**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a residents medication was given as prescribed and failed to ensure medication orders were transcribed correctly to avoid a significant medication error. This failure resulted in six of R9's medications being mistakenly discontinued without a physicians order. As a result of this failure R9 developed worsening psychiatric symptoms (paranoia) and was sent to the emergency room for evaluation. This applies to 1 of 7 residents (R9) reviewed for physician orders in the sample of 31. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/1/23, when the facility discontinued R1's medications without a physician order. V1 (Administrator) was informed of the Immediate Jeopardy on 8/30/23 at 2:21 PM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 8/31/23 however, noncompliance remains at a level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R9's face sheet shows she was admitted to the facility on [DATE] and has diagnoses including: Type 2 diabetes with diabetic neuropathy, migraine without migrainosus, depression, adjustment disorder with depressed mood, vascular dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R9's 8/3/23 minimum data set shows she has on going pain and depression. R9's active care plan initiated on 11/30/22 shows R9 has a severe mental illness and has symptoms of delusions, paranoia and poor insight and judgement. R9's care plan also shows she has potential for pain due to migraines and a history of a fracture. R9's physician order summary (p.o.s) show the following medication orders were all discontinued on 8/1/23 : Effexor XR (Venlafaxine HCl ER-extended release) (Anti-depression and anxiety medication) 150 milligrams (MG.) 1 tablet per day start date 10/26/22, bupropion HCL ER (SR) 150 MG. (Anti-depressant) 1 time per day start date 10/26/22, lamotrigine 25 MG. 3 times per day, (anti-seizure medication and also mood stabilizer) start date 10/26/22, Topiramate 25 MG./ Topamax 1 time per day, (medication to treat epilepsy and migraines) start date 10/25/22. Duloxetine (Anti-depressant/anti-anxiety) 60 MG. 1 time per day start date 6/9/23, and Gabapentin 400 MG. (used for neuropathy pain) 1 capsule 3 times a day start date 6/8/23. There are no notes in R9's electronic medical record indicating who discontinued the medications or why. A consultation report completed by V26 (Psychiatric Nurse Practitioner) on 6/30/23, shows he saw R9 and made no medication adjustments. The report identifies R9 is on the following psychotropic medications: Venlafaxine for depression and anxiety, Bupropion and duloxetine for depression, Lamictal and Topamax for mood stabilizers. The consultation report also says a gradual dose reduction of those medications are contraindicated and R9 is not a candidate at that time due to on going symptoms. R9's 8/1/23 9:13 PM, nursing progress note shows R9 had returned from a doctor appointment and the doctor will fax a consultation report to the nurses station. The consultation report from a pain doctor on 8/1/23 at 3:16 PM, shows a prescription to increase R9's Gabapentin order to 600 MG. 3 times a day for neuropathy pain, and to change/ add Cymbalta 30 MG every 12 hours or two times a day. R9's MAR and pos show those ordered were not carried out. A consultation report completed by V26 (Psych NP) on 8/29/23 states the following: Patient was last seen by writer on 6/30/23 and no medication changes were made. Cymbalta, Wellbutrin, Effexor, Lamictal, Topamax and Melatonin were discontinued on 8/1/23 for unknown reason. The report shows that R9 is having depression an increased episodes of inappropriate behaviors, insomnia, anxiety and agitation. R9's Medication Administration Summary (MAR) from 8/1/23 to 8/31/23 show she received 1 dose of Effexor, bupropion, Duloxetine, and Topiramate on 8/1/23 and then it was discontinued and no further doses were received in August. R9 missed 30 doses of each of those medications in the month of August. The MAR also shows R9 received 3 doses of each of Gabapentin and lamotrigine on 8/1/23 (ordered to be given 3 times a day) and then it was discontinued and no further doses were given in August. In total R9 missed 90 doses of each of those medications. R9's Nurse Practitioner Progress Note completed by V27 (Nurse Practitioner/NP) on 8/8/23 at 9:47 AM, shows R9 is having an increase in paranoid symptoms. Nursing progress notes for 8/29-8/30/23 show R9 was increasingly paranoid and was calling 911 to report feeling unsafe and seeing people with a knife hidden being their ear. Police arrived at the facility and R9 made an allegation of an assault occurring. R9 was sent to the emergency room for evaluation. Medication orders were obtained for R9 to be started on a mood stabilizer (Depakote) and a anti psychotic medication (Seroquel) due to her psychotic symptoms. R9 returned from the emergency room on 8/30/23. On 8/30/23 at 9:05 AM, V2 (Director of Nursing) said she was not aware why R9's psychotropic and pain medications were stopped abruptly but she will investigate it. At 9:56 AM, V2 said what happened with R9's medication was R9 had went out for a doctor appointment to the pain clinic on 8/1/23 and then returned to the facility. The nurse on duty ( V22-Nurse Supervisor) mistakingly thought R9 had went to the hospital so she discontinued all of R9's medications. When R9 returned to the facility later that evening V22 tried to add the medications back and missed a few. V2 said V22 should not have discontinued R9's medications and she also did not call the physician to verify any of the pain doctors new orders. On 8/30/23 at 9:33 AM, V26 (Psych NP) said he was called to see R9 on 8/29/23. He said he could not figure out who stopped and why her psychiatric medications were stopped. He verified he was not the one who had given orders to discontinue those medications. V26 said he would say that R9 was having an increase in her paranoia from the last time he saw her until yesterday. At 12:56 PM, V26 said the obvious effect of R9 being off her medications would be an increase in psychiatric symptoms including mood, paranoia, and hallucinations. On 8/30/23 at 10:22 AM, (V22) said she made a huge mistake with R9's medication orders. She said she was told by another nurse that R9 was in the hospital so automatically I discontinued the medication orders and then when R9 returned and I learned she only went to a medical appointment I tried to reinstate her orders and I thought I had gotten everything but I missed a few. No one ever questioned it until now why all of R9's psychotropic medications and some of her pain medications were stopped. V22 said she did not call any physicians to verify any of the orders after R9 returned from the pain appointment. V22 said she should not have discontinued the medications, and it is protocol that after appointments or hospital stays the medication orders are verified with the physician and carried out but she missed the new orders also. On 08/30/23 11:56 AM - V27 (NP) said her office was not called to discontinue R9's psychiatric or pain medications and she believes R9's topamax and lamotrigine medications were being used more for migraines. She said she would be even more concerned if R9 had a active seizure disorder and if the medications were for seizures then missing them would put her at risk for an increase in seizures. V27 said by R9 missing her other medications there could be changes in mood and behaviors and increased pain. V27 said the facility should contact their office if a resident goes out and comes back to verify medication orders. On 8/31/23 at 9:11 AM, R9 said she does not recall making any accusations to anyone. She was paranoid about talking with this surveyor and stated, Maybe I need my family here I don't know what you are up too. R9 said she has diabetic neuropathy and has pain all the time. On 8/31/23 9:08 AM, V31 (Licensed Practical Nurse/LPN) said R9 been asking for increased amounts of PRN (as needed) norco (pain medication) this past week and has an increase in paranoia. He said he was there on 8/29/23 in the evening when R9 called 911 and was later sent to the hospital. R9 was seeing people with pocket knives, and saying she doesn't feel safe in facility. On 8/31/23 9:13 AM- V24 (Certified Nursing Assistant/CNA) said R9 has had increase in paranoia over this past month and has been hallucinating seeing children, cats, and monkeys. The facility provided Transcription of Physician Orders- Procedure effective date 11-3-22 says nurses should review the discharge summaries or records from other facilities and verify with the residents physician of any new or changes in medication orders. All orders should be checked to verify they were entered into the electronic medical record correctly. The Immediate Jeopardy that began on 8/1/23 was removed on 8/31/23 when the facility took the following actions to remove the immediacy: 1. Staff involved and all Nurses on the AM and PM shifts were in-serviced on 8/30/23 about discontinuing physician orders, medication administration policy and transcription of orders. 2. The Nurse Consultant/DON will perform chart audits for all discontinued medication orders for the month of August 2023. 3. The Nurse Consultant will provide in-servicing and training for licensed nurses including agency and prn nurses who are on vacation or medical leave. They will be required to completed the in-servicing before the start of their shift. All nurses will receive the in-servicing by 9/9/23. 