SAN JOAQUIN COMMUNITY HOSPITAL

Report ID: 5VC411, California Department of Public Health

Reported Entity: SAN JOAQUIN COMMUNITY HOSPITAL

Issue:

Based on observation and interview, the facility failed to discreetly conduct an interview with one sampled patient which resulted in violation of the patient's right for privacy and confidentiality of health information. Findings:During an observation on 10/20/14, at 3:25 PM, in the waiting area, there were 6 patients sitting and waiting. The Customer Service Representative (CSR) called the patients one at a time to go into the interview rooms located behind the reception area where they conduct their interviews. The doors of the interview rooms were kept open and remained open during the entire interview process. Personal information disclosed during the interview could be heard in the hallway and in the waiting area. The interview door was unable to close when a patient in a wheelchair entered the room, as the wheelchair blocked the door.During a concurrent observation and interview with the Director of Regulatory Compliance (DRC), on 10/20/14, at 4:08 PM, she confirmed the interview rooms were too small for a patient in a wheelchair. The door was kept open while the patient was being interviewed. She stated, the doors of the interview rooms were kept opened due to space issue. She stated the doors can be closed and when closed it was observed the interview room was more quiet and the sound from inside the room was blocked, preventing the staff and other patients from overhearing conversations inside the interview room. During an interview with Staff 1, on 10/20/14, at 4:10 PM, she confirmed the doors in the interview rooms were kept open at all times even if there were interviews going on. When asked if she could hear the interviews from outside the interview room, she answered, "Yes." She also confirmed there were patients and families who can hear the personal information. During an interview with Staff 2, on 10/20/14, at 4:19 PM, she stated she interviews patients and verifies personal informations before they go to diagnostics (tests and exams used to identify diseases). She stated, she usually leaves the interview room door open unless the patient asks for the door to be closed. She stated, "I am new here and I see others leave the doors open so I keep my door open, too." When asked if the doors should be closed, she answered, "Absolutely yes, we should protect the privacy and confidentiality of patient's personal informations."During an interview with Staff 3, on 10/20/14, at 4:47 PM, she stated there was a patient who was very angry last week about the door being left open. She stated, the patient was upset that the interview could be overheard by other patients and staff in the facility. She stated, "It (door) should be closed during interviews."The facility policy and procedure titled, "Policy: Workforce Awareness and Compliance Related to HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule" undated, indicated in part: "Compliance-Key Elements, The HIPAA Privacy and Security requirements extend beyond traditional concepts of patient-provider confidentiality. It is essential for all Adventist Health entities to take necessary steps to see that all workforce members know what is required, and understand the policies and procedures concerning compliance with the regulations. The HIPAA Privacy and Security Rules mandate that every covered entity have necessary and appropriate protections in place to control access to protected health information (PHI) and to prohibit unauthorize access to and dissemination of such information. Privacy cannot be protected unless the provider, payer and health plan take appropriate steps to guard that information and make reasonable and appropriate efforts to see that members of the workforce comply with privacy and security policies and procedures."

Outcome:

Deficiency cited by the California Department of Public Health: Patients' Rights