Failure to Maintain Resident Confidentiality by Posting Clinical Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records as required by its own policies and state regulations. During an observation, a sign was found posted above the head of a resident's bed that stated "Honey Thick and Aspiration Risk," which included clinical information visible to others. This was confirmed by a registered nurse during an interview. The facility's policies specifically prohibit posting signs with clinical or personal information in areas visible to others, and require the protection of residents' protected health information. The resident involved had diagnoses of muscle weakness, dementia, and anxiety, and was at risk for aspiration, with a physician's order for honey consistency fluids. The posted sign directly referenced these medical conditions and care needs, making confidential information accessible to anyone entering the resident's room. The deficiency was identified during a review of facility policies, clinical records, and staff interviews.