Confidential Medical Information Left Unattended on Medication Cart
Penalty
Summary
A deficiency occurred when confidential medical information was left unattended and visible on top of a medication cart in the 500 hall. The narcotic book was open to a resident's narcotic sheet, displaying the resident's name, medication name, directions for use, frequency of use, indication, and remaining count. Additionally, two empty medication cards for two other residents, including their names, medication names, and usage directions, were also left exposed. During this time, no nurse was present at the cart, and two staff members along with one resident walked by, making the information accessible to unauthorized individuals. When a nurse returned to the cart, she acknowledged that she had forgotten to close the narcotic book and recognized that leaving the information visible was a violation of privacy and confidentiality. The Director of Nursing, in the presence of the Administrator, confirmed that this was a HIPAA violation and stated that staff receive education on HIPAA requirements during orientation and annually. The incident was identified through record review, observation, and staff interviews.