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Based on interview and document review the hospital failed to implement their procedure to notify the Director of Clinical Care Services when a patient had a change in condition for 1 of 5 patient records reviewed (Patient #1).

Failure to report a change in condition promptly puts patients at risk for inadequate care and/or delays in receiving specialized care.

Findings included:

1. Document review of the hospital's organization structure, revised 08/20 showed that the Wound Care coordinator submits changes in the patients skin condition to the Chief Clincal Officer.

Document review of the hospital's policy titled "Core: Event reporting system," approved 06/20 showed that in addition to completing an adverse event report for serious physical and psychological events which was sent to the hospital quality department, staff were to verbally notify the Chief Clinical Officer of serious events.

Review of the wound care coordinator job description revealed they were to report to the Chief Clinical Officer any worsening changes to a patient's wound.

2. Review of Patient #1's medical record showed that:

a) The patient was admitted to the long-term acute care hospital on 12/13/20. The discharge paperwork sent with the patient from the acute care hospital to the long-term acute care hospital revealed the patient had a "deep tissue pressure injury" to their sacrum which was dark purple and non-blanchable (indicative of a pressure injury that involves the full thickness of the skin and will eventually develop necrotic tissue that will need to be debrided to determine the full extent of the tissue injury).

b) The long-term acute care hospital noted the deep tissue pressure injury to the sacrum on admit. On admission staff ordered a specialized bed for the patient to prevent the patient from developing any further skin issues. Staff repositioned the patient every 2 hours. The hospital continued the foam non adhesive dressing to the sacral area to be changed evey 3 days or changed if the dressing became soiled. The patient had a dietary consult upon admission and every week while they were a patient.

c) The wound care nurse examined the patient's wound weekly. On 01/04/21, the wound care nurse reported to the wound care coordinator that the patient's wound on the sacrum had developed black necrosis in the middle of the sacral pressure ulcer. The pressure ulcer was staged as unstageable (full thickness tissue loss which the extent of the loss cannot be determined until the necrotic tissue is removed). The wound care nurse completed an event report about the change in condition of the patient's wound and submitted the report to the quality department.

d) On 01/25/21, hospital staff transferred the patient to another hospital for a CT scan for worsening pancreatitis as the hospital did not have a CT scan. At the time of the transfer the physician reported that the patient needed a wound care consult for the sacral pressure ulcer which needed surgical wound debridement that the hospital did not offer.

e) On 01/29/21 the patient had a surgical debridement to their sacral pressure ulcer at the acute care hospital. and the ulcer was a stage 4 (full thickness and tissue loss).

3. On 02/10/21 at 12:30 PM, the investigator interviewed the Chief Clinical Officer (Staff #1). Staff #1 verified the above information. Staff #1 stated that the wound care coordinator informed her of the wound changes on the day the hospital transferred the patient to the acute care hospital. Staff #1 stated that had the wound care coordinator, wound care nurse, and nursing staff let her know of the patient's wound changes the patient's transfer to the acute care hospital for surgical debridement of the pressure ulcer would have occurred earlier that 01/25/21.