VA Heartland Network (VISN 15)

Report ID: SPE000000077191, U.S. Department of Veterans Affairs

Reported Entity: VISN 15 Kansas City, MO

Issue:

Late Entry: A notice of a privacy complaint was shared with the VAMC Privacy Officer (PO) soon after 02/16/12 by the Quality Management (QM) Service. The complaint was described in a Notice of TORT Claim dated 02/16/12. The PO was not provided with the TORT Claim Notice letter or specific information at this time. A verbal report from QM Service was provided to the PO to include the location (ward) of an inpatient stay and a description of handwritten and CPRS notes that were found by family in the Inpatient Ward waiting area by a family member. At the time of the verbal notification, the PO conducted a physical assessment of area, interviewed staff and attempted to determine if the family had voiced a privacy complaint or that they found the Veteran's records in the waiting room area to staff. The PO could not substantiate a verbal report of the privacy violation that was provided by QM. On 05/16/12, the PO received a Notice of OCR Complaint through the VHA Privacy Office. Through a briefing with the Medical Center Director on the OCR complaint, specific information related to a TORT claim was shared with the PO. The TORT claim included a signed affidavit from the Veteran's family member claiming to have found patient medical records (6-pages total with 5-pages containing personally identifiable information (PII) and protected health information (PHI) and one-page with no identifiers) in the Inpatient Family Waiting Room. Per the claimant, the papers were found on 10/30/11. It was a worksheet and CPRS Notes dated 10/28/11. The papers were found in a magazine rack and were retrieved and held by the family member per affidavit. A review of the medical record mentions the family member by name at the patient's bedside, but no mention of found medical records is documented. The original 6-pages of PHI remain in custody of the family. The VAMC was provided copies as part of TORT. It is not believed that any misuse of the PHI has occurred. The Veteran is since deceased. As a mishandling/inappropriate disclosure is confirmed by the family member's signed affidavit and copies of 6-pages of medical records with TORT Claim, a PSET Incident is entered. Update: 06/27/12: The Veteran's Next of Kin will be sent a notification letter.

Outcome:

Privacy Officer has provided re-training to IP Ward staff on appropriate safeguarding of patient medical records (all formats). Privacy Officer will continue to monitor compliance through routine EOC round and ad hoc observations and Privacy training presentations.