Health inspection·October 11, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff protect and maintain residents privacy and confidentiality for one of two sampled residents (Resident 2) when a Charge Nurse (CN) 2 released Resident 2's medical information to Resident 1's family member (FM 1). Residents Affected - Few This deficient practice resulted in Resident 2's medical information released to other people who do not have the rights to know about. Findings: During a review of Resident 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 1/1/2024, the H&P indicated, Resident 2 was admitted to the facility with diagnoses including but not limited to chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), ventilator dependent (a medical device to help support or replace breathing), dysphagia (difficulty swallowing), and status post gastrotomy (an artificial external opening into the stomach for nutritional and medication administration) tube placement. During a review of Resident 2's Nutritional assessment dated [DATE], the nutritional assessment indicated, Resident 2 received Vital 1.2 (a type of feeding formula for patients who receive enteral feeding [tube feeding, a way to deliver nutrition and hydration through the feeding tube]) at 40 milliliters per hour (ml/hr, unit of measures) for 20 hours daily. During an interview on 10/28/2024 at 9:26 a.m. with Resident 1's family member (FM 1), FM 1 stated the Charge Nurse (CN 2) had told her (FM 1) that Resident 2's tube feeding was off for five hours on one occasion. During an interview on 10/28/2024 at 10:13 a.m. with CN 2, CN 2 stated the following: when she (CN 2) was providing education to FM 1 regarding the importance of receiving tube feeding per physician order, she (CN 2) informed FM 1 that Resident 2's tube feeding was off for five (5) hours. CN 2 stated FM 1 was not Resident 2's family member so she (CN 2) should not have discussed Resident 2's medical information with FM 1. CN 2 stated she (CN 2) did not state Resident 2's name but she used Resident 2's room number as the identifier. CN 2 stated, I would be more careful and should not say anything (about discussing Resident 2's medical information) to others. During an interview on 10/28/2024 at 2:54 p.m. with the Nurse Manager (NM 1), NM 1 stated the following: to maintain and protect patients privacy and confidentiality, the facility expected all staff not to discuss any resident information or matter with anyone who were not related to or not Page 1 of 2 555380 555380 10/11/2024 Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few authorized to know about that resident. Nursing staff should not discuss any residents matter to other residents' family members. Using the room number as the identifier would be considered as violation of resident's privacy as others could identify that particular resident based on the room number. During a review of the facility's policy and procedure (P&P) titled, Patient Rights and Responsibilities, dated 2/2023, the P&P indicated, Patients Rights . 13. The right to the confidentiality of his or her clinical records. The right to confidential treatment of all communications and records pertaining to your care and stay in the hospital. During a review of the facility's the policy and procedure (P&P) titled, HIPAA (Health Insurance Portability and Accountability Act of 1996) Privacy Rule, dated 9/2022. The P&P indicated, Protected Health Information. The Privacy Rule protects all individually identifiable health information held for transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper or oral . 'individually identifiable health information' is information . that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. 555380 Page 2 of 2