EISENHOWER MEDICAL CENTER

Report ID: S2C611, California Department of Public Health

Reported Entity: EISENHOWER MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to ensure all patient protected health information (PHI) was kept protected, which resulted in the unauthorized access of the patient's confidential information (Patient 5). Patient 5's confidential information was given to Patient 6, on February 3, 2014, when Patient 6 was provided with discharge instructions from the Emergency Department (ED). This resulted in the unauthorized disclosure of Patient 5's protected health information (PHI).Findings:On February 28, 2014, at 11:51 a.m., an interview was conducted with the Deputy Information Privacy Officer (DIPO). She stated: a. On February 3, 2014, Patient 6 was seen at the facility ED and was discharged home. Patient 6 was given discharge instructions and a transition record which provided the highlights of the ED visit.b. On February 5, 2014, Patient 6's family member contacted an employee in the Health Information Management Department (HIM) stating Patient 6 was in receipt of Patient 5's discharge instructions and transition record.c. On February 5, 2014, Patient 6's family member returned Patient 5's discharge instructions and transition record to HIM, and obtained the correct discharge instructions and transition record for Patient 6.d. The Registered Nurse who discharged Patient 6 from the ED did not follow the facility's policy and procedure for correct patient identification by highlighting the patient's name on the discharge instructions and transition record.Patient 6 and Patient 6's family member received and had an opportunity to view Patient 5's PHI, which included name, gender, date of birth, medical record number, account number, ED orders, diagnosis, physician's name, and disposition.Patient 5 was informed of the disclosure of her protected health information (PHI) via a letter dated and mailed on February 12, 2014, to her last known address.The California Department of Public Health (CDPH) was notified via a facsimile received on February 12, 2014, and a letter dated and mailed on February 12, 2014, of the unauthorized access of Patient 5's PHI.The facility policy and procedure titled "Aftercare Instructions to Patients" reviewed/revised January 20, 2014, revealed "... All sheets of the discharge paperwork will be highlighted for correct patient verification. ..."The facility policy and procedure titled "Information Privacy" reviewed/revised December 19, 2011, revealed "... (facility name) will take all necessary steps to avoid unauthorized or unlawful access, use or disclosure of protected health information ... Whenever possible, the Information Privacy Officer will contact the individual or organization to whom the information was inappropriately or unlawfully accessed, used or released and requested that no further access, use or disclosure of the information is made and to return or destroy the information. The Information Privacy Officer will contact the Department of Public Health and report the breach within (5) five days of discovery. The Information Privacy Officer will contact the patient within (5) five days of discovery to inform him or her of the unauthorized access, use of disclosure and the plan or step's taken to mitigate it. ..."

Outcome:

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