Unauthorized Individual Present During Resident Care and Medication Administration
Penalty
Summary
A deficiency occurred when an LPN brought their 15-year-old daughter onto the 300 Hall unit during their shift, allowing her to be present while preparing and administering medications, as well as providing resident care. The daughter was introduced to other staff, escorted the LPN into resident rooms, and observed the LPN taking a resident's blood pressure and administering medications to residents, including a male resident in the hallway. The LPN admitted to asking a female resident for permission for her daughter to observe care and acknowledged the inappropriateness of the situation, recognizing it as a violation of HIPAA regulations. Multiple staff members confirmed the daughter's presence and involvement, and video footage corroborated that the daughter was at the medication cart, observed medication administration, and was behind the nurse's station desk. The Nursing Home Administrator and Director of Nursing reviewed the footage and acknowledged that the LPN's actions had the potential to violate resident privacy and confidentiality of protected health information (PHI), as required by federal regulations.
Plan Of Correction
F-583 ELEMENT I Residents residing on Unit 300 hall (short stay rehab unit) on May 24, 2025, no longer reside in the facility. LPN “D” is no longer employed at the facility. ELEMENT II Residents residing within the facility have the potential to be affected. Residents residing on Unit 300 hall with the potential for unauthorized disclosure of protected health information had no negative effects due to this practice. Rounds were made throughout the facility to validate that no HIPAA-related information is discussed or visible in non-confidential areas; no concerns were noted. ELEMENT III The facility policies with respect to HIPAA, Standard of Nursing Practice, and Notice of Privacy were reviewed and deemed appropriate. Active staff were re-educated on the facility's policy regarding HIPAA to ensure compliance with maintaining personal privacy and medical records in accordance with CFR (s): 483.10(h)(1)-(3)(i)(ii). In addition, the professional license nurses were re-educated on the Standard of Nursing Practice. ELEMENT IV The DON/designee will audit the resident areas to validate that no HIPAA-related information is discussed or visible in non-confidential areas weekly for 4 weeks and monthly for 2 months. Any areas of concern will be addressed immediately. Findings from the audit will be brought to the Monthly QAPI Meeting for further review and recommendations. The DON is responsible for obtaining and maintaining compliance.