Unauthorized Disclosure of Resident PHI via Email
Summary
A deficiency occurred when the Social Services Director (SSD) sent an email containing a resident's Face Sheet (Admission Record) and information regarding podiatry care needs to an unauthorized recipient, specifically another resident's family member. The email included protected health information (PHI) such as the resident's Medicaid, Medicare, and insurance policy numbers, home address, care providers, emergency contact, and financial representative. The SSD stated that the email was sent by mistake, confusing the intended recipient, a medical provider with the same first name as the family member who received the email. The resident whose information was disclosed had a history of anemia, chronic pain, and gout, and was noted to have severely impaired cognition, requiring substantial to maximal assistance with activities of daily living. The resident was able to make needs known but could not make medical decisions. The SSD recognized the error and attempted to recall the email but did not report the incident to facility leadership or follow the facility's policy for handling breaches of PHI. Interviews with the Administrator and Director of Nursing revealed that the facility's protocol required immediate reporting of any PHI breach to leadership, investigation of the incident, and notification of the resident or responsible party. The facility's policy also specified that access to resident records should be limited to authorized staff and business associates, which was not followed in this instance.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 8 was informed of the breach on March 26, 2025, and was assured that the facility would take all appropriate steps to mitigate any potential negative consequences resulting from the incident. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. Beginning on March 27, 2025, the Social Services Director conducted outreach to residents within the facility to identify any additional potential breaches and to ensure there were no further incidents or concerns related to the confidentiality of Protected Health Information (PHI). No additional findings were identified as a result of this review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 27 to March 28, 2025, licensed nurses and department supervisors participated in an in-service training conducted by the Administrator or designee. The training focused on the protection of residents' rights to privacy and the confidentiality of Protected Health Information (PHI), in accordance with HIPAA regulations. On March 27, 2025, the Administrator conducted a one-on-one training with the Social Services Director, emphasizing the importance of secure communication practices and the protection of residents' rights to privacy and the confidentiality of Protected Health Information (PHI), in compliance with HIPAA regulations. The Social Services Director will adhere to safe communication practices and will promptly report any potential breaches of confidentiality to the Administrator for further review and appropriate action. How the facility plans to monitor its performance to make sure that solutions are sustained: The ADMIN/designee will provide any negative findings to QAPI committee monthly x 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: April 1st, 2025
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
A facility failed to keep residents’ personal and medical records secure and confidential. Medical record review showed hospice notes were entered directly into the EMR for three residents, and the regional clinical director stated the hospice previously used was given full access to the EMR for all residents. The Resident Rights policy stated residents have a right to secure and confidential personal and medical records.
Failure to Deliver Resident Mail Promptly: The facility failed to ensure residents could send and receive mail and other materials in a timely manner. In a group interview, multiple residents stated they never received mail or that mail was not distributed on Saturdays because the AD did not work weekends. The AD said she passed mail Monday through Friday and was unsure who handled Saturday delivery, while the Administrator said weekend nursing staff were expected to pass mail. The facility policy required mail delivery within 24 hours of receipt.
A cognitively intact female resident with Guillain-Barre Syndrome, depression, muscle weakness, and dependence on staff for toileting received incontinent care from two CNAs while her roommate was present in the room, and the privacy curtain was not pulled at any time. The resident’s care plan documented a self-care deficit and need for assisted incontinent care, and facility policies on perineal care and resident rights required staff to provide privacy, including use of doors, curtains, and blinds. In post-incident interviews, both CNAs acknowledged that privacy should have been provided during the care and recognized that doing so is part of respecting resident rights and dignity, while the DON and Administrator confirmed their expectation that staff follow these privacy practices.
Two cognitively intact male residents with diabetes, one with additional psychiatric diagnoses, received blood glucose checks and, for one resident, an insulin injection in an open area near the nurse’s station rather than in a private setting, exposing their medical treatment to others. Facility leadership, including the DON and Administrator, acknowledged that facility policy and practice required such medical treatments to be performed in residents’ rooms to protect privacy and confidentiality of personal and medical records, and that providing these services in public areas was inconsistent with resident rights and privacy standards.
Electronic Medical Records Left Visible on Unattended Computers
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when electronic medical records were left open and visible to others. Facility policy stated resident health information must remain private and that the MAR must remain closed or covered when not in direct use. Resident #76, who was admitted with diagnoses including hypertension, diabetes, and malnutrition and had a BIMS score of 8 indicating moderate impairment, was observed on 5/11/2026 at 2:37 PM with the wound care cart unattended and the computer on top of the cart open to the resident's electronic medical record and available for public view. The wound care nurse later returned and confirmed the screen had been left open to Resident #76's record. Resident #41, who was admitted with diagnoses including acute respiratory failure with hypoxia, essential hypertension, type 2 diabetes mellitus, and paroxysmal atrial fibrillation and had a BIMS score of 13 indicating cognitive intactness, was observed during medication administration on Cart 700 on 5/12/2026 at 7:40 AM when RN A walked away from the medication cart leaving the computer open and the resident's electronic medical record available for public view. A later observation at 8:01 AM showed RN A entering a room while the computer remained open with Resident #41's electronic medical information still visible. RN A confirmed the screen was open and available for public view, and the President of Clinical Operations later confirmed the electronic medical record should not be unattended and left open for public view.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Protect Confidential Medical Records
Penalty
Summary
The facility failed to ensure residents’ personal and medical records remained secure and confidential. Medical record review showed that resident #26 received hospice services beginning on 1/2/26, resident #83 received hospice services beginning on 1/21/26, and resident #84 received hospice services beginning on 2/5/26, and the hospice provided documented notes directly into the electronic medical record system. During interview on 5/6/26 at 12:44 PM, the regional clinical director stated the only hospice used prior to a change in operator was given full access to the electronic medical record for all residents. Review of the facility’s Resident Rights policy stated residents have a right to privacy and confidentiality of personal and medical records and the right to secure and confidential records.
