Failure to Secure Resident Medical Information and Maintain Confidentiality
Penalty
Summary
The facility failed to ensure the confidentiality of personal and medical records for eight residents. On the specified date, an untitled piece of paper containing the blood pressure, pulse rate, and oxygen saturation of these residents was left on top of a nurse's cart parked in the hallway. Additionally, a laptop on the same cart was left open and unattended, displaying the residents' pictures and indicating their skilled nursing status. The cart was positioned facing the hallway, where several staff members were observed walking back and forth, making the information accessible to unauthorized individuals. Interviews with staff confirmed that the nurse had left the cart to assist a resident and did not secure the paper or close the laptop before leaving. The nurse acknowledged that best practice would have been to secure all resident information before leaving the cart unattended. The Director of Nursing (DON), Administrator, and Assistant Director of Nursing (ADON) all stated that personal and medical information should be protected and not visible to unauthorized individuals, including staff not involved in the residents' care, visitors, and vendors. They confirmed that the information left exposed included vital signs, names, pictures, and care levels, all of which are considered protected health information. A review of the facility's policy on confidentiality and personal privacy indicated that the facility is required to safeguard the personal privacy and confidentiality of all resident personal and medical records. The observed actions were inconsistent with this policy, as sensitive information was left exposed and unattended in a public area, accessible to individuals without authorization.