Unattended Medical Records Expose Resident Information
Penalty
Summary
Facility staff failed to protect the medical records of six residents when a respiratory therapist left therapy notes containing sensitive information unattended on top of a therapy cart in a hallway. The unattended document included residents' names, room numbers, medications, oxygen requirements, diagnoses, and vital signs such as oxygen saturation, heart rate, respiratory rate, and breath sounds. This cart was located in a public area where other staff, residents, and visitors frequently passed by, making the information easily accessible to unauthorized individuals. Observations confirmed that the paper with residents' information was left open and unattended on the therapy cart. A licensed vocational nurse acknowledged that anyone walking by could see the residents' medical information and identified this as a violation of HIPAA regulations. The nurse further stated that staff are aware they should not leave papers with residents' information exposed, and that this was a breach of privacy. Interviews with another respiratory therapist and the director of nursing confirmed that the proper procedure is to keep such documents secured inside a locked drawer of the therapy cart, not left out in the open. Both staff members emphasized the importance of maintaining confidentiality and privacy of residents' health information. A review of the facility's policy and procedure also indicated that staff should not divulge clinical information in public areas and must keep medical records secure and confidential.