SAN ANTONIO REGIONAL HOSPITAL

Report ID: 81HS11.01, California Department of Public Health

Reported Entity: SAN ANTONIO COMMUNITY HOSPITAL

Issue:

Based on interview, and record review, the facility failed to ensure the confidential treatment of the laboratory results for Patient A, when the laboratory results were inadvertently given to Patient B upon discharge. This resulted in a breach of protected health information (PHI) for Patient A.Findings:On January 23, 2014 at 8:45 AM, an unannounced visit was made to the facility to investigate an entity reported incident of a breach of PHI for Patient A.During an interview with the Director of Nursing Operations on January 23, 2014 at 9:05 AM, she explained that both Patients A and B were being discharged at approximately the same time. The RN (RN 1) gave Patient B his discharge instructions and inadvertently included the laboratory results for Patient A. Patient B's wife recognized the error when they got home and notified us."During the same interview, Patient A's laboratory form was reviewed. The form contained Patient A's full name, medical record number and the laboratory results done on January 9, 2014, and January 10, 2014.A review of the facility policy and procedure titled, "Confidentiality, Protecting Confidential Information,"July 2012, indicated, "Confidential information must be protected from unauthorized uses, disclosures..."On January 23, 2014 at 10:00 AM, the Director of Nursing Operation stated that "RN 1 had not looked at every paper when providing discharge instructions which resulted in the breach."

Outcome:

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

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: N2RB11.01