EISENHOWER MEDICAL CENTER

Report ID: WKG111.01, California Department of Public Health

Reported Entity: EISENHOWER MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to ensure Patient A's Protected Health Information (PHI) was not disclosed to an entity not authorized to receive the information. This failed practice resulted in the unauthorized access to Patient A's name, date of birth, facility account number and medical record number. Findings:On July 18, 2012, the facility notified the California Department of Public Health that a one-page discharge order containing Patient A's name, date of birth, facility account number and facility medical record number was given to the wrong patient. On November 8, 2012, an unannounced visit was made to the facility to investigate this entity reported breach of PHI. In an interview with the Compliance Specialist, on November 8, 2012, at 10:20 a.m., the Compliance Specialist stated a Medical Assistant gave the wrong pre-labeled form to Patient B. The Compliance Specialist stated the employee did not double check the label with the patient and a pre-labeled discharge instruction form was given to the wrong patient. The Compliance Specialist stated clinic staff realized the error and contacted the unintended recipient, who was unaware of the error. On November 8, 2012, the document titled "Discharge Instruction Form," was reviewed. The document contained Patient A's name, date of birth, facility account number, and facility medical record number. The document was signed by the unintended recipient. On November 8, 2012, the facility policy titled "Discharge Instructions," with a last reviewed/revised date of February 29, 2012, was reviewed. The policy indicated its purpose was to establish the proper method for the completion of discharge instructions for clinic and primary care patients. The policy indicated all patients would receive written instructions, that were explained to the patient or significant other. The instructions are signed by the patient or significant other to acknowledge understanding of the instructions. On November 8, 2012, the facility's policy and procedure titled "HIPAA-Use and Disclosure of Protected Health Information," with a last reviewed/revised date of November 18, 2011, was reviewed. The policy indicated:"To protect the patient's right to privacy and confidentiality; at no time will names or information be shared with any person who does not have a need to know in order to provide care." The policy defines PHI as "individually identifiable health information relates to an individual's health status or condition ... Information is considered PHI where there is a reasonable basis to believe the information can be used to identify an individual." A second policy titled "Patient Identification Policy and Procedure," with a last reviewed/revised date of January 3, 2011, was reviewed on November 8, 2012. The policy indicated it was an organization-wide policy and it applied to all services and care settings. The policy indicated in locations such as medical offices, all patients in the office will be identified using patient name and date of birth, prior to receiving examination or treatment.The facility failed to ensure Patient A's Protected Health Information was not disclosed to an entity not authorized to receive the information.

Outcome:

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

Related Reports:

8 other violations reported on the same date. Note that other citations may be about the same event: 344D11.01, 6OHG11.01, FN0S11.01, QB3N11.01, R16P11.01, RLV511.01, SF0R11.01, SPOW11.01