Failure to Secure Electronic Medical Records Exposes Resident Information
Penalty
Summary
A deficiency occurred when a nurse (LVN) left her computer unattended on a medication cart with a resident's confidential medical information visible on the screen. The LVN had been documenting on the computer and left to retrieve an 'Oxygen in Use' sign for another resident, leaving the monitor displaying sensitive details such as the resident's name, recent re-admission, presence of a suprapubic catheter, and current medical status. The LVN acknowledged that she failed to properly close or lock the computer screen, resulting in the exposure of protected health information. The resident involved had a history of neuromuscular dysfunction of the bladder, severe cognitive impairment, and required an indwelling suprapubic catheter. The facility's policy and staff interviews confirmed that all resident information is to be kept confidential and only accessible to authorized personnel. The incident was observed and confirmed by facility leadership, who reiterated the expectation that staff must secure electronic medical records when left unattended to prevent unauthorized access.