Failure to Protect Confidentiality of Resident’s Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of one resident’s personal and medical information when staff posted a document containing protected health information directly above the resident’s bed in a semi-private room. During a room tour, the surveyor observed a paper that included the name of the company performing PASARRs, the resident’s full name, the full name and address of the facility, and a statement that the resident is a [NAME] Class Member who requested not to proceed to assessment. This information was clearly visible to visitors, staff, and the roommate. When asked about the posting, the resident stated they did not know what the paper was and that a nurse had put it there. The resident’s face sheet documented diagnoses including major depressive disorder, borderline personality disorder, and mild intellectual disabilities, and a BIMS score of 5 indicating severely impaired cognition. On a subsequent tour two days later, the surveyor again observed the same paper with the resident’s personal and medical information posted above the bed. Review of the electronic medical record revealed no documentation that the resident had consented to having personal medical information displayed in view of others. Facility policies on HIPAA and Resident Rights state that medical records must remain confidential and that residents are entitled to privacy and confidentiality, but these policies were not followed in this instance.
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