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Based on record review and interview the facility failed to ensure that there was a 2 day response to grievances filed with the facility as per facility policy in 3 of 3 complaints reviewed; that there was a formal, written notice of the investigation into and facility decision on grievances filed as per facility policy in 3 of 3 complaints reviewed (patient #s 9, 11 and 12); that there was a physician order present every 24 hours for patients requiring the use of restraints in 2 of 4 (Patient #'s 5 & 10) restraint charts reviewed and that every 2 hour checks/assessments were being completed on patients in restraints in 4 of 4 (Patient #'s 4, 5, 9 & 10) restraint charts reviewed out of a total universe of 10 closed and open medical records.

Findings include:

The facility failed to ensure there was a 2 day response to grievences filed. See tag A-0122.

The facility failed to ensure that there was a formal, written notice of the investigation into the filed grievance and notice of results after investigation. See tag A-0123.

The facility failed to ensure that there was a physician order present every 24 hours for patients requiring the use of restraints. See tag A-0168.

The facility failed to ensure that staff were performing every 2 hour restraint assessments on patients in restraints. See tag A-0205.

Based on record review and interview the facility failed to ensure that there was adequate staffing on the floor for patient care assessments and cares to be completed; that patient weights were being monitored weekly; that there was documented re-weighs if weights were 3 pounds different from previous weight; that the Registered Nurse (RN) was notified of weight changes; that a reassessment was completed by dietician after weight changes; and that the physician was notified of weight change as per facility policy in 4 of 10 (Patient #'s 1, 4, 5 & 8) medical records out of a total universe of 10 closed and open medical records reviewed.

Findings include:

The facility failed to ensure that there was adequate staffing on the floor for patient care assessments and cares to be completed. See tag A-0392.

The facility failed to ensure that patient weights were being taken weekly as ordered, re-weighs being completed as per facility policy and that nurses, physicians and dieticians were being notified and completing assessment of weight losses. See tag A-0392.

Based on record review and interview the facility failed to ensure that there was a 2 day response to grievances filed with the facility as per facility policy in 3 of 3 complaints (patients # 9, 11 and 12) reviewed.

Findings include:

The facility document titled "Patient Grievances, Complaints, and Advocacy Services-Hospital" #3.070 last revised 9/21 was reviewed. This document revealed "DEFINITIONS: Complaint: A complaint is a formal or informal written or verbal concern, made to the hospital by a patient or the patient's representative, regarding the patient's care. Grievance: A complaint that cannot be resolved at the time of complaint becomes a grievance. "PROCEDURE:...3. The original grievance and complaint form is forwarded to the Patient Family Representative. 4. The Patient Family Representative or designee must review the grievance with the patient/representative within two (2) business days of the grievance being made."

A "Patient Grievance and Complaint" dated 6/20/2022 was reviewed. This document revealed that Patient #9's son and Power of Attorney (POA) filed a grievance with Nurse Case Manager E on the following concerns: long call light wait times, call light placed where Patient #9 could not reach, "area under folds were not clean and had an odor", Patient #9 lying in urine and fecal matter upon son visiting, a Certified Nursing Assistant (CNA) came into room and said that Patient #9 did not need to be changed, son had to show CNA that linens were soaked under the patient and that oral cares were not being provided correctly and it was leading to increased thrush in Patient #9's mouth."

On 6/27/2022 (7 days later) Director of Quality C called Patient #9's POA. Director of Quality C documented the phone call "Called complainant to acknowledge the complaint and follow up. Under "Review and Proposed Resolution:" there was documented "6/27/2022 Shared with leadership."

There was no documented contact of complainant within 2 days per facility policy.

A "Patient Grievance and Complaint" dated 6/6/2022 was reviewed. This document revealed that Patient #11's mother had a conversation with Nurse Case Manager F and expressed concerns about Patient #11's care including: hygiene-craddle cap and teeth not brushed, patient up in chair longer than the physician ordered 2 hour periods, mom had to empty patients foley (catheter used to drain bladder) catheter herself twice, patient in urine soaked clothing with visible new areas of skin irritation and breakdown and patient had not had a shower in months. Nurse Case Manager F reported the complaints via e-mail to CNO B and Director of Quality C.

On 7/7/2022 (32 days later) Director of Quality C documented "QAPI (Quality) COMPLAINT FOLLOW UP" that documented "Chart determined I&O's (intake and output) have been recorded daily and foley care has been provided as ordered...Bariatric shower had been ordered and received. Pt (patient) received a shower as requested, and then refused any further showers, stating it was too uncomfortable."

