Failure to Maintain Resident Medical Record Confidentiality
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to maintain the confidentiality of a resident's medical information. The LVN left an Emergency Kit Charge Slip, which included the resident's name and details of prescribed medications (Tramadol 50 mg PO and Ativan 0.5 mg PO), on the nurse's station counter. This document was left in plain view, accessible to staff, visitors, and others, rather than being properly secured in the medication room as intended. The LVN later stated she did not recall leaving the information on the counter. The incident was substantiated by a photograph provided by a family member, showing the Emergency Kit Charge Slip visible on the nurse's station ledge. Interviews with facility staff confirmed that resident records are considered confidential and should not be left unattended or visible in public areas. The facility's policies on resident rights and confidentiality require that all resident information be safeguarded to protect privacy.