Failure to Protect PHI on Unattended Medication Carts
Penalty
Summary
Surveyors identified a failure to maintain confidentiality of residents' protected health information (PHI) related to unsecured medication carts with visible electronic records. With a facility census of 60 residents and a sample of 15, observations showed a medication cart parked in the east hallway with a laptop on top, the screen unlocked and displaying a resident’s PHI, including medications, date of birth, allergy information, and code status. This screen was visible to anyone passing by, and no nursing staff were in view of the cart at the time of the observation. A similar observation was made in the west hallway, where another medication cart was parked with an unlocked laptop displaying a resident’s medications, date of birth, allergy information, and code status, again with no nursing staff present. Licensed nurses interviewed stated that the medication cart should be locked and the laptop screen cleared or closed when staff walk away, and an administrative nurse confirmed the expectation that laptop screens be closed or resident information cleared when staff are not working at the cart. The facility’s Confidentiality and Privacy of Information policy, last approved in 10/2025, documented that all resident information would be treated confidentially and that resident records of all types would be safeguarded to protect confidentiality.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.