Failure to Secure Resident Medical Record on Medication Cart Laptop
Penalty
Summary
Facility staff failed to secure and protect the privacy and confidentiality of a resident's medical record. On one occasion, staff left a resident's point of care information open and visible on the electronic medical record system at the medication cart laptop, making the information accessible to unauthorized individuals. A certified medication aide acknowledged that the screen should not be left unlocked with resident information displayed. A licensed nurse confirmed that both the medication cart and the laptop screen should always be locked when unattended, and an administrative nurse stated that nursing staff are expected to lock any screen on the laptop and secure the medication cart when not in direct sight. The facility's policy requires that protected health information not be used or disclosed except as permitted by law.