Failure to Protect Confidential Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' protected health information on the West Unit when staff left electronic and written records unattended and visible. A surveyor observed an unattended medication cart outside a resident room with an open laptop displaying the electronic Medication Administration Record (eMAR) for Resident #4, including the resident's name, photograph, date of birth, vital signs, and medication orders. A white sheet of paper on top of the same cart, left face-up, listed three residents' names along with a medication name and strength under each name. The cart and information were unattended until a CNA-M returned, at which time she acknowledged she should have closed the laptop and turned the resident information sheet upside down before leaving the cart. On the same unit, a surveyor later observed a clipboard left face-up on the nurse's station countertop with no staff nearby. The assignment sheet on the clipboard contained the names of 17 residents, their room numbers, meal intakes, and bathing information. A smaller attached sheet listed the names and vital signs of two residents. This information remained visible and accessible to residents and visitors. During interviews, the DON acknowledged the observations and stated that she had previously educated nursing staff not to leave the clipboard on the countertop.
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