**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to consistently and accurately obtain weights, recognize significant weight loss, and provide consistent assistance with eating and cueing for 1 of 4 sampled residents (Resident 33) reviewed for nutrition. Resident 33 experienced a significant 14.6% weight loss from 05/27/2024 to 07/10/2024. This failure placed the resident at risk for further decline in their weight, unintended consequences of poor nutrition, and decreased quality of life. Findings included . Review of the facility policy titled Nutritional Management, dated 12/27/2023, showed that weekly weights would be obtained on new admissions for 4 weeks. After assessing the weight accuracy, the Licensed Nurse or Nursing Assistant would record the weight in the resident's electronic medical record under vital signs. Re-weighs were required for any unplanned 3-pound (lb) variance from week to week. Resident 33 admitted on [DATE] with diagnoses which included protein calorie malnutrition, fractured hip, fractured left arm and advanced dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of the hospital records showed a weight of 110 lbs. on 05/22/2024 and 114 lbs. on 05/24/2024. The resident's height was documented as 66 inches. The resident's Body Mass Index (BMI) was 18.4 which was underweight (below 18.5) for their height. Review of the facility's Registered Dietician (RD) admission assessment dated [DATE] used the hospital admission weight of 110 lbs. and goals were identified as: 1. Maintain current weight of 110 lbs. +/- 3% with no significant weight changes through the next review date. 2. Gradual weight gain is permissible due to low BMI. 3. Provide support, encouragement for resident to comfortably consume as much foods, and beverages as possible The RD assessment further stated Resident 33's average daily intake was likely not meeting the requirements for calories and protein and an appetite stimulant may be appropriate if the resident's weight continued to trend down and appetite was poor. Review of the care plan dated 06/06/2024 showed the RD goals were included with the following interventions: • Monitor, record, report to Provider as needed signs and symptoms of malnutrition: • Needs cueing and cleanup with meals/fluids, • Assist with meals as (they) allow. Needs to Eat where (they) can be monitored by nursing. • Provide and serve supplements as ordered: Ensure (nutritional supplement) with all meals. • RD to evaluate and make diet change recommendations as needed. • Resident eats in dining area. • Resident eats in room. Review of Resident 33's POLST (Physician's Orders for Life Sustaining Treatment) form dated 05/25/2024 showed a check mark in the box next to preference is to discuss medically assisted nutrition options, as indicated. The POLST was signed by the resident's Power of Attorney and provider on 05/25/2024. Review of facility's nutrition at risk assessment dated [DATE] showed Resident 33 was identified as being at risk for malnutrition due to age, impaired cognition, need for assistance with activities of daily living, low BMI, intake less than 50%, three or more medications, inflammation and current diagnosis impacting the resident's ability to eat. In an observation on 07/09/2024 at 9:12 AM, Resident 33 was observed lying in bed with their breakfast tray in front of them. Their eyes were closed. A bowl of hot cereal and hard cooked egg were on the tray, both untouched. The utensils were still lined up neatly on a clean folded napkin. There were three full lidded cups on the tray. One contained a chocolate shake and the other two contained water. There were no staff present in the room at the time of this observation. An observation on 07/09/2024 at 12:12 PM, showed Resident 33 was in their wheelchair. The resident appeared thin and frail. The resident was wearing a loose fitting t-shirt. Their left arm was in a sling (a bandage that supports and protects an injured arm, wrist, or hand) and they were fidgeting with the strap. The resident's lunch tray arrived and was placed in front of the resident who was sitting alone at a round table in the small common TV area of the unit. The meal was meatloaf, bread, scalloped potatoes, zucchini and a bowl of fruit. There was one full glass of a nutrition shake and one full glass of water. At 12:25 PM, the resident picked up a spoon and attempted to pick up a piece of fruit. After several attempts, they were able to pick up one grape and eat it. At 12:30 PM the resident was able to pick up a piece of pineapple with the spoon and it dropped, but after a few attempts, they were able to pick it up and eat it. At 12:35 