Failure to Protect Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records as required by their own policies and procedures. In one instance, a 77-year-old resident who was discharged from the facility did not receive all of his prescribed medications, and instead, another resident's inhaler was mistakenly sent home with him. The error was discovered when the discharged resident's daughter found the inhaler while sorting through the medications provided by the facility and subsequently notified the facility. In a separate incident, a home health physical therapist evaluating the discharged resident at home found a therapy note in the electronic medical record that belonged to a different resident who was still admitted at the facility. The therapy note included personal information such as the resident's name, date of birth, and plan of care. The facility's own documentation confirmed that a page of another resident's therapy notes was included in the discharge documents sent to the home health agency. These events demonstrate that the facility did not ensure that only the appropriate resident's information was released, resulting in breaches of confidentiality for at least two residents.