ST BERNARDINE MEDICAL CENTER

Report ID: 4N8L11.01, California Department of Public Health

Reported Entity: ST BERNARDINE MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to protect Patient A's medical information. This breach caused Patient A's protected health care information to be released.Findings:The facility self reported on 9/28/11 that a technician in the Health Information Management (HIM) Department (Employee B) had inadvertently faxed a portion of the mother ' s emergency visit (Patient B) along with the requested minor ' s emergency visit (Patient A) record to the pediatrician ' s office. The protected health information (PHI) for Patient B that was inadvertently faxed to the pediatrician ' s office consisted of the following:a. Name.b. Age.c. Date of birthd. Lab orders.e. Medications.f. Treatment orders.g. Diagnosis.h. Physical examination and findings.i. Medical history.j. Triage assessment.k. Radiology report.l. Discharge instructions.m. Physician name.n. Medical record number.o. Encounter number.During an interview with the health information officer on 3/28/12, she confirmed that Employee B had violated the facility ' s policy of safeguarding Patient B ' s health information. The health information officer stated that the documents were not double checked before it was faxed.Review of the facility ' s policy and procedure titled " Safeguarding PHI and Sensitive Information " , effective date: 1/5/09 indicated, " It is the policy of ... to provide appropriate access to its information based on a need-to-know basis while preserving its confidentiality and integrity. The ... facility shall implement reasonable and appropriate administrative, technical, and physical safeguards ... "

Outcome:

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

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: 28DN11.01