Scripps Mercy Hospital

Report ID: 397611.02, California Department of Public Health

Reported Entity: SCRIPPS MERCY HOSPITAL

Issue:

Based on interview and record review, the hospital failed to ensure its policy and procedure relative to the facsimile (fax) transmission of protected health information, was implemented. The failure to follow the hospital procedure resulted in a misdirected and unauthorized release of health record information, belonging to 1 of 1 sampled patients (Patient 1).Findings:An onsite visit of the hospital was conducted on 5/23/12, in response to a hospital report about an inadvertent and unauthorized release of Patient 1's health record information via facsimile transmission. On 5/23/12 at 3:40 P.M., an interview was conducted with a staff coordinator from Patient Relations and Risk Management. She indicated that on 5/08/12, Patient 1's Physical Therapy and Discharge notes were being faxed by the physical therapist to the patient's physician. A wrong fax number however, was dialed thus leading to the mis-directed, inadvertent and unauthorized release of Patient 1's health information to another person (private residence). The document contained the following information: patient's name, date of birth, medical record number, account number, physician's name, summary of patient's progress at discharge and dates of treatments. A review of the hospital's policy and procedure entitled Transmission of Facsimile Information, dated December 2011, was done during the visit. The hospital's policy provided a clear guidance on the appropriate procedures for management of facsimile transmissions in order to safeguard the confidentiality and security of information, including patient protected health information. Per hospital policy, the sender of fax information should verify the accuracy of the fax number and the intended recipient before sending the fax. The fax number should be validated to ensure the numbers entered were accurate and current. The transmittal confirmation should be checked to ensure the information went to the correct number and the right person.It was reported during the interview with the coordinator for Risk Management and Patient Relations on 5/23/12 at 3:40 P.M. that a patient care access representative was the person who wrote down the wrong fax number for Patient 1' s physician. The access representative staff and physical therapist failure to validate the accuracy of the physician's fax number information prior to sending out the document was in violation of the hospital's policy and procedure on facsimile transfer of information and patient's right to confidentiality of his/her health record information.

Outcome:

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

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: 397611.01