EISENHOWER MEDICAL CENTER

Report ID: OK5Z11, 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 7). Patient 7's confidential information was given to Patient 8 by a staff member of the facility's Breast Center on August 5, 2014. This resulted in the unauthorized disclosure of Patient 7's protected health information (PHI).Findings:On August 13, 2014, at 10:20 a.m., an interview was conducted with the Deputy Information Privacy Officer (DIPO). She stated: a. On August 5, 2014, at the facility Breast Center, Patient 8 was given an envelope which contained ultrasound and mammogram assessments and a compact disc (CD) which contained the images of the ultrasounds and mammogram observations. b. On August 5, 2014, the Breast Center staff member discovered Patient 8 had been given the ultrasound and mammogram assessments and the CD which belonged to Patient 7.c. On August 6, 2014, Patient 8 was contacted and she returned the ultrasound and mammogram assessments and the CD, belonging to Patient 7, to the facility Breast Center on August 7, 2014. d. The Breast Center staff member did not follow the Breast Center's policy and procedure for verifying the documents as belonging to the patient prior to giving the ultrasound and mammogram assessments and the CD to Patient 8 on August 5, 2014.Patient 8 received and had an opportunity to view Patient 7's PHI, which included name, date of birth, medical record number, gender, dates of examinations, physicians' names, examination results, and the examination images on the CD.Patient 7 was informed of the disclosure of her protected health information (PHI) via a letter dated and mailed on August 12, 2014, to her last known address.The California Department of Public Health (CDPH) was notified via a facsimile received on August 12, 2014, and a letter dated and mailed on August 12, 2014, of the unauthorized access of Patient 7's PHI.The facility policy and procedure titled, "Request for Films or Images on CD or Film," revised July 12, 2011, revealed, "... All images on CD or films will be checked by the film librarian for correct patient name, address on envelope and images prior to release to the patient or health care provider. ... The patient will be asked to sign and date the release form upon picking up the CD and/or films. ... Once the patient picks up the requested records the signed release form will be forwarded to the film librarian to track in Magview and send to medical records for scanning into HPF. ..."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