Unauthorized Access to Former Resident's Medical Records After Discharge
Penalty
Summary
A deficiency occurred when a registered nurse working in the admissions office accessed the external hospital medical records of a resident through an online portal after the resident had left the facility against medical advice (AMA) and with no intention to return. The nurse used the hospital's portal, which is intended for reviewing records of patients being referred or expected to return to the facility, to access the resident's emergency department records the day after the resident's departure. This access was performed without the resident's consent and after the treatment relationship had ended. The resident involved was an older female with a complex medical history, including chronic kidney disease, urinary retention requiring a suprapubic catheter, recurrent urinary tract infections, bladder cancer, and chronic pain. Facility policies, the hospital-facility agreement, and user confidentiality agreements all required that medical records be accessed only for individuals with an authorized treatment relationship and with appropriate consent. The nurse's actions violated these requirements, resulting in a breach of confidentiality and the resident's rights.