Failure to Deliver Resident Mail Promptly
Penalty
Summary
The facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility through means other than the postal service, for 6 confidential residents reviewed for communication privacy rights. During a confidential group interview, 6 of 9 members stated they never received mail, and 3 of 9 residents stated mail was not distributed at the facility on Saturdays because the Activity Director did not work on Saturdays. During interviews, the Activity Director stated she was responsible for delivering mail and that she passed residents' mail Monday through Friday, but was not present on weekends and was not sure whether any staff were assigned to pass mail on Saturdays. She also stated that when she arrived on Monday, mail was in her box to pass out. The Administrator stated her expectation was for mail to be passed on Saturday by weekend staff, and that there was not one specific person assigned to pass mail on the weekend, only nursing staff in general. Record review of the facility policy titled Resident Right to Privacy in Communication stated that mail or other materials should be delivered to the resident within 24 hours of delivery by the postal service, including a post office box, and outgoing mail should be delivered to the post office within 24 hours except when there is no regularly scheduled postal delivery and pick-up service.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
Surveyors identified a failure to provide personal privacy during incontinent care for 1 of 7 residents reviewed. The resident was an adult female with Guillain-Barre Syndrome, anxiety, major depressive disorder, muscle weakness, and a need for assistance with personal care. Her MDS showed she was cognitively intact with a BIMS score of 15, usually understood and was understood by others, and was dependent on staff for toileting. Her care plan, revised 1/3/26, documented a self-care deficit related to impaired physical mobility and called for incontinent care with one-person staff assist. On 4/29/26 at 1:16 p.m., CNA A, with assistance from CNA B, provided incontinent care to the resident while her roommate was lying in bed with eyes closed. During this care, the CNAs did not pull the privacy curtain at any time. In interviews, CNA B acknowledged that the privacy curtain should have been pulled and admitted the resident had not been provided privacy, stating she forgot to ensure the curtain was pulled and recognizing privacy was needed so no one could watch and so the resident was covered. CNA A stated that during incontinent care the door should be shut or the privacy curtain pulled and believed the curtain had been shut during this care, and identified resident rights as the reason for providing privacy. The DON and Administrator both stated their expectation that staff provide privacy during personal care by closing the door, pulling the privacy curtain, and closing the blinds, consistent with the facility’s Perineal Care procedure and Resident Rights policy, which require providing privacy and treating residents with dignity and respect, including privacy and confidentiality.
Failure to Protect Resident Privacy During Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure residents' rights to personal privacy during medical treatment and personal care for two residents who received glucose monitoring and insulin administration in public areas. On a specified date, staff obtained blood glucose readings for both residents and administered an insulin injection to one resident in an open setting rather than in a private location. These actions occurred despite facility expectations that such care be provided in residents' rooms to protect personal and medical information. Resident #1 was an adult male, initially admitted in January 2025, with a diagnosis of Type 2 diabetes mellitus and prescription orders for multiple diabetic medications, including Insulin Aspart, Tresiba, metformin, and glucagon. His Quarterly MDS showed a BIMS score of 13, indicating he was cognitively intact, and he required insulin injections six days per week. Physician orders directed Insulin Aspart administration three times daily at set times. On the cited date, his glucose reading and insulin injection were provided in a non-private setting, contrary to his care plan focus on diabetes management and the facility’s stated practice. Resident #2 was an adult male with an initial admission in 2019 and readmission in 2024, with diagnoses including diabetes mellitus, dementia, bipolar disorder, and schizophrenia. His Comprehensive MDS documented a BIMS score of 15, indicating he was cognitively intact, and he required insulin injections seven days per week. He also had orders for Insulin Aspart three times daily. On the same date, his glucose reading was obtained in an open area rather than in his room. Interviews with the DON and Administrator confirmed that facility practice and policy required treatments such as glucose checks and insulin injections to be completed in residents’ rooms to maintain privacy and confidentiality of medical information, and that providing such care in open areas was inconsistent with the facility’s resident rights and privacy policy. Record review of the facility’s undated Resident Rights policy stated that residents have the right to personal privacy and confidentiality of personal and medical records, and that personal privacy includes accommodations, medical treatment, and personal care. The DON stated that privacy protections included administering orders in a private setting and that care needed to be completed in residents’ rooms, describing provision of such care in open areas as a HIPAA violation because it could share diagnosis information with others nearby. The Administrator similarly stated that glucose readings and insulin injections should be completed in residents’ rooms due to privacy concerns and that performing these treatments at the nurse’s station exposed residents’ diagnoses and treatments. Documentation from the HR coordinator showed the last facility-wide in-service on resident rights occurred in November 2025.
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