Failure to Safeguard Confidential Resident Care Log in Public Hallway
Penalty
Summary
The deficiency involves the facility’s failure to safeguard a resident’s confidential medical information in accordance with its policy on confidentiality of personal and medical records. The facility’s policy dated 12/2022 defined keeping information confidential as safeguarding written and other stored information from unauthorized disclosure without the consent of the individual or representative. Resident 4, who had been admitted on an unspecified date and whose H&P dated 7/19/25 documented no capacity to make medical decisions, had a Resident Care Log binder containing personal health information. On 1/9/26 at 1538, this binder was observed tucked on the railings outside the resident’s room in a hallway leading to the facility’s main entrance, rather than being secured. From 1538 to 1557 on the same day, multiple staff and visitors were observed repeatedly walking past the binder without acknowledging or securing it, including CNAs and groups of visitors exiting near the front entrance. During an interview and concurrent observation at 1609, an LVN acknowledged the binder in the hallway and stated the resident’s family liked to have it there. When the binder was opened, it contained the resident’s name, room number, and care notes. The LVN acknowledged that people walked up and down the hallway near the front exit. In a subsequent interview at 1634, the DON verified that the Resident Care Log binder was not supposed to be in the hallway, stated it should be in the resident’s room, and acknowledged that the binder contained the resident’s name, confirming that the medical record was not properly safeguarded from unauthorized access.
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