Henry Ford Health Hospital

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 38269 Based on interview and record review, the facility failed to ensure that a patient’s point of origin and guardian status were reviewed and applied to discharge plan, resulting in 1 (P-1) of 15 patients reviewed, being discharged to a location where the patient did not reside without notification to the patient’s legal guardian. Findings include: On 05/12/2026 at 1330 review of the medical record for P-1 revealed she was a 69 year old female residing in an Adult Foster Care (AFC) home. P-1 presented to the Emergency Department (ED) on 02/02/2026 with abdominal pain. P-1 arrived via Emergency Medical Services (EMS). Diagnostic evaluation revealed no acute findings. The EMS run sheet dated 02/02/2026 at 1459 documented the pickup location as an AFC/nursing home. The AFC address was listed as the point of origin. The medical record also contained documentation of P1’s guardian group name and phone number. During an interview on 05/12/2026 with the Director of Emergency Department (Staff D), Staff D confirmed that the EMS run sheet and guardian information were present in the electronic medical record (EMR) at the time of the patient’s visit. On 05/13/2026 at 1035, Staff B and Staff D confirmed that the patient’s AFC residence and guardian information were available in the EMR but were not reviewed prior to discharge. Staff B and Staff D acknowledged that no attempts to contact the AFC or the guardian were documented. Review of the ED discharge record showed that P-1 was discharged on 02/03/2026 at 0230 via a public ride share service to a homeless shelter. No documentation was found indicating that the AFC or guardian was notified prior to discharge. Review of an ED physician note dated 02/04/2026 at 1436 (Staff T, MD) showed that the AFC administrator contacted the ED seeking information regarding P-1’s disposition. The administrator reported that P1 had been transported to the ED via EMS and had not returned. Staff T documented that ED records contained no reference to the AFC in the EMS intake, triage note, or subsequent notes. Staff T confirmed that P-1 had been discharged to a community shelter. Staff T contacted the shelter and the AFC administrator to provide updates. No incident report, complaint/grievance, or police report related to the incident was found during record review. On 05/13/2026 at 1020, the Director of Risk Management (Staff B) confirmed that the facility’s ED discharge policy (Policy #18441538) did not include specific procedures requiring verification of a patient’s point of origin or guardian status prior to discharge. Review of policy on 05/13/2026 revealed “Policy Stat ID 18441538 “Discharge of Patient from the Emergency Department ... Background; Emergency Department staff are required to provide appropriate discharge instructions, follow up referrals, return to work/school note and /or medical devices as indicated. Policy; All patients discharged from the Emergency Department will be provided with appropriate instructions, follow-up, referrals, prescriptions, return to work/school note and or medical devices as indicated. Accurate documentation of the discharge process is key to supporting safe practice.” Procedure A. This procedure applies to Emergency Department Registered Nurses. Discharge of Patient from the Emergency Department. B. Assess the patient’s capabilities to be discharged home per self and the method that patient is going home. · KEYPOINT: If the patient cannot safely be discharged to self (elderly, confused, decreased mental capacity, etc. ...), inform the staff physician. The physician will call the home number on the patient chart to give an update on the patient. If unable to contact any significant other, the physician will notify the social worker or patient advocate. They will attempt to locate family and/or arrange safe transportation home. The patient may not be discharged without appropriate notification of family ...”