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F0583
D

Failure to Protect Resident Health Information During Communication

Clayton, North Carolina Survey Completed on 10-30-2025

Penalty

Fine: $255,500
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a nurse used a personal, non-secure phone to text a resident's name and medical information to the Nurse Practitioner, rather than using a secure and private communication method. The nurse was not aware that this was a violation of privacy protocols, as he had not received training on secure communication or been informed of any secure messaging application available for use. The interim Director of Nursing confirmed that the facility did not have a HIPAA-compliant secure messaging system in place and that staff were expected to call and verbally communicate with the Nurse Practitioner when necessary. The incident involved a resident who had recently been admitted after hospitalization and had a gastrostomy tube placed. The nurse became involved when the resident experienced bleeding from the gastrostomy tube site and, unable to find medical history or orders in the electronic record, attempted to contact the former DON without success. Out of concern for the resident and a lack of guidance on secure communication, the nurse texted the resident's information to the Nurse Practitioner. This action resulted in a failure to protect the privacy and confidentiality of the resident's medical records.

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