Failure to Protect Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records during the discharge process. When a resident was discharged home, the discharge papers provided to the family included medical records belonging to two other residents. These records contained sensitive information such as full names, addresses, telephone numbers, sex, dates of birth, citizenship, contact persons with their information, and medical diagnoses. The documents were confirmed to be the face sheets of the two other residents, and their inclusion in the discharge packet was verified by both the Director of Nursing and another staff member. The facility's policy on confidentiality, last revised in October 2017, states that personal privacy and confidentiality of all residents and medical records must be safeguarded, with access limited to authorized staff and business associates. Despite this policy, the incident resulted in the unauthorized disclosure of protected health information for two residents, as confirmed by review of the documents and staff interviews. The affected residents had significant medical conditions, including non-traumatic intracerebral hemorrhage, essential hypertension, anoxic brain damage, tracheostomy status, and chronic respiratory failure.