A resident with multiple neurological and psychiatric diagnoses, who was severely cognitively impaired, had her medical confidentiality breached when her family member was given an envelope for a physician visit that, while correctly labeled on the outside, contained another resident's medical records. The unit secretary, who prepared appointment envelopes in advance with clinical documents such as progress notes, face sheet, MD orders, MAR, and consult report, acknowledged that she provided the mislabeled packet to the family, resulting in disclosure of another resident's private medical information.
Failure to provide privacy during medication administration: an LPN was observed giving meds to a resident in the hallway in front of the nursing station instead of in the resident’s room. The resident had dementia and moderate cognitive impairment. Staff acknowledged meds should be administered in the room with privacy, and the DON stated meds are to be given in rooms.
Confidential records were left visible on medication carts, including a bingo card with resident medical information and a paper census with residents’ pictures and medical information. An RN stated she forgot to turn the bingo cards over, and an LPN stated paperwork should be turned over to protect resident information. In a separate event, an RN administered medications to a resident with moderate cognitive impairment in the hallway in front of the nursing station while the resident was being escorted by family members, even though the RN stated meds are to be given in rooms for privacy.
Failure to Maintain Resident Privacy During Care: Two residents were observed with privacy curtains that did not fully cover the bed area during care. One resident was cognitively intact and stated the curtain was too narrow, while the other had severe cognitive impairment and was exposed when the curtains separated and opened in the middle. The ES Manager confirmed one curtain was too narrow and the other curtains were not hung with enough overlap to provide privacy.
Failure to Protect Resident Information on Medication Cart and Vitals Machine: An unattended computer screen on a medication cart and an unattended vitals machine screen were left open with residents' information visible. An RN stated the screen should have been closed, and the DON and ADON confirmed staff are to close or lock these devices to protect resident information. The facility's confidentiality policy states resident records will be protected and safeguarded.
Failure to protect resident confidentiality was cited after surveyors observed an unattended med cart computer screen on the 100-wing with residents' information visible and a posting with residents' medical information on a bulletin board in front of Unit 1. An RN stated the screen should be closed or put to sleep when away from the cart, and the DON stated the laptop should be closed or locked and that the posting should not have been displayed because it contained residents' medical information.
Failure to Protect Resident Information and Privacy: Surveyors observed multiple unattended medication carts and a nursing station with open computer screens and unsecured paperwork showing resident information. Staff acknowledged that screens should be closed and documents covered or turned over when unattended. Surveyors also observed an RN administering medications to a cognitively intact resident with the room door open, while the DON and nursing supervisors stated that doors or curtains are to be closed during medication administration.
Failure to Protect Resident Confidentiality During Medication Administration: An RN left a computer screen open on a medication cart during med pass, leaving resident information visible, and another RN administered meds to a resident in the hallway instead of in the resident's room. Staff acknowledged that HIPAA requires protecting patient information, locking screens and carts, and maintaining privacy during care.
Failure to protect resident information occurred when an RN left paperwork with residents' personal medical information unattended on top of a med cart and later left a computer screen open with resident information visible on the 2nd-floor unit. An LPN closed the screen after noticing it, and the DON stated staff are to close computer screens and turn paperwork over to keep resident information private.
Staff used personal cell phones to photograph and video a resident experiencing pain and behavioral changes, as well as to routinely capture wound images, and then texted these images to the NP for assessment and treatment recommendations. A RN and the Wound Care Nurse reported storing these images on their personal devices and were unaware of any signed consents authorizing this method of communication. The Administrator did not object to the practice for medical purposes but acknowledged she could not ensure confidentiality once images were on staff devices. Facility policy required explicit written consent for imaging, prohibited unauthorized transmission of resident images, and treated photographs as health care records, yet there was no evidence of resident consent, authorization, or secure, encrypted transmission for the use of personal devices.
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