Failure to Protect Residents' Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical information. During an observation at the Northside Nursing station, a demographic sheet containing a resident's information was found visible and unattended on the counter. Staff I, an LPN, acknowledged the breach, explaining that the paperwork was left by a person who came to pick up a deceased resident. The LPN confirmed that no resident information should be visible or left unattended, indicating a lapse in following the facility's protocol for safeguarding residents' information. Additionally, during a dining observation, paperwork containing residents' information was found unattended on a chair in the dining room. The Assistant Director of Nursing (ADON) was informed and confirmed that the paperwork should not have been left unattended. The Director of Nursing (DON) stated that the facility has measures in place to protect residents' information, but the observations indicate these measures were not effectively implemented. The facility's policy on HIPAA security measures emphasizes the importance of maintaining the confidentiality and integrity of residents' information, which was not adhered to in these instances.
Plan Of Correction
1. The resident demographic sheet was removed from the counter and secured in the resident's chart. The unattended paperwork ("activities haircut list") was removed from the dining room chair and secured. 2. A facility-wide audit was conducted to ensure no other resident's information was inappropriately placed and visible. No other information was found visible. 3. All staff training/education was provided by the DON/Designee on ensuring resident privacy and confidentiality. *Resident privacy and confidentiality training will be included in new hire and annual education. 4. The DON/Designee will conduct daily (for 5 weeks) facility observation rounds audit to ensure that no resident information is visible. The results of this audit will be reviewed at the monthly QA meeting until compliance has been determined.