Breach of Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure residents' right to personal privacy and confidentiality of medical records during a recertification survey. This deficiency was observed in two of the four units surveyed. Specifically, licensed nurses left computer screens unlocked and unattended, exposing private medical information during medication administration. On Unit 2, a Licensed Practical Nurse left the computer screen open while attending to a resident's blood pressure, and on Unit 3, another Licensed Practical Nurse did the same while administering medications. Both nurses acknowledged the importance of maintaining confidentiality and admitted to not securing the computer screens. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed the facility's policy and the legal requirement to protect residents' health information under the Health Insurance Portability and Accountability Act. The facility's policy emphasizes the responsibility of all employees to safeguard the confidentiality and integrity of resident information. Despite these policies, the observed actions of the nursing staff during medication administration compromised the privacy of residents' health information.
Plan Of Correction
Plan of Correction: Approved April 1, 2025 I. Immediate Action LPN #1 and LPN #2 were given 1:1 education on HIPAA and protecting residents information. II. Identification a. DON and ADON observed all LPN’s give med pass on each unit. b. DON and ADON issued competencies to identify and potential issues. c. Facility respectfully states that all residents have the potential to be affected by this deficiency. III. Systemic Changes a. Administrator and DON reviewed Privacy Policy and Personal Health Information Pledge of Confidentiality on 3/3/25 and found it to be compliant. b. DON in-serviced all nursing staff on HIPAA and procedure when walking away from medication cart or electronic medical record kiosk. IV. Monitoring a. DON developed audit tool to ensure nursing personnel are properly following HIPAA protocols in the facility. Specifically, audit will focus on HIPAA and procedure when walking away from medication cart and or electronic medical record kiosk. b. DON/Designee will observe 5 nursing staff members at random weekly to ensure HIPAA protocol compliance. c. Audit will be conducted Weekly x 4, Monthly x 3, Quarterly x 2 V. Responsibility The ADON will be responsible to ensure correction of this deficiency.