Failure to Protect Resident Medical Record Confidentiality
Penalty
Summary
A deficiency occurred when the Assistant Director of Nursing (ADON) left a computer screen displaying a resident's confidential medical information open and facing the hallway while she entered the resident's room. The exposed information included the resident's name and insulin order, and the ADON could not recall if the diagnosis was also visible. The resident involved was a male with Type 2 Diabetes and severe cognitive impairment, as indicated by a BIMS score of 5. The ADON acknowledged that she had received on-the-floor training regarding medication pass and was aware that computer screens should be closed when unattended, but she could not remember receiving formal or HIPAA-specific training since starting at the facility two months prior. Interviews with facility leadership, including the Administrator (ADM) and Director of Nursing (DON), confirmed that the expectation was for resident information to be kept confidential and that leaving such information exposed could constitute a HIPAA violation. Review of facility policy also reflected the requirement for privacy and confidentiality of residents' personal and medical records. The incident was identified through observation, interview, and record review, and it was determined that the facility failed to ensure the confidentiality of the resident's medical information.