Confidentiality Breach of Resident's Medical Records
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's personal and medical records, specifically for one resident diagnosed with quadriplegia and tracheostomy status. During an observation, it was noted that a paper containing the resident's first name and clinical assessment findings was taped to the wall outside the resident's room, visible from the hallway. This paper included information pertinent to the resident's treatment, such as suctioning instructions for the tracheostomy, and was dated January 4, 2025. During a staff interview, the Nursing Home Administrator acknowledged that the paper should have been placed on the back of the resident's door to prevent it from being in plain sight from the hallway.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R18. 2) The Facility immediately removed the written paper on January 7, 2025. 3) All resident rooms were inspected for any personal identifying information outside of their rooms. Two: system changes and measures that will be taken: 1) All staff will be educated on the privacy of our residents. 2) Any privacy concerns will be addressed by Nursing Administration. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with privacy outside of their rooms, then five (5) random residents 1x a week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.