ST HELENA HOSPITAL-CLEARLAKE

Report ID: 7X4W11, California Department of Public Health

Reported Entity: ST HELENA HOSPITAL-CLEARLAKE

Issue:

Based on staff interviews, and record review, the facility violated Health and Safety Code section 1280.15 when it failed to safeguard Patient 1's medical information according to the facility's policy and procedure to prevent disclosure of medical information when Staff C took Patient 1's medical information from the acute care hospital for personal use.Findings:On 12/10/10 at 8:29 a.m., the California Department of Public Health received a faxed report from the facility that a breach of patient health information had occurred.During an interview on 1/21/11 at 9 a.m., and again on 1/31/12, Administrative Staff A stated on 12/7/10, she received a telephone call from a family member of Patient 1 stating a medical record belonging to Patient 1 had been found in the home of Staff C. Administrative Staff A stated she asked the family member to bring the record to Administrative Staff A's office at the facility. Administrative Staff A stated she notified Administrative Staff B. After reviewing the record together, it was determined that the record was a carbon copy of the original Emergency Department Record belonging to Patient 1. Administrative Staff A stated the original reports are filed in the patient's chart and the carbon copy of the report was filed in a separate locked storage area. Administrative Staff A stated awhile ago ( no time frame given) there had been problems with original Emergency Department records getting lost, so the facility decided to copy the original emergency records and keep the copies in a separate locked storage area for six months. Administrative Staff A stated every month the emergency department record copies that were six months old were pulled and destroyed. She stated since Staff C was a medical records clerk, one of her job assignments was to pull the six month old emergency report copies and destroy them.During an interview on 1/21/11 at 9:30 a.m., Administrative Staff B stated she and Administrative Staff A had a meeting with Staff C on 12/9/10, who admitted she had taken the records home for her own personal use. Administrative Staff B stated Staff C stated she was aware that it was against the facility's policy to remove medical records from the facility without authorization, and that staff are required to maintain confidentiality of patient's health information. Staff C stated she did not see any problem taking the record since it was going to be destroyed anyway. Administrative Staff B stated Staff C was terminated immediatelyReview of the facility's policy for Removal of Medical Records, dated 6/1993 and reviewed every year, the last being 11/11, indicated medical records shall not be taken outside the hospital except upon receipt of a subpoena, court order, statue or specific written authorization of the administrative offices, and any information of a medical nature in the possession of the facility must not be revealed by any staff of the hospital or the chart removed from the premises except as outlined as stated above.

Outcome:

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