F0583

D

Unsecured PHI Document Left on Medication Cart

Auburn, California Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

A deficiency occurred when a document containing residents’ personal and medical information was left unsecured on top of a medication cart in Station 3 hallway during a survey observation. The document included residents’ names, room numbers, cognitive status (A&O status), code status, diagnoses, and information about how they take medications (such as whether they take pills whole). During an interview, a licensed nurse acknowledged that he had left this document on top of the medication cart and stated that he was not supposed to do so and that it was a violation of residents’ rights. Later, when shown photographs of the document on the cart, the DON confirmed that the document should not have been there. The facility’s policy on Protected Health Information (PHI), revised April 2014, states that all personnel with access to resident and facility information are responsible for managing and protecting such information to prevent unauthorized release or disclosure.

This failure to secure the document containing PHI for a census of 167 residents had the potential to compromise the privacy of residents, as noted in the survey findings.