On 7/7/2022 when asked Administrator G why follow up was completed on 7/7/2022 Administrator G responded "This was completed today only because our QA Director was out with COVID. As a result of the circumstances here, we are working on a process pursuant to which the QA director's designee would conduct a preliminary/interim investigation in her absence, to be reviewed and finalized upon her return."

There was no documented contact of complainant within 2 days as per facility policy.

A "Patient Grievance and Complaint" dated 6/26/2022 was reviewed. This document revealed that Patient #12's spouse had e-mailed Case Manager G that Patient #12 did not receive a meal (supper) tray. E-mail documented from spouse "Told the nurse that came in to change dressing and was told too late now kitchen is closed now. Sorry but that excuse doesn't fly, could you please see that a mix up like that does not happen again."

On 7/6/2022 requested the investigation and follow up into above complaint, none was provided.

There was no documented contact of complainant within 2 days as per facility policy.

Based on record review and interview the facility failed to ensure that there was a formal, written notice of the investigation into and facility decision to grievances filed with the facility as per facility policy in 3 of 3 complaints (patients #9, 11 and 12) reviewed.

Findings include:

The facility document titled "Patient Grievances, Complaints, and Advocacy Services-Hospital" #3.070 last revised 9/21 was reviewed. This document revealed "PROCEDURE:...b. In its resolution of the grievance, the hospital must provide the patient with the written notice of its decision. Written notice must include: a. Hospital contact person, b. Steps taken on behalf of the patient to investigate the grievance. c. Results of the grievance process. d. Date of the investigation completion. e. Additional patient rights if dissatisfied with resolution. i. The right to file with outside agencies AND ii. The right to request an internal appeal process."

A "Patient Grievance and Complaint" dated 6/20/2022 was reviewed. This document revealed that Patient #9's son and Power of Attorney (POA) filed a grievance with Nurse Case Manager E on the following concerns: long call light wait times, call light placed where Patient #9 could not reach, "area under folds were not clean and had an odor", Patient #9 lying in urine and fecal matter upon son visiting, a Certified Nursing Assistant (CNA) came into room and said that Patient #9 did not need to be changed, son had to show CNA that linens were soaked under the patient and that oral cares were not being provided correctly and it was leading to increased thrush in Patient #9's mouth." On 6/27/2022 (7 days later) Director of Quality C called Patient #9's POA. Director of Quality C documented the phone call "Called complainant to acknowledge the complaint and follow up...In regards to the other pieces of his complaint, he said he has made multiple complaints about her care (Quality has never received them). And that he has been told that they would be shared with the head of the department and corrected, but nothing has been corrected...I told him I would bring these to the attention of leadership and staff and to call me directly if she were to return (to facility) and we would make a plan to ensure that her care is up to standards and I gave him my extension." Under "Review and Proposed Resolution:" documentation revealed "6/27/2022 Shared with leadership."

An interview was conducted with Patient #9's POA on 7/6/2022 at 3:40 PM. When asked if he received any information from the facility in follow up to grievance filed POA stated "I have had no response at all. On the phone I was told my complaints would be brought up with the leaders but no one has ever gotten back to me." When asked if there had been any written or verbal information on the investigation into grievance allegations or written notice of facility's decision on grievance POA stated "No. Nothing."

An interview was conducted with Director of Quality C on 7/6/2022 at 12:05 PM. When asked for the investigation into the allegations and the written notice of decision within 7 days (per facility policy) of the filing of the grievance Director of Quality C stated "No. We don't do that." When facility grievance policy was read to Director of Quality C, stated "That policy needs to be revised."

There was no documented written notice of its decision including Hospital contact person, steps taken on behalf of the patient to investigate the grievance, results of the grievance process, date of the investigation completion, additional patient rights if dissatisfied with resolution, the right to file with outside agencies and the right to request an internal appeal process.

A "Patient Grievance and Complaint" dated 6/6/2022 was reviewed. This document revealed that Patient #11's mother had a conversation with Nurse Case Manager F and expressed concerns about Patient #11's care including: hygiene-craddle cap and teeth not brushed, patient up in chair longer than the physician ordered 2 hour periods, mom had to empty patients foley (catheter used to drain bladder) catheter herself twice, patient in urine soaked clothing with visible new areas of skin irritation and breakdown and patient had not had a shower in months. Nurse Case Manager F reported the complaints via e-mail to CNO B and Director of Quality C.

