EISENHOWER MEDICAL CENTER

Report ID: SPOW11.01, California Department of Public Health

Reported Entity: EISENHOWER MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to ensure Patient A's Protected Health Information (patient's name, date of birth, address and phone number) was not disclosed to an entity not authorized to receive the information. This had the potential to result in misuse of private information.Findings:On October 25, 2012, the facility reported to the California Department of Public Health that Patient A's PHI was inadvertently faxed to the wrong physician. On November 8, 2012, at 10:15 a.m., an unannounced visit was made to the facility to investigate this breach of Patient A's Protected Health Information (PHI).In an interview with the Compliance Specialist on November 8, 2012, at 11 a.m., the Compliance Specialist stated Patient A's mammogram results were faxed to the wrong physician. The Compliance Specialist stated, the two physician's had the same first and last names, but only one had a fax number. The document was faxed to the physician's office, who reported to the facility he was not involved in Patient A's care. On November 8, 2012, a copy of the document faxed to the wrong physician was reviewed. The document had fax imprinted on the top, indicating it had been faxed to Physician B, and then faxed back to the facility. The document contained Patient A's name, date of birth, address, phone number and date of service. The facility's policy and procedure titled "Communication of Mammography Results to the Health Care Provider," indicated a written mammography report would be sent to the health care provider as soon as possible, within five to seven days.On November 8, 2012, the facility's policy and procedure titled "HIPAA-Use and Disclosure of Protected Health Information," with a last reviewed/revised date of November 18, 2011, was reviewed. The policy indicated:"To protect the patient's right to privacy and confidentiality; at no time will names or information be shared with any person who does not have a need to know in order to provide care." The policy defines PHI as "individually identifiable health information relates to an individual's health status or condition ... Information is considered PHI where there is a reasonable basis to believe the information can be used to identify an individual." The facility failed to ensure Patient A's Protected Health Information was not disclosed to an entity not authorized to receive the information.

Outcome:

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

Related Reports:

8 other violations reported on the same date. Note that other citations may be about the same event: 344D11.01, 6OHG11.01, FN0S11.01, QB3N11.01, R16P11.01, RLV511.01, SF0R11.01, WKG111.01