Failure to Secure and Protect Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality and security of residents' personal and medical records as required by its own policies and state regulations. Observations on multiple occasions revealed that computers at the nurse's station on the North Wing of the First Floor Nursing Unit were left logged into the electronic charting software without staff present, leaving residents' electronic medical records accessible and unsecured. Staff were observed leaving the area for extended periods while the electronic health record system remained open, and multiple unidentified staff were seen passing by the unattended, open charting program. Additionally, an overflowing box containing medical records and clinical documentation with resident identifiers was found unsecured and accessible in a hallway adjacent to the main kitchen. The box was awaiting pick-up by an off-site storage company, but there was no clear timeline for when this would occur, leaving the records exposed to anyone passing by, including housekeeping staff. These actions and inactions directly resulted in a failure to protect residents' rights to secure and confidential personal and medical records.