Failure to Protect Resident Information and Ensure Accurate Medical Documentation
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain accurate medical records in accordance with accepted professional standards. During an observation, a CNA left an open binder containing residents' activities of daily living (ADL) documentation unattended on a bedside table near a resident's room while assisting another resident. Interviews with the CNA, another CNA, and the DON confirmed that the binder contained confidential health information and should have been closed and returned to the nursing station to protect resident privacy. The facility's policy required reasonable and appropriate measures to protect the confidentiality of resident information. Additionally, the facility failed to ensure the accurate transcription of a physician's telephone order for wound care for a resident with multiple diagnoses, including COPD, diabetes mellitus type II, and hemiplegia, who had severely impaired cognition and required substantial assistance. The telephone order for collagenase ointment application to a pressure ulcer did not include instructions for a dry dressing, which the LVN acknowledged was an omission. The facility's policy required that all resident documentation be complete and accurate, but this was not followed in this instance.