VA Southwest Health Care Network (VISN 18)

Report ID: PSETS0000083661, U.S. Department of Veterans Affairs

Reported Entity: VISN 18 El Paso, TX

Issue:

The Driver's License of Veteran A was mistakenly handed back to Veteran B by a Volunteer handling Wheelchairs at the front greeting desk. Veteran B noticed the error and returned the incorrect Driver's License of Veteran A. Then Volunteer noted that Driver's License of Veteran B was missing and had been mistakenly handed to Veteran A. Volunteer drove to house of Veteran A and returned the correct Driver's License and asked for return of Veteran B Driver' License. He was told by Veteran B (mentally impaired) that there was no Driver's License available. The Volunteer checked with the caregiver. No Driver's License was found. He checked with veteran A's wife and still no Driver's License was found or returned. the incident was reported late to the Privacy Officer (PO) noting that the Driver's License of Veteran A is still missing. The Driver's License contains Veteran B's full name, address, date of birth and Driver's License number, and picture. Update: 12/13/12:Two Veterans will be sent a letter offering credit protection services.

Outcome:

Update to ticket per fact-finding: Clarification noted that Volunteer Service Assistant (not a Volunteer) drove to Veteran B's house and returned his license with the intention of retrieving Veteran A's license. Veteran B was unable to find Veteran Veteran A's license. Veteran B and his caregiver have been called numerous times to ask if Veteran A's license had been found. Veteran B's caregiver has also been unable to find the Veteran A's drivers license. The information desk and wheelchair area has been thoroughly searched for Veteran A's missing ID. On 12/10/12 Chief of Volunteer Services called Veteran B again and Veteran B claims that he never received his ID back - even though hand-delivered by Volunteer Service Assistant and documented/timed. Veteran B seems unable to remember certain details, including his phone number. It is possible that he doesnt remember the ID being returned. Wife of Veteran B said that they thoroughly cleaned the car and did not find Veteran A's driver's license card. Lessons learned and Corrective Actions taken include re-emphasis of requirement that Privacy Officer will immediately be notified of any privacy issues regarding Volunteer Services in the future. Additionally a new certification question will be added to the ID/wheelchair checkout process. to verify correct ID and the Veteran/customer will be asked to verify the address listed on the ID as a means of verification. Re-training of Chief, Volunteer Services conducted to reinforce privacy issues and immediate reporting. Findings and mitigation/corrective action communicated to leadership. Letters offering credit monitoring prepared for director's signature/notification to Veteran A and Veteran B with explanation of privacy issue. Recommend ticket closure based on above fact-finding and letters offering credit monitoring to be uploaded to PSETS per facility Privacy Officer. 01/14/2013 Letters offering credit monitoring (redacted) uploaded to PSETS. Recommend ticket closure based on above documentation, mitigation and corrective action. Submitted: JWinstead, Privacy Officer EPVAHCS