Failure to Secure Electronic Health Records at Documentation Station
Penalty
Summary
Surveyors observed that an ICARE documentation station, used by CNAs and RNAs to record resident care tasks and interactions, was left open and accessible in a high-traffic hallway near the entrance to a wing. The open station displayed a resident's personal and clinical information, including code status, allergies, diet, and required treatment monitoring. Staff interviews confirmed that the station should have been closed and exited out after use to maintain privacy and comply with HIPAA requirements. The Director of Nursing and other staff acknowledged that leaving the station open was not in accordance with facility policy or privacy regulations. Review of the facility's policy confirmed the expectation for privacy and confidentiality of resident records.