REDLANDS COMMUNITY HOSPITAL

Report ID: CJZS11, California Department of Public Health

Reported Entity: REDLANDS COMMUNITY HOSPITAL

Issue:

Based on interview, and record review, the facility failed to ensure the confidential treatment of protected health information (PHI) for Patient A and Patient B, when a Registered Nurse (RN 1) gave Patient A's prescription for medication to Patient B upon discharge and gave patient B's prescription for medication to Patient A. This failure resulted in a breach of Patient A's and B's PHI.During a phone interview on April 13, 2015 at 4:15 PM, with the Health Information/Privacy Officer (HIPO) regarding an entity reported incident of a beach of a PHI for Patient A and Patient B detected on March 13, 2015. The HIPO stated that Patient A's and Patient B's prescription for medication were switched. Patient A was given Patient B's prescription for medication and Patient B was given Patient A's prescription for medication at time of discharge by RN 1. The HIPO stated when RN 1 was at lunch, Registered Nurse 2 (RN 2) was providing lunch break coverage. RN 2 stapled the prescription for medication to the discharge paperwork. RN 1 returned from lunch and did not verify all discharge paperwork belonged to the correct patient before discharging Patient A and Patient B. The HIPO stated the facility's discharge process is to double check each page of the discharge packet at time of discharge. Double check each page for correct name to verify all discharge documents belong to the correct patient. During a phone interview with RN 1, on April 17, 2015 at 11:15 AM, she stated RN 2 put the discharge packets with the prescriptions together while providing RN 1's lunch break coverage. Discharge instructions was given to Patient A and family member. RN 1 stated, "I checked each page to make sure the correct name was on each page of the discharge instructions and prescription." RN 1 further said, I overlooked that the name on the prescription was not the correct patient's name. RN 1 stated the same thing happened with Patient B. Discharge instructions was given to Patient B and family member. RN 1 stated, "None of us noted it was another patient's name on the prescription." Subsequently, Patient A was given Patient B's prescription and Patient B was given Patient A's prescription upon discharge. When asked how the incident happened, RN 1 stated, "Not sure why it happened." "We did not catch the prescripion was for the other patient, neither of us caught it." When asked what the facilitys discharge process is, RN 1 stated, once the patient meets discharge criteria an Anesthsiologist assesses the patient and signs the patient out. Discharge paperwork is generated and printed out. Discharge instructions are explained to the patient and the RN and the patients both sign. The RN's signature signifies the patient was educated on the discharge instructions and the verification that all discharge paperwork belongs to the correct patient.During a review of the documentation that was been disclosed to Patient A and Patient B, the document contained Patient A's and Patient B's name, date of birth, medical provider, date of visit and medications.A review of the facility's undated policy and procedure titled,"Patient Privacy And Security" indicate "staff will provide appropiriate access to patient information based on need to know basis while preserving its confidentiality and integrity."The failure of RN 1 to verify that all discharge instructions belonged to the intended recipient, Patient A and Patient B, resulted in the unauthorized release of Patient B's PHI to Patient A and Patient A's PHI to Patient B.

Outcome:

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