EISENHOWER MEDICAL CENTER

Report ID: 49H611.01, California Department of Public Health

Reported Entity: EISENHOWER MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to ensure all patient protected health information (PHI) was kept protected, which resulted in the unauthorized access of the patient's confidential information (Patient 1). Patient 1's confidential information was given to Patient 2 when Patient 2 was discharged from the facility on January 14, 2013. This resulted in the unauthorized disclosure of Patient 1's protected health information (PHI).Findings:On February 8, 2013, at 11:15 a.m., an interview was conducted with the Director of Compliance (DC). She stated: a. On January 14, 2013, at 5:30 p.m., Patient 2 was discharged from the facility. Patient 2 was given discharge instructions and signed the "Discharge Instructions Signature Page."b. On January 24, 2012, the Director of Health Information Management was reviewing the record for Patient 2 and discovered the "Discharge Instructions Signature Page" contained Patient 1's PHI and had been signed by Patient 2. c. On January 28, 2013, Patient 2's responsible party was notified of the incorrect "Discharge Instructions Signature Page" being signed by Patient 2 and was requested to shred the document. d. Both Patient 1 and 2 had the same last name, and when the nurse printed the "Discharge Instructions Signature Page" for Patient 2, she actually printed the "Discharge Instructions Signature Page" for Patient 1. The nurse had Patient 2 sign and gave Patient 2, Patient 1's "Discharge Instructions Signature Page."Patient 2 received and had an opportunity to view Patient 1's PHI, which included name, medical record number, and account number.Patient 1 was informed of the disclosure of her protected health information (PHI) via a letter dated and mailed on January 31, 2013, to her last known address.The California Department of Public Health (CDPH) was notified via a facsimile dated January 31, 2013, of the unauthorized access of Patient 1's PHI.The facility policy and procedure titled "Patient Identification Policy and Procedure" revised January 3, 2011, revealed "... Patient identification at (name of facility) must be performed utilizing at least two of the following patient identifiers prior to any examination, provision of services, communication, treatment or procedures. ..."The facility policy and procedure titled "Information Privacy" reviewed/revised December 19, 2011, revealed "... (facility name) will take all necessary steps to avoid unauthorized or unlawful access, use or disclosure of protected health information ... Whenever possible, the Information Privacy Officer will contact the individual or organization to whom the information was inappropriately or unlawfully accessed, used or released and requested that no further access, use or disclosure of the information is made and to return or destroy the information. The Information Privacy Officer will contact the Department of Public Health and report the breach within (5) five days of discovery. The Information Privacy Officer will contact the patient within (5) five days of discovery to inform him or her of the unauthorized access, use of disclosure and the plan or step's taken to mitigate it. ..."

Outcome:

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

Related Reports:

2 other violations reported on the same date. Note that other citations may be about the same event: 5B2V11.01, PD1H11.01