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F0583
E

Failure to Protect Resident Confidentiality Through Improper Disposal of PHI

North Hollywood, California Survey Completed on 04-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect the confidential personal and medical information of 15 sampled residents by improperly disposing of documents containing protected health information (PHI). During an observation in the kitchen, a diet type report listing 13 residents' names, room numbers, allergies, and diet orders was found in the handwashing trash can mixed with soiled paper towels. The Assistant Dietary Supervisor confirmed that the report contained sensitive information and should have been placed in a designated locked container for confidential disposal, as per facility protocol. Staff interviews revealed that the report was not handled according to established procedures, and it was unclear who discarded it in the trash. Additionally, in Nursing Station 3, a handwritten document listing the names of two residents along with their medications and dosages was found in a regular black plastic trash bin. Both the LVN who wrote the document and another LVN acknowledged that this was a violation of confidentiality and that such documents should be shredded. The Director of Nursing also confirmed that the facility failed to protect resident privacy by not ensuring proper disposal of documents containing medical information. Review of facility policy indicated that staff are required to receive training on the privacy and security of PHI, but these protocols were not followed in these instances.

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