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N0202
D

Privacy Breach of Resident Information

North Miami, Florida Survey Completed on 03-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to uphold residents' right to privacy of personal information, as evidenced by multiple observations of unattended paperwork containing residents' information left visible in public areas. During a morning observation at the North Nursing station, a demographic sheet with a resident's information was found unattended on the counter. Staff I, an LPN, acknowledged the breach, explaining that the paperwork was left by someone who came to pick up a deceased resident. The LPN confirmed that no resident information should be visible and stated that they usually keep all residents' information with them. Later, during a dining observation, paperwork with visible resident information was found unattended on a chair in the dining room. The ADON, who was present in the room, was informed and retrieved the paperwork, confirming it contained residents' information and should not have been left unattended. The DON was interviewed and reiterated that the facility has measures in place to safeguard residents' information, emphasizing that no resident information should be visible or left unattended. A review of the facility's HIPAA Security Measure policy indicated that reasonable and appropriate measures should be implemented to protect residents' identifiable information.

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.

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