COMMUNITY HOSPITAL OF SAN BERNARDINO

Report ID: E3BU11, California Department of Public Health

Reported Entity: COMMUNITY HOSPITAL OF SAN BERNARDINO

Issue:

Based on interview, and record review, the facility failed to ensure that the post-partum (after birth) nurse (RN 1) verified the name on the WIC (Women, infants and children) form matched Patient B's name. This resulted in RN 1 giving Patient A's WIC form to Patient B. This resulted in a breach of Patient A's confidential protected health information (PHI)>Findings:On May 5, 2014 at 1:15 PM, a phone interview was conducted with the Facility Privacy Officer (FPO) regarding a breach of PHI for Patient A on March 27, 2014. She stated she would have the nurse who was responsible for the breach return the call.A phone interview was conducted with RN 1 on May 5, 2014 at 1:50 PM. She stated, "I was the nurse for both patients (Patients A and B) in post partum. Patient B came back the following day and told me that she had gone to WIC, but it was not her name on the form." When RN 1 was asked to describe what happened to cause the error, she stated, "