An interview was conducted with Patient #11's mother on 7/6/2022 at 4:00 PM. When asked if she received any information from the facility in follow up to grievance filed mother stated "I didn't get anything formally but it seemed like it got better after I talked to the case manager." When asked if there had been any written or verbal information on the investigation into grievance allegations or written notice of facility's decision on grievance Patient #11's mom stated "No."

On 7/7/2022 (32 days later) Director of Quality C documented "QAPI (Quality) COMPLAINT FOLLOW UP" that documented "Chart determined I&O's (intake and output) have been recorded daily and foley care has been provided as ordered...Bariatric shower had been ordered and received. Pt (patient) received a shower as requested, and then refused any further showers, stating it was too uncomfortable."

On 7/7/2022 when asked Administrator G why follow up was completed on 7/7/2022 Administrator G responded "This was completed today only because our QA Director was out with COVID. As a result of the circumstances here, we are working on a process pursuant to which the QA director's designee would conduct a preliminary/interim investigation in her absence, to be reviewed and finalized upon her return."

There was no documented written notice of its decision including Hospital contact person, steps taken on behalf of the patient to investigate the grievance, results of the grievance process, date of the investigation completion, additional patient rights if dissatisfied with resolution, the right to file with outside agencies and the right to request an internal appeal process.

A "Patient Grievance and Complaint" dated 6/26/2022 was reviewed. This document revealed that Patient #12's spouse had e-mailed Case Manager G that Patient #12 did not receive a meal (supper) tray. E-mail documented from spouse "Told the nurse that came in to change dressing and was told too late now kitchen is closed now. Sorry but that excuse doesn't fly, could you please see that a mix up like that does not happen again."

On 7/6/2022 requested the investigation and follow up into above complaint, none was provided.

Based on record review and interview the facility failed to ensure that there was a physician order present every 24 hours for patients requiring the use of restraints in 2 of 4 (Patient #'s 5 & 10) restraint charts reviewed out of a total universe of 10 open and closed medical records.

Findings include:

The facility document titled "Medical Restraint-Hospital" #14.260 last revised 1/21 was reviewed. This document revealed "Discontinuation of Restraint: A physician no less than every calendar day evaluates the need for restraint...Any restraint not reordered within the next calendar day will constitute a discontinued order. Nursing is responsible to remove restraints if physician does not reorder within one calendar day."

A review of Patient #5's open medical record was conducted on 7/5/2022. Patient #5 had a physician order for bilateral soft wrist restraints, video monitoring, lap belt, siderails x 4 and wanderguard. There was no physician order documented for the use of restraints on 6/24/2022 but there was documented restraint flowsheet charting that restraints were in place on Patient #5 on that date.

A review of Patient #10's open medical record was conducted on 7/6/2022. Patient #10 had a physician order for lap belt, siderails x 4 and video monitoring. There was no physician order documented for the use of restraints on 5/27/2022 but there was documented restraint flowsheet charting that restraints were in place on Patient #10 on that date.

An interview was conducted with Chief Nursing Officer B and Quality Coordinator A on 7/5/2022 (Patient #5) & 7/6/2022 (Patient #10) medical record review. When asked if there was a physician order present in the medical record on the above patients and stated dates Chief Nursing Officer B stated "No. There isn't one and there should be."

Based on record review and interview the facility failed to ensure that every 2 hour checks/assessments were being completed on patients in restraints in 4 of 4 (Patient #'s 4, 5, 9 & 10) restraint charts reviewed out of a total universe of 10 closed and open medical records reviewed.

Findings include:

The facility document titled "Medical Restraint-Hospital" #14.260 last revised 1/21 was reviewed. This document revealed "Ongoing assessment of the patient's well-being while in restraints is made hourly by the nurse. The nurse will document in the EMR (electronic medical record) every two hours. Documentation will include: time, neurovascular check completed, skin integrity check, safety check, range of motion, re-assessment of restraint use, and alternative interventions. If there are any exceptions to the defined normal limits, the nurse must then also document in the comments section of the restraint flowsheet...Monitoring means that the patient will be seen to determine if the use of restraint continues to be safely applied, and if there appears to be a need for an assessment of the patient to occur. Ongoing assessment means that the patient will be evaluated to determine the patient's response to the restraint, and if the patient has any care needs. This assessment shall include checking the patient's hydration and circulation; the patient's level of distress and agitation; or skin integrity, and may provide for general care needs (e.g., eating, hydration, toileting, and range of motion exercises). This assessment shall also determine if the patient continues to require restraint."

