Breach of Resident Health Information Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records during a recertification survey and abbreviated survey. Specifically, the health information of another resident was mistakenly attached to the discharge summary of Resident #535 and given to Resident #535's designated representative. This breach occurred when the nurse responsible for discharging Resident #535 printed the discharge summary and inadvertently attached another resident's health information record to it. The designated representative of Resident #535 informed the Administrator about receiving the incorrect health information, but they could not recall the name of the other resident involved and were unable to provide copies of the returned health information record. Resident #535 had been admitted to the facility with diagnoses of Diabetes, Hypertension, and Muscle Weakness and was discharged to the care of their family.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice? The documentation that was given in error was returned by the family member and given to the Administrator. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice? The discharge list for all residents scheduled for discharge will be reviewed daily and discharge documents double checked prior to preparing discharge. A two-person verification process will be put into place to ensure the privacy and confidentiality of all residents for discharge. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? To correct the deficient practice, all staff clinical and non-clinical will receive training and education on the following policies: HIPAA Information Security Policy, HIPAA Internet and Intranet Use, and HR-Sanctions for Breach of HIPAA. The training and education will be coordinated by the ADON and/or designee. This training will also be provided on an annual basis and to all new hires and contract staff. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change)? An audit of all discharged residents will be completed 1 X week for 1 month by RN Supervisor or Designee, then Monthly X 3 months. The data will be submitted to the DON and/or designee, and results of audits will be reported to the QAPI Committee monthly by the Director of Nursing/Designee for 3 months for action as appropriate.