Failure to Safeguard Resident Protected Health Information in Elopement Binder
Penalty
Summary
The facility failed to ensure residents’ right to personal privacy and confidentiality of personal and medical records for four residents identified as having elopement potential. Surveyor observation revealed a yellow notebook labeled “Elopement Binder” placed on a table by the front door. In addition to elopement policies and procedures, this binder contained full admission records for four residents, including their names, dates of birth, Social Security numbers, Medicare and Medicaid numbers, home addresses, and contact phone numbers. The binder was intentionally placed at the front door, as well as at each nurse’s station, so it could be easily located in the event of an elopement. During interviews, the DON stated that residents in the Elopement Binder had been determined to have the potential to leave the facility without notice and acknowledged that resident personal information is protected information with restricted access under HIPAA and should not be left where anyone could access it. The DON reported that the ADON was responsible for maintaining the binder and that she was unaware that full admission records were included. The ADON stated she had not initiated the Elopement Binder but continued the existing practice and confirmed that the front-door binder should not have contained residents’ personal information, only the binders at the nurses’ stations. The Administrator stated that resident personal information was restricted to a limited number of staff, such as the business office, social worker, and other IDT members, and that such information should not be left out where anyone could access it. Review of the facility’s policy on safeguarding and storing protected health information indicated the facility’s policy was to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of residents’ identifiable information and to safeguard against unauthorized release of information and records.
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