Violation of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to protect a resident's right to privacy and confidentiality when a video of a resident being hit with a broom by the Director of Nursing (DON) was recorded by a staff member and subsequently shared on social media. The incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and diagnoses including Major Depressive Disorder, Dementia, and Epilepsy. The video was recorded by an LPN who was present during the incident and later sent it to a friend who posted it online. This breach of privacy was discovered when local police were notified of the video circulating on social media. Interviews with facility staff revealed that the LPN who recorded the incident was unaware of the privacy and confidentiality policies, despite the facility's policy prohibiting the use of personal electronic devices to record residents without express permission. The Assistant Director of Nursing (ADON) and the Licensed Nursing Home Administrator (LNHA) confirmed that staff were trained on these policies upon hire and biannually. However, the LPN did not adhere to these guidelines, resulting in a violation of the resident's privacy and confidentiality rights.
Plan Of Correction
Immediate Action On 12/30/2024 HIPAA privacy and confidentiality education began. U.S. FOIA (b) (6) contacted Board of Nursing on 12/30/2024 to report involvement in incident, and to report the two nurses who observed, recorded video and did not intercede to help, but sent the video to a friend to post. Those nurses no longer work at facility. C.N.A. #1 and C.N.A. #3 were reported to Department of Health as well. Other residents having potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. What measures will be put into place or systemic changes made to ensure that the deficient practice will not return: On 12/30/2024, education was given to all staff on HIPAA privacy and confidentiality. The interim DON/designee will audit education sign-in sheets to assure all staff have been educated on the HIPAA protocols. The audits will be completed weekly for four weeks and then monthly for the next four months. Education on HIPAA confidentiality and privacy will be given monthly for six months. Education on HIPAA confidentiality and privacy will become part of our orientation education as well as our annual education. The Administrator/DON/designee will audit compliance with the education on HIPAA confidentiality and privacy and conduct 5 random staff assessments and tests to assure staff have a true understanding of HIPAA confidentiality and privacy. How the facility plans to monitor its performance to make sure that solutions are sustained: The results of the weekly and monthly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on February 21, 2025.