Health inspection·November 15, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews, the facility failed to protect resident's clinical records for 2 of 6 residents (Residents #1 & #5) reviewed for clinical records, in that: MA A failed to lock and disable access to Resident #1's electronic health record while he walked away from his medication cart. LVN B failed to lock and disable access to Resident #5's electronic health record while she walked away from her medication cart. This failure could affect residents by having their records viewed and accessed by unauthorized personnel and violate the HIPAA. The findings included: Record review of Resident #1's face sheet, dated 11/15/2023, reflected an [AGE] year-old female with an admission date of 11/04/2023 and an admitting diagnosis of OTHER FORMS OF ACUTE ISCHEMIC HEART DISEASE (inadequate blood supply (circulation) to a local area due to blockage of the blood vessels supplying the area.) Record review of Resident #5's face sheet, dated 11/15/2023, reflected a [AGE] year-old female with an admission date of 07/10/2023 and an admitting diagnosis of CEREBRAL INFARCTION DUE TO EMBOLISM OF RIGHT MIDDLE CEREBRAL ARTERY (a stroke caused by a blood clot.) Observation on 11/15/2023 at 11:12 AM revealed an unattended medication cart with a computer displaying the physician's orders for Resident #1. Interview on 11/15/2023 at 11:14 AM, MA A stated the unattended medication cart was his. MA A stated he walked away to provide a different resident a cup of orange juice and would normally never leave his computer unlocked. MA stated he was last trained on the HIPAA and resident privacy in the last few months. MA A stated he left it unlocked by accident. MA A stated the risk associated with leaving the EHR open and accessible would be a violation of the HIPAA. Observation on 11/15/2023 at 12:30 PM revealed an additional unattended medication cart with a computer displaying the physician's orders for Resident #5. Interview on 11/15/2023 at 12:34 PM, LVN B stated the unattended medication cart was hers. LVN B Page 1 of 2 675974 675974 11/15/2023 Medina Valley Health & Rehabilitation Center 913 Hwy 90 W Castroville, TX 78009

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she walked away to provide medications to a different resident and normally would never leave her computer unlocked. LVN B stated she was last trained on the HIPAA and resident privacy recently but unsure when. LVN B stated she left it unlocked by accident and that due to leaving it unlocked, it potentially left a breach of Resident #5's privacy and violate the HIPAA. Interview on 11/15/2023 at 3:25 PM, the ADM stated it was her expectation that any staff who had access to resident records ensure no one but authorized personnel have access to confidential records. The ADM stated nurses and medication aides were expected to lock their computers if they walked away to protect the privacy of the resident's clinical records. The ADM stated failing to lock their computers created a potential breach of the HIPAA. Record review of the facility's policy titled, Confidentiality of Personal and Medical Records, dated 1/20/2023, reflected, This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record. 675974 Page 2 of 2