Resident Health Information Left Unsecured During Medication Pass
Penalty
Summary
A licensed vocational nurse (LVN) failed to safeguard resident-identifiable information by leaving a computer open and unattended during medication administration, with a resident's electronic health record visible to unauthorized individuals. This incident was directly observed by surveyors, and the LVN acknowledged that this action was a violation of the facility's policy, which requires staff to close or lock computer monitors when leaving the medication cart. The Director of Nursing (DON) confirmed that staff are expected to lock their screens before leaving the area to prevent unauthorized access to resident information. The resident involved had been admitted with multiple diagnoses, including a left femur fracture, difficulty walking, diabetes, and hypertension, and was assessed as cognitively intact. The facility's policies on HIPAA compliance and resident dignity require the protection of confidential clinical information and the maintenance of resident privacy. The failure to secure the electronic health record resulted in the potential for the resident's information to be disclosed to individuals not involved in their care.