EISENHOWER MEDICAL CENTER

Report ID: 3YOT11.01, 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 7). Patient 7's confidential information was shared with a visitor who did not have access to Patient 7's "Privacy Code" on July 13, 2014. This resulted in the unauthorized disclosure of Patient 7's protected health information (PHI).Findings:On July 21, 2014, at 2:55 p.m., an interview was conducted with the Deputy General Council (DGC). He stated: a. On July 13, 2014, the Registered Nurse (RN), caring for Patient 7, asked a visitor at the patient's bedside what medications Patient 7 was taking. The visitor responded by saying "what medications" and the RN responded by saying his "HIV (human immunodeficiency virus) medications."b. Neither Patient 7 nor Patient 7's personal representative had provided this individual with Patient 7's "privacy code."c. The RN self reported the breach when she discovered her error in providing Patient 7's PHI to an unauthorized visitor.Patient 7's visitor was provided verbal information that Patient 7 was taking medications for HIV, and the RN disclosed the type of medications that may have been prescribed for Patient 7.Patient 7 was informed of the disclosure of his protected health information (PHI) via a letter dated and mailed on July 17, 2014, to his last known address.The California Department of Public Health (CDPH) was notified via a facsimile received on July 17, 2014, and a letter dated and mailed on July 17, 2014, of the unauthorized access of Patient 7's PHI.The facility policy and procedure titled "Privacy Code" reviewed/revised March 21, 2013, revealed "... Each member of the workforce is responsible for adhering to this policy by verifying that individuals have the patient's Privacy Code prior to disclosing the patient's PHI. ... Prior to the disclosure of PHI, the individual requesting the patient's PHI must give the patient's Privacy Code which is a four digit code to the workforce member. ..."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

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: 256T11.01