EHR Left Unattended, Compromising Resident Privacy
Penalty
Summary
Staff failed to maintain the privacy and confidentiality of a resident's medical records when an electronic health record (EHR) was left open and unattended at a nurses' station. During an observation with the Director of Nursing (DON), it was noted that the EHR containing the resident's personal and medical information was accessible, with no staff present to monitor the workstation. The DON confirmed that staff are required to lock EHRs when not in use to prevent unauthorized access, as leaving them open poses a risk of exposing protected health information. The resident involved had been admitted with diagnoses including hypertension, type 2 diabetes mellitus, and a history of falls. Assessment records indicated the resident was dependent on staff for several activities of daily living and was able to understand and communicate. Facility policy required that computer terminals be shielded from public view and that users log off or clear screens when leaving workstations unattended, which was not followed in this instance.