Failure to Protect Resident Health Information During Text Communication
Penalty
Summary
The deficiency involves the facility’s failure to maintain the privacy and confidentiality of a resident’s personal and medical information when communicating about a fall event. Resident #1 had a diagnosis of cerebral infarction, a BIMS score of 15/15 indicating no cognitive impairment, and was dependent with ADLs and transfers while using an electric wheelchair independently. The resident had an identified risk for falls and alteration in mobility, with care plan interventions including assistance with ADLs, ensuring the call bell was in reach, determining causative factors of falls, and monitoring and administering pain medication as ordered. On the morning of 1/7/2026, Resident #1 was being transported for a scheduled medical appointment in a wheelchair-accessible van. The nurse aide reported that the resident refused assistance during transfer into the van and fell backwards out of the wheelchair, landing supine on the pavement and striking the back of the head. Facility documentation and a reportable event form indicated that the wheelchair became caught on an object while the resident was seated, causing it to tilt and tip over. An RN assessment was completed, the resident initially denied pain or discomfort and insisted on proceeding to the scheduled appointment, and later hospital imaging identified an acute displaced L2 transverse process fracture. Following notification of the fall, RN #2, the night shift supervisor, used his personal, non‑encrypted cell phone to text the facility APRN about the incident, including the resident’s full name and clinical information such as the head injury, neurological status, refusal to stay for monitoring, vital signs, and initiation of the facility fall protocol. RN #2 acknowledged that his phone was not encrypted and that he could not verify whether the text was secure. Although the APRN reportedly had an encrypted messaging application, there was no confirmation that RN #2’s device or method of communication was secure, and the facility did not provide a policy regarding the use of personal cellular devices to communicate resident information. This resulted in a failure to safeguard the confidentiality of the resident’s personal and medical records from unauthorized disclosure.
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