PM they were able to cut into the corner of the scalloped potatoes and get a small piece; they were having difficulty as it was sticky and had not been cut up for the resident. At 12:38 PM the resident picked up the nutrition shake and took a few drinks. No staff were observed to cue, encourage or assist the resident with eating their meal. In an observation on 07/11/2024 at 12:42 PM, Resident 33 had their lunch tray in front of them which was untouched. The resident was looking at the TV and noted to be preoccupied with the sling on their left arm, the strap had slid down over their other arm, and they were pulling on the Velcro. Their hands were underneath the clothing protector and lap blanket they had on. The resident reached for the cup of nutrition shake and took a drink of it. The resident began hitting their armrest with the closed fist of their right hand and stated Please, please, then sighed, and began to push their wheelchair away from the table. Staff S, Certified Nursing Assistant (CNA), walked by and whispered in the resident's ear, then wheeled the resident into their room. Staff S exited the room and stated they took the resident to the restroom and the resident had stated they were done eating. The tray was observed to have one cracker missing from a saltine cracker package and the cup of nutrition shake was almost gone. No staff were observed to cue, encourage or offer to assist the resident during this meal. Record review of Resident 33's meal intake records for 05/25/2024 through 07/09/2024 showed there were 137 total meals: 45 breakfast meals- only 11 total breakfast meals showed the resident consumed 50% or greater of the meal. 46 lunch meals- only nine total meals showed the resident consumed 50% or greater of the meal. 46 dinner meals- only 11 total meals showed the resident consumed 50% or greater of the meal. There were 31 meals during this period that the resident was documented as having consumed 50% or greater of the meals. The other 106 meals were all documented as refused, blank (no documentation of the meal), 0%, or 25%. Review of Resident 33's clinical record on 07/09/2024 showed the vital signs section had one weight of 140 lbs. documented on 05/27/2024. No progress notes or other documentation of the discrepancy (26 lbs.) between the hospital's most recent weight and the facility's admission weight were found. Review of Resident 33's clinical record showed a pre-admission hospital weight of 114 on 05/24/2024 and a facility weight on 05/27/2024 of 140 lbs., which showed a 26 lb. weight gain which had not been reviewed by the facility. The facility had no other weights documented in the resident's record. In an interview on 07/10/24 at 11:24 AM, Staff B, Director of Nursing (DNS), stated there were worksheets filled out by the shower aids that included weights and they kept those in their office. The worksheets were not considered part of the medical record. Staff B stated that the showers and weights were supposed to be entered into the system after they were reviewed by the nurse. On 07/10/2024 at 11: 45 AM, Staff C, Assistant DNS (ADON) provided copies of worksheets titled (Staff E's) showers, or (Staff O's) showers and the dates. The worksheets contained a list of all the showers and weights that were assigned to be done by that shower aid (CNA) on a given day. The following dates showed handwritten weights for Resident 33: • 05/27/2024= 140 lbs. (Staff O's showers) • 06/05/2024= 140.2 lbs. (Staff E's showers) • 06/12/2024= 141.2 lbs. (Staff E's showers) • 06/18/2024= 141.2 lbs. (Staff O's showers) • 06/26/2024= 143 lbs. (Staff E's showers) • 06/27/2024= 141.6 lbs. (Staff E's showers) • 07/03/2024= 142.5 lbs. (Staff E's showers) There were no signatures to indicate who had obtained the weights, only the name of the assigned shower aid printed at the top of the sheet. There were observed to be different styles of handwriting on the sheets. There was no documentation showing what type of scale was used for each weight. There was a space for nurse's initials on the far right but none of the entries for Resident 33 included a nurse's initials. In an interview on 07/11/2024 at 9:14 AM, Staff D, Registered Nurse (RN)/Case Manager, stated (Staff O, CNA) was no longer employed at the facility. Staff D stated that Staff E, CNA assisted with showers on their unit and the process was for the shower aids to weigh residents on their shower day and when they entered the weights in the computer there was a place to document what type of scale was used. The nurses were responsible to obtain weights for residents who had a daily weight or other weights that needed