Confidential Medical Records Misrouted in Discharge Paperwork Mix-Up
Penalty
Summary
The deficiency involves the facility’s failure to maintain confidentiality of personal and medical records for two residents during the discharge process. One resident (R4), who was cognitively intact, independent in ADLs, and diagnosed with COPD, chronic respiratory failure, anemia, obesity, hyperlipidemia, HTN, and a history of falls and smoking, was discharged home with medications and discharge instructions. The Social Service Director (V13) reported that on the day of discharge, she prepared discharge paperwork for R4 and another resident (R5) in large, unsealed yellow envelopes and accidentally gave each resident the other’s envelope. R4 later stated that she took the envelope home, removed the prescriptions and gave them to her daughter to take to the pharmacy, and then threw the remaining papers in the trash, indicating she had received paperwork that was not hers. The second resident (R5) was also cognitively intact, independent in ADLs, and had multiple diagnoses including diverticulitis, MRSA, morbid obesity, respiratory failure, COPD, emphysema, major depressive disorder, atrial fibrillation, carotid artery stenosis, cardiomegaly, lumbar disc degeneration, AAA, CHF, hyperlipidemia, HTN, cardiac pacemaker, hernia, and anxiety disorder. R5 was discharged home under the care of her daughter (V17), who declined home health services and stated she would care for her mother at home. At discharge, R5 and her daughter were given an envelope containing papers, medications, and prescriptions. V17 reported that when she took the envelope to the pharmacy, the pharmacist informed her that the prescriptions were not for her mother but for another resident (R4), revealing that R5’s discharge packet contained another resident’s protected health information. Interviews with staff clarified how the mix-up occurred and confirmed that confidential information was exchanged between the two residents. V13 stated that she had two residents leaving at the same time, gathered each resident’s discharge paperwork into unsealed yellow envelopes, and mistakenly handed each resident the other’s envelope. She also stated she had asked R5 and her daughter to review the paperwork with her before leaving, but the daughter refused, saying the paperwork was already in R5’s bag. The DON (V2) explained that the facility typically provides a 30‑day supply of medications rather than paper prescriptions, but R5’s daughter refused the 30‑day supply and insisted on paper prescriptions, which were then placed in R5’s discharge envelope. The Administrator (V1) confirmed that the facility did not retain copies of the discharge paperwork given to R4 and R5 and stated an expectation that staff maintain resident confidentiality and ensure residents receive the correct paperwork, consistent with the facility’s Resident Rights and HIPAA policies that require privacy and confidentiality of personal and medical records.
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