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:
A facility failed to ensure residents promptly received personal mail on Saturdays for 3 of 3 confidential residents reviewed. Residents stated they often had to wait until Monday for mail, while the Activity Director, BOM, DON, and Administrator gave conflicting accounts of who was responsible for weekend mail distribution and acknowledged there was no system in place to ensure Saturday delivery.
A GCA used a cellphone to video record a resident during ADL care in the resident’s room without consent while an NA was providing care. The resident was cognitively impaired, dependent for ADLs, and had behavioral symptoms and care rejection. The GCA said she believed she needed proof of what she witnessed, while the NA said she did not know she was being recorded. Facility leaders confirmed recording residents was prohibited and that the recording occurred during care.
Clinical Information Shared Without Permission: A resident admitted with altered mental status, hallucinations, and possible dementia had transfer referrals sent to other facilities by the SW without the resident’s or POA’s permission. The resident’s record showed a BIMS score of 13, while the care plan and elopement assessment documented cognitive concerns and a desire to go home. The family stated they had not requested referrals and were already arranging memory care placement, and the POA said she did not authorize sharing the resident’s information.
PHI Left Exposed on Medication Cart: An open laptop on an unattended med cart displayed a resident’s EHR, and multiple papers with residents’ PHI were left visible on top of the cart, including diet orders, med lists, appointment information, physician notes, and personal effects records. Facility leadership stated resident information and computer screens should be secured and not left visible or unattended.
A resident's care plan was posted in another resident's room, and a family member observed the wrong care plan inside a closet door and reported it to the DON. The family member said the resident's own care plan had been posted earlier, then went missing and was replaced with another resident's care plan. The DON verified the issue and stated the care plan should be in the right room for the right resident.
A caregiver violated a resident’s privacy during incontinence care by using a personal cell phone to contact an outside CNA who was not employed by the facility while the resident was present. Staff observed the caregiver on a video call, and a written statement noted the camera was turned toward the resident’s buttocks area and the mess on the floor.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
Keep residents' personal and medical records private and confidential was deficient because the facility did not ensure residents promptly received their mail on Saturdays for 3 of 3 confidential residents reviewed for resident rights to receive personal mail. During a confidential group interview, 3 residents stated they did not always receive mail on Saturdays and had to wait until Monday when the Activity Director passed it out. During interviews, the Activity Director stated mail should be delivered to residents on Saturdays and that the facility had previously been cited for not delivering mail on Saturdays, with the solution being for the RN Supervisor to deliver mail on Saturday. The Business Office Manager stated weekend mail was placed in a locked box outside her door, that she was the only one with a key, and that there were times she gave Saturday mail to the Activity Director to distribute. The DON stated she was unaware residents were not receiving mail on Saturdays but expected mail to be delivered then, and the Administrator stated there was no system in place to ensure residents received mail on Saturdays.
Unauthorized Video Recording During Resident Care
Penalty
Summary
The facility failed to provide personal privacy during ADL care when a GCA used a cellphone to video record a resident while care was being provided in the resident’s room, without resident representative consent. The resident involved had diagnoses including diffuse traumatic brain injury without loss of consciousness and vascular dementia with mood disturbance. The admission MDS indicated the resident was cognitively impaired, had physical and verbal behavioral symptoms directed toward others, rejected care, and was dependent on others for ADLs. According to the investigative summary, staff reported the resident was resistant to care and combative at times. On the day of the incident, an NA asked the GCA to witness care because of the resident’s known behaviors. The GCA entered the room and sat behind the NA while the NA provided care. After the care was completed, the GCA began video recording while the NA was dressing the resident into a gown. The NA stated she did not know the GCA was recording and did not ask her to record the care. The GCA stated she recorded the care because she believed she needed proof of what she witnessed and thought that was what the NA wanted her to do. She also stated she did not tell the NA she was recording and later deleted the video. The DON, Scheduler, Nurse, and Administrator all confirmed that video recording or taking pictures of residents was not allowed in the facility and that the recording occurred during resident care in the room. The report also states the GCA had received orientation training on protecting patient privacy and HIPAA.
