SHARP CHULA VISTA MEDICAL CENTER

Report ID: HJMD11.02, California Department of Public Health

Reported Entity: SHARP CHULA VISTA MEDICAL CENTER

Issue:

Based on interview and record review, the hospital failed to safeguard protected health information (PHI) from unauthorized person(s) in accordance with their policies and procedures, for 1 of 1 sampled patient (Patient 1). Findings:On 5/1/12 at 4:49 P.M., the hospital reported to the Department that an unauthorized disclosure of patient information occurred when Patient 1's facesheet was inadvertently given to a paramedic (unauthorized person).A review of Patient 1's medical record was conducted beginning on 5/11/12 at 9:35 A.M. Patient 1 was admitted to the hospital on 4/24/12 per the facesheet. The following confidential patient information was found on Patient 1's facesheet: full name, date of birth, age, marital status, sex, full address, home phone number, medical record number, emergency contact information, name of medical insurance, physician name and listed diagnoses.An interview with the unit clerk was conducted on 5/11/12 at 11:28 A.M. The unit clerk stated that the her responsibility was to make copies of the patient's medical records and have the registered nurse (RN) review the copies to ensure the correct documents were released to an authorized person. She further explained that if a patient was being transported by ambulance, the RN or designee (a unit clerk), will make two copies of the facesheet. She stated that one copy of the facesheet was given to the ambulance personnel, and the other copy was sent with the patient to the receiving facility. The unit clerk stated that she inadvertently handed the paramedic staff Patient 1's facesheet. She stated that the facesheet belonged to Patient 1's roommate. A review of the hospital's policy entitled "Outpatient SVCS (services)- BHS: Interagency Patient Transfer", effective date of 2/09, was conducted on 5/11/12. The policy stipulated that "If patient is being transported by ambulance, RN, or designee, will make two copies of the face sheet: one copy of the face sheet is given to the EMR (Emergency Medical Responder) personnel, and one copy is sent with the patient to the receiving facility."An interview with the manager (3 East) was conducted on 5/11/12 at 11:45 A.M. The manager stated that the hospital's policy related to outpatient services- interagency patient transfer was not implemented when the unit clerk did not give Patient 1's facesheet to the RN for review. He acknowledged that Patient 1's facesheet contained confidential patient information that was not protected from unauthorized person(s) when the unit clerk gave the paramedic staff the wrong patient's facesheet.A review of the hospital's policy entitled "Confidentiality of Information", effective date of 8/09, was conducted on 5/11/12. The policy indicated that under "Safeguarding of Information. Sensitive information collected and/or generated within the [hospital name] shall be maintained in such a manner that access to it is restricted to those with a need to know. Information will be restricted to those with a legal right under authorization, those participating in treatment, payment, healthcare operations and as mandated by state and federal laws in accordance with [hospital name] policies."

Outcome:

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

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: HJMD11.01

1 other violation reported on the same date. Note that other citations may be about the same event: PZCM11.01