Confidentiality Breach in Medical Record Handling
Penalty
Summary
The facility failed to ensure the confidentiality of residents' personal and medical records for one out of three residents reviewed for confidentiality. Specifically, the Administrative Coordinator sent the care plans of one resident to the representative of another resident in error. This occurred when the representative of a resident requested medical records to be forwarded to the resident's physician, but the records sent included the care plans of a different resident. The error was identified when the physician's office notified the representative about the incorrect records. The incident involved residents with significant cognitive impairments and complex medical histories, including diagnoses such as vascular dementia, cardiomyopathy, mood disorder, major depression, and pulmonary embolism. The Administrative Coordinator acknowledged that the mistake happened because they were rushed to send the documentation before a deadline, resulting in the wrong resident's information being compiled and sent. The facility's policy requires confidential treatment of all personal and medical records, but this was not followed in this instance.