Privacy Breach When Wrong Discharge Medications and Instructions Given to Another Resident
Summary
The facility failed to ensure the privacy and confidentiality of a resident's health information when discharge medications and paperwork for one resident were mistakenly given to another resident's representative. Resident #70, who was cognitively intact and required supervision with ADLs, was discharged on 09/30/25. At discharge, LPN #142 accidentally provided Resident #70's representative with Resident #71's medications and written discharge instructions instead of Resident #70's. Resident #71 had been admitted with diagnoses including cerebral infarction, seizures, and sepsis and had active physician orders for multiple medications, including Norvasc, aspirin, Biotin, Cozaar, folic acid, Keppra, Lipitor, methotrexate, metoprolol, polyethylene glycol, prednisolone eye drops, sennoside, and Synthroid. The error was not identified by facility staff until shift change, when the night shift nurse was unable to locate Resident #71's medications in the medication cart. The Administrator and DON reported that nursing staff realized the wrong medications and discharge instructions had been given to Resident #70 approximately two to three hours after the resident left the facility. Resident #70's representative later reported the incident to the police and confirmed that the facility had sent home another resident's medications and discharge instructions, and that none of those medications had been taken. Both the Administrator and Resident #70's representative confirmed that private health information for Resident #71 had been disclosed to Resident #70 and her representative, contrary to the facility's HIPAA policy, which states that the facility will protect the privacy and confidentiality of residents' individually identifiable health information.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LVN left a medication cart computer monitor active and unsecured during med pass, visibly displaying a resident’s eMAR and private clinical details in a hallway near resident rooms. The screen was left open a second time while the LVN stepped away to retrieve keys, and the LVN later acknowledged the exposure was an unauthorized sharing of PHI and a HIPAA violation. The DON, ADM, and CCN stated that leaving the terminal open allowed others to view private resident information.
Failure to Provide Privacy During Incontinent Care: A resident with severe cognitive impairment, an indwelling catheter, and assistance needs for ADLs was observed receiving perineal/incontinent care by two CNAs without the privacy curtain being drawn, leaving him exposed from the waist down while his roommate was in the room. The resident stated he felt uncomfortable and wanted the curtain closed every time. Staff acknowledged that privacy during care was required for dignity, but one CNA said he did not pull the curtain because he thought it was not working.
A CMA left a locked med cart unattended with the laptop screen unlocked, allowing A resident's personal medical information and medications to be visible. The CMA said she was not sure whether the screen needed to be locked or hidden when away from the cart, and later interviews confirmed the cart and laptop screen should be locked whenever staff step away.
Failure to provide privacy during wound care. An LPN assessed and applied a dressing to a resident while the resident was eating lunch, with the room door open and the privacy curtain not pulled. The interaction was visible from the hallway, and the LPN and Unit Manager confirmed privacy should have been provided and that dressing care should not occur during mealtime.
A resident’s pharmacy slip containing his name and medication information was left on the ledge of the nurse’s station and remained visible during repeated observations when no staff were present. The LVN said the slip should have been secured inside the nurse’s station, and the ADON, DON, and Administrator all identified the information as confidential and not meant to be left in view of others.
Improper Release of PHI: A staff member released a resident’s requested medical records to the resident’s son, but the packet also included skilled progress notes and other PHI for 12 unrelated residents. The error occurred when the staff member printed records from the EMR using only the first few letters of the resident’s name and did not recognize that multiple residents’ documents had been selected before sending the scanned records by secure email.
