SALINAS VALLEY MEMORIAL HOSPITAL

Report ID: XBJX11.01, California Department of Public Health

Reported Entity: SALINAS VALLEY MEMORIAL HOSPITAL

Issue:

Based on interview and record review, the hospital failed to prevent the unauthorized disclosure of patient health information (PHI) for one of one sampled patient (1), when a staff member disclosed Patient 1's sensitive diagnosis to a visitor. The failure resulted in the disclosure of Patient 1's PHI to an unauthorized individual. Findings:The California Department of Public Health received a faxed report on 10/29/14, which indicated on 10/24/14 a physician (MD A) entered Patient 1's room to consult with the non-English speaking patient. MD A noticed a visitor in Patient 1's room and asked if she was a family member. When the visitor answered "yes", MD A asked if she would translate for MD A, and she agreed. Using the visitor as a translator, MD A consulted with Patient 1. At the end of the consultation, MD A advised Patient 1 to seek treatment for his "sensitive diagnosis", which the visitor translated to Patient 1. Patient 1 wanted to keep his "sensitive diagnosis" private.During an interview on 11/13/14 at 10:40 a.m., the interim privacy officer (PO) stated MD A entered Patient 1's room to consult with him. After entering Patient 1's room she noticed a visitor at the bedside who spoke English to MD A. MD A asked the visitor if she was a family member and she replied "yes". MD A asked the visitor if she would interpret for her and the visitor agreed. MD A had a conversation with Patient 1 with the visitor as her interpreter. The PO stated, at the end of the conversation, MD A mentioned Patient 1 needed to get treatment for his "sensitive diagnosis", then left the room. The PO stated MD A returned to Patient 1's room to retrieve an electronic interpreter (hand-held electronic equipment used as a language interpreter) she had left in the room. Using the electronic interpreter, Patient 1 requested to speak with the hospital's CEO. The PO stated the CEO and MD A spoke with Patient 1 who notified them the visitor was not a family member, and Patient 1 wanted to keep his "sensitive diagnosis" private. The PO further stated staff is supposed to ask all visitors to leave the room when discussing any patient medical information.During an interview on 11/13/14 at 11:30 a.m., MD A stated she had twice asked Patient 1's visitor if she was a family member, and she said "yes" both times. MD A stated Patient 1's visitor was speaking English to her so she asked if the visitor could interpret for MD A. MD A stated at the end of the conversation, she mentioned Patient 1 should get treated for his "sensitive diagnosis", since he had not been compliant in the past. MD A stated, when she went back later to get her electronic interpreter, Patient 1 had asked to speak with the CEO. MD A further stated hospital staff were trained to ask if it was ok to talk with others in the room, and she should have asked Patient 1 if it was ok for the visitor to stay. A review of a copy of a letter dated 10/28/14, from the hospital to Patient 1 indicated, on 10/24/14 MD A allowed a visitor in Patient 1's room to interpret a consultation between Patient 1 and MD A in which PHI was disclosed. A review of a copy of the hospital's 4/2/14 "Release of Patient's Confidential Health Information Policy" indicated when releasing information at the bedside to the patient when visitors are present, staff should respect the patient's right to privacy by verifying with the patient if discussing their care in front of the visitor is ok.

Outcome:

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

Related Reports:

5 other violations reported on the same date. Note that other citations may be about the same event: PDUQ11.01, PDUQ11.02, PDUQ11.03, PDUQ11.04, PXRO11.01