Failure to Maintain Confidentiality of Resident Electronic Medical Record
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident’s personal and medical records when the resident’s electronic medical record (EMR) was left open and unattended on a medication cart. The resident was an adult female with cerebral palsy, major depressive disorder, mood disorder due to a known physiological condition, and intellectual disabilities, with an initial admission date in 2022 and a recent readmission. A Quarterly MDS assessment documented a BIMS score of 15, indicating intact cognition with normal memory and recall. Her care plan noted a risk for cognitive impairment related to mild intellectual disorders, with interventions to monitor and report changes in cognitive function. Despite this, during an observation on the 100 hall, her EMR was visible on the cart screen, displaying her room location, date of birth, allergies, code status, and medications. During an interview shortly after the observation, the respiratory therapist who had been administering an inhaler to the resident acknowledged leaving the medical record open and unattended, explaining she was trying to quickly administer medication and did not realize the record remained open. She stated that leaving medical records open allowed anyone to view the documents. The DON stated that medical records should not be left open when staff walk away from the cart and should be locked, noting that wandering eyes could view residents’ information and that this constituted a HIPAA violation. The administrator reported that the EMR has a built-in timeout and that staff can minimize the screen to lock it before walking away, and also noted that in-services on confidentiality are conducted periodically. The facility’s Resident Rights policy, revised in 01/2025, states that residents have the right to personal privacy and to secure and confidential personal and medical records, and the right to refuse release of such records except as allowed by law.
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