§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 a review of facility policy, resident record review, resident interview, and staff interviews, it was determined the facility failed to protect the right of resident personal privacy and confidentiality of medical records for one of two residents (Resident R1).
Findings Include:
Review of facility policy titled "Protected Health Information (PHI), Safeguarding Electronic" last reviewed 11/30/23, informed this facility ensures the confidentiality, integrity and availability of all e-PHI created, maintained, received, or transmitted by our information system. Employees and staff have access to e-PHI only to the degree that such access is appropriate for their job requirements and responsibilities.
Review of Resident R1's record indicated the resident was admitted to the facility on 9/22/23, and discharged on 2/8/24. Diagnoses included spinal stenosis (the space inside of the backbone is too small, causing pressure on the spinal cord and nerves), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes, atrial fibrillation (A-Fib - irregular, rapid heartbeat that causes poor blood flow), hypertension (high blood pressure), hyperlipidemia (high cholesterol), and anxiety.
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of needs) dated 1/27/24, indicated the diagnoses remained current. The Brief Interview for Mental Status (BIMS - a screening tool used to determine cognition) indicated a score of 15, indicating the resident was cognitively intact.
During an interview on 3/13/24, at 12:20 p.m. Resident R1 informed being discharged from the facility on 2/8/24. When the resident arrived home, they realized they were also given the discharge information belonging to another resident, Resident R2.
During an interview on 3/13/24, at 2:20 p.m. the Assistant Director of Nursing confirmed the facility failed to protect the right of resident personal privacy and confidentiality of medical records
28 Pa. Code: 211.5(b) Clinical records.
28 Pa. Code: 201.29(j) Resident rights.
| | Plan of Correction - To be completed: 04/02/2024
1. R1 no longer resides in the facility.
2. Current residents who are discharging from the facility will be reviewed by 2 licensed staff to ensure correct patient discharge paperwork is sent with the correct patient.
3. DON/NHA or designee will educate licensed staff on the facility discharge policy.
4. Audits will be performed by the DON/NHA or designee on discharges and appropriate paperwork weekly x4 weeks. 5. Findings of audits will be brought to the Quality Assurance and Performance Improvement Committee for further review and recommendations.
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