**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interviews, and review of the facility policy titled, Physical and Nutritional Supports, 03-522, the facility failed to maintain acceptable parameters of nutritional status, to include body weight, for one of one resident (R) R#4 reviewed for nutritional status; resulting in significant weight loss of 5.82% in 30 days. Findings include: Review of facility's policy titled Physical and Nutritional Supports, 03-522 reviewed 12/2/21, page 6 of 15 Section E - Significant Weight Loss/Gain or Severe Weight Loss/Gain ii indicates Medical staff are notified immediately of weight loss or gain that falls outside of the established parameters for the specific individual, and/or if there is an unintentional significant or severe loss or gain from the previous month. It is the responsibility of the staff member that identifies the weight loss or gain to notify the unit charge nurse who notifies the medical staff and dietician. Review of the record indicates R#4 was admitted to the facility on [DATE]. R#4 has diagnoses of profound intellectual disabilities, mixed receptive-expressive language disorder, cerebral palsy, other specified chromosome abnormalities, unspecified lack of coordination, dysphagia, epilepsy, constipation, history of normocytic/normocytic anemia, reflux dysphagia/ high risk for aspiration, history of recurrent aspiration, percutaneous endoscopic gastrostomy (peg), nothing by mouth (NPO). Review of R#4's April 2022 Physician Orders (PO) revealed the following: Enteral Feeding Fluids - 1200 CALORIES per day: 1 can Two Cal HN + 140 ml of BOTTLED WATER with a rate 85 ml/hour from 12 midnight to 8 a.m. daily via G-tube. 300 ml of BOTTLED WATER every 6 hours at 12 a.m., 6 a.m., 12 p.m., 6 p.m. Flush lumen with 30 ml of warm BOTTLED WATER after administration of medications, Calcium/Vitamin D 500 mg-200 International Units (IU), Multivitamin liquid 15 ml, Potassium Chloride 10% solution 20meq/15 ml (10 meq), Sodium Chloride 1 Gm Tablet. According to the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 3/2/22, R#4 had a Brief Interview for Mental Status (BIMS) of 99, which indicated the resident has a severe cognitive impairment. Review of R#4's care plan revealed a care plan initiated 12/3/21 with a revision date of 4/27/22, listed at risk for inadequate nutrition: as evidenced by (AEB) any weight gain/loss. R#4's expected outcome: Will maintain weight within ideal range. The interventions for R#4 include: Nurse/DCS will maintain an accurate weight record. Ideal Weight Range: 115-125 pounds, refer to physician any weight loss of five pounds or a weight gain of five pounds or more, R#4 will receive prescribed diet and/or supplement as ordered by the physician in consultation with the Dietitian as indicated, Diet by tube: 1 can Two Cal HN + 140 ml bottled water at 85 ml/hr. from midnight to 8 a.m. daily. Give 300 ml bottled water every 6 hours at 12 a.m., 6 a.m., 12 p.m., 6 p.m., Nurse/Dietician will monitor fluid intake, caloric needs and other dietary needs as indicated, R#4 teaching in terms she can understand regarding dietary modifications and plan of care, routine review by licensed nurse at least quarterly. Review of R#4's EMR revealed a significant weight loss of -5.82% / 6.7 lbs. within the 30-day timeframe of 3/1/22 through 4/4/22. Review of the resident's record revealed a Quarterly Health and Incident Review and Nursing Care Recertification dated 4/21/22. April 2022 weight was discussed in this meeting with the interdisciplinary team that included the Physician, Registered Nurse, and Dietician. Observation on 5/1/22 at 8:43 a.m., R#4 was lying in bed. The head of bed was elevated. The kangaroo feeding pump was on with water infusing to the peg tube as ordered. Interview on 5/1/22 at 9:06 a.m. with Certified Nursing Assistant (CNA) AA, she verified the current for R#4 weight of 108.5 on 4/4/22 was the current weight for R#4. She also stated that the CNA's are responsible for obtaining the monthly weights at the beginning of each month and the weights are then given to the nurses and that the nurses instruct the CNA's when reweighs are needed. CNA AA stated that all weights are communicated to the nurse because a weight loss or gain of 5 pounds is a trigger for them to do something for the residents. Interview on 5/1/22 at 9:18 a.m. with Licensed Practical Nurse (LPN) BB, revealed that nurses are responsible for tracking the residents' weights. She also stated that the nurses should notify the physician and RN Supervisor as soon as they are aware a resident has a loss or gain of 5 pounds or more. After looking through the paper record and electronic record, she verified that the physician was not informed of R#4 weight loss until 4/21/22. Interview on 5/1/22 at 10:41 a.m. with Registered Nurse (RN), Nurse Manager (NM) CC, revealed that the nurses are responsible for recording weights and notifying the physician and dietician if there is a weight gain or loss of 5 pounds or more. She also stated that the physician should be notified at the time the significant weight loss or gain is identified. Interview on 5/1/22 at 11:33 a.m. with the Director of Nursing (DON), revealed that it is the nurse's responsibility to notify the physician and the RN Nurse Manager of weight loss and weigh gain of 5 pounds or more. She stated that the physician should be notified as soon as the nurse is aware of the significant weight changes. She reviewed meeting notes and R#4's weight was not addressed with the physician until 4/21/22. She reviewed the paper and electronic record and verified that the physician was not notified. DON stated, No he was not notified prior to 4/21/22, I have looked, it is what it is.