Failure to Protect PHI by Posting EBP Lists in Shower Rooms
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LVN left a medication cart computer monitor active and unsecured during med pass, visibly displaying a resident’s eMAR and private clinical details in a hallway near resident rooms. The screen was left open a second time while the LVN stepped away to retrieve keys, and the LVN later acknowledged the exposure was an unauthorized sharing of PHI and a HIPAA violation. The DON, ADM, and CCN stated that leaving the terminal open allowed others to view private resident information.
Failure to Provide Privacy During Incontinent Care: A resident with severe cognitive impairment, an indwelling catheter, and assistance needs for ADLs was observed receiving perineal/incontinent care by two CNAs without the privacy curtain being drawn, leaving him exposed from the waist down while his roommate was in the room. The resident stated he felt uncomfortable and wanted the curtain closed every time. Staff acknowledged that privacy during care was required for dignity, but one CNA said he did not pull the curtain because he thought it was not working.
A CMA left a locked med cart unattended with the laptop screen unlocked, allowing A resident's personal medical information and medications to be visible. The CMA said she was not sure whether the screen needed to be locked or hidden when away from the cart, and later interviews confirmed the cart and laptop screen should be locked whenever staff step away.
Failure to provide privacy during wound care. An LPN assessed and applied a dressing to a resident while the resident was eating lunch, with the room door open and the privacy curtain not pulled. The interaction was visible from the hallway, and the LPN and Unit Manager confirmed privacy should have been provided and that dressing care should not occur during mealtime.
A resident’s pharmacy slip containing his name and medication information was left on the ledge of the nurse’s station and remained visible during repeated observations when no staff were present. The LVN said the slip should have been secured inside the nurse’s station, and the ADON, DON, and Administrator all identified the information as confidential and not meant to be left in view of others.
Improper Release of PHI: A staff member released a resident’s requested medical records to the resident’s son, but the packet also included skilled progress notes and other PHI for 12 unrelated residents. The error occurred when the staff member printed records from the EMR using only the first few letters of the resident’s name and did not recognize that multiple residents’ documents had been selected before sending the scanned records by secure email.
Unsecured eMAR Screen Exposed Resident Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident’s personal and medical records for 1 of 13 residents reviewed. During an observation on 06/04/2026 at 8:39 AM during medication pass on Hall B, an LVN was observed walking away from the medication cart to administer medications while the cart’s computer monitor remained active and unsecured, visibly displaying the eMAR and private clinical details of a resident. The cart was positioned in the hallway near resident rooms, exposing the screen to residents passing through the corridor. During a second observation on 06/04/2026 at 8:42 AM, the same LVN again walked away from the Hall B medication cart to retrieve keys from another nurse, and the computer screen was again left fully open and active with residents’ private eMAR information displayed. In interviews later that morning, the LVN acknowledged that leaving a resident’s personal health information visible on an open monitor was an unauthorized sharing of patient information and a HIPAA violation. The DON, ADM, and CCN each stated that leaving a computer terminal open with resident information allows others to see private information that is not supposed to be shared, and that screen security is the responsibility of the nurse assigned to that cart and unit.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure privacy during incontinent care for one resident. During an observation of perineal care with an indwelling catheter, CNA D and CNA E provided care to the resident without pulling the privacy curtain, leaving the resident nude from the waist down while care was being performed. The resident’s roommate was present in the room and was looking at his cell phone during the care. The resident was a male with diagnoses including heart failure, obstructive and reflux uropathy, unspecified dementia, and age-related physical debility. His MDS assessment reflected a BIMS score of 7, indicating severe cognitive impairment. He had an indwelling catheter, including a suprapubic catheter and nephrostomy tube, and required partial/moderate assistance with toileting hygiene, showering/bathing, personal hygiene, and dressing. His care plan stated that he required incontinent care promptly when found wet or soiled and that clothes and linens were to be kept clean, dry, and wrinkle free. During interview, the resident stated he did not feel okay when the privacy curtain was not closed while staff were cleaning his private parts because someone could enter the room, and his roommate could see him being exposed. He stated staff rarely pulled the privacy curtain when changing him or his roommate and that he wanted the curtain pulled every time he received incontinent care. Staff interviews reflected that privacy during incontinent care was expected and related to resident dignity, but CNA D stated he did not pull the curtain because he thought it was not working, and later said it did work when he checked it. The DON stated the facility policy was to have the curtain pulled during incontinent care and that staff were responsible for providing privacy.