4. The Nurse Consultant/ DON will train all newly hired nurses will also receive education regarding the new policy on a second double check system where new orders are verified by two nurses. This will be completed by in house nurses by 8/30/23. Any staff on vacation or on leave will be notified via telephone. On going education for new hires and agency staff will continue prior to the start of their shift for all new hires. 5. The Nurse Consultant and DON will conduct char audits for all charts of all residents who have had appointments or hospital stays in the month of August 2023. These audits will be done by 9/1/23. Future audits will be completed daily for two weeks, then two times per week for four weeks, followed by weekly for six weeks. 6. The medical director and attending physician were notified of the medication error on 8/30/23. 7. An emergency QA meeting was held by the facility on 8/30/23. The audit findings will continue to be reviewed during QA meetings. Findings of the QA audit will be used during QAPI review and will determine compliance level and additional follow up as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R9's face sheet shows she was admitted to the facility on [DATE] and has diagnoses including: Type 2 diabetes with diabetic neuropathy, depression, anxiety, adjustment disorder with depressed mood, vascular dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R9's electronic medical record shows she had a dietary assessment completed on 10/27/23 on admission, a quarterly dietary evaluation/assessment was completed on 2/1/23 (both completed by a former dietary manager). The next dietary evaluation was not completed until 8/29/23 after V6 Registered Dieitican (RD) was made aware of R9's significant weight loss by the surveyor. R9's weight and vitals summary shows she weighed 245 lbs. on 6/8/23 and weighed 220.5 lbs. on 7/19/23 a 10% - 24.5 lb weight loss in one month. R9's 8/11/23 weight was 223 lbs. R9's electronic medical records dated 5/1/23-8/29/23 were reviewed. These records showed no documentation R9 was ever assessed by V6 (RD) even after R9 sustained a significant weight loss. 8/29/23 1:07 PM, V7 (non-certified Dietary Manager)- said he is responsible for the quarterly dietary assessments and then gets the RD involved after he sees the resident. He said he was not aware of R9's significant weight loss and that there really is no process in place for notifying him of significant weight loss for residents. V7 said now that he is aware of R9's significant weight loss he will notify V6 and let her know because she would be the person to recommend interventions. On 8/29/23 at 1:41 PM, V6 (RD) said R9's weight loss should have triggered in the computer for a significant weight loss. She said it was towards the end of the month when she got the resident weights for July so she decided to wait to see Augusts weights. She said she can't speak for the programmers, but this is pretty concerning that PCC (electronic medical record/EMR) is not triggering significant weight loss. V6 said she does not believe she has done any assessment on R9, the last quarterly assessment was last done in 2/1/2023. (No quarterly assessment was done in May or August of 2023 no significant weight loss assessment has been done as of today). V6 said the computer should have also triggered for a quarterly assessment and then V7 should completed those, but if the computer does not trigger it then he would not know to do one and quarterly assessments are being missed. On 8/29/23 at 2:01 PM, V1 (Administrator) said V6 (RD) is responsible to be reviewing weights to see who triggers for significant weight loss. 5.) R79's face sheet shows he was admitted to the facility on [DATE] and has diagnoses including: end stage renal disease, type 2 diabetes, congestive heart failure and acquired absence of below the knee amputation. R79 had a dietary evaluation completed on admission on [DATE], and again on 3/20/23. R79's 3/20/23 assessment completed by V6 (RD) shows he had a recent unplanned weight loss a current pressure injury. R79 went to the hospital for a medical procedure and a dietary re-assessment was completed on 5/1/23 upon his return. R79's EMR shows There are no additional quarterly or significant change dietary assessments or evaluations done on R79 after 5/1/23. R79's weights and vitals summary showed on 4/1/23 he weighed 366.3 pounds. On 8/6/23 he weighed 324 pounds. A total weight loss of 42.3 pounds (11.55%) in 4 months. On 8/28/23 at 10:53 AM, R79 said he has lot a lot of weight loss, over 85 lbs. and no one from dietary is seeing him that he is aware of. On 8/28/23 at 1:14 PM, V7 (non-certified Dietary Manager) said he is unaware if the facility follows the 3 month weight loss if it is 7.5%, he thinks the facility