Search Privacy Violations, Breaches and Complaints
This database was last updated in December 2015 ago and should only be used as a historical snapshot. More recent data on breaches affecting 500 or more people is available at the U.S. Department of Health and Human Services’ Breach Portal.
SHARP CHULA VISTA MEDICAL CENTER
Cited by the California Department of Public Health for a violation of California’s Health and Safety Code relating to medical privacy during an inspection that began on January 16, 2014. Also cited in 46 other reports.
Report ID: XPWC11.01, California Department of Public Health
Reported Entity: SHARP CHULA VISTA MEDICAL CENTER
Issue:
Based on interview, record and document review the hospital failed to ensure that Patient 1's personal and protected health information (PHI) was kept confidential when a Registered Nurse (RN) 2 gave Patient 2 a copy of Patient 1's discharge instructions with copies of three prescriptions. As a result of this failure, Patient 2 had access to Patient 1's personal information. Findings:An on site investigation of an entity reported privacy breach was initiated on 1/16/14. It was reported to the California Department of Public Health that, on 10/4/13 an unauthorized and inadvertent disclosure of Patient 1's medical information was inadvertently given to Patient 2.On 1/16/14 at 1:40 P.M., an interview was conducted with the Manager of Patient Relations (MPR). The MPR stated that Patient 2 had mailed Patient 1's discharge instructions and copies of three prescriptions back to the hospital with a letter. The letter sent by Patient 2, indicated that Patient 1's forms were mixed up with Patient 2's records. On 1/16/14 at 3:20 P.M., an interview was conducted with the Manager of the Progressive Care Unit (MPCU). The MPCU stated that Patient 2 was discharged around the time that Patient 1 had been admitted. MPCU stated that RN 2 was the primary nurse for both Patient 1 and Patient 2. MPCU stated that the discharge process was that the nurse was to print the the discharge papers and copy the original prescriptions. The nurse was then to give the patient the instructions and have the patient sign that it was received. The patient was given the originals and the copy of both the discharge instructions and prescriptions were to be placed into the patients medical chart. On 4/9/14 at 8:40 A.M., an interview was conducted with RN 2. RN 2 stated that the process to discharge a patient was to copy the discharge instructions and any prescriptions. RN 2 stated she would review the discharge instructions with the patient, have the patient sign, give the patient the original and put the copies in the patients medical chart. RN 2 stated that what happened was when Patient 1 was admitted, that the copies of Patient 2's discharge papers were placed into Patient 1's "Welcome Folder" and given to Patient 1. RN 2 stated the discharge of Patient 2 and the admission of Patient 1 happened so quick. A review of Patient 1's documents that were given to Patient 2 was conducted. The following PHI of Patient 1 included: 1) Patient 1's "Discharge/Home Care Instructions", dated 10/3/13, that contained Patient 1's name, date of birth (DOB), medical record number, home address, home phone number, diagnosis, primary care providers name and phone number.2) Copy of Patient 1's three prescriptions that included Patient 1's name, and DOB.A review of the hospital's policy and procedure, entitled "Health Information, Access, Use and Disclosure", dated 11/12, indicated "...3. Category III: Disclosure Requiring Authorization from the Patient/legal Representative a. Disclosure of Protected health Information for any reason... requires patient/legal representative authorization." The policy and procedure entitled, "Discharge From Patient Care Area", dated 07/12, indicated "IV. Procedure: E. Review the discharge instructions (including medications) with patient and /or family. have the patient sign instructions, give patient copy, and place a copy in chart..." This policy was not followed when RN 2 did not place the discharge copy into Patient 1's chart, instead put the copy into the welcome folder of Patient 2.The Registered Nurses failure to put Patient 1's discharged documents in the medical chart prior to the admission of Patient 2, resulted in the inadvertent and unauthorized release of protected health record information. This was also in violation of the patient's right to confidentiality of all communications and record pertaining to health care received at the hospital.
Outcome:
Deficiency cited by the California Department of Public Health: Patients' Rights