Failure to Protect Resident Medical Record Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of personal and medical records for five residents, as required by policy. On the specified date, a piece of paper containing the names, vital signs, and blood sugar readings of five residents was left exposed and unattended on top of a nurse's cart in a hallway. The cart was unattended and located in an area with frequent staff traffic, making the information visible to unauthorized individuals. The residents involved had various medical conditions, including diabetes mellitus and hypertension, and their medical information was documented on the exposed paper. The information included sensitive data such as blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and blood sugar levels. The exposure occurred when an LVN left the cart to administer treatment to a resident, leaving the paper unsecured. Facility staff, including the ADON, Administrator, and DON, acknowledged that the residents' information was confidential and should not have been left exposed. They confirmed that the expectation was for all staff to protect residents' personal and medical information at all times, and that leaving such information unattended constituted a violation of privacy and confidentiality policies.