just follows the 5% and 10% weight loss to determine significant weight loss. V7 said R79 was last seen by him on 4/24/23 and he was not aware of significant weight loss for R79. On 8/8/23 at 1:35 PM, V6 (RD) said she was not aware of significant weight loss for R79 and she last saw him on 5/1/23. V6 said he also should have triggered in the computer for significant weight loss and a quarterly assessment but for some reason did not. The facility's Weight Assessment and Intervention policy dated 2020 showed, The goal is to ensure adequate parameters of nutritional status are maintained by preventing unintentional weight loss . Any weight change of 5% of more since the previous weight assessment shall be re-taken the next day to confirm. If the weight is verified, nursing will notify the appropriate designated individuals such as the physician, Registered Dietician, Dining Services Manager, or other members of the interdisciplinary team within 24 hours. Verbal notification must be writing . The policy defined significant weight loss as a loss of 5% of a resident's weight in one month, 7.5% in three months, or 10% in six months. The facility's Registered Dietician Roles and Responsibilities policy dated 2020 showed, The Registered Dietician will provide routine scheduled consultations to monitor compliance with state and federal regulations and plan nutritional care for residents. The policy showed the Registered Dietician (RD) will assess/monitor the nutritional needs of residents and keep the physician and appropriate staff informed of the nutritional status of residents. The policy showed the RD will provide nutrition documentation for residents according to established schedules and guidelines including assessment and changes in resident nutritional plans . The Immediate Jeopardy that began on 3/27/23 was removed on 9/1/23, when the facility took the following actions to remove the immediacy: 1. R144's dietary orders have been updated to reflect current recommendations including Ensure (7/31/23) and frozen nutritional treats (8/1/23). Weights are currently being monitored-monthly weight increase of 3 lbs in August. R144 will be reassessed by Dietician on 9/1/23. 2. R9's dietary orders have been updated to reflect current recommendations including Glucerna (8/30/23). Weights are currently being monitored-monthly weight increase of 2.5 lbs. Reviewed by Dietician on 8/29/23. Resident will be reassessed by Dietician on 9/1/23. 3. R37's dietary plan has been updated to reflect current recommendations. Weights are currently being monitored-monthly weight increase of 2.3 lbs. Reviewed by dietician on 8/29/23. Resident will be reassessed by Dietician on 9/1/23. 4. R79's dietary orders have been updated to reflect current recommendations including Glucerna (8/30/23). Weights are currently being monitored. Reviewed by the Dietician on 8/30/23. Resident will be reassessed by Dietician on 9/1/23. 5. R69's dietary orders have been updated to reflect current recommendations including frozen nutritional treats (8/29/23) and calorie count for 3 days (8/30/23). Weights are currently being monitored-monthly weight increase of 2.5 lbs. Reviewed by the Dietician on 8/28/23. Resident will be reassessed by Dietician on 9/1/23. 6. Medical Director was notified of Immediate Jeopardy 8/31/23 at 1:32 PM. 7. Facility will audit current residents and all new admissions in the last 30 days to ensure required dietary assessments are completed by a Registered Dietician by 9/7/23. 8. All residents' weights will be obtained by nursing and the restorative team by 9/1/23. 9.The facility Weight Policy was updated to include that losses greater than 5 lbs in one calendar month will be referred to RD and MD will be informed. The DON, ADON, and/or Designee will monitor weights to discover loss prior to it becoming significant. 10. Facility nurses and CNAs will be educated on reporting changes in intake, changes in diet preferences, and changes in condition to the DON, ADON, and/or designee. 11. The facility held an emergency QAPI meeting on 8/31/23 to discuss the policy relating to dietary assessments, quarterlies, and significant changes, along with interventions for residents with significant weight loss. 12. The Nurse Consultant, Director of Nursing, and/or designee will conduct chart audits to review that residents who have had significant weight loss will have interventions implemented starting 8/28/23. 13. The Nurse Consultant, Director of Nursing, and/or designee will audit to ensure that all required admission, readmission, quarterly, annual, and significant change assessments are completed by a Registered Dietician. Future audits will be completed daily for two weeks, then two times per week for four weeks, followed by weekly for 6 weeks. Any findings of noncompliance will be immediately reported to the Attending Physician and Family. 