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 53399 Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide a medical screening exam (MSE) for 2 patients (P-3, P-4) of 20 patients reviewed, resulting in the potential for less than optimal outcomes for P-3 and P-4. Findings include: See tags: 2406 Failure to provide a MSE”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45245 Review of the medical records titled “Brief HPI (History of Present Illness)” and “Physical Exam” dated 12/17/25 at 1526 and authored by triage physician (Staff VV) revealed “(P-3) is a 68-year-old male poorly controlled hyperglycemic sent from endocrinology clinic out of concern for possible DKA (diabetic keto-acidosis; a life threatening consequence of prolonged high blood sugar). Blood sugar measurement at triage was 472 milligrams per deciliter (normal is 80 to 120 milligrams per deciliter). Further review of the medical record on 02/04/26 revealed that P-3 left without continuing service at 1710 and length of stay was documented as 3 hours and 50 minutes. Review of facility policy titled “Management of DKA/HHS in the Emergency Department at (facility),” #15360236 revealed, “Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar states (HHS) are life threatening emergencies caused by absolute or relative insulinopenia that result in hypoglycemia and metabolic derangement. The pillars of management of both conditions are similar: frequent monitoring ·fluid electrolyte replacement ·restoration of circulating volume and organ perfusion ·hyperglycemia correction -precipitant identification.” Review of document titled “Patient Care Timeline,” revealed that P-3 was ordered a “stat” (immediate) medication infusion of 0.9 Sodium Chloride bolus (large quantity over short period) of 1000 milliliters, stat laboratory blood analysis, stat EKG (heart electrical study), stat venous blood gas analysis and stat chest x-rays. Documentation of EKG 12 Lead was completed at 1536. No other orders were completed. Record review of the Medication Administration Record and interview with ED manager (Staff W) on 02/04/26 at 1115 confirmed that physician (Staff VV ’ s) stat orders for 0.9 Sodium Chloride bolus were not completed during P-3 ’ s ED visit. Review of facility policy titled, “Medication Administration and Documentation on the Electronic Medication Administration Record (eMAR),” #16148648, eff. 07/24, failed to provide any definitions or time frames for the administration of ’ stat ’ ordered medications. An interview was conducted with ED manager (Staff W) on 02/04/26 at 1115. Staff W was questioned what is the expected time frame for ’ stat ’ orders to be completed. Staff W replied, “I don ’ t know. Everything in ED is stat.” Staff W was then queried if P-3 ’ s high blood sugar was treated. Staff W replied, “No, I can ’ t see that it was treated.” 53399 Based on interview and record review, the facility failed to provide a Medical Screening Exam for 2 (P-3, P-4) of 20 patients reviewed, resulting in the potential for less than optimal outcomes for P-3 and P-4. Findings include: Review of P-4’s medical record revealed “On 12/18/2025 at 1535, P-4 presented to the Emergency Department with a chief complaint of “Syncope” (passing out) and was designated by facility “Left the Emergency Department before Treatment Completed” (LBTC) at 1933. P-4 was not provided with a Medical Screening Examination (MSE) by qualified medical personnel. There was no evidence P-4 received any physician orders, diagnostic testing, or treatment for their medical condition. Time(s) Events 1535 “Patient arrived via walk in entrance with chief complaint of syncope” 1545 “Vital signs were within normal limits except mild tachycardia at 112” 1645 “Nursing note says that patient left, however fainted in the parking lot and returned” 1649 “New vital signs show very similar stable vitals” 1933 “Staff attempted to move patient into Advanced Triage, however she was not found and determined to have left without completing service” On 02/04/2026 at 1100 Registered Nurse, Triage Staff X when queried about P-4’s Emergency Department visit stated, “(P-4) arrived as a walk in and I was working in the Quick look Triage area with (Staff Y).” Staff X stated, “P-4 stated they had passed out and felt like they were going to pass out when walking.” “(Staff Y) took a set of vitals on the patient which were “In normal range”, except their heart rate was a little tachycardic (Fast)” “All of the Advanced Triage bays were full, we were busy.” “P-4 was crying and seemed scared, but she did not meet the criteria to be a CAT 1(Emergency), or to be elevated right to Advanced Triage to be seen by the Advanced Triage Physician. P-4 was instructed to wait in the waiting room.” Staff X was further queried if any assessments or diagnostic tests had been completed within Quick Look triage such as an Electrocardiogram (EKG), or a Physician Assessment? Staff X stated, (P-4) did not meet the criteria for an EKG to be completed because of their age, and the Physician assessment is completed in Advanced Triage.” On 02/04/2026 at 1330 Chief Medical Officer, Staff - I was queried, would a patient