Failure to Protect Resident PHI on Medication Carts
Penalty
Summary
Nursing staff on two separate units failed to safeguard resident-identifiable information by leaving nurse run sheets containing protected health information (PHI) unattended and visible on medication carts. On Unit 500, a nurse run sheet listing residents' names, room numbers, and diagnoses was observed left in plain view on the medication cart without staff present. Staff interviews confirmed that the run sheet should have been protected and not visible to unauthorized individuals, and staff acknowledged the importance of maintaining PHI confidentiality for resident rights. Similarly, on Units 200 and 300, a printed nurse run sheet with full names, room numbers, and diagnoses for 15 residents was left unattended and visible on a medication cart, with no nursing staff nearby. Staff confirmed the document was left unattended and agreed that PHI should not be visible to unauthorized individuals. Facility policy and admission agreements reviewed indicated an expectation to protect and maintain the confidentiality of all residents' PHI.