Failure to Maintain Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of clinical records for two residents when two pharmacy medication cards belonging to one resident were sent home with another resident upon discharge. Specifically, a resident was discharged with medication cards for sulfamethoxazole and lisinopril that were prescribed for a different resident. The medication administration records confirmed that the discharged resident did not have orders for these medications, while the other resident did. The pharmacy cards contained protected health information, including the resident's full name, physician information, medication details, and the conditions for which the medications were prescribed. Interviews with facility staff revealed a lack of awareness regarding the error. The assistant director of nursing stated that nurses are responsible for reviewing medications with residents at discharge but was unaware that the wrong medications had been sent. The registered nurse denied sending the incorrect medications, and the director of nursing was not initially aware of the incident but later verified the error through documentation. The family of the discharged resident confirmed receipt of the other resident's medications and provided photographic evidence.