Patient #4 had a physician order for siderails x 4 and video monitoring. Restraint flowsheets dated 7/5/2022 - 6/23/2022 were reviewed. On the following dates there was either no documented checks every 2 hours on restraint flowsheets or incomplete documentation: 7/2/2022-no documented checks from 12:01 AM until 8:00 AM (8 hours); 6/30/2022-incomplete documentation ("done" entered under safety checks all other areas blank) on the 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM and 5:00 PM entries and no entries after 5:00 PM (7 hours); 6/29/2022-no documented checks after 6:00 PM (6 hours); 6/28/2022 & 6/25/2022-no documented checks after 6:00 PM (6 hours) and 6/23/2022-incomplete documented checks ("done" under safety checks all other areas blank) at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM and 5:00 PM and no documented checks from 5:00 PM until 10:00 PM (5 hours).

An interview was conducted with Chief Nursing Officer B and Quality Coordinator A on 7/5/2022 at 3:50 PM. When restraint flowsheets revealed the above listed documentation CNO B stated "Yep they missed it."

Patient #5 had a physician order for bilateral soft wrist restraints, video monitoring, lap belt, siderails x 4 and wanderguard. Restraint flowsheet's dated 6/17/2022 - 6/28/2022 were reviewed. On the following dates there were no documented checks every 2 hours on restraint flowsheets: 6/28/2022 & 6/27/2022-no documented checks from 4:00 PM until midnight; 6/26/2022-no documented checks from 8:00 AM until midnight; 6/25/2022-no documented checks 2:00 AM until 8:00 AM (6 hours); 6/24/2022-no documented checks from 6:00 AM until 10:00 PM (16 hours); 6/21/2022-no documented checks from 12:00 AM until 8:00 AM (8 hours) or after 6:00 PM until 12:00 PM (6 hours); 6/19/2022-no documented checks from 2:00 AM until 8:00 AM (6 hours); 6/18/2022-no documented checks from 6:00 AM until 12:00 PM (18 hours) and 6/17/2022-no documented checks from 1:00 PM until 12:00 PM (11 hours).

An interview was conducted with Chief Nursing Officer B and Quality Coordinator A on 7/5/2022 at 4:15 PM. When restraint flowsheets revealed the above listed documentation CNO B stated "Yep they missed it."

Patient #9 had a physician order for 1 soft wrist restraint and siderails x 4. Restraint flowsheet's dated 6/30/2022 - 7/5/2022 were reviewed. On the following dates there are no documented checks every 2 hours on restraint flowsheets: 7/5/2022-no documented checks from 12:00 AM until 7:00 AM (7 hours) and none completed from 7:00 PM until 12:00 PM; 7/4/2022-no documented checks completed for the entire 24 hours; 7/3/2022-no documented checks after 6:00 AM; 7/2/2022-no documented checks from 12:00 AM until 7:30 AM (7 hours); 6/30/2022-no documented checks from 6:00 PM until 12:00 PM (6 hours) and 6/29/2022-no documented checks completed for the entire 24 hours,

An interview was conducted with Chief Nursing Officer B and Quality Coordinator A on 7/6/2022 at 10:15 AM. When restraint flowsheets revealed the above listed documentation CNO B stated "Yep they missed it."

Patient #10 had a physician order for lap belt, siderails x 4 and video monitoring. Restraint flowsheet's dated 6/30/2022 - 7/5/6/2022 were reviewed. On the following dates there were either no documented checks every 2 hours or incomplete documentation (blank areas) on restraint flowsheet's: 7/2/2022-no documented checks from 12:00 AM until 8:00 AM (8 hours) and after 6:00 PM until 12:00 PM (6 hours) and 6/30/2022-no documented checks from 12:00 AM until 7:00 AM (7 hours) and incomplete documentation ("done" entered under safety checks all other areas blank) on the 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM and 5:00 PM entries.

An interview was conducted with Chief Nursing Officer B and Quality Coordinator A on 7/6/2022 at 11:45 AM. When restraint flowsheets revealed the above listed documentation CNO B stated "Yep they missed it."

