Unattended Medication Cart with Open EMR Exposes Resident Records
Penalty
Summary
Surveyors identified a deficiency in safeguarding resident-identifiable information when a medication cart was observed unattended in the hallway in front of a resident room. The cart contained a laptop that was logged into the electronic medical record system, with the screen displaying access to multiple resident records. At the time of the observation, no staff member was present at the cart to monitor or secure the device or the information displayed. During an interview shortly after the observation, the Interim Director of Nursing stated that the facility’s expectation is that resident records are to remain secured to prevent unauthorized access, confirming that the observed practice did not align with facility expectations for protecting resident medical records.
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