Failure to Protect PHI by Posting EBP Lists in Shower Rooms
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ Protected Health Information (PHI) by posting detailed Enhanced Barrier Precautions (EBP) lists in multiple shower rooms. Surveyors observed that on the 2nd, 3rd, and 4th floors, documents titled "2nd Floor EBP," "3rd Floor EBP," and "4th Floor EBP" were posted on shower room mirrors at the entrances. These documents contained resident names, room numbers, and the reasons for EBP for a total of 59 residents out of 194. The lists were used to remind staff which residents required personal protective equipment (PPE) such as gowns, gloves, masks, and face shields during showers. During interviews conducted at the time of the observations, multiple CNAs confirmed that the posted lists were used as reminders for staff about which residents were on EBP and what PPE was needed when providing showers. CNA staff on each of the three floors acknowledged that the lists contained residents’ private information and that such information should not be posted in public areas where anyone entering the shower room could read it. One CNA indicated that they believed the Infection Preventionist (IP) had hung the lists. Additional interviews with licensed nurses, RNs, the Quality Assurance Nurse (QAN), the IP, and the Director of Nursing (DON) further established that facility staff understood that residents’ private information should not be posted in public areas and should be protected. The DON stated that PHI should not be posted in a public area like a shower room and emphasized that PHI should be kept in a secured area to prevent disclosure to the public. Review of facility policies on Residents’ Rights and Protected Health Information showed that unauthorized release, access, or disclosure of resident information is prohibited and that personnel are responsible for managing and protecting PHI, limiting its use or disclosure to the minimum necessary. Despite these policies, the facility allowed PHI to be posted openly in shower rooms, resulting in the cited deficiency.
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