Based on record review and interview the facility failed to ensure that there was adequate staffing on the floor for patient care assessments and cares to be completed for 2 of 10 (patients 9 and 11) patients; and failed to ensure that patient weights were being monitored weekly; that there was documented re-weighs if weights were 3 pounds different from previous weight; that the Registered Nurse (RN) was notified of weight changes; that a reassessment was completed by dietician after weight changes; and that the physician was notified of weight change as per facility policy in 4 of 10 (Patient #'s 1, 4, 5 & 8) medical records out of a total universe of 10 closed and open medical records reviewed.

Findings include:

The facility document titled "Vital Signs" #7.052 date implemented 9/21 was reviewed. This document revealed "Weight: Weight will be assessed upon admission and weekly on Sundays with follow up attempts on Monday."

The facility document titled "Weights" #7.800 last reviewed on 4/21 was reviewed. This document revealed "5. All weights are to be compared to the last weight obtained. If a variance of three pounds or more is noted, patient must be re-weighed. If the variance is confirmed it is the nurse's responsibility to notify the physician and dietitian of the variance."

The facility document titled "Nutrition Screen and Assessment" #12.030 last reviewed 6/20 was reviewed. This document revealed "2. Nutrition Assessments: A. The registered dietitian performs a nutrition assessment on all hospital patients within four business days of admission. The assessment is based on current clinical practice...which includes, but is not limited to: Review of the current diagnosis. Past medical, social and diet history. Clinical, anthropometric and biomedical appraisal. Subjective information. Determination of estimated nutrition needs...C. The dietitian, utilizing the nutrition care process including diagnosis, intervention, and goals develops a nutrition assessment and care plan. Plan is revised based on the reassessment of the patient. D. Routine dietitian reassessments will be performed at least every two weeks for hospital patients...or when a change in patient condition occurs. The patients plan of care, treatment goals, and nutrition plan(s) are revised as needed. E. It is the dietitian's responsibility to optimize the patient's and resident's nutritional status and recommend appropriate nutrition intervention(s) including, but not limited to: diet order from the medical staff approved diet manual, supplements, enteral feeding regimen, weight regimen, parenteral nutrition formulation and appropriate lab tests."

Examples of short staffing:

An interview was conducted with Patient #9's POA (Power of Attorney) on 7/6/2022 at 3:40 PM. Patient #9 had been a patient at the facility from 5/23/2022 - 6/6/2022 went to an acute hospital and returned to the facility 6/29/2022 and was currently a patient. Patient #9's POA/son filed a complaint with the facility on 6/20/2022 with allegations of the following: patient waited (while son in room) 90 minutes for someone to answer the call light; multiple times the call light was not placed within Patient #9's reach; skin under abdominal folds were not being cleaned and had an odor; his mother was lying in urine and fecal matter. A CNA (Certified Nursing Aide) came into room and checked on patient and said she was dry. The son had to call her (CNA) back to show her that his mother was soaked underneath to the sheets and ask for her to be cleaned up; oral cares were not being done and lead to oral thrush and he was told his mother fell out of bed when she has restraints on. When asked about the above allegations POA became very upset and loud "The care there is so ridiculous. They don't have enough staff to take care of these patients...Nobody was taking care of her (explanative) wounds she had or her trach (tracheostomy-hole made in wind pipe to maintain an airway) cares. When she got to the hospital they couldn't believe how badly infected her site was. I did not want her to go back to that (explanative) place again but I had no choice. I feel awful that she is there again. If they don't have enough staff to take care of these people they should stop taking admissions."

An interview was conducted with Patient #11's mother on 7/6/2022 at 4:00 PM. Patient #11 had discharged from facility on 7/2/2022 and his mother, a nurse, lives in Texas but had been in the area while Patient #11 was in the facility. On 6/6/2022 the mother spoke with a case manager about the following concerns regarding her sons care; the patient was "visible" dirty, huge build up of skin on his feet from not being washed, cradle cap, and teeth unbrushed; is only supposed to be up in the chair for 2 hours a day due to inability to offload pressure and new wounds to his buttocks. Staff did not keep track of time spent up. Mom reports that he is up three plus hours and then she has to ask staff to put him to bed; she has had to empty foley (catheter used to drain bladder) twice while visiting. No one even came in to check it or is recording intake and output; she has found him in bed with shorts on that are soaked with visible new areas of skin irritation and breakdown; and when she mentions to staff care concerns they have no knowledge of him or his plan of care. Mom stated "If these things are going on when I am here I worry about what is happening when I am not. When asked about the facility and her care concerns Patient #11's mom stated "I know they are short staffed but so is everyone. It was very obvious. He (Patient #11) was supposed to be helped with meals they would set him up but when he didn't like what was served they wouldn't get him anything else. They said we couldn't bring him in food either. It was all the "comfort" things they are lacking because they don't have enough staff. There was no paper towels in the dispenser in his room on a Saturday once and I asked for more and they told me they don't have housekeeping in on the weekends."

