Failure to Secure and Maintain Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality and security of residents' personal and medical information by leaving identifiable health records in clear acrylic wall file holders located in publicly accessible hallways. Specifically, outside the Medical Records office, documents such as a determination regarding a resident's skilled care therapy status, a hospital progress note detailing x-ray and MRI results, a hospital discharge summary with diagnoses and medication lists, and an after-visit summary with medication changes were observed to be left unattended and visible. These records contained sensitive information that could be easily accessed by unauthorized individuals passing by. Similarly, outside the physician's office, additional confidential documents were found in a wall file holder. These included pharmacy reviews for new admissions, a hospice plan of care, standing hospice orders, admission certifications, faxed requests for physician signatures on chest x-rays, a resident's admission face sheet with personal identifiers, and a physician's discharge summary with medical history. Staff interviews confirmed that these documents were stored in these locations, and it was acknowledged that such information should not be left in areas accessible to the public.