Failure to Safeguard Resident Privacy and Confidentiality of Records
Penalty
Summary
Surveyors identified a deficiency in the facility's protection of resident privacy and confidentiality of medical records. During observations, a note containing information about a resident's allowed visitors and specific steps to follow was found posted on the computer screens of both medication carts. This note was visible to anyone in the area, thereby exposing confidential resident information. The Director of Nursing (DON) confirmed that the signs were intended to inform all staff, including PRN nursing staff, about visitor restrictions for the resident, but acknowledged that the signs should have been flipped to the blank side when not in use to prevent displaying resident information. Additionally, during a medication administration observation, the Electronic Medication Administration Records (EMAR) screen on one of the medication carts was left unlocked and unattended, with a resident's EMAR information visible. A registered nurse admitted to forgetting to lock the computer before leaving to administer medications, acknowledging awareness of the requirement to secure the computer screen when not present with the medication cart. The facility's policy on resident rights and confidentiality was reviewed and indicated a commitment to providing personal privacy and confidentiality of records. However, the observed actions of leaving confidential information visible on both physical notes and electronic screens demonstrated a failure to adhere to these policies and federal regulations regarding the safeguarding of residents' personal and medical information.
Plan Of Correction
1. Resident #23 posted information was immediately removed on and a search of the common facility areas was conducted to ensure that no other resident information was visible to outside sources, no other issues were found. 2. Medication carts and computer were checked for identifiable resident information and no other issues were found. 3. The DON or designee will educate current staff to ensure that personal and/or confidential information is safeguarded. 4. HR will be responsible for training new hires on measures to safeguard information and HIPAA compliance. 5. On all departments were re-educated by the DON on the importance of residents' rights to privacy to ensure that residents' names are kept confidential and not posted. 6. The nurse on cart B who left the computer screen open, unattended was re-educated by DON on the importance of locking his screen when moving away from the cart. 7. On an in-service was held by the DON with all the nurses on confidentiality and privacy of residents' information related to safeguarding personal and confidential information. 8. Nursing supervisor will monitor for compliance daily and Director of Nursing or designee will make random checks weekly to ensure that residents' rights to confidentiality and privacy are not being violated for the next 3 months. 9. Findings will be reported monthly in the QA meeting until substantial compliance has been determined, to ensure compliance has been achieved.