Clinical Information Shared Without Permission
Penalty
Summary
The facility failed to keep a resident’s clinical information private and confidential when the social worker sent transfer referrals to other nursing facilities without the resident’s and responsible party’s permission. The resident was admitted from the hospital with diagnoses including altered mental status, hallucinations, and type 2 diabetes mellitus without complications. Her admission MDS showed a BIMS score of 13, indicating she was cognitively intact, and the initial care plan noted anxiety medication use and impaired cognitive function or thought processes related to a new environment. The resident’s elopement assessment also documented cognitive impairment or a diagnosis associated with impaired judgment or wayfinding, a history of elopement or attempted elopement, family concern about unsafe leaving, and that the resident had verbally expressed a desire to go home. Hospital discharge notes documented suspected dementia with psychosis, neurology consultation, continued low-dose Seroquel and as-needed antipsychotics, possible Lewy body dementia, and a note about dependence counseling and weaning off a medication. The social worker documented that transfer referrals were sent to area nursing facilities as per the resident’s wishes. During interview, the family representative stated the resident and family had not requested referrals to other facilities and had already been arranging placement at a memory care facility, waiting for that facility’s room to be remodeled. The family representative also stated they were told the resident could not stay at the facility and that no discharge notice was given. Facility interviews showed the admission and discharge process was discussed at admission and during the 72-hour care plan meeting. The administrator, ADON, MDS coordinator, operations manager, and social worker stated the team discussed discharge planning, alternate placement, and that the resident wanted to move. The social worker stated he used nurses to translate and confirmed through nursing notes that the resident wanted to move, while also stating he doubted the resident had dementia because of the BIMS score. The POA stated she did not ask for referrals to be sent to other facilities and did not believe it was right that the resident’s information had been shared without permission. The facility’s discharge planning policy stated the discharge process should involve the resident and representative and document relevant resident information in the clinical record.
PHI Left Exposed on Unattended Medication Cart
Penalty
Summary
The facility failed to safeguard protected health information (PHI) for 4 of 4 residents identified in the report. During observation of the 300 hall, a laptop computer was left open on an unattended medication cart and displayed one resident’s electronic health record. In the same observation, multiple documents containing residents’ PHI were left exposed on top of the cart, including a diet order communication form with a room number, a medication list, appointment information, a physician appointment summary with physician notes, and an inventory of personal effects form for four different residents. Record review of the facility’s privacy policy stated that confidential or protected health information on desks or in other publicly accessible areas must be secured in designated work areas or locked storage, and computer screens must be locked when staff step away. During interviews, the Unit Manager stated that computer screens should be locked and patient information should not be left visible, the Corporate Director of Nursing stated all resident information must be secured and that staff are responsible for doing so, and the Administrator stated resident information should be secured by the person handling it and that leaving it visible and unattended could allow unauthorized access.
Resident Care Plan Posted in Wrong Room
Penalty
Summary
The facility did not ensure the security and privacy of medical information for one resident when R7's care plan was posted in R1's room. The facility's Resident Rights document states residents have the right to confidentiality concerning personal and medical information, and the HIPAA document prohibits leaving resident information accessible to people who have no right to see it. A family member observed R7's care plan posted inside the door of R1's closet and reported that it showed R7's name and care plan content. The family member stated R1's care plan had been posted previously, but it went missing and R7's care plan was posted instead. The DON later verified that another resident's care plan had been posted in R1's room and stated that a care plan should be in the right room for the right resident.
Privacy Breach During Incontinence Care
Penalty
Summary
Keep residents' personal and medical records private and confidential was violated when a caregiver used a personal cell phone during incontinence care for a resident who had an episode of bowel incontinence. During the care, the caregiver contacted a CNA who was not employed by the facility to ask for advice about how to handle the resident's resistance to care, allowing an unauthorized person to be involved while the resident was present. Facility records and staff statements showed the caregiver was observed on a phone call while performing incontinence care, and the call was identified as a video call because the camera was on. A written statement noted the caregiver turned the camera toward the resident's buttocks area and the mess on the floor. In an interview, the caregiver stated she called someone for advice on caring for someone resistant to care and identified the person as a CNA who was not employed by the facility; she denied that the call was a video call.
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