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Based on record review, and interview the facility failed to ensure the nursing staff evaluated the care provided to 1 of 1 patients (patient #1) who developed a stage 2 pressure wound to his bilateral buttock. The facility provided no policy instructing the staff to record and report reduced or absent nutritional intake for patient #1 which contributed to a 6 pound weight loss from May 27, 2024 through June 25, 2024.

Findings included.

On the morning of 07/23/2024 interviews with the Director or Nurses (DON) staff #4 and the Assistant Director of Nurses (ADON), staff #5 stated "Yes, patient #1 developed a stage two pressure wound to his bilateral buttock." When the DON and ADON were asked about patient #1's weight loss, both replied." We'd need to check on that. I'm not sure if he had lost weight."

During the review of the medical record for patient #1 the DON was asked to assist in the identification and review of the record that would reflecting patient #1's meal intake, from the date of admission on May 27, 2024 through patient #1's discharge on June 25, 2024. Staff #2 stated, "It looks like when his medications were being changed, he didn't eat well. When he began to adjust to the new med's he started eating again".

Patient #1 was served three meals each day. The following is the intake recorded. The form instructs liquid intake in ML's (milliliters), and a supplement provided and consumed must be named. Patient's #1's diet was regular texture.

05/27/24: 0 Breakfast, 0 Lunch, 0 Dinner Supplement 120 Supplement (not named).
05/28/24: 118 Breakfast, 0 Lunch, 480 Dinner, 0 Supplement.
05/29/24: 240 Breakfast, 240 Lunch, 0 Dinner, 0 Supplement.
05/30/24: 0 Breakfast, 0 Lunch, 480 Dinner, 0 Supplement.
05/31/24: 480 Breakfast, 480 Lunch, 480 Diner, 120 Supplement (not named)
06/01/24: 240 Breakfast, 0 Lunch, 240 Dinner, 120 Supplement. (not named)
06/02/24: 360 Breakfast, 240 Lunch, 0 Dinner, 120 Supplement. (not named)
06/03/24: 0 Breakfast, 0 Lunch, 0 Dinner, 360 Supplement. (not named)
06/04/24: 240 Breakfast, 240 Lunch, 240 Dinner 270 Supplement. (not named)
06/05/24: 240 Breakfast, 355 Lunch, 350 Dinner, 240 Supplement. (not named)
06/06/24: 0 Breakfast, 240 Lunch, 240 Dinner, 0 Supplement. (not named)
06/07/24: 0 Breakfast, 0 Lunch, 480 Dinner, 1 ensure.
06/08/24: 240 Breakfast, 240 Lunch, 240 Dinner, 240 Supplement. (not named)
06/09/24: 360 Breakfast, 240 Lunch, 0 Dinner 0 Supplement.
06/10/24: 0 Breakfast, 0 Lunch, 240 Dinner, 1 ensure and 360 Supplement (not named).
06/11/24: 240 Breakfast, 240 Lunch, 240 Dinner, ensure 237 Supplement and 120 Supplement (not named).
06/12/24: 0 Breakfast, 0 Lunch, 240 Dinner, 120 Supplement (not named).
06/13/24: 600 Breakfast, 240 Lunch, 120 Dinner, 120 Supplement (not named).
06/14/24: 400 Breakfast, 400 Lunch, 600 Dinner, supplement illegible and Supplement 120 (not named).
06/15/24: 0 Breakfast, 240 Lunch, 240 Dinner, 0 supplement.
06/16/24: 240 Breakfast, 240 Lunch, 240 Dinner Supplement illegible and 240 supplement (not named)
06/17/24: 0 Breakfast, 0 Lunch, 360 Dinner Supplement 1 ensure, other 240.
06/18/24: 480 Breakfast, 400 Lunch, 480 Dinner, 0 Supplement.
06/19/24: 360 Breakfast, 240 Lunch, 240 Dinner, 0 supplement, 240 other.
06/20/24: 240 Breakfast, 240 Lunch, 200 Dinner, 240 Supplement (not named).
06/21/24: 360 Breakfast, 480 Lunch, 360 Dinner, 0 supplement.
06/22/24: 300 Breakfast, 300 Lunch, 240 Dinner, 0 Supplement.
06/23/24: 480 Breakfast, 360 Lunch, 0 Dinner, 0 Supplement.
06/24/24: 480 Breakfast, 480 Lunch, 240 Dinner, 0 supplement.
06/25/24: 360 Breakfast, 400 Lunch, Discharged.

Patient #1's medical record reflected that out of 30 days (90 meals) of admission, patient #1 had no recorded intake for 24 meals with 3 named or identified nutritional supplement for meal replacement.

Staff #2, the Director of Nursing, was asked for a policy that would explain how the staff collected and documented a patient's nutritional intake. After reviewing the facility's database no policy was found. The Administrator, staff #1 confirmed, "No, we don't have a policy". The facility did not have a policy instructing the staff on how to determine and document a patient's nutritional intake. The nutritional intake includes both the liquid and solid intake.

Patient #1's medical record did not include documentation reflecting solid nutritional intake (a percentage of food ingested).

Further review of the medical record revealed patient #1's admission weight was 144.8 pounds. There was no recorded change in patient #1's weight. The "Vital Signs/Intake and Output Flowsheet" provided a place at the top of each page for admission weight to be recorded and current weight to be recorded. Neither the admission weight, or patient #1's current weight were recorded on any of the 30 daily "Vital Signs/Intake and Output Flowsheet" forms. The ADON was asked if pt #1 was ever reweighed after admission. She replied, "A weekly weight is required". After reviewing a nursing clipboard which held raw data, a discharge weight of 136 lbs was found. Patient #1's weight change had not been recorded in his medical record. There was no evidence the physician had been made aware of pt #1's decreasing nutritional intake or of their weight loss. This was confirmed by interview with the DON, who stated, "No, I don't see where the physician was notified".