A resident with dementia, severe cognitive impairment, and total dependence for ADLs was resting in bed with her door open when another resident wandered into the room and began moving the blankets covering her. Staff, including an LPN and CNAs, reported that residents on the memory care unit were allowed to wander without boundaries, including entering other residents’ rooms. This practice conflicted with the facility’s policy requiring respect for resident dignity and privacy, resulting in a failure to protect the resident’s privacy while she was in bed.
Surveyors found that staff failed to protect resident PHI when two unattended medication carts were left in hallways with open computer screens displaying residents’ MAR and treatment orders. In each instance, the cart was left alone for several minutes with identifiable medical information visible, and the CMA and LN involved later acknowledged they should have closed the screens to maintain confidentiality, contrary to the facility’s stated residents’ rights policy.
Surveyors found that PHI was not kept confidential when two unattended medication carts in separate hallways were left with unlocked laptop screens displaying a resident’s medications, DOB, allergy information, and code status, visible to anyone passing by and without nursing staff in view. Nursing staff and an administrative nurse acknowledged that carts should be locked and laptop screens closed or cleared when unattended, and facility policy required safeguarding all resident records to protect confidentiality.
Surveyors observed a medication cart parked in a hall with a laptop left unlocked and unattended by a CMA, displaying a resident's PHI including medications, date of birth, allergies, and code status, visible to anyone passing by. Staff interviews confirmed that facility policy requires medication carts to be locked and laptop screens to be closed or hidden when out of staff’s line of sight, and that staff had been in-serviced on these confidentiality expectations.
A treatment cart was left unsecured and unsupervised in a hallway, with its laptop open and displaying a resident's PHI in direct view. An LPN was unsure about the requirement to lock medication carts and acknowledged that PHI should not be left open on unattended computers, contrary to facility policy.
A CNA took and shared a video of a resident with severe dementia, depicting the resident in a state of incontinence, without consent. The video was shown to another CNA during shift change, who reported the incident. The facility's policy prohibits such actions, but staff had not received recent documented education on privacy expectations.
A resident's protected health information (PHI) was left visible on an unattended nursing cart across from the nurse's station. Staff interviews confirmed that computers should be locked when not attended to protect PHI, and facility policy requires resident privacy to be maintained.
Staff left a resident's electronic medical record open and visible on a medication cart laptop, failing to secure protected health information. A CMA and a nurse both confirmed that screens and carts should be locked when unattended, in accordance with facility policy.
Staff entered resident rooms without proper announcement or waiting for acknowledgment, including while residents were resting or using the phone. Some staff admitted to entering rooms if residents were asleep or on the phone, and administrative staff confirmed that the facility lacked a specific policy on resident rights and privacy.
Staff left a resident's electronic medical record open and visible on a wall kiosk monitor, failing to secure the resident's private health information. Interviews with CNA, LN, and administrative nursing staff confirmed that this action was not in line with facility policy, which requires staff to maintain resident privacy and confidentiality.
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