Electronic Medical Records Left Visible on Unattended Computers: Two residents' EMRs were left open and visible on unattended computers during wound care and med pass. One resident had HTN, DM, and malnutrition with moderate cognitive impairment, and another resident had acute respiratory failure with hypoxia, HTN, DM2, and Afib with intact cognition. Staff confirmed the screens were left open and available for public view.
PHI was left visible on an unattended med cart when an RN stepped away to enter a resident's room and left the computer screen unlocked. The resident's PHI was displayed in the hallway, and the RN confirmed it was not protected and was available for public view. The Administrator stated the screen was expected to be locked when left unattended.
Resident PHI was left unsecured in multiple areas of the facility. A phlebotomist left a lab binder open at the nurses' station with a daily log showing resident names, room numbers, and lab tests, and daily report sheets with code status, transfer status, continence status, names, and room numbers were observed visible at the nurses' station and in a lobby chair. An LPN, DON, and ED all stated the documents contained protected information and should have been secured.
PHI Left Visible on Medication Cart Computers: An LPN and an RN walked away from medication carts with computer screens left open and visible to the public. Resident identifiers and medical information, including names, MRNs, room numbers, and photos, were displayed on the screens for multiple residents, despite facility policy requiring PHI safeguards and staff to log off when leaving the work area.
Resident PHI Left Visible on Medication Cart Computer: During medication administration, an LPN left a medication cart computer screen open with a resident’s PHI displayed and visible to the public. The resident had diagnoses including diabetes, muscle weakness, and anxiety. The LPN stated she forgot to lock and cover the screen before leaving the cart, and confirmed the PHI was not protected. The IP stated staff were expected to lock and cover the screen to maintain resident privacy.
A facility failed to keep resident PHI private when a skilled med cart was left in the hallway with a laptop screen facing outward and open to one resident's eMAR, while an open narcotic sign-out book exposed another resident's controlled substance reconciliation log. An LPN confirmed the information was visible to passersby, and the ADON stated the residents' sensitive health information should not have been open to view.
A medication cart with a computer logged into the electronic medical record system was left unattended and accessible to the public after an RN went to lunch, resulting in residents' personal health information being visible and unprotected. Facility staff confirmed the failure to secure electronic records as required by HIPAA policy.
A facility failed to keep resident personal and medical information private when a shift-to-shift communication sheet listing residents' names and medical conditions was left on top of a medication cart and a medication card label with a resident's name was stored in view on the side of the cart above clean cups. An LPN acknowledged the information should not have been visible, and the DON stated staff were expected to secure and cover confidential information before leaving the cart.
An LPN left a medication cart computer screen unlocked while entering a resident's room, leaving the resident's PHI visible to others. The resident had diagnoses including cirrhosis of the liver, history of falling, and muscle weakness. The LPN confirmed the screen was not protected, and the DON stated staff were expected to lock the screen when walking away from the cart.
Sensitive health information was left visible and unattended on a medication cart, including data displayed on a computer screen and a written shift-to-shift communication sheet listing residents' names and medical conditions. An LPN failed to secure this information before leaving the cart, and the ADON confirmed the breach of confidentiality.
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