Failure to Protect Confidential Electronic Medical Record on Medication Cart
Penalty
Summary
The facility failed to protect the confidentiality of one resident’s personal and medical records when the resident’s electronic medical record was left visible and unattended on a medication cart computer. The resident had been admitted with diagnoses including atherosclerotic heart disease, gastroesophageal reflux disease, and age-related osteoporosis. During an observation at the nurse station, the medication cart computer was found open with the resident’s medical record displayed, including the resident’s name, picture, and medication list, while staff walked past the cart. In a concurrent observation and interview, an LVN acknowledged that she had not locked the medication cart computer before leaving to assist another resident and confirmed that the resident’s medical information was visible to people walking in the hallway. The DON stated that the resident’s medical records should not be left unattended and that staff not involved in the resident’s care, other residents, and visitors could potentially have unauthorized access to the records. Review of the facility’s policy titled “General Provisions” indicated that protected health information is confidential, will only be released in accordance with HIPAA policies, and that active records are to be located in an area not accessible to unauthorized persons.
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