Condition noted when changing diaper; care manager notified but he forgot to tell doc; second report made 3.5 months later; two weeks after that, patient brought to ER. That's the timeline the story lays out.
Did no one change the diaper in that 15 week period between reports? Don't they wash the patient when doing so? Not one staff member thought to make an additional report in between?
if that is even remotely close to what happened, shut 'em down. Shut them down now.
Balls!, cried the Queen, if I had two I would be King!
And the King laughed, not because he had to, but because he had two!