Failure to Protect Resident Medical Record Privacy During Medication Administration
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain the privacy of medical records during medication administration for two of three sampled residents. Observations revealed that a medication cart laptop was left open and unattended on the 2nd floor, displaying a resident's personal information and medication administration record (MAR) in a location accessible to staff and visitors. In one instance, a registered nurse left the laptop open while walking away into a resident's room, leaving the resident's information visible. The nurse acknowledged that the information should not have been exposed. A similar incident occurred with another resident, where a nurse left the medication cart laptop open outside the resident's room, again exposing the resident's personal information and MAR. Both nurses interviewed confirmed that resident information should not be visible to others. The Director of Nursing also confirmed that residents' private information and MARs should not be exposed for staff and visitors to see. The residents involved had significant medical histories, including conditions such as pneumonia, acute respiratory failure, congestive heart failure, diabetes, hypertension, and orthopedic aftercare.