An interview was conducted with Chief Nursing Officer (CNO) B on 7/5/2022 at 10:00 AM. When requested facility policy on staffing CNO B stated "We don't have one. On our 2 units the ratio for nurses is 6:1 and for CNA's (Certified Nurses Aides) it is 7:1."

The facility staffing for both units (South and East) from 5/1/2022 - 7/5/2022 (total of 65 days) were reviewed. On the following dates the staff to patient ratio was documented at a higher level (more patients to staff) than CNO B stated was the standard on either nights or day shifts and/or there was no one documented as assigned to some patients: 7/4/2022, 7/3/2022, 7/2/2022, 6/29/2022, 6/28/2022, 6/27/2022, 6/28/2022, 6/19/2022, 6/18/2022, 6/17/2022, 6/16/2022, 6/14/2022, 6/13/2022, 6/12/2022, 6/9/2022, 6/8/2022, 6/7/2022, 6/5/2022, 6/4/2022, 6/3/2022, 6/2/2022, 6/1/2022, 5/31/2022, 5/30/2022, 5/29/2022, 5/28/2022, 5/27/2022, 5/26/2022, 5/25/2022, 5/24/2022, 5/23/2022, 5/22/2022, 5/20/2022, 5/18/2022, 5/17/2022, 5/16/2022, 5/15/2022, 5/14/2022, 5/13/2022, 5/12/2022, 5/10/2022, 5/5/2022 & 5/3/2022 a total of 43 days out of 65 (66% of the days short staffed).

An interview was conducted with CNO B on 7/5/2022 at 11:05 AM. When asked to review the dates CNO B stated "I know you are right. We were short staffed on all of those dates."

Examples of weights not rechecked or weight losses addressed:

Patient #1 was admitted to the facility on 5/6/2022 and discharged back to an acute care hospital on 6/3/2022. Admission weight (5/6/2022) for Patient #1 was 255 pounds. Review of weekly weights revealed the following: 5/15/2022 was 245.6 pounds (10 pounds under admission weight 9 days later), 5/27/2022 was 234.8 pounds (down 10.8 pounds from previous weight 12 days prior) and on 5/29/2022 was again 234.8 pounds. Patient #1 had a 20.2 pound weight loss in 23 days. Patient #1 had nausea, vomiting and decreased appetite and received as needed antiemetic's (medication to stop nausea and vomiting) documented on nursing progress notes beginning on 5/11/2022 (5 days after admission). There was documented decreased oral intake, nausea and/or vomiting in nursing progress notes on 5/11/2022, 5/22/2022, 5/25/2022, 5/29/2022, 5/30/2022, 6/1/2022 & 6/2/2022. There was documented weakness and decrease in physical functioning (had to be hoyer lifted back to bed from commode and had been pivot transferring) in the nursing progress notes on 5/25/2022. There was documented notification of physician of Patient #1's decreased appetite and nausea in nursing progress notes on 5/11/2022 & 5/30/2022. On 6/3/2022 nursing progress note documented "Per physician pt is being sent out to (acute care hospital name)."

The providers "Discharge Summary" dated 6/3/2022 revealed "Hospital course: Nausea/vomiting. started about 1-2 weeks perior to d/c (discharge), unclear etiology, ddx (differential diagnosis) medication induced, kidney issues (creatine had increased) vs. (versus) gERD (gastric esophageal disease) vs. other, fluconazole (antibiotic) decreased, renal was consulted and started IVFs (intravascular fluids), Repeat labs from today pending...given persistent symptoms, no improvement, will send to ER (emergency room) for further evaluation...Given persistent symptoms, no resolution with interventions, reasonable to send for expedited work up. patient stable on transfer...Generalized deconditioning."

