, she started the resident on supplements. When the computer identified the weight loss of 8% it was not her working day and she addressed it when she came back and requested a speech evaluation. The DON was interviewed on 8/24/21 at 3:10 p.m. She said nurses' responsibility was to report weight loss to the physician, which they did. It was up to the physician and RD to conduct an assessment and determine appropriate interventions for the weight loss. She said they discussed residents' weight loss in interdisciplinary (IDT) meetings on 8/6/21 and 8/9/21. In both cases the physician was notified. She said her understanding was that the resident did not have a good appetite and frequently refused meals. She said she spoke with family yesterday and the family was aware of the weight loss. She did not document her discussion with family. She said it was up to the RD and physician to discuss the details of the resident's health with the family. The nursing home administrator (NHA) was interviewed on 8/24/21 at 3:30 p.m. She stated she would expect the facility to follow the policy and procedure when a resident experienced a weight loss. She stated she would expect for interventions to be put into place for weight loss or poor intake and if the interventions were not effective. She would expect for all interventions and discussions to be documented in the resident's record. -Additional documentation regarding Resident #17's weight loss was not provided by the exit of the survey on 8/24/21.