Violation of Resident Privacy Due to Public Posting of Dietary Status
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, specifically for two residents who had their dietary status posted outside their rooms, visible to the public. Resident #3, diagnosed with cerebral palsy and quadriplegia, was dependent on a feeding tube for nutrition and had an NPO (nothing by mouth) order. Observations during the survey revealed that signs indicating the NPO status were placed outside the resident's room on multiple occasions, which was visible to visitors and non-pertinent staff. Similarly, Resident #13, who also had cerebral palsy and was dependent on a feeding tube, had their NPO status posted outside their room. Interviews with various staff members, including the Social Services Director, Certified Nurse Aide, LPN, and RN Unit Manager, confirmed that the posting of such information was a violation of the residents' privacy. Despite staff education on maintaining confidentiality, the facility's actions led to the exposure of sensitive health information, contravening the residents' rights to privacy.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 F583- Personal Privacy/Confidentiality of Records: Crouse Community Center will ensure all residents their right to privacy and confidentiality. Corrective action: For resident # 3 and resident # 13, NPO signage was removed from the resident’s door and replaced with a water drop symbol with an “X” through it on (MONTH) 13, 2025. Other residents: Thickened Liquids-Swallowing eval policy was updated to include new symbol for NPO. All other residents on an altered fluid consistency were reviewed to ensure that the appropriate symbol was on their door as per policy. Discrete facility approved signage will be utilized to ensure privacy and confidentiality to all residents. Medical abbreviations will not be placed on residents' doors, only discrete symbols. Systemic Changes: Thickened liquids policy was updated with staff education on the new symbol utilized for NPO residents. Discrete facility approved signage will be used as a communication tool for staff; medical abbreviations will not be utilized. Residents' diet, diagnosis, and/or conditions will not be displayed as to protect their privacy and confidentiality. Monitoring: Audits will be conducted by the Director of Nursing to ensure confidentiality and privacy are not violated by using medical signage. The audit will be reported to QAPI monthly with 100% compliant threshold expected. Responsible Party: Director of Nursing