Failure to Secure and Maintain Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to ensure the secure and confidential storage of residents' personal and medical records, as required by its own policies and HIPAA regulations. Surveyors observed three brown paper bags and one large black trash bag containing confidential resident information left open and unattended at the nurse's station. Staff interviews confirmed that these bags, filled with resident documents, had been at the nurse's station for several weeks due to the absence of designated shred box containers. Staff were instructed to place confidential documents in these bags, and the director of nursing acknowledged that the facility did not have shred boxes at the time of the survey. Additionally, a locked medication cart was found unattended in the hallway with its computer screen visible to passersby, displaying a portion of a resident's medication administration record. Both the regional nurse consultant and a registered nurse confirmed that the screen should not have been visible to the public and that there was a lock button available to secure the screen. These actions and inactions resulted in the failure to maintain the privacy and confidentiality of residents' medical records.