ST. HELENA HOSPITAL CENTER FOR BEHAVIORAL HEALTH

Report ID: IHYE11, California Department of Public Health

Reported Entity: ST. HELENA HOSPITAL CENTER FOR BEHAVIORAL HEALTH

Issue:

Based on interview and administrative document review, the hospital failed to keep personal health information protected, when Patient 1's medical information was voluntarily divulged by a healthcare worker to a family member not authorized to receive the information.This failure resulted in a breach of personal medical information.Findings:During record review, a Clinical Nursing Note, dated 5/22/14, indicated that Patient 1's was a minor, admitted on 5/22/14, was a danger to herself with suicidal ideation's and five weeks pregnant. The noted indicated Patient 1 was monitored every 15 minutes for safety.A Clinical Nursing Note, dated 5/23/14, indicated Patient 1 has not told her mom, dad or ex-boyfriend she was pregnant and was feeling a lot of anxiety because she needed to let her family know about her pregnancy. A Clinical Nursing Note, dated 5/31/14 at 5:07 p.m., entered by License Nurse (LN) A, indicated he spoke with Patient 1's father and notified him of Patient 1's pregnancy. The note indicated LN A subsequently told Patient 1 that he had inadvertently notified her father about her pregnancy and apologized for the lapse [in judgement].During a telephone interview on 6/26/14 at 9:14 a.m., LN A stated he could not remember the date it happened, but while working the morning shift at around 10 or 11 a.m., he received a call asking how Patient 1 was doing. LN A volunteered the information of Patient 1's pregnancy. Upon realizing the mistake, LN A met with Patient 1 right away to inform her and apologized for the mistake. LN A stated Supervisor B told him there was an issue and asked LN A to write a report.During a telephone interview on 6/26/14 at 3:17 p.m., Management Staff C stated the facility first found out about the incident on 5/29/14, because the nursing supervisor informed her of a possible breach that was still under investigation. On 5/30/14, the nursing supervisor reported that Patient 1 did not want the family members to know of her pregnancy. Review of the facility policy and procedure titled, "HIPAA - CONFIDENTIALITY OF PROTECTED HEALTH INFORMATION," affecting all departments/services, under Policy Outline: Section B: Breach of Patient Confidentiality, it indicated that breaching patient confidentiality could occur in a variety of ways...1. "Carelessness, is defined as a breach that occurs when patient information is unintentionally or carelessly accessed or reviewed by oneself, and/or revealed to others without a legitimate need to know the patient information."The facility became aware of the breach on 5/29/14, and Patient 1 was immediately notified by Licensed Nurse A on 5/28/14.

Outcome:

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