Failure to Safeguard Resident PHI on Medication Cart and Census Documents
Penalty
Summary
Surveyors identified a deficiency related to failure to safeguard residents' protected health information (PHI) on the 600-unit. During an observation of the unit medication cart located by the fireplace in the common room, a white piece of paper containing PHI, including resident names and vital signs, was left unattended and visible to anyone nearby. An LPN confirmed that the paper contained PHI and had been left visible on the cart. In a separate observation, the 600-unit medication cart was left unattended outside a resident room with PHI displayed on the computer screen, including full resident names, prescribed medications, and allergies, and an RN confirmed that this information was visible to anyone walking by and that best practice is to ensure PHI is not visible to everyone. Additional observations showed that the daily unit census, containing full resident names and room numbers, was left unattended and visible on the 600-unit medication cart. An LPN confirmed that this PHI was visible to anyone walking by and stated that such information should always be covered to protect resident PHI. In an interview, the DON stated that the expectation is for PHI to be protected and not open for anyone's ability to view. These observations and staff confirmations demonstrate that PHI for residents on the 600-unit was repeatedly left exposed in common and hallway areas where unauthorized individuals could access it.
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