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Based on medical record review, interview and policy review the hospital staff failed to notify the physician immediately of the discovery of newly developed pressure ulcers to obtain orders for treatment for one patient (Patient 1) of the seven sampled patients. This failure of immediate notification to the physician of pressure ulcers for Patient 1, left the pressure ulcers without treatment and the potential to worsen.

Findings Include:

A review of the policy "Physician Notification of Change in Condition" revised 01/09/19 indicated "The physician will be notified immediately of any adverse change in patients' condition ..." The staff did not follow hospital's policy.

Review of Patient 1's "Nursing Admission Skin/Integument Assessment" dated 07/26/19 completed by Staff F, Registered Nurse, (RN) showed documentation stating, "bottom red/purple." There was no documentation that explained "bottom red purple " or indicated the anatomical location of the red/purple discoloration of the patient's skin in the field provided in the assessment form. There was no physician's order to address "bottom red/purple" description of patient's skin.

Review of Patient 1's physician admission history and physical (H&P) dated 07/27/19, had no assessment finding of impaired skin integrity documented.

Review of Patient 1's discharge summary dated 09/17/19, showed no documentation of skin breakdown as discharge diagnosis. The patient was discharged on 08/2819.

Review of wound care nurse's documentation of Patient 1's skin assessment completed by Registered Nurse (RN) E, on 07/29/19, three days after Patient 1's admission, showed that patient skin integrity was intact.

An interview on 10/11/19 at 2:50 PM Staff E, RN stated that on 08/27/19 (one day prior to Patient 1's discharge) photographic records of skin assessments showed right heel ulcer 2.5 cm long x 5.5 cm wide (centimeter), and on right lateral ankle 1.5 cm long x 1.2 cm wide, and left heel ulcer 1.5 cm long x 1.3 cm wide. This is the only evidence to confirm skin breakdown since the initial assessment on 07/26/19.

An interview on 10/10/19 at 4:43 PM, Staff C, Medical Director (MD), (Patient 1's physician) stated that he is readily available to patients and staff and would have expected to be notified of any concerns or change in patient's condition. Staff C, MD, was unaware of Patient 1's development of pressure ulcers.

An interview on 10/11/19 at 10:29 AM Staff F, RN, who completed the "Admission Skin Integument Assessment" on 07/26/19 indicating "bottom red/purple" explained it referred to Patient 1's sacral region and acknowledged failure to indicate the anatomical area on the diagrams provided in the assessment field. Staff F, RN, added that the impression was that the documentation would be understood "since there is only one bottom." She stated she did a complete assessment of Patient 1's body and no identified pressure areas were made to indicate any pressure ulcers present on Patient 1's heels and ankles at the time of admission.

During an interview on 10/11/19 at 1:18 PM, Staff B, Chief Compliance Officer (CEO), stated, "it is the expectation for staff to report abnormal findings to patients' physician upon discovery."

During an interview on 10/11/19 at 2:50 PM, Staff E, RN, stated that his findings of Patient 1's skin assessment on 08/27/19 was not communicated to the patient's physician. He explained that the physician's next scheduled on-site visit was 08/30/19 and that he intended to communicate the assessment findings for Patient 1 during the 08/30/19 on site visit of Patient 1's physician but that the patient was discharged on 08/28/19.

Further interview of Staff E, RN, on 10/11/19 at 2:50 PM acknowledged he is aware of the expectation to report abnormal findings and that he failed to notify Patient 1's physician about the new pressure ulcers discovered on 08/27/19.

Based on the review of clinical record documentation and hospital staff interviews the facility failed to update the clinical record to include the development of pressure ulcers during a hospital stay. This failure put the patient at risk for complications related to the failure to provide care to prevent pressure ulcers, complication of worsening pressure ulcers, increased risk of infection related to open pressure ulcers and the development of additional pressure ulcers. This affected one sampled patient (Patient 1) of the seven patients included in the sample.

Findings Include:

Review of Patient 1's "Nursing Admission Skin/Integument Assessment," dated 07/26/19, completed by Staff F, Registered Nurse (RN), showed documentation stating, "bottom red/purple." There was no documentation that explained "bottom red purple " or indicated the anatomical location of the red/purple discoloration of the patient's skin in the field provided in the assessment form. There was no physician's order to address "bottom red/purple" description of patient's skin. There was no care plan documentation to address the skin discoloration indicated in the admission skin assessment.

Review of Patient 1's "Physician Admission History and Physical" dated 07/26/19 showed no documented evidence of impaired skin integrity/decubiti (pressure ulcers).

Review of the skin assessment dated 07/29/19 completed by Staff E, Registered Nurse (RN) identified as the wound care nurse, three days after the Patient 1's admission indicated that Patient 1's skin integrity was intact.

During an interview on 10/10/19 at 4:43 PM, Staff C (Patient 1's physician) stated, "that he is readily available to patients and staff and would have expected to be notified of any concerns or change in patient's condition immediately." Staff C stated he/she was "unaware of Patient 1's decubiti [pressure ulcer]."

During an interview on 10/11/19 at 2:50 PM Staff E, RN stated that on 08/27/19 [one day prior patient's discharge] "the photographic records of the skin assessment showed right heel ulcer 2.5 cm long x 5.5 cm wide [centimeter] and on right lateral ankle 1.5 cm long x 1.2 cm wide, and left heel ulcer 1.5 cm long x 1.3 cm wide." This is the only evidence to confirm skin breakdown since the initial assessment on 07/26/19.

The documentation of the wound care nurse's assessment findings on 8/27/19 by Staff E, RN was not documented in the patient's permanent medical record. Patient 1 was discharged on 8/28/19. The documentation was added as late entry, on 10/10/19 after the surveyor interviewed Staff E, RN to determine when Patient 1's skin breakdown was first identified.

A review of the physician's discharge summary dated 09/17/19 showed no documentation of impaired skin integrity /decubiti (pressure ulcer).