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Based on document review and interview, the facility failed to follow policies and procedures to meet the nutritional needs of one of ten Medical Records (MR) reviewed (patient #1).

Findings included:

1. Policy and Procedure review indicated:
A. 1. Policy Assessment/Re-Assessment- Interdisciplinary Patient, # HPC 02-001 PRO, last updated 10/2016, which indicated: Rationale: 5. To determine the appropriate care, treatment and services to meet the patient's needs during hospitalization; scope interdisciplinary. Procedure: 1. Physician d. Patients are reassessed by the physician or his/her designee daily and progress notes entered into the medical record.
B. Review of Policy Assessment/Re-Assessment- Interdisciplinary Patient, # HPC 02-001 PRO, last updated 10/2016, which indicated: 4. Nutrition Services a. The registered dietician initiates an initial nutrition assessment and the nutrition care process within 72 hours of admission.
C. Review of Policy Interdisciplinary Care Conference, # H-PC 02-003, last updated 6/2016 which indicated: Patient care is delivered according to each patient's unique needs. Participation is recommended from the following disciplines: vi. Food and Nutrition Services.
D. Review of Policy Weight Measurement, # H-PC 04-011, last updated 6/2016, which indicates: Weight measurement is scheduled as follows: Physician's Order.

2. Medical Record Review
A. Per Nursing graphic record review starting with admission on 11/8/2017, admission weight was 86.5 kg. (191 lb.); on 11/9/2017, weight was 88.6 kg.; ; on 11/18/2017, weight was 78.3 kg.;on 11/20/2017 weight was 77.0 kg.; on 11/21/2017 weight was 77.2 kg.; on 11/22/2017 weight was 77.3 kg.; on 11/24/2017 weight was 74.4 kg.; on 11/26/2017 weight was 74.6 kg.; on 11/28/2017 weight was 75.1 kg.; on 11/30/2017 weight was 70.5 kg,; on 12/01/2017 weight was 69.7 kg.; on 12/3/2017 weight was 70.4 kg.; on 12/4/2017 weight was 70.1 kg,; on 12/5/2017 weight was 69.6 kg.; on 12/7/2017 weight was 71.5 kg.; on 12/9/2017 weight was 66.2 kg,; on 12/10/2017 weight was 65.9 kg.; and on 12/11/2017 (day of discharge) weight was 65.4 kg. (144 lb.) Physician #1 wrote an order for patient #1 to have daily weights measured on 11/18/2017. Daily weights were not done on 11/23/2017, 11/27/2017, 12/2/2017, 12/6/2017 and 12/8/2017. Per these values patient lost 47 lb. while hospitalized.
B. 1. Physician #1's progress notes and orders for TPN lacked documentation of patient #1's weight decreases, needed for TPN formulation. TPN order sheets indicated that due to patient #1 being nothing by mouth, on 11/8/2017, physician #1 initiated TPN for patient #1, using a dosing weight of 72.9 kg on order sheet. This weight for dosing was less than patient's admission weight of 86.5 kg. The order was for 710 calories per liter with 1080 ml to infuse over 24 hours; 822 calories. On 11/9/2017, physician #1 ordered TPN for patient #1, using a dosing weight of 72.9 kg on order sheet. The order was for 510 calories per liter with 1800 ml to infuse over 24 hours; 918 calories. On 11/13/2017 physician #1 ordered TPN for patient #1, using a dosing weight of 72.9 kg on order sheet. The order was for 510 calories per liter with 1000 ml to infuse over 24 hours; 510 calories. The dosing weights listed on the TPN order sheets did not change throughout the patient's entire inpatient stay.
C. Patient #1 was admitted on 11/8/2017 and had an initial nutrition assessment on 11/15/2017, 7 days later. The initial nutrition assessment was done by part-time staff member #7, Registered Dietician, which indicated increased protein needs for healing as evidenced by pressure ulcer with enterocutaneous fistula, need of TPN, NPO status. Body mass index 37.7. Energy needs 1200-1400 calories per day. All TPN ordered calorie counts were less than 1200 calories per day, with the highest being 918 calories per day. Weekly Interdisciplinary Care Conference Records during the time patient #1 was hospitalized, indicated: on 11/14/17, 11/21/17, 11/28/17 and 12/5/2017 had no nutritional representative at any of the meetings.

3. Staff interview indicated:
A. On 01/16/2018 at 1315 hours, staff member #5, Pharmacy Director, indicated in interview that pharmacy is supposed to look at weights and update on medicine sheets for weight dosing. This updating of weights for TPN orders using weight for calculation, were never changed.
B. On 01/16/2018 at 1445 hours, staff member #1, CCO, indicated in interview that we are looking for a dietician, but they mainly want to work fulltime, and budgeting has decreased hours for one here. We now have a RN filling in part-time.