Failure to Notify Responsible Party and Maintain Confidentiality of Medical Records
Penalty
Summary
The facility failed to ensure the right to personal privacy and confidentiality of personal and medical records for one resident, as required. Specifically, nursing staff did not notify the correct responsible party (RP) listed on the resident's face sheet following an unwitnessed fall and subsequent transfer to the hospital. Instead, staff communicated with a family member who was not designated as the RP, resulting in the actual RP not being informed in a timely manner about the resident's fall, abnormal x-ray findings, and hospital transfer. The resident involved was an elderly male with multiple complex medical conditions, including atrial fibrillation, hypertension, diabetes, metabolic encephalopathy, and a history of falls. He was cognitively impaired, dependent on staff for most activities of daily living, and at risk for pressure injuries. After an unwitnessed fall, the resident complained of back pain, and x-rays revealed abnormal findings. Orders were obtained for further evaluation, and the resident was sent to the hospital. Documentation and interviews confirmed that the RP listed on the face sheet was not notified promptly; instead, another family member was contacted and provided with information about the resident's condition and care. Interviews with staff and the RP confirmed that the RP did not receive notification about the fall or hospital transfer until much later, and only after he sought information himself. Nursing staff acknowledged confusion regarding which family member to contact and admitted to not verifying the correct RP before disclosing information. The documentation also showed inconsistencies in notification records, and the responsible staff did not follow established protocols for ensuring the correct party was informed of significant changes in the resident's condition.