Failure to Protect Resident PHI on Unattended Medication Cart Laptop
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's protected health information (PHI) when a medication cart laptop was left unlocked and unattended in a hallway. During observation, a medication cart was parked against the wall in A hall with a laptop on top. The Certified Medication Aide (CMA) assigned to the cart walked away into a resident's room, leaving the computer screen unlocked and open. The screen displayed a specific resident's PHI, including the resident's medications, date of birth, allergy information, and code status, making this information visible to anyone passing by the cart. Interviews with staff confirmed that this practice was inconsistent with facility policy and expectations. The CMA stated she had stepped away from the cart to help a resident and acknowledged that the policy required locking the medication cart and pushing the hide button on the laptop. A Licensed Nurse stated that medication carts should be locked and the laptop screen either closed or hidden when out of staff's visual range. An Administrative Nurse stated the policy was to lock the cart and either close the laptop or use the hide screen button, and that staff had been in-serviced on these requirements. The facility's Confidentiality policy documented that confidentiality must be maintained for all health information, including electronic, and that a breach occurs when information can be intercepted by unauthorized persons and connected to a specific individual.
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