having their vitals checked, and being assessed by a triage Registered nurse be considered a Medical Screening Evaluation (MSE)” Staff I replied, “No it would not.” Staff I was further queried, Did P-4 receive a MSE while being seen in the Emergency Department? Staff I replied, “No they did not.” Staff I was further queried, what an acceptable time frame would be for a patient experiencing syncopal episodes (Passing out) to have an MSE? Staff I stated, “I do not know the answer to that question.” Policy Review: “Triage Process Using Emergency Severity Index (ESI)” last approved 09/16/2025. “The Emergency Severity Index (ESI) is a tool for use in emergency department (ED) triage. The ESI triage algorithm yields rapid, reproducible, and clinically relevant stratification of patients into five groups, from level 1 (most urgent) to level 5 (least urgent). The ESI provides a method for categorizing ED patients by both acuity and resource needs. The policy states that “A Registered Nurse will assess each patient presenting to the Emergency Department according to the ESI 5 level triage system.” P-4 was not assigned an ESI triage ranking while in the Emergency Department.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 45245 Based on interview and record review, the facility failed to provide a safe discharge plan for 1 (P-1) of 20 patients reviewed for Discharge Planning, resulting in poor health outcomes and subsequent death. Findings include: See tag 0807 - Failure to identify and provide discharge needs.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45245 Based on interview and record review, the facility failed to follow it’s policy regarding wound assessment and documentation, for 1 (P-1) of 10 patients reviewed, resulting in the increased potential for missed infections and treatment delays, for all patients receiving wound care. Finding include: Review of “History of Present Illness (HPI)” dated 06/18/25 at 0922 revealed, “(P-1) is a 67-year-old male, past medical history of heart failure with low ejection fraction...Reviewed discharge summary from February 20, 2025 when patient presented with very similar presentation required (diuretic; removes excess fluid) drip for volume (fluid in body) control.” Review of “Flowsheets” dated 06/18/25 at 1652 revealed that P-1 had a leg wound assessed and documented as “scab, cracked.” Review of P-1’s medical record on 08/20/25 at 0930 with Nurse Executive (Staff D) revealed that the wound was located on P-1’s lower right leg and was documented as “Venous Ulcer Pretibial Proximal Right.” “Dressing Status” listed “wound observed, dressing rescued.” Site assessment states “Dry, red”. Peri-wound assessment lists “Black;intact.” Drainage as “none” and Wound Care lists “Enzymatic debridement; Open to air.” Further review of the medical record demonstrated documentation that P-1’s leg wound was assessed and treated daily, however, no wound treatment orders or wound medication orders were located in the medical record. During chart review on 08/20/25 at 0940, Nurse Executive Staff D was queried for the size, depth, color and staging of P-1’s leg wound. Staff D stated that the wound dimensions and staging were not documented in the medical record. During interview with Nurse Executive Staff D on 08/20/25 at approximately 1000, Staff D was questioned if she expected wounds to be measured when assessed? Staff D stated, “No, if its a venous ulcer.” Staff D was next questioned “Why not?” Staff D stated, “It’s not a pressure injury.” Staff D was next questioned if a Wound Ostomy Nurse (WOCN) consult was ordered for P-1. Staff D searched the medical record and replied, “They did not consult the wound nurse, I could not find one (order).” Staff D was next questioned if she expects nurses to assess and document non-pressure injury wounds. Staff D stated, “I expect them to describe it, and if its big enough, to measure it. I would expect some description.” Review of facility Wound Care policy titled “Pressure Injury Prevention,” #18160590, effective 05/25, revealed “If a pressure injury or any other alterations to intact skin are present, clearly describe and document the alterations including: Appearance of the wound bed, drainage, surrounding skin, and odor. 1. Measurements in centimeters of length, width, and depth of pressure injury or other skin alteration (see Attachment 5 for more detailed wound assessment and documentation terminology). 2. STAGE of pressure injury, used only if wound is a pressure injury 3. Indicate if Present On Admission (POA). 4. Notify the provider of findings.””

