Failure to Maintain Confidentiality of Resident Clinical Records
Penalty
Summary
Facility staff failed to maintain the confidentiality of a resident's clinical record by printing and distributing a progress note without proper authorization. An LPN was asked by another LPN, through a CNA and with the involvement of a former staffing coordinator, to print a specific progress note related to backdated medication orders for a resident. The LPN expressed hesitation but proceeded to print and hand over the document, believing she had no alternative. The document was then given to the requesting LPN, who later admitted via text message to the director of nursing that she had destroyed the document after being questioned about its possession. Interviews with administrative staff revealed confusion regarding why the document was printed, as the requesting LPN should have had access to print it herself. The executive director and director of nursing both confirmed that the document was printed and distributed without proper oversight, and the facility's own policy states that residents have a right to secure and confidential personal and medical records. The incident involved multiple staff members and resulted in a breach of confidentiality for the resident's clinical information.