Unattended Unlocked Med Cart Computer Exposed Resident Health Information
Penalty
Summary
The facility failed to maintain privacy and confidentiality of a resident’s personal and medical information when a medication cart computer was left unlocked and unattended, displaying identifiable health information. The affected resident had multiple diagnoses, including hypotension, history of TIA and cerebral infarction without residual deficits, unspecified dementia, acute respiratory failure with hypoxia, major depressive disorder, and anxiety disorder. The resident’s care plan identified confusion and poor decision-making related to cognitive impairment, with interventions such as explaining procedures and reorienting as needed. Physician orders for several PRN medications, including Loperamide, Ondansetron, Hydroxyzine, and an aluminum/magnesium hydroxide suspension, were present in the record. On the survey date at 6:18 AM, a medication cart was observed unattended with an unlocked device on top that displayed the resident’s full name, date of birth, photo, room location, code status, and medications. During interview, the LPN responsible for the cart stated she thought she had locked the computer and acknowledged that failing to close the computer could allow others to access patient information, though she could not recall the term for this. The DON stated that an open medication cart computer would be a HIPAA violation and that facility policy requires nursing computers to be locked in compliance with HIPAA. The administrator similarly stated that leaving medication cart computers open would be a HIPAA violation if someone saw them and that resident information, including first and last names, should be protected. Review of the facility’s “Confidentiality of Information” policy, last reviewed March 1, 2025, showed that the facility is to safeguard all resident records to protect confidentiality, which was not followed in this instance.
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