Health inspection·July 31, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, for one (Resident 1) of five residents, the facility failed to ensure the right resident records were released when it was requested on June 9, 2023. Residents Affected - Few The facility failure to safeguard medical record had resulted to inadvertent release of wrong resident identifiable records to an unauthorized person which had the potential of the records to be used in an inappropriate manner. Findings. On July 10, 2023, at 11:12 a.m., an unannounced visit was conducted to investigate a complaint with an allegation of 800 pages of wrong resident medical records which were released to an unauthorized person. On July 10, 2023, at 12:06 p.m., the Medical Record Director was interviewed. MRD stated that on June 9, 2023, she released a stack of multiple records to a RP. MRD stated that the situation was chaotic and she had not kept a copy of what record she provided the RP. MRD stated she did not realize the mistake until RP came back on June 19, 2023, informing her she had received the wrong patient records. MRD stated the mistake occurred because Resident 1 had the same lastname. MRD stated resident's records are confidential and if it were released to the wrong person, the person's identity can be made public, can be used for something illegal if it get to the wrong person. MRD stated the process of releasing a resident's medical record should have been to: * Make sure RP fill out the Release of Information Form ; * Verify the name , and date of birth , to confirm it is the right resident; * Inform the DON (Director of Nursing) and ADM (Administrator); * Verify the RP is authorized to receive the medical record; and * Prepare the chart, make copies, and release the record. On July 10, 2023, at 2:13 p.m., the DON was interviewed. The DON stated, the mistake happened Page 1 of 2 555365 555365 07/31/2023 Palm Terrace Care Center 11162 Palm Terrace Lane Riverside, CA 92505

F 0842 Level of Harm - Minimal harm or potential for actual harm because the residents had the same lastname and it was chaotic at the time. The DON stated, to prevent it from happening, a name alert had to be in place and no matter what is going on, staff have to maintain the accuracy of the record and remain compliant when releasing documents. The DON stated, the record had to be verified by 2 persons to make sure the record being released was matching the medical record number, name, and DOB of the resident. Residents Affected - Few A review of the facility undated document titled, Your HIPAA Responsibilities , indicated .Do not disclose/release an entire record unless releasing it is reasonably necessary to accomplish the purpose of the disclosure .Verifying copies of records do not contain information for other patients/residents. Verifying identity and authority of those requesting and accepting PHI (Protected Health Information). Obtain a valid authorization before disclosing PHI .Log all disclosure/releases of PHI. Complete the Breach log for all breaches and notify your compliance partner or Privacy Officer. Provide patient or resident with copies of signed documents. File all documentation in the patient's or resident's medical record. A review of the facility's undated policy and procedure titled, Release of Information , indicated, POLICY: It is the policy of this facility that the facility maintains the confidentiality of each resident's personal and clinical records. PROCEDURES: Each resident is assured of confidential treatment of his or her personal and medical records .2. Release of resident information .will be governed by the principle that the facility's first concern is for the protection of the rights of the resident. 3. Access to the resident's medical records will be limited to the staff and consultants providing services to the resident .4. Resident records, whether medical, financial, or social in nature, are safeguarded to protect the confidentiality of the information .and are available only to authorized personnel . 555365 Page 2 of 2