Breach of Resident Medical Record Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records. A family member of one resident requested and received that resident's medical records from the facility, but the packet also included another resident's personal information, including date of birth, insurance details, diagnoses, and complete care plan. Review of the medical record package confirmed that the private and clinical information of the second resident was improperly included. The Director of Nursing verified that the records sent contained the additional resident's confidential information and notified the affected resident's family of the breach. Facility policy requires that all medical records be released only with a valid request and in accordance with state and federal laws.