to be done at a specific time or more often than with their shower. Staff D was asked to review the weight documentation in the computer for Resident 33 which showed only the one weight which was 26 lbs. greater than the most recent hospital weight. Staff D stated they reviewed the weights for the unit weekly and was not aware of the weight discrepancy and missing weight documentation for Resident 33. In an interview on 07/11/2024 at 09:47 AM, Staff D (accompanied by Staff C) stated they had reviewed the weights for Resident 33 and stated the weight (140 lbs.) was entered into the system incorrectly. Staff D stated the weight for Resident 33 was entered as 140 lbs. and it should have been 114 lbs. The incorrect weight had been struck out and a weight of 114 lbs. was now in the system. Staff D was shown the shower worksheets which contained weights that were never entered into the computer system and were showing as consistent with the (now) struck out weight, and discussed observations of the resident's poor intakes and observation of the general thin appearance of the resident which did not match what the shower worksheet weights documented. Staff D stated they were not sure what the resident's correct weight was. In an observation with Staff D on 07/11/2024 at 10:05 AM, Resident 33 was weighed in the shower room on the wheelchair scale. Staff D was observed to zero the scale and the resident was in their chair with the footrests on. The resident was wheeled onto the scale and the combined weight was observed to be 169 lbs. and was verified several times. The wheelchair was weighed separately with the footrests and weighed 71.7 lbs. After subtracting the wheelchair weight, the resident's actual weight was 97.3 lbs., which was a 16.7 lb. (14.6%) weight loss since admission based on the baseline hospital weight of 114 lbs. The resident's BMI was now 15. Review of the medical record, care plans through 07/10/2024 showed no documentation of notification to the provider, POA or additional interventions related to the inaccurate weights. In an interview and observation on 07/12/2024 9:22 AM, Staff E, CNA, Shower Aide, reviewed the process for weights and weight documentation during shower assignments. Staff E stated they assisted with showers on Resident 33's unit sometimes and the weights were done using the shower chairs. Staff E demonstrated obtaining the weight of a shower chair, zeroing the scale and noted the weight of the shower chair was 17 lbs. which Staff E stated was close to what all the shower chairs weighed. Staff E stated if a resident received a bed bath, they used the Hoyer (mechanical) lift to get their weight. Staff E stated they would enter the weights into the computer at the end of their shift. Staff E was asked about weights for Resident 33 and said they did not remember being the one to obtain any of Resident 33's weights. Staff E stated that sometimes the nurses or the CNAs on the floor would get the weights and write them on the shower worksheets and suggested that was what may have occurred. In an interview on 07/12/2024 at 10:11 AM, Staff N, LPN, stated the nurses or CNAs did not get the weights on their unit. Staff N stated there would have been no reason for them to get (Resident 33's weight) as they were not on a daily weight (or other specifically ordered weight) so the shower aids would have been the ones to get weights for Resident 33. Staff N stated all residents should be getting weighed once a week but there was nothing in the system that notified them if someone did not have a weight. Staff N stated the unit managers reviewed the weights. In an interview on 07/12/2024 at 12:09 PM, with Staff B, DNS and Staff C ADON, Staff B stated the goal was for residents to be weighed weekly and those weights documented in the computer system along with the type of scale used. Staff B stated residents should be re-weighed if there was a discrepancy. The Unit Managers reviewed weights weekly and if there was a change of three lbs. up or down, or if they triggered for weight loss of 5%, or 10%, they would be discussed in the facility team meeting, they would assess the resident and notify the provider, the RD, and the family. Staff B and C stated they had not been aware of Resident 33's weight loss and did not know why the weight documentation was consistently inaccurate for the resident on the worksheets, or how their weights had not been entered into the system or reviewed by any licensed nurses or the Unit Manager according to the policy. Refer to WAC 388-97-1060 (3)(h) This is a recurring deficiency previously cited on the Statement of Deficiencies dated April 25, 2023.