SAN FRANCISCO GENERAL HOSPITAL

Issue: Based on interviews and document reviews, the hospital failed to ensure the provision of Quality Assessment and Performance Improvement as evidenced by:1. The hospital Quality Assessment Performance Improvement (QAPI) program failed to set priorities for it performance improvement activities that…

Outcome: Deficiency cited by the California Department of Public Health: QAPI

Issue: Based on interview, tape recordings, and record review, the hospital failed to maintain the confidentiality of Patient 1's protected health information (PHI - personal identifiers [name, medical record number, etc.], health status, care received, payment of services, demographics [age, gender,…

Outcome: Deficiency cited by the California Department of Public Health: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS

Issue: Based on interview and document review the hospital Quality Assessment Performance Improvement (QAPI) program failed to track missing persons as a quality indicator to improve contracted security services. The QAPI program had identified issues with missing persons since 2010 and…

Outcome: Deficiency cited by the California Department of Public Health: DATA COLLECTION & ANALYSIS

Issue: 2. The Governing Boby failed to ensure that Patient Rights were protected and enforced when a safe patient environment was not provided and patient privacy was not ensured. (See A115, A144 and A146)3. The facility failed to ensure nursing services…

Outcome: Deficiency cited by the California Department of Public Health: GOVERNING BODY

Issue: Based on interview and record review, the facility failed to ensure the protection of Patient 1's medical information from the unauthorized access by Staff 1.Findings: Without need or authorization, Staff 1 utilized the facility's computer system to access Patient 1's…

Outcome: Deficiency cited by the California Department of Public Health: Medical Record Availability

Issue: Based on interview and record review, the facility, despite best efforts, was unable to notify the patient involved in the breach of medical information.Findings:During an interview on 7/3/13 at 8:30 AM, the facility's Privacy Officer (PO) stated that Patient 1…

Outcome: Deficiency cited by the California Department of Public Health: Medical Breach

Issue: Based on interview and record review, the facility failed to prevent the unauthorized access when Patient 1's personal health information (PHI) was posted on a public Website. Findings:During an interview on 7/3/13 at 8:30 AM, the facility's Privacy Officer (PO)…

Outcome: Deficiency cited by the California Department of Public Health: Health & Safety Code 1280

Issue: Based on interview and record review, the facility failed to ensure the protection of Patient 1's medical information from the unauthorized posting on a public Webster.Findings:Without authorization from Patient 1, her personal health information (PHI) was posted on a public…

Outcome: Deficiency cited by the California Department of Public Health: Medical Record Availability

Issue: Based on interview and record review, the facility failed to prevent the unauthorized access to Patient 1's confidential medical information by Staff 1.Findings:During an interview on 7/3/13 at 9:30 AM, the facility's Privacy Officer (PO) related the details of her…

Outcome: Deficiency cited by the California Department of Public Health: Health & Safety Code 1280

Issue: Based on interview and record review, the facility failed to ensure the protection of Patient 1's medical information from the unauthorized access and disclosure by Staff 1.Findings:Without need or authorization, Staff 1 accessed Patient 1's protected medical information through the…

Outcome: Deficiency cited by the California Department of Public Health: Medical Record Availability