14. Findings of the QA audit shall be used to determine the level of compliance and need for additional training will be completed immediately and shall be submitted to the QAPI Committee for review and follow-up. Based on interview and record review the facility failed to complete quarterly and significant change dietary assessments on residents. The facility failed to ensure dietary assessments were completed by the Registered Dietician. The facility failed to identify resident weight loss prior to the weight loss becoming significant. The facility failed to ensure weight loss treatment interventions were initiated in a timely manner, once resident weight loss was identified. These failures resulted in R37, R69, R144, R9, and R79 sustaining a significant weight loss. These failures apply to 5 of 10 (R37, R69, R144, R9, R79) residents reviewed for weight loss in the sample of 31. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/27/23, when the facility's Registered Dietician (V6) failed to assess and complete a dietary assessment on R37, upon her admission to the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 8/31/23 at 12:46 PM. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 9/1/23 however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. R37's admission Record dated 3/27/23, showed R37 was admitted to the facility with diagnoses of dementia and a left hip wound related to recent hip surgery. An admission dietary profile for R37, dated 4/13/23, showed the profile was completed by V7, a non-certified Dietary Manager. R37's electronic medical records dated 3/27/28-4/25/23 were reviewed and showed no admission dietary assessment was completed by V6 Registered Dietician (RD). R37's Weight Report dated 8/29/23 showed R37 weighed 119.4 pound (lbs) upon admission to the facility. The record showed R37 weighed 118 lbs on 4/4/23 and 89 lbs on 4/25/23 which resulted in a significant weight loss of 24.5 % (29 lbs) in 21 days. R37's dietary note date 4/26/23, showed V6 RD's first visit/assessment of R37. The note showed R37 was not assessed by V6 RD until 28 days after admission and not until after R37 had sustained significant weight loss. A Dietary Note for R37, dated 5/15/23, showed R37 was assessed by V6 RD. The note showed, unintended weight loss . The note showed R37 was started on a diuretic on 4/21/23 but R37 had only been on the medication three days prior to the significant weight loss being discovered. On 8/29/23 at 10:00 AM, V6 RD stated, I am not full time or part time in the facility. I work in the facility on a consulting basis. I don't complete the admission, quarterly (every 3 months), or annual dietary assessments on the residents. The CDM (certified dietary manager) does those assessments. I don't routinely see residents unless they have significant weight loss, pressure wounds, are on dialysis, or require tube feeding. A resident could potentially be in the facility for months to years before I would need to see them. I don't see residents with dementia or with surgical wounds unless they have significant weight loss. Dementia and surgical wounds can put residents at risk for weight loss but those are not reasons or triggers for me to see a resident. The goal is to intervene before weight loss becomes significant. I did not see (R37) until after she had already had significant weight loss. I don't know why her admission dietary assessment was not completed until 4/13/23. I don't know exactly why she had such a significant weight loss. V6 RD stated she was aware V7 was not a certified Dietary Manager. On 8/29/23 at 1:12 PM, V7 Dietary Manager stated he was not certified in dietary management but, he was currently enrolled in school for dietary management. V7 stated he had no certifications in food service management, did not have an associate's degree, and had no past work experience in long term care facilities. V7 stated, I do the admission, quarterly, and annual dietary assessments on residents. The admission assessment should be done within 48 hours of admission. I am not sure why I did (R37's) admission assessment so late. I must have overlooked it. Nursing should be monitoring residents for weight loss. I only look at weights when I am doing a residents' quarterly assessments . V7 stated he did not routinely complete residents' dietary assessments collaboratively with V6 RD, despite him not being a certified dietary manager. V7 stated he had never completed a dietary assessment on a resident prior to him being hired by the facility. On 8/31/23 at 8:23 AM, V13 Nurse Practitioner (NP) stated the expectation is that the Registered Dietician assesses residents upon admission