Failure to Maintain Privacy and Confidentiality of Medical Records at Discharge
Penalty
Summary
A resident was discharged from the facility and was mistakenly given another resident's medical record at the time of discharge. Both residents involved had been discharged on the same day, and their medical records were placed in folders on top of the nurse's station. A nurse inadvertently provided the wrong medical chart to the departing resident. The error was not identified until 24 hours later, when the resident presented the incorrect medical chart at the emergency room, and hospital staff recognized the mistake and notified the facility. The residents involved had diagnoses including stroke and pain, respectively. The facility's policy, as provided by the Executive Director, states a commitment to protecting residents' rights, including access to their own personal and medical records and ensuring privacy and confidentiality. The incident resulted in a failure to maintain the privacy and confidentiality of a resident's medical record.