Failure to Protect Resident Confidentiality by Posting Clinical Information Publicly
Penalty
Summary
The facility failed to protect the privacy and confidentiality of a resident's medical information by posting a sign indicating "NPO" (Nothing by Mouth) on the outside of the resident's door, making this clinical instruction visible to anyone passing by in the hallway. The facility's policy states that residents have the right to personal privacy and confidentiality of their medical records, including medical treatment information. During interviews, the DON acknowledged that the sign was posted for staff awareness but admitted uncertainty about whether the resident or her family had been informed or given permission for the sign to be displayed. The resident herself confirmed she had not been asked for permission, and her representative also stated he was not consulted about the sign placement. Staff interviews revealed that care information, including NPO status, was accessible to staff through the Kardex and electronic health records, making the public posting of the sign unnecessary. The DON further acknowledged that staff from various departments, as well as visitors and family members, could see the sign, which contained confidential care information. The resident involved had been admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction and was receiving enteral feedings per physician order. The resident's cognitive status was moderately impaired, as indicated by a BIMS score of 12.