Unauthorized Disclosure of a Resident's Medical Records to Another Resident's Representative
Penalty
Summary
The facility failed to maintain privacy and confidentiality of a resident's personal and medical records when the Social Services Director (SSD) provided the wrong chart to another resident's responsible party. Resident 2, who had been admitted with a lumbar vertebral fracture, type 2 DM, COPD, and dementia, had documentation indicating severely impaired cognition and a lack of decision-making capacity. Resident 1, admitted with encephalopathy, depression, and dementia, also had severely impaired cognition but was documented in the H&P as having capacity to understand and make decisions. During a meeting, Responsible Party 1 (RP 1) requested medical records for Resident 1, and the SSD printed records from the printer and handed them to RP 1 without verifying that they belonged to the correct resident. RP 1 later informed the facility that the records received were for a different resident, identified as Resident 2. Interviews with the Medical Records Director (MRD) and the Director of Nursing (DON) revealed that facility policy required any requester of medical records to complete an Authorization for Release of Records, which must be reviewed and approved by the MRD, DON, and Administrator before records are released. The MRD and DON both stated that the SSD should not have provided Resident 2's medical records to RP 1 and that the established authorization and review process was intended to prevent disclosure of records to the wrong recipient. Review of facility policies on release of records and resident rights confirmed that records are to be released only upon properly completed authorization and that residents have rights to privacy and confidentiality of their records.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.