Unauthorized Disclosure of Resident PHI via Email
Summary
A deficiency occurred when the Social Services Director (SSD) sent an email containing a resident's Face Sheet (Admission Record) and information regarding podiatry care needs to an unauthorized recipient, specifically another resident's family member. The email included protected health information (PHI) such as the resident's Medicaid, Medicare, and insurance policy numbers, home address, care providers, emergency contact, and financial representative. The SSD stated that the email was sent by mistake, confusing the intended recipient, a medical provider with the same first name as the family member who received the email. The resident whose information was disclosed had a history of anemia, chronic pain, and gout, and was noted to have severely impaired cognition, requiring substantial to maximal assistance with activities of daily living. The resident was able to make needs known but could not make medical decisions. The SSD recognized the error and attempted to recall the email but did not report the incident to facility leadership or follow the facility's policy for handling breaches of PHI. Interviews with the Administrator and Director of Nursing revealed that the facility's protocol required immediate reporting of any PHI breach to leadership, investigation of the incident, and notification of the resident or responsible party. The facility's policy also specified that access to resident records should be limited to authorized staff and business associates, which was not followed in this instance.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 8 was informed of the breach on March 26, 2025, and was assured that the facility would take all appropriate steps to mitigate any potential negative consequences resulting from the incident. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. Beginning on March 27, 2025, the Social Services Director conducted outreach to residents within the facility to identify any additional potential breaches and to ensure there were no further incidents or concerns related to the confidentiality of Protected Health Information (PHI). No additional findings were identified as a result of this review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 27 to March 28, 2025, licensed nurses and department supervisors participated in an in-service training conducted by the Administrator or designee. The training focused on the protection of residents' rights to privacy and the confidentiality of Protected Health Information (PHI), in accordance with HIPAA regulations. On March 27, 2025, the Administrator conducted a one-on-one training with the Social Services Director, emphasizing the importance of secure communication practices and the protection of residents' rights to privacy and the confidentiality of Protected Health Information (PHI), in compliance with HIPAA regulations. The Social Services Director will adhere to safe communication practices and will promptly report any potential breaches of confidentiality to the Administrator for further review and appropriate action. How the facility plans to monitor its performance to make sure that solutions are sustained: The ADMIN/designee will provide any negative findings to QAPI committee monthly x 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: April 1st, 2025
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to protect resident medical information on the 2B med cart. During a med pass, an RN left the cart unattended in the hallway with the computer screen open and displaying identifiable resident information, and later confirmed that anyone passing by could see residents' personal and confidential data.
An LPN on the Cardinal Unit left a laptop screen open and papers with resident personal information on top of the med cart outside a resident room, making the information visible to anyone passing by. The LPN confirmed the screen was not closed and the papers were left exposed, contrary to the facility policy for maintaining confidentiality during med administration.
A resident's door had a posted "Feeder" sign, and meal tickets for several residents were placed where they could be seen by the public on a hall. The sign and tickets contained resident-specific information, including names, room numbers, and dietary instructions, and staff confirmed the postings were used to direct feeding and meal service. The DON stated the postings were HIPAA and resident rights issues because they exposed PHI and affected resident dignity and privacy.
An LVN left 19 residents’ medical records tucked under a laptop on an unattended treatment cart in a hallway. The records included names, DOBs, diagnoses, treatment plans, and several wound photos, and the LVN stated this violated HIPAA and residents’ privacy and confidentiality rights.
Failure to Protect Resident Confidential Information: A resident’s shower sheet containing personal health information was left unattended on the nurse counter in full view at the 400-nurse station. The ADON, Administrator, and DON all identified the incident as a HIPAA and privacy violation, and CNA B stated she had no reason for leaving the information uncovered despite prior HIPAA training.
Opened Resident Mail: Two cognitively intact residents did not receive unopened correspondence. One resident received VA mail that had been opened and taped shut, and staff and family still had the envelope. For another resident, staff opened and sorted cards and letters from the public, said some were inappropriate, and did not ask the resident whether he wanted the mail opened or read to him. Staff acknowledged residents have the right to receive mail unopened, and facility records showed no care plan focus related to mail privacy.
Failure to Protect Resident Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on one of five medication carts, the 2B Medication Cart. During a medication pass observation, the Registered Nurse left the medication cart unattended in the hallway with the computer screen open and displaying resident information. In an interview shortly afterward, the RN confirmed that the cart had been left unattended with the screen open and that identifiable resident information could be seen by anyone passing by, resulting in a failure to keep residents' personal and confidential medical information private.
Resident Information Left Visible on Medication Cart
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on one of five units, the Cardinal Unit. The facility policy on Medication Administration/Disposition stated that confidential resident health information is to be maintained during medication administration, with the electronic health record in privacy mode when the nurse is away from the medication cart and paper documentation kept in a closed binder. During an observation on the Cardinal Unit, an LPN left the laptop screen open and papers displaying resident personal information on top of the medication cart outside a resident room, making the information visible to anyone passing by. In an interview shortly afterward, the LPN confirmed that the laptop screen was not closed and that papers with resident personal information were left on the medication cart.