and quarterly to monitor residents for weight loss, weight gain, or any changes in nutritional needs. V13 stated any changes need to be reported to the physician or nurse practitioner immediately. V13 stated, If a Registered Dietician is not assessing residents at least quarterly, changes in a resident's condition could get missed which includes not catching a resident's weight loss. If weight loss is not caught in time, residents could develop malnutrition and/or wounds. On 8/31/23 at 8:23 AM, V1 Administrator stated V6 RD should be completing admission, quarterly, annual, and significant change dietary assessments on all residents. V1 stated she was notified on 8/30/23, that V6 RD was not completing the necessary dietary assessments on all residents. V1 stated, I didn't know, until yesterday, that (V6 RD) was not doing all the assessments. Nursing is responsible for monitoring residents for weight loss. (V6 RD) is responsible for running the weekly weights to see who triggers for significant weight loss or is losing weight. We want to stop the weight loss before it become significant. The Registered Dietician is also responsible for making sure the residents get the proper nutrition, proper diet, and for noticing any changes in weight. V1 stated because V7 (Dietary Manager) was not certified, he was not to be completing any resident dietary assessments, on his own. On 8/30/23 at 10:55 AM, V32 Regional Director of Operations stated, We have some concerns about (V6 RD's) job performance. We are in the process of letting her go. All resident admission, quarterly, annual, and significant change dietary assessments should be completed by the Registered Dietician. V32 stated he was aware V7 Dietary Manager was not certified. 2. R69's admission Record dated 2/11/22 showed R69 had diagnoses including Parkinson's disease, dementia, dysphagia, and muscle wasting/atrophy. R69's electronic medical records dated 8/1/22-8/27/23 were reviewed. The records showed the last dietary profile/assessment completed on R69 was 2/21/23, done by the previous CDM. No quarterly dietary assessment dated on or around 5/21/23 was noted for R69. R69's Weight Report printed 8/29/23 showed R69 weighed 143.2 lbs in May 2023 and 129.9 lbs in August 2023. This showed R69 sustained a significant weight loss of 9.3% (13.3 lbs) in three months. A Dietician Evaluation for R69, was completed by V6 Registered Dietician on 8/28/23, after R69 had sustained significant weight loss. The note showed, Unintended weight loss . V6 RD started R69 on nutritional supplements/weight loss treatment interventions on 8/28/23. On 8/29/23 at 10:00 AM, V6 RD stated, I didn't see (R69) until yesterday (8/28/23). Her last dietary assessment was completed on 2/21/23. I am not sure why she did not have as assessment done in May 2023. No one called me from the facility to tell me she was losing weight. I ran the facility's weight reports sometime during the middle of July (2023). I knew about (R69's) weight loss in July (2023) but did not put any interventions or supplements in place until yesterday. It was an oversight on my part. It got overlooked. That was my responsibility. On 8/29/23 at 1:01 PM, V13 Nurse Practitioner (NP) stated she was not aware of R69's significant weight loss from May 2023-August 2023. V13 stated, We should have been notified of (R69's) weight loss as soon as it was discovered so we could have implemented interventions. If (V6 RD) was aware of (R69's) weight loss in July (2023), she should have implemented interventions immediately. 3. R144's admission Record dated 4/5/23 showed R144 was admitted to the facility with diagnoses of a stroke (CVA/cerebral infarction), dementia, aphasia (inability to verbally communicate), and subdural hemorrhage (brain bleed). An admission dietary profile for R144, dated 4/16/23, showed the profile was completed by V7, the non-certified Dietary Manager. R144's electronic medical records dated 4/5/23-7/27/23 were reviewed and showed no admission dietary assessment completed by V6 RD. R144's Weight Report dated 8/31/23 showed R144 weighed 135 lbs in June 2023 and 120 lbs in July 2023. This showed R144 sustained a significant weight loss of 11.1 % (15 lbs) in one month. A Dietician Evaluation for R144, was completed by V6 RD on 7/28/23, after R144 had sustained significant weight loss. The note showed, Unintended weight loss related to decreased PO (oral) intakes as evidenced by chart review . On 8/31/23 at 9:18 AM, V6 RD stated she was unaware R144's oral intake had decreased until after R144 had sustained significant weight loss. V6 stated, I didn't assess her until after she had significant weight loss. I did not see her upon admission because she wasn't on dialysis, tube fed, and didn't have any pressure wounds.