Failure to Honor Resident’s Request to Withhold Medical Information From Family Contact
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident’s medical information by notifying a family member about the resident’s change in condition after the resident had clearly withdrawn consent for such disclosures. The resident, who had intact cognition and was documented as self-responsible with capacity to understand and make decisions, had diagnoses including type 2 diabetes mellitus, hypertension, and chronic kidney disease. His admission record listed a family member as his first emergency contact. On 12/24/2025, the resident told an RN that he no longer wanted this family member to be informed about his care because she lived far away, could not visit, and he did not want her to worry. This request was documented in a progress note. The resident later reported feeling frustrated and distrustful of the facility because his request for privacy was not honored. Despite the documented request and the resident’s capacity for decision-making, a Change in Condition Evaluation dated 1/4/2026 showed that the same family member was notified when the resident developed new nasal drip, congestion, and cough. During interviews, the RN acknowledged that the family member should not have been notified and that the resident’s right to privacy and autonomy should have been honored. The DON confirmed that the resident had capacity, was self-responsible, did not want the family member informed of his care, and that the facility did not obtain or act upon the resident’s wishes, including not removing the family member from the face sheet as emergency contact. Facility policies on Resident Rights and Confidentiality of Information and Personal Privacy stated that residents have a right to privacy and confidentiality and that the facility would strive to protect residents’ privacy regarding medical treatment and personal care, but these were not followed in this case.
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