Unsecured Medication Cart Exposes Resident PHI
Penalty
Summary
A medication cart on unit 300 was observed left unattended with the electronic medical record (EMR) screen open, displaying a resident's protected health information (PHI) in a hallway accessible to staff and residents. The cart was not secured, and the EMR was visible to unauthorized individuals. The LPN responsible for the cart confirmed leaving it unsecured with PHI visible, acknowledging this was not in compliance with facility protocol. The unit manager and Director of Nursing both confirmed that staff are expected to lock the cart and secure the EMR screen when not in use, as per facility policy. The resident whose PHI was exposed had been admitted for operative recovery from a total left knee replacement and had a history of borderline diabetes, lipidemia, and hypertension. The resident was cognitively intact at the time of the incident. Facility policies reviewed stated that residents' privacy must be safeguarded and that medication carts should be locked at all times when not in use or not within constant vision.