Failure to Safeguard Resident Medical Records
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of a resident's medical records when a computer displaying the resident's information was left unattended and the screen was not turned off. This incident was observed at a nurse's station, where the computer showed the resident's medical record without any staff present. Interviews with the Registered Nurse Supervisor, MDS Nurse, and Director of Nursing confirmed that staff are expected to log out or turn off the computer screen when leaving it unattended to prevent unauthorized access to protected health information (PHI). The resident involved had a history of post laminectomy syndrome, arthrodesis status, and postural kyphosis, and required significant assistance with daily activities. Facility policy and procedures reviewed indicated that all personnel are responsible for safeguarding resident information to prevent unauthorized disclosure, in accordance with HIPAA and state law. The failure to log out or secure the computer resulted in a violation of the resident's right to privacy and confidentiality.