Unattended Medication Cards Lead to Breach of Resident Confidentiality
Penalty
Summary
A deficiency occurred when a nurse (LVN A) left a resident's medication blister cards, which displayed the resident's name and medication information, unattended on top of a medication cart in the hallway. This incident was observed when LVN A was administering medications to a resident and was interrupted by another resident calling for assistance. LVN A left the medication cards on the cart and entered another resident's room, leaving the cart and the medication cards unattended for about one minute. The unattended medication cards contained identifiable information, including the resident's name, date of birth, and details of prescribed medications. The medication cart was located in a public area of the hallway, in front of the resident's doorway, and was accessible to other residents, visitors, and staff during the time it was left unattended. Multiple staff interviews confirmed that leaving medication cards unsecured on the cart is against facility policy and is considered a breach of confidentiality, as the information on the cards is protected health information under HIPAA regulations. The resident whose information was exposed had complex medical needs, including cognitive and physical impairments, and required multiple medications for various conditions such as anxiety, depression, hypertension, and muscle weakness. The facility's policies require that all medications and related records be secured and locked in the medication cart when not in use, and staff are trained to never leave such information unattended. The incident was confirmed through observation, record review, and staff interviews, all of which indicated that the nurse failed to follow established protocols for maintaining the confidentiality and security of resident medical records.