ADVENTIST MEDICAL CENTER - REEDLEY

Report ID: XPG511, California Department of Public Health

Reported Entity: ADVENTIST MEDICAL CENTER - REEDLEY

Issue:

Based on staff interview, facility and administrative document review, the hospital failed to keep Protected Health Information (PHI) confidential when:1. Patient 1's abdominal ultrasound report was mistakenly faxed to a physician not associated with Patient 1's care. 2. Patient 2's Mammography report was mistakenly faxed to a physician not associated with Patient 2's care. These failure placed the PHI for Patient 1 and Patient 2 at a potential risk for unauthorized use.Findings:Refer to CA003029891. On 4/23/12 at 1:50 p.m. Staff 1 (Privacy Officer) stated on 3/12/12 Patient 1's abdominal ultrasound report was mistakenly faxed to an outside physician, who was not associated with Patient 1's care. On 4/23/12 at 1:57 p.m., Staff 1 stated the ultrasound reported contained Patient 1's name, date of birth, date of service, medical record number, attending physician, diagnosis and abdominal ultrasound results. The facility policy and procedure number 1000.08.09 titled Confidentiality of Protected Health Information contained the following documentation: "Adventist Health is committed to protecting the privacy and security of protected health information (PHI)...It is the policy to maintain confidentiality for patients and employees at all times and under all circumstances. ...Breach of patient confidentiality through carelessness is when patient information is unintentionally or carelessly accessed, reviewed, or revealed without a legitimate need to know the patient information." The facility's policy and procedure number 1000.03.14, titled "Faxing Patient Protected Health Information contained the following documentation: "It is the sender's responsibility to be aware of the content of the faxes they are sending, to exercise caution in faxing confidential information, and to take precautionary steps to: validate the fax number, key in correct fax number, confirm fax sent to correct fax number, as well as, request is appropriate and meets minimum necessary."Refer to CA003061602. On 4/23/12 at 1:50 p.m. Staff 1 on 4/9/12 the facility became aware of a possible privacy breach. The facility's internal investigation revealed on 4/3/12 Staff 2 (Radiology Clerk) mistakenly faxed Patient 2's mammography report to an outside physician, who was not associated with Patient 1's care. On 4/23/12 at 1:57 p.m., Staff 1 stated the mammography reported contained Patient 2's name, date of birth, date of service, medical record number, attending physician and mammography results. The facility policy and procedure number 1000.08.09 titled Confidentiality of Protected Health Information contained the following documentation: "Adventist Health is committed to protecting the privacy and security of protected health information (PHI)...It is the policy to maintain confidentiality for patients and employees at all times and under all circumstances. ...Breach of patient confidentiality through carelessness is when patient information is unintentionally or carelessly accessed, reviewed, or revealed without a legitimate need to know the patient information." The facility's policy and procedure number 1000.03.14, titled "Faxing Patient Protected Health Information contained the following documentation: "It is the sender's responsibility to be aware of the content of the faxes they are sending, to exercise caution in faxing confidential information, and to take precautionary steps to: validate the fax number, key in correct fax number, confirm fax sent to correct fax number, as well as, request is appropriate and meets minimum necessary."

Outcome:

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