Failure to Protect Resident PHI During Medication Administration
Penalty
Summary
Surveyors identified a deficiency related to failure to maintain privacy of residents' personal and medical records during medication administration. On multiple occasions on the same day, two RNs prepared medications at a medication cart with an electronic medical record (EMR) screen displaying residents' protected health information and then entered resident rooms without locking the computer screen. For one resident with diabetes, muscle weakness, cognitive communication deficit, need for assistance with personal care, hypertension, constipation, and congestive heart failure, an RN left the EMR open showing the resident's name, room number, diagnoses, and medications visible to anyone passing by. The RN confirmed in interview that she had not locked the computer screen to protect the resident's personal health information. Similar observations were made for five additional residents with various diagnoses including eating disorder, cerebral palsy, acute kidney failure, gastrointestinal hemorrhage, anxiety disorder, constipation, exposure to viral communicable diseases, malignant neoplasms of the pancreatic duct and kidney, depression, dementia, urinary tract infection, urine retention, neuromuscular dysfunction of the bladder, slow transit constipation, altered mental status, and congestive heart failure. In each case, the RN prepared medications at the cart, left the EMR screen active and visible with the resident's name, room number, diagnoses, and medications, and then entered the resident's room to administer medications without securing the screen. Both RNs involved acknowledged during interviews that they had not locked the computer screens to protect the residents' personal health information.
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