Unsecured eMAR Screen Exposed Resident Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident’s personal and medical records for 1 of 13 residents reviewed. During an observation on 06/04/2026 at 8:39 AM during medication pass on Hall B, an LVN was observed walking away from the medication cart to administer medications while the cart’s computer monitor remained active and unsecured, visibly displaying the eMAR and private clinical details of a resident. The cart was positioned in the hallway near resident rooms, exposing the screen to residents passing through the corridor. During a second observation on 06/04/2026 at 8:42 AM, the same LVN again walked away from the Hall B medication cart to retrieve keys from another nurse, and the computer screen was again left fully open and active with residents’ private eMAR information displayed. In interviews later that morning, the LVN acknowledged that leaving a resident’s personal health information visible on an open monitor was an unauthorized sharing of patient information and a HIPAA violation. The DON, ADM, and CCN each stated that leaving a computer terminal open with resident information allows others to see private information that is not supposed to be shared, and that screen security is the responsibility of the nurse assigned to that cart and unit.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure privacy during incontinent care for one resident. During an observation of perineal care with an indwelling catheter, CNA D and CNA E provided care to the resident without pulling the privacy curtain, leaving the resident nude from the waist down while care was being performed. The resident’s roommate was present in the room and was looking at his cell phone during the care. The resident was a male with diagnoses including heart failure, obstructive and reflux uropathy, unspecified dementia, and age-related physical debility. His MDS assessment reflected a BIMS score of 7, indicating severe cognitive impairment. He had an indwelling catheter, including a suprapubic catheter and nephrostomy tube, and required partial/moderate assistance with toileting hygiene, showering/bathing, personal hygiene, and dressing. His care plan stated that he required incontinent care promptly when found wet or soiled and that clothes and linens were to be kept clean, dry, and wrinkle free. During interview, the resident stated he did not feel okay when the privacy curtain was not closed while staff were cleaning his private parts because someone could enter the room, and his roommate could see him being exposed. He stated staff rarely pulled the privacy curtain when changing him or his roommate and that he wanted the curtain pulled every time he received incontinent care. Staff interviews reflected that privacy during incontinent care was expected and related to resident dignity, but CNA D stated he did not pull the curtain because he thought it was not working, and later said it did work when he checked it. The DON stated the facility policy was to have the curtain pulled during incontinent care and that staff were responsible for providing privacy.
Failure to Protect Resident Medical Record Privacy
Penalty
Summary
The facility failed to ensure staff secured and protected the privacy and confidentiality of Resident 8's medical record. On 06/02/26 at 07:55 AM, a CMA left a locked medication cart unattended with the laptop screen unlocked, and Resident 8's personal medical information and medications were visible on the screen. When the CMA returned at 07:57 AM, she confirmed she was assigned to that medication cart and stated she was not positive whether the screen needed to be locked or hidden when she was away from the cart. Later interviews confirmed that medication carts and laptop screens should be locked whenever a medication aide or nurse walks away from the cart. The facility's Confidentiality of Personal and Medical Records policy stated that residents have the right to secure and confidential personal and medical records, including confidentiality of all information contained in a resident's records regardless of the form of storage or location.
Failure to Provide Privacy During Wound Care
Penalty
Summary
Privacy during wound care was not provided for one sampled resident. During observation on 6/1/26 at 12:16 PM on the Dogwood unit, an LPN was preparing supplies from a wound care cart outside Resident #93's room while the resident sat on the side of the bed eating lunch. The LPN rolled up the resident's right shirt sleeve and began assessing the area where a bandage would be applied while the resident continued eating salad and the LPN documented and labeled the dressing. When ready to apply the dressing, the LPN asked the resident to put the salad down. The interaction was observed from the hallway with the door open and no privacy curtain pulled, and five people were seen walking by the room. The LPN later confirmed the door and privacy curtain were open and should have been closed for privacy during wound care. The Unit Manager also confirmed that it is never appropriate for a dressing to be applied or removed during mealtime and that privacy should always be provided for wound care.
Confidential resident medication slip left visible at nurse’s station
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when a pharmacy slip with Resident #1’s name and medication information was left on the ledge of the nurse’s station and remained there during two observations. Resident #1 was an [AGE] year-old male admitted to the facility with peripheral vascular disease and a non-pressure ulcer to the left calf. His MDS reflected that he was cognitively intact with a BIMS score of 13, and his care plan included treatment for an actual skin impairment related to a venous wound of the left calf. The pharmacy slip was observed on top of the nurse’s station ledge at 7:30 a.m. and again at 7:58 a.m., with no staff inside the nurse’s station during either observation. The slip contained the resident’s name and medication information. During interviews, an LVN stated the slip was the facility’s copy for the medication delivered for the resident and should have been secured inside the nurse’s station. The ADON and DON both stated the information should have been protected and kept confidential, and the Administrator stated the slip should not have been visible to others and noted the facility was correcting the same non-compliance from a prior visit.
Improper Release of Protected Health Information
Penalty
Summary
The facility failed to ensure the confidentiality of residents’ protected health information when it released medical records for one resident to that resident’s son and included records belonging to 12 other residents. An email from the resident’s son notified the facility that the scanned packet contained a total of 786 pages and included information from other residents. Facility leadership later verified that the breach occurred when staff scanned requested medical information and sent it by secured email, resulting in protected health information for 12 unrelated residents being disclosed. During interview, the Managed Care Coordinator stated she printed a report from the EMR by entering the first few letters of the resident’s name, saw the resident’s name on the top page, and then scanned the information to the son without recognizing that multiple residents’ records had been selected. The report identified that skilled progress notes containing protected health information for 12 residents were included in the release. The facility policy required PHI to be handled, stored, and communicated in accordance with regulations and required that release of PHI be limited to authorized staff and logged.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.