§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.
§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.
§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.
§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
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Observations:
Based on observation, review of facility policy, review of clinical record and staff interview, it was determined that the facility failed to ensure that resident's privacy regarding the public exhibition of photographs was protected for seven of eleven residents observed. (Residents R1, R2, R3, R4, R5, R6, and R7)
Findings include:
Review facility policy regarding confidentiality of information and personal privacy the most recent revision date of October 2017, reveal that under section "Policy Statement": The facility will protect and safeguard resident confidentiality and personal privacy. Under section "Policy Interpretation and Implementation: #1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. #7. Release of information including video, audio or computer stored information will be handled in accordance with resident rights and privacy policies. #8. Residents may initiate a request to release information contained in the record and charge to themselves or anyone they wish. Such requests will be honored only upon the receipt of a written sign and dated request from the resident or representative. #9. Residents may refuse a request for the release of (and the facility must keep confidential) medical and personal records, unless the release is required by law or: #a. For treatment, payment, or healthcare operations. # b. For public health activities. #c. For reporting of abuse, neglect, or domestic violence. #d. For health oversight activities. #e. For judicial and administrative proceedings. #f. For law enforcement purposes. #g. For organ donation purposes. #h. for research purposes. #i. To coroners, medical examiners and funeral directors. #j. To avert a serious threat to health or safety.
Observation of the lobby area of the facility conducted during entrance of the facility on June 6, 2024, at 8:45 a.m. revealed an electronic screen showing a slide show of images of staff and residents. Further observation revealed that the screen was also showing along with resident and staff images, facility advertisements on staff recruitment and other announcements.
Interview with Director of Therapeutic Recreation, Employee E3 conducted over the telephone on June 6, 2024, at 10:23 a.m. confirmed that resident's photos were shown in the electronic screen located at the lobby area of the facility. Further Employee E3 also revealed that the resident consent for their photos to be used by the facility was in the admission packet.
Interview with Admission Department Personnel, Employee E4 conducted on June 6, 2024, at 10:56 a.m. identified 11 residents whose photos were shown in the electronic screen at the facility lobby area (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11).
Review of Resident R1's clinical record revealed that a consent for photograph did not have the resident signature on the form.
Review of Resident R2's clinical record revealed that there was no consent for photograph.
Review of Resident R3's clinical record revealed that there was no consent for photograph.
Review of Resident R4's clinical record revealed that there was no consent for photograph.
Review of Resident R5's clinical record revealed that there was no consent for photograph.
Review of Resident R6's clinical record revealed that there was no consent for photograph.
Review of Resident R7's clinical record revealed that there was no consent for photograph.
Interview with Nursing Home Administrator, Employee E1 conducted on June 6, 2024, at 11:55 a.m. confirmed that there was no consent for residents whose photographs appear on the electronic screen located in the lobby of the facility.
28 Pa. Code 201.29(i) Resident rights
28 Pa. Code 211.12(d)(3) Nursing services
| | Plan of Correction - To be completed: 06/08/2024
Residents R1, R2, R3, R4, R5, R6, and R7 have had consents for photography forms revieewed with them for their approval or denial of the use of their photos
All residents in the facility will have consents reviewed for approval or denial of the use of their photos at the center by Admissions director
Education regarding resident photography consents will be provided to admissions by NHA or designee
A weekly audit of new admission for the week will be conducted by AD/designee
The findings of the audit will be brought to QI mtg monthly for three months and qurterly thereafter
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