ST HELENA HOSPITAL-CLEARLAKE

Report ID: H8B011, California Department of Public Health

Reported Entity: ST HELENA HOSPITAL-CLEARLAKE

Issue:

Based on interview and record review, the facility failed to prevent unauthorized access and disclosure of Patient 1's protected health information, when Patient 1's visit summary was given to Patient 2 on discharge. This failure allowed the unlawful or unauthorized access to Patient 1's protected health information.Findings:The California Department of Public Health was notified on 9/23/13 that a breach of protected health information occurred on 9/18/13.During an interview on 11/7/13 at 2:15 p.m., Administrative Staff A stated that on 9/26/13, she was notified by Management Staff B that a copy of Patient 1's visit summary was given, in error by Unlicensed Staff C to Patient 2 when leaving the family health center on 9/18/13. The protected health information included Patient 1's name, medical record number, date of birth, age, gender, home address, telephone number, date of visit, physicians names, vital signs, future laboratory orders, diagnoses, allergies, medications, problems and health issues. During an interview on 11/7/13 at 2:15 p.m., Administrative Staff A also stated that the breach was discovered by Patient 2's Wife after the visit, and she called Management Staff B on 9/18/13, to report the error and that same day Patient 2 returned the visit summary he was given in error to Unlicensed Staff D.During an interview on 11/7/13 at 2:15 p.m., Administrative Staff A further stated that it was an error on Unlicensed Staff C's part as she did not check two patient identifiers before handing out the visit summary and that currently there was no specific policy and procedure for handing out copies of visit summaries to patients.

Outcome:

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