Unauthorized Access to Resident Medical Records
Penalty
Summary
The facility failed to safeguard resident medical records and confidential information, leading to unauthorized access. During a tour of the 200 hall, a two-tiered rack containing white binders with room numbers and a book with resident-specific information was observed in the hallway. These binders, which included sensitive information such as resident names, dates of birth, diagnoses, and insurance details, were easily accessible to anyone walking down the hallway, including residents, family members, vendors, and visitors. Similar observations were made during subsequent tours, indicating that the binders remained unsecured and accessible. Additionally, during a tour of the nursing station, resident paperwork containing specific medical information was found on top of the nursing station counter, also easily accessible to anyone who approached. There were no staff members present at the nursing stations during these observations, further increasing the risk of unauthorized access to sensitive information. The Director of Nursing (DON) acknowledged that resident records have always been kept on the cart in the hallway and not secured behind the nurse's stations, and that papers should not be left on medication carts or counters without being turned over. The Nursing Home Administrator (NHA) confirmed that the resident records have been in the hallway since her arrival and agreed that they were easily accessible to anyone in the halls. The facility's policy on resident rights and medical records emphasizes the importance of maintaining confidentiality and safeguarding resident information, yet the observed practices did not align with these standards. The facility's failure to secure resident records and prevent unauthorized access constitutes a deficiency in maintaining the confidentiality of resident information.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Two tier racks and paperwork were relocated to a secured and confidential area for 100 and 200 hallways. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; By, a quality review was completed by Nursing Home Administrator on two tier racks and paperwork for 100 and 200 hallways were relocated to a secured in confidential area. No additional residents were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By, staff were educated on the components of Resident Records - Identifiable Information with an emphasis safeguarding resident medical records and confidential medical information in a confidential manner that would prevent unauthorized access by the Nursing Home Administrator. Newly hired staff will be educated on the components of Resident Records - identifiable Information with an emphasis safeguarding resident medical records and confidential medical information in a confidential manner that would prevent unauthorized access by the Nursing Home Administrator/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Nursing Home Administrator/Designee to conduct random audits of 4 nursing stations 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that resident medical records and confidential medical information are safeguarded in a confidential manner. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.