F0583

D

Unsecured Electronic Medical Record and Medications Left Visible on Unattended Med Cart

Cambridge, Maryland Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

Facility staff failed to maintain the privacy and confidentiality of resident medical records when an electronic medical record was left visible on an unattended computer screen. During a complaint survey on the 200-nursing unit, a surveyor observed Resident #10’s electronic medical record displayed on an open computer screen atop an unattended medication cart positioned in the hallway outside a resident room. Resident #2’s medications were also on display on the cart, and additional information in the electronic record was accessible on the screen. The cart and computer were unattended until Staff (LPN) #21 returned to the cart, at which time the surveyor informed the LPN that the resident’s medical record had been left open and visible, and the LPN acknowledged having left the computer screen open.

These observations demonstrate that staff did not ensure that electronic medical records and medication information were secured when the medication cart was left unattended in a public hallway, resulting in resident medical information being exposed and not kept private and confidential.