Failure to Secure Resident Medical Records During Medication Pass
Penalty
Summary
A deficiency occurred when LVN F failed to secure a computer during a medication pass, leaving a resident's medical records visible and accessible in the hallway. The incident was observed as LVN F retrieved IV medication from the medication cart and entered the resident's room without locking or closing the computer screen, which displayed the resident's medical information. The nurse later acknowledged forgetting to close the record and recognized this as a violation of privacy and HIPAA regulations. The resident involved was a female with diagnoses including staphylococcal arthritis, chronic pain, anemia, hypertension, heart failure, and stage 3 kidney disease. She was receiving IV antibiotics as ordered, and her cognitive status was intact according to her BIMS score. Facility policies reviewed indicated requirements for staff to maintain privacy and confidentiality of resident records, which were not followed in this instance.