Failure to Protect Resident Medical Record Privacy
Penalty
Summary
The facility failed to ensure staff secured and protected the privacy and confidentiality of Resident 8's medical record. On 06/02/26 at 07:55 AM, a CMA left a locked medication cart unattended with the laptop screen unlocked, and Resident 8's personal medical information and medications were visible on the screen. When the CMA returned at 07:57 AM, she confirmed she was assigned to that medication cart and stated she was not positive whether the screen needed to be locked or hidden when she was away from the cart. Later interviews confirmed that medication carts and laptop screens should be locked whenever a medication aide or nurse walks away from the cart. The facility's Confidentiality of Personal and Medical Records policy stated that residents have the right to secure and confidential personal and medical records, including confidentiality of all information contained in a resident's records regardless of the form of storage or location.
Failure to Provide Privacy During Wound Care
Penalty
Summary
Privacy during wound care was not provided for one sampled resident. During observation on 6/1/26 at 12:16 PM on the Dogwood unit, an LPN was preparing supplies from a wound care cart outside Resident #93's room while the resident sat on the side of the bed eating lunch. The LPN rolled up the resident's right shirt sleeve and began assessing the area where a bandage would be applied while the resident continued eating salad and the LPN documented and labeled the dressing. When ready to apply the dressing, the LPN asked the resident to put the salad down. The interaction was observed from the hallway with the door open and no privacy curtain pulled, and five people were seen walking by the room. The LPN later confirmed the door and privacy curtain were open and should have been closed for privacy during wound care. The Unit Manager also confirmed that it is never appropriate for a dressing to be applied or removed during mealtime and that privacy should always be provided for wound care.
Confidential resident medication slip left visible at nurse’s station
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when a pharmacy slip with Resident #1’s name and medication information was left on the ledge of the nurse’s station and remained there during two observations. Resident #1 was an [AGE] year-old male admitted to the facility with peripheral vascular disease and a non-pressure ulcer to the left calf. His MDS reflected that he was cognitively intact with a BIMS score of 13, and his care plan included treatment for an actual skin impairment related to a venous wound of the left calf. The pharmacy slip was observed on top of the nurse’s station ledge at 7:30 a.m. and again at 7:58 a.m., with no staff inside the nurse’s station during either observation. The slip contained the resident’s name and medication information. During interviews, an LVN stated the slip was the facility’s copy for the medication delivered for the resident and should have been secured inside the nurse’s station. The ADON and DON both stated the information should have been protected and kept confidential, and the Administrator stated the slip should not have been visible to others and noted the facility was correcting the same non-compliance from a prior visit.
Improper Release of Protected Health Information
Penalty
Summary
The facility failed to ensure the confidentiality of residents’ protected health information when it released medical records for one resident to that resident’s son and included records belonging to 12 other residents. An email from the resident’s son notified the facility that the scanned packet contained a total of 786 pages and included information from other residents. Facility leadership later verified that the breach occurred when staff scanned requested medical information and sent it by secured email, resulting in protected health information for 12 unrelated residents being disclosed. During interview, the Managed Care Coordinator stated she printed a report from the EMR by entering the first few letters of the resident’s name, saw the resident’s name on the top page, and then scanned the information to the son without recognizing that multiple residents’ records had been selected. The report identified that skilled progress notes containing protected health information for 12 residents were included in the release. The facility policy required PHI to be handled, stored, and communicated in accordance with regulations and required that release of PHI be limited to authorized staff and logged.
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