Failure to Secure Electronic Health Record Screen and Protect Resident Privacy
Penalty
Summary
The facility failed to maintain confidentiality of a resident’s electronic health record (EHR) when a nurse left the record open and visible on a medication cart computer. During a medication pass observation, RN Staff #169 gathered medications for Resident #159 and then turned and walked into the resident’s room. When the nurse returned to the medication cart, surveyors observed that Resident #159’s EHR remained open and in view on the screen. Staff #169 confirmed that the visible record belonged to Resident #159 and acknowledged that anybody could see it. Multiple staff interviews confirmed awareness that leaving computer screens unsecured poses a risk to resident privacy and could constitute a HIPAA violation. The social services director stated that leaving a computer screen unsecured would be a risk for a HIPAA violation. A CNA reported that charting on certain screens may be visible to residents, noted there is a way to lock the screen, and stated that leaving the screen open is a HIPAA violation. An LPN stated that if staff need to leave their computer, they must secure it because anyone could access resident information. The DON confirmed that documentation is done in the EHR and that leaving a computer screen unsecured could allow someone to see HIPAA information. The facility’s Resident Rights policy prohibits unauthorized release, access, or disclosure of resident information and requires that all access or disclosure comply with current privacy laws.
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