Confidential Resident Information Posted in Public View
Penalty
Summary
The facility failed to protect the confidentiality of resident health information when a sign reading "Feeder" was posted on a resident's door. The resident's family member, who was the resident's representative and power of attorney due to dementia and Alzheimer's disease, reported seeing the sign taped to the door of the resident's private room and showed a screenshot of the posted sign. The family member told an LVN that the sign was demeaning and degrading, and the LVN later confirmed that the sign had been on the resident's door and that she removed it. The facility also failed to keep meal ticket information private for six residents on the 700 Hall. During observation, six lunch meal tickets were seen posted behind the name plate of two residents' rooms, and the tickets included each resident's name, room number, and dietary notes with special instructions. The tickets were visible to the public and anyone with access to the hall. CNA staff stated that residents on the hall ate in their rooms and that meal tickets were placed on the wall behind the name plate so kitchen staff could serve the correct meals. Interviews with CNA staff and the LVN showed that staff were aware the meal tickets contained resident information and were used to guide meal service, but the tickets were still placed where they could be seen by others. The DON stated that a sign posted on a resident's door with medical information would be a HIPAA violation and a resident rights issue, and that meal tickets in public view would also violate HIPAA. The facility policy stated that PHI should not be intentionally or unintentionally disclosed and that written PHI should not be easily accessible to unauthorized staff or visitors.
Unattended resident records left under laptop on treatment cart
Penalty
Summary
The facility failed to protect the privacy and confidentiality of 19 residents’ medical records when LVN 8 left the records tucked under a laptop computer on top of an unattended treatment cart in the hallway between Nursing Station 1 and a resident room. During the tour, surveyors observed two binder-clipped stacks and one loose stack of papers under the laptop computer on Treatment Cart A. When the surveyor looked at the documents, the papers were identified as medical records for Residents 7, 9, 13, 23, 26, 27, 33, 39, 45, 53, 55, 57, 60, 65, 82, 101, 106, 107, and 129. The records contained resident names, dates of birth, diagnoses, and treatment plans. Several of the records also contained black-and-white photographs of wounds, including those for Residents 7, 23, 45, 55, 57, 65, 106, and 107. The loose pages included nursing assignments for the same day. LVN 8 stated the records were placed under the laptop because they were believed to be safer there and later stated that leaving them there unattended violated HIPAA and residents’ rights to privacy and confidentiality. The residents whose records were exposed had a range of conditions, including dementia, severely impaired cognition, fluctuating capacity, dysphagia, diabetes, Parkinson’s disease, hemiplegia, malnutrition, and mobility limitations. Some residents were documented as lacking capacity to understand and make medical decisions, while others had severely impaired cognition or fluctuating capacity. Facility staff interviewed after the observation stated that medical records should not be left under a laptop computer on a treatment cart and that such records were accessible to anyone in the hallway.
Failure to Protect Resident Confidential Information
Penalty
Summary
The facility failed to protect the confidentiality of personal health care information for 1 of 8 residents reviewed. On 07/30/2026 at 10:15 AM, during observation of the 400-nurse station, a shower sheet for Resident #1 was left unattended for approximately three minutes in full view on the nurse counter. The shower sheet was used to document scars, skin abnormalities, or wounds, and it contained the resident’s personal, private information. Record review showed Resident #1 was an [AGE]-year-old female admitted on [DATE] with diagnoses of paralytic ileus, essential hypertension, and lymphedema. During interviews, the ADON stated staff were trained on HIPAA and resident rights and acknowledged that leaving resident information in the open could allow others to see wound information and affect privacy. The Administrator stated leaving the shower sheet open at the nurse station was a HIPAA violation and a dignity violation. The DON also stated leaving patient information open on the desk and leaving the desk was a HIPAA violation and privacy concern. CNA B stated she had no reason for leaving the resident’s personal information uncovered and said she had been trained to turn shower sheets over or put them in her pocket.
Opened Resident Mail
Penalty
Summary
The facility failed to allow two residents to receive unopened mail at the facility. For Resident #35, record review showed a male resident with diagnoses including COPD, hypertension, age-related physical debility, and cognitive communication deficit, while his annual MDS assessment showed a BIMS score of 15, indicating he was cognitively intact. His care plan contained no focus or intervention related to his ability to receive mail in the facility. Resident #108 was also cognitively intact, with a BIMS score of 14, and had diagnoses including Type 2 diabetes, Parkinsonism, and PTSD; his care plan likewise contained no focus or intervention related to receiving mail in the facility. Resident #108 stated he received a piece of mail from the VA that had been opened and taped shut, and his family member had the opened envelope. The envelope was observed and appeared to have been opened with a letter opener and then taped. The REC stated that she and the security guard handled mail, that she sorted mail when it was received, and that mail addressed to residents was opened and then sent to the corporate office or to family members. She also stated that residents have the right to receive mail unopened and that she did not understand why Resident #108’s mail was opened. For Resident #35, staff stated that cards and letters from the public were opened and sorted because some were considered inappropriate, and that staff did not speak with Resident #35 before opening them. AA R stated the resident was not asked whether he wanted the cards opened in front of him or filtered, and acknowledged that residents have the right to open their own mail. Resident #35 stated he received cards that were opened. The AD stated staff had a meeting and said the cards must be read to him, while the ADM stated the resident should have made the decision about whether to read the cards and that one card was filtered out. The FM stated the facility had permission to do everything they did and that the facility read a bad card and the FM told the facility not to read it to him.
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