KAISER FOUNDATION HOSPITAL - RIVERSIDE

Report ID: TFKJ11, California Department of Public Health

Reported Entity: KAISER FOUNDATION HOSPITAL, RIVERSIDE

Issue:

Based on interview and record review, the facility failed to prevent unauthorized disclosure of protected health information (PHI) for one patient, (Patient 1). The case manager faxed part of Patient 1's medical record to a private residence. This resulted in the potential for misuse of Patient 1's PHI.Findings:On March 9, 2015, at 8:50 a.m., the Director of Accreditation, Regulations and Licensing (DARL) was interviewed. The DARL stated the Case Manager (CM) was to fax Patient 1's Face Sheet, Physician Progress Notes, and History & Physical, to a Skilled Nursing Facility (SNF), in anticipation of Patient 1 being discharged. The DARL stated, On February 26, 2015, when the CM faxed Patient 1's information to the SNF, she entered the wrong fax number, and the information was received at a private residence. The resident notified the facility of the error on February 27, 2015, at which time he agreed to shred the documents.A copy of Patient 1's information that was faxed to the private residence was reviewed, and contained the following PHI:- Name;- Date of Birth;- Address and telephone number;- Insurance number; Medical record number;- Diagnoses;- Physical exam results;- Current medications;- Lab and radiology results;- Hospital summary;- Assessment and plan of care; and - Past medical history.The policy and procedure titled, HIPAA Confidential Communication - Alternative Address or means of Delivery," dated September 1, 2014, was reviewed. the policy indicated, "Releasing PHI Via Facsimile (FAX)... Enter fax number and confirm the number on the display before pressing "start" button to transmit..."

Outcome:

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