The initial "Adult Nutritional Assessment" was completed by Registered Dietician (RD) D on 5/9/2022 (3 days after admission). Patient #1 was given a diet order for a regular, diabetic diet with 5 carbohydrates a meal and thin liquids and supplements including Juven (to promote wound healing) once a day, Boost Glucose control twice a day and Prostat (protein). A "Nutrition Follow-Up Assessment" was completed 5/23/2022 (2 weeks later) by RD D and documented "Weight Change Comments: No new weight since admission (weight documented as completed on 5/15/2022 and patient had lost 10 pounds since admission)...Estimated needs per Ideal Body Weight Comments: Monitor wt, intake, BG (blood glucose)...need to adjust carbohydrate level...Goals: Patient will consume 75% of estimated needs. Promote adequate intake to support wound healing. Assess education and discharge needs." Patient #1 was discharged to an acute hospital on 6/3/2022. There was no documented re-assessment of decreased appetite, nausea or 20 pound weight loss since admission by RD D.

There was no documented re-weigh as per facility policy if weight is 3 pounds different from previous weight for any of the above weights.

There was no documented notification to the nurse of weight change or documentation of the nurse notifying the physician of the patients weight loss.

There was no documented weight check weekly on 5/22/2022 as per facility policy.

An interview was conducted with RD D on 7/6/2022 at 3:45 PM. When asked if increased reassessments were being done on patients if they had a weight loss RD D stated "Our policy says we can do every 7 to 14 days but it is based on our professional judgement...A lot of times when there are weight losses I attribute it to fluid fluctuations."

An interview was conducted with Chief Nursing Officer B and Quality Coordinator A on 7/5/2022 at 1:00 PM. When asked for re-weights on the days when weights were 3 pounds off from previous reading or notification to nursing and physician of weight change (as per facility policy) CNO B stated "It wasn't done.

Patient #4 was admitted to the facility on 1/27/2022. Admission weight for Patient #4 was 155.4 pounds. Review of weekly weights (5/1/2022 - 7/5/2022) revealed the following: 5/2/2022 weight was 166.1 pounds, 5/15/2022 weight was 171.2 pounds (up 5.1 pounds from previous weight), 6/12/2022 weight was 174.3 pounds (up 5.6 pounds from previous week), 6/19/2022 weight was 169.5 pounds (down 4.8 pounds from previous weight) and 6/26/2022 weight was 173.4 pounds (up 3.9 pounds from previous weight.

There was no documented re-weigh as per facility policy if weight is 3 pounds different from previous weight for any of the above weights.

There was no documented notification of nurse of weight change or documentation of the nurse notifying the physician of the patients weight loss.

An interview was conducted with Chief Nursing Officer B and Quality Coordinator A on 7/5/2022 at 3:30 PM. When asked for re-weights on the days when weights were 3 pounds off from previous reading or notification to nursing and physician of weight change (as per facility policy) CNO B stated "It wasn't done.

Patient #5 was admitted to the facility on 5/16/2022. Admission weight for Patient #5 was 160.1 pounds. Review of weekly weights revealed the following: 6/6/2022 was 169.4 pounds (up 9.3 pounds since admission), 6/12/2022 was 180.8 pounds and 7/3/2022 was 175.3 pounds (4.7 pounds less than previous weight of 180 pounds).

There was no documented re-weigh as per facility policy if weight is 3 pounds different from previous weight for any of the above weights.

There was no documented notification of nurse of weight change or documentation of the nurse notifying the physician of the patients weight loss.

An interview was conducted with Chief Nursing Officer B and Quality Coordinator A on 7/5/2022 at 2:30 PM. When asked for re-weights on the days when weights were 3 pounds off from previous reading or notification to nursing and physician of weight change (as per facility policy) CNO B stated "It wasn't done.

Patient #8 was admitted to the facility on 6/21/2022. Admission weight for Patient #8 was 179.2 pounds. Review of weekly weights revealed the following: 6/26/2022 was 176 pounds (down 3 pounds in 5 days) and of 7/3/2022 of 173.8 (5.4 pounds less than admission weight).

There was no documented notification of nurse of weight change or documentation of the nurse notifying the physician of the patients weight loss of 5 pound weight loss in 12 days.

An interview was conducted with Chief Nursing Officer B and Quality Coordinator A on 7/6/2022 at 10:00 AM. When asked for re-weights on the days when weights were 3 pounds off from previous reading or notification to nursing and physician of weight change (as per facility policy) CNO B stated "It wasn't done.