CMS SOM App. PP, Tag F583

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(h)(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.

DEFINITIONS §483.10(h)

“Confidentiality” is defined as safeguarding the content of information including video, audio,

or other computer stored information from unauthorized disclosure without the consent of the

resident and/or the individual’s surrogate or representative. If there is information considered too

confidential to place in the record used by all staff, such as the family’s financial assets or

sensitive medical data, it may be retained in a secure place in the facility, such as a locked

cabinet in the administrator’s office. The record must show the location of this confidential

information.

“Promptly” means delivery of mail or other materials to the resident within 24 hours of delivery

by the postal service (including a post office box) and delivery of outgoing mail to the postal

service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up

service.

“Right to personal privacy” includes the resident’s right to meet or communicate with

whomever they want without being watched or overheard. Private space may be created flexibly

and need not be dedicated solely for visitation purposes.

GUIDANCE §483.10(h)

Each resident has the right to privacy and confidentiality for all aspects of care and services. A

nursing home resident has the right to personal privacy of not only his or her own physical body,

but of his or her personal space, including accommodations and personal care.

Residents in nursing homes have varying degrees of physical/psychosocial needs, intellectual

disabilities, and/or cognitive impairments. A resident may be dependent on nursing home staff

for some or all aspects of care, such as assistance with eating, ambulating, bathing, daily

personal hygiene, dressing, and bathroom needs. Only authorized staff directly involved in

providing care and services for the resident may be present when care is provided, unless the

resident consents to other individuals being present during the delivery of care. During the

delivery of personal care and services, staff must remove residents from public view, pull

privacy curtains or close doors, and provide clothing or draping to prevent exposure of body

parts.

Photographs or recordings of a resident and/or his or her private space without the resident’s, or

designated representative’s written consent, is a violation of the resident’s right to privacy and

confidentiality. Examples include, but are not limited to, staff taking unauthorized photographs

of a resident’s room or furnishings (which may or may not include the resident), or a resident

eating in the dining room, or a resident participating in an activity in the common area. Taking

unauthorized photographs or recordings of residents in any state of dress or undress using any

type of equipment (for example, cameras, smart phones, and other electronic devices) and/or

keeping or distributing them through multimedia messages or on social media networks is a

violation of a resident’s right to privacy and confidentiality.

Personal and medical records include all types of records the facility might keep on a resident,

whether they are medical, social, fund accounts, automated, electronic, or other. Care must be

taken to protect the privacy of personal information on all residents, including gender identity

and sexual orientation.

Posting signs in residents’ rooms or in areas visible to others that include clinical or personal

information could be considered a violation of a resident’s privacy. It is allowable to post signs

with this type of information in more private locations not visible to the public. An exception

can be made in an individual case if a resident or his or her representative requests the posting of

information at the bedside (such as instructions to not take blood pressure in right arm). This

does not prohibit the display of resident names on their doors nor does it prohibit display of

resident memorabilia and/or biographical information in or outside their rooms with their consent

or the consent of his or her representative. (This does not include isolation precaution

information for public health protection, as long as the sign does not reveal the type of infection).

Personal resident information must be communicated in a way that protects the confidentiality of

the information and the dignity of residents. This includes both verbal and written

communications such as the presence of lists of residents with certain conditions such as

incontinence and pressure ulcers at nursing stations in view or in hearing of residents and

visitors. This does not include clinical information written in a resident’s record.

Privacy for visitation or meetings might be arranged by using a dining area between meals, a

vacant chapel, office or room; or an activities area when activities are not in progress.

Arrangements for private space could be accomplished through cooperation between the

facility’s administration and resident or family groups so that private space is provided for those

requesting it without infringement on the rights of other residents.

All residents have the right to privacy in their communications, including justice involved

residents. Additional guidance on mail, telephone, electronic communications and visitation

rights are addressed in §483.10(g)(6)-(9), F576 and §483.10(f)(4)(i)(A)-(G), F562. See

§483.90(e)(1)(iv), F914, for full visual privacy around beds.

With the exception of the explicit requirement for privacy curtains in all initially certified

facilities (see §483.90(e)(1)(v), F914), the facility is free to innovate to provide privacy for its

residents. This may, but need not, be through the provision of a private room.

PROCEDURES §483.10(h)

• Observe for situations where facility staff may not be honoring the resident’s privacy,

including during visits, treatment, or leaving medical records out for public view.

• During interviews with residents, their representatives, visitors or families determine if

their privacy has been honored by facility staff.

• Interview the representative of the Office of the State Long-Term Care Ombudsman who

serves residents of the facility, to determine if the facility allows him/her to examine the

resident’s records with the permission of the resident or resident representative or as

otherwise authorized by State law.

• Are there signs regarding care information posted in view in residents’ rooms? If these

are observed, determine if such signs are there by resident or resident representative

direction. If so, these signs are allowable.

• Is personal resident information communicated in a way that protects the confidentiality

of the information and the dignity of residents?

• If concerns are found, interview staff regarding facility policy or procedures regarding

protecting resident privacy and confidentiality.