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
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555365
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555365
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/31/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Terrace Care Center
11162 Palm Terrace Lane
Riverside, CA 92505
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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 .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555365
If continuation sheet
Page 2 of 2
