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Based on observation, interview and policy and procedure the facility failed to maintain the confidentiality of medical records for 1( patient #3) of 10 sampled patients.

Findings:

During an observation on 08/12/16 at 10:53 AM, of the 600 hallway, the computer kiosk on a rolling stand revealed the computer was opened to reveal Patient #3 clinical record. The computer screen was open, not covered to conceal the patients information facing the hallway. The patients name and clinical information was visible/and could be read by anyone passing in the hallway.

During an interview on 08/12/16 at 11:03 AM with the 600 hallway Registered Nurse ( RN) stated she had entered the patients room and left the computer screen opened. The RN stated she thought the Unit Manager was watching the computer.

A review of the facility's policy and procedure titled " Administrative, Technical and physicals safeguards of confidential and protected information" dated 09/18/2013 revealed the facility will take reasonable steps to safeguard confidential and protected information from any intentional or unintentional access. The workforce must adequately safeguard confidential and protected information in all forms including paper, electronic, verbal and visual representations.

Based on record review and interviews the facility failed to ensure that 1( patient # 1) of 10 sampled patients did not develop a facility acquired pressure wound.

Findings:

A clinical record review of patient #1 initial nursing assessment dated 02/19/16 did not show that the patient was admitted to the facility with a pressure wound.There is no nursing documentation from 02/19/16 to 02/29/16 to show that the patient received nursing assessments addressing the patients skin surfaces especially to the coccyx area. There is no documentation in the patient ' s clinical record to show that the patient had skin sweeps completed each shift. The night shift nurse on 02/29/16 documented Patient #1 had a stage 2 pressure ulcer on her coccyx and referred the patient to the wound and ostomy nurse.

A review of the wound/ostomy consult dated 03/01/16 revealed an area of discoloration measuring 8 X 8 CM over sacrum area is non-bleachable and deeply mottled/purplish in color. Skin starting to lift. These finding are consistent with a suspected Deep Tissue Injury (DTI) potential for rapid evolution to a stage 3 or 4 pressure ulcer even with optimal treatment.

A review of the wound/ostomy consult dated 03/01/16 revealed an area of discoloration measuring 8 X 8 CM over sacrum area is non-bleachable and deeply mottled/purplish in color. Skin starting to lift. These finding are consistent with a suspected DTI potential for rapid evolution to a stage 3 or 4 pressure ulcer even with optimal treatment. Medications had been ordered.

A review of the wound/ostomy consult dated 03/08/16, revealed an area of discoloration measuring 9 X 8 CM over sacrum with a 3 X 4 CM area of black dried eschar at the interior portion of the wound area is non-blanch able and deeply mottled/purplish in color. Skin starting to lift. These finding are consistent with a suspected DTI potential for rapid evolution to a stage 3 or 4 pressure ulcer even with optimal treatment. Now that necrotic tissue formed Santyl ointment application recommended.

A review of the Division of Plastic and Reconstructive Surgery consult dated 03/09/16, subjective: Reason for request: sacral decubitus. The patient was admitted to the facility on 02/19/16 following a house fire. Plastic surgery was consulted for a sacral decubitus ulcer. Per burn service and nursing staff the patient had a small decubitus " wound " when she presented initially. The wound seemed to have healed until - 10 days ago when the patient required pressor support. The patient is now off pressors, but her decubitus ulcer seems to have worsened following pressors.

A review of the nurse ' s notes dated 03/11/16 at 5:46 PM, revealed problem: impaired skin integrity, risk for. Goal maintains integrity of skin and tissues. Interventions: Assess skin integrity. Dressing change done bedside. Physciain to see wounds. Necrotic area to coccyx covered with dressing.

A review of the wound/ostomy consult dated 03/22/16 revealed the pressure wound is managed by burn surgery and plastics

A review of the plastics notes procedure date of 03/11/16 at 5:46 PM, revealed procedure: debridement of skin. Pre-Operative diagnosis: Sacral ulcer. The patient had a sacral wound requiring debridement.

A review of the plastic and reconstructive surgery consult dated 03/09/16 revealed no surgical intervention at that time continue the pressure wound treatment.Will give wound further time to declare itself plastic surgery to follow.

Record review of the facility's policy titled, " Pressure Ulcer Prevention and Treatment and Care of Non-Surgical Wounds" dated 04/13/16, showed that RN's are responsible for skin and wound assessments, identifcation of risk factors, implementation of interventions and ongoing monitoring of patients skin/wound, in conjunction with the multidisciplinary team.

















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