Failure to Maintain Medical Record Confidentiality and Privacy During Personal Care
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of one resident’s medical record when an LPN left a medication cart computer screen unattended in a hallway with identifiable medical information visible. For Resident #118, who had intact cognition and multiple diagnoses including diabetes, mild cognitive impairment, hypothyroidism, hypertension, generalized anxiety disorder, dementia, personality disorder, peripheral vascular disease, and bipolar disorder, surveyors observed that the computer screen on the unattended medication cart displayed the resident’s medication list along with the resident’s picture, name, and room number. The LPN later confirmed she had left the medical information visible and acknowledged she was supposed to lock the screen before walking away, contrary to the facility’s written policy on confidentiality and personal privacy. The facility also failed to ensure privacy during personal care for another cognitively intact resident with incontinence. Resident #54, who had diagnoses including anemia, hypothyroidism, chronic pain, hearing loss, viral herpes, major depressive disorder, insomnia, restless leg syndrome, rhinitis, and hypertension, was care planned to receive assistance with toileting and incontinence care. During observation, an agency CNA provided incontinence care with the resident’s door open and the privacy curtain not pulled, leaving the resident’s perineal area and buttocks visible from the hallway. The CNA stated the resident did not like her door closed but acknowledged she could have pulled the privacy curtain. The resident later reported she had never told staff to leave the door open during care and that most staff usually closed the door or at least pulled the curtain, and the care plan contained no documentation that the resident requested the door remain open during care, which conflicted with the facility’s policy to safeguard personal privacy.
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