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 45245 Based on interview and record review, the facility failed to provide a safe discharge plan for 1 (P-1) of 20 patients reviewed for Discharge Planning, resulting in poor health outcomes and subsequent death. Findings include: Review of the medical record revealed that P-1 had two admissions to the facility of concern in 2025, (1.) 06/18/25 through 06/27/25 (nine days) and (2.) 07/15/25 through 07/16/25 (19 hours). Review of “History of Present Illness (HPI)” dated 06/18/25 (first admission) at 0922 revealed, “(P-1) is a 67-year-old male past medical history of heart failure with low ejection fraction of 14% with severe left ventricular (LV) hypokinesis (poor wall motion) status post AICD (automated internal cardiac defibrillator), EtOH (alcoholic) cirrhosis, type 2 diabetes, prior LV thrombus (blood clot) on Xarelto (blood thinner), atrial fibrillation presents for evaluation of lower extremity edema and shortness of breath...Reviewed discharge summary from February 20, 2025 when patient presented with very similar presentation required Bumex (diuretic; removes water) drip for volume (of fluid in body) control. Following this he was discharged home on GDMT (goal directed medical therapy) however also has had issues with hypotension.. Review of HPI (2nd admission), dated 07/15/25 at 1535 revealed (P-1) is a 67-year-old male with past medical history... brought into the resuscitation room via ambulance after being found down... I was able to get a hold of the patient’s brother (redacted) who confirmed that the patient would want CPR (cardio-pulmonary resuscitation), intubation, and all advanced life-saving means. He also reports that over the past week, the patient has been doing poorly. States that he has noticed that his brother has had increased leg swelling and belly swelling.” P-1 was admitted to the facility with Sepsis (life-threatening infection) on 07/15/25 and expired the following morning. Review of “Consults” dated 06/23/25 at 1556 revealed that P-1 was evaluated by Palliative medicine for decision making capacity, stating, “Patient not able to verbalize disease course and treatment plan; (patient wearing winter jacket in 90-degree heat.)” Psychiatric evaluation revealed “grossly oriented to place and person, not to context, unclear of time orientation.” Judgement is impaired, as evidenced by general medical problems and needs OR ongoing monitoring and/or treatment of medical needs, refusal to take medication as prescribed (refusal of general care).” Review of P-1’s medical record on 08/20/25 at 0930 with Nurse Executive (Staff D) revealed that a wound was located on P-1’s lower right leg and was documented as “Venous Ulcer Pretibial Proximal Right.” “Dressing Status” listed “wound observed, dressing resecured.” Site assessment states “Dry, red”. Peri-wound assessment lists “Black; intact.” Drainage is ‘none’ and Wound Care lists “Enzymatic debridement; Open to air.” Staff D was queried for the size, depth, color and staging of the wound. Staff D stated that the wound dimensions and staging were not documented in the medical records. Staff D was next requested to review P-1’s ‘After Visit Summary (AVS; Discharge Instructions) for wound care instructions. Staff D stated that no wound instructions were present. Staff D was next questioned if P-1’s AVS should include wound care instructions? Staff D stated, “I don’t know.” Staff D also reviewed the “Problem List” on the AVS and confirmed that ‘wound’ was not listed as a problem P-1 encountered during his visit. During interview with Case Manager (CM) (Staff N) on 08/19/25 at 1130, Staff N was questioned how she identifies patient needs upon discharge. She reviews needs upon discharge, such as equipment, home care and durable medical equipment. Staff N stated, “He was once again ambulating, with a cane and walker. I talked to the manager of his NSO (Neighborhood Service Organization; home for chronically homeless) and confirmed with him that P-1 was to be discharged back to the home. They didn’t express any concerns.” Staff N was next questioned what medical needs she identified? Staff N stated, “He had no medical needs.” Staff N was questioned if P-1’s leg wound was discussed in morning rounds with physicians? Staff N stated, “There was no talk of wounds.” Staff N was next questioned if she reviews patient records for wounds or decision-making capacity? Staff N stated, “There were no dressings or medical needs. He has capacity for taking medications, but not for complex decisions.” Staff N was next questioned if she was in contact with Adult Protective Services (APS) regarding P-1. Staff N stated that the medical team called APS to express concerns about P-1’s ability to self-care. Staff N was questioned if that was usual for the medical team to call APS? Staff N stated, “Oh yea, all the time. If APS wants to take the case, they follow-up. They do a safety evaluation of the home. APS was to assess and take over.” Staff N was questioned if she attempted to notify family members that P-1 was being discharged? Staff N stated, “We attempted to contact the brother and friend (listed as emergency contacts) to no avail, throughout his admission. Thats why the manager contacted APS.” Review of “Progress Notes,” dated 06/27/25 at 1527 revealed that APS was contacted three hours prior to P-1’s discharge (1815), “Received a call from APS (adult protective services) regarding patient care. APS states someone will be out to evaluate patient within the next 72 hours.” An interview was conducted with P-1’s Pulmonologist (lung doctor) (Staff GG) on 08/20/25 at 1212. Staff GG was questioned about P-1’s mental capacity. Staff GG stated that P-1 was “Alert and Oriented x3, but didn’t appreciate his medical needs, such as environmental safety and the need to be compliant with medications. Staff GG stated that P-1’s leg wound “Did not appear infected or worrisome, if his CHF (congestive heart failure) resolved, the wound would heal.” Staff GG was questioned how the wound appeared? Staff GG stated, “It was not infected based on exam, not red, no cellulitis or draining, no leukocytosis (high white blood cell count).” Staff GG was questioned if P-1 was on antibiotics? Staff GG stated, “No antibiotics, Santyl (debridement cream) is fine.” Staff GG was next questioned if P-1’s wound resolved prior to discharge? Staff GG quickly reviewed the medical record and replied, “The wound did not resolve, he refused assessment of the wound on 06/27/25 at 0817.” Staff GG was questioned if P-1 would need to continue the wound care regimen of Santyl and dressing changes after discharge? Staff GG replied, “Yes and No. We felt the wound would heal with meds (taken for CHF) and dressing changes.” Staff GG was questioned if P-1’s wound had a dressing when he was discharged? Staff GG replied, “Yes.” Staff GG was questioned when P-1’s dressing would next need to be changed? Staff GG stated, “That would be based on the assessment of Home Care nurses.” Staff GG was questioned what P-1 needed home care nurses to do for him? Staff GG reviewed the medical record and stated, “He needs his medications administered daily and his dressings changed. He needed Home Care.” Review of “Orders,” failed to demonstrate any wound care orders ordered for P-1’s wound treatment. Review of “Discharge Summary” dated 06/27/25 at 1556 revealed that P-1 was discharged to home or self-care, with two ambulatory referrals to Cardiac Rehabilitation clinic and Hepatology (Liver) service. “Follow-up” is listed as “No follow-up provider specified.” “Future Appointments” and “Home Health Future Appointments” was left blank.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45245 Based on interview and record review, the facility failed to ensure that licensed nursing personnel adhered to the facility’s policy and procedure regarding the submission of an incident report when a pressure ulcer is identified, resulting in two (P-2, P-3) of 10 patients reviewed, acquiring a pressure injury, and the increased potential for harmful adverse outcomes for all patients. Findings include: Review of facility policy titled “Tier1: Pressure Injury Prevention,” #1597299, eff. 07/22, revealed that patients are assessed by two nurses for skin wounds upon or within 8 hours of admission. Additionally, a “Braden” skin risk assessment is completed within 24 hours of admission and again daily or with change in patient condition. The policy contains 5 attachments which correspond with Braden scale values, dictating the various interventions and protocols to follow. Further review under paragraph (K.) revealed “Discovery of a hospital acquired pressure injury (HAPI) must be reported using the online risk reporting process (RL Solutions Incident Reporting).” Review of P-2’s chart with wound care RN Staff BB on 01/07/24 at 1204 determined that P-2 entered the facility on 08/20/24 with no sacral wound documented and was discharged with a Stage 4 sacral wound on 11/04/24. Review of the “Adverse Events (RL Solutions)” report log on 01/06/25 failed to demonstrate P-2’s wound information being entered. At 1500 on 01/07/24, the Chief Nursing Officer (Staff B) stated “We just looked it up and our policy says all PUI’s (pressure ulcer injuries) should have an RL (incident report).” 47415 On 1/6/2025 at 1400 medical record review for P-3 was conducted with Staff L. The review revealed the following: The initial inpatient nursing assessment was conducted on 7/8/24 at 2146, a 4 eyed skin assessment was documented indicating skin was within normal limits, without impairment. Braden scale during stay ranged from 12 -16 - indicating higher risk for skin breakdown. On 7/13/24, a deep pressure tissue injury (DTI) to the coccyx was recorded in the record in the record described at 5.5 centimeters (cm) in length, 8cm in width, on 7/16/24 coccyx wound documented as a stage 2. On day of discharge 7/22/24, wound was described as evolving DTI to sacrococcygeal area, skin moist, necrotic, non-blanchable, painful sloughing, with state of healing as worsening. (6cm x 6cm, depth 0.1cm), outpatient wound care recommended, as well as home treatment plan. On 1/6/25, review of risk event log contained no entry for P-3. Review of the risk report log revealed, an online risk report was not filed for the pressure injury acquired by P-3 after admission. On 1/7/25, interview conducted with Wound Care Staff BB who stated risk reports are not filled out for deep tissue injuries. On 1/7/25, review of policy titled, “Pressure Injury Prevention”, dated 7/25/24 revealed: “Discovery of a hospital acquired pressure injury (HAPI) must be reported using the online risk reporting process...A root cause analysis will be done on Stage 3, stage 4, deep tissue injuries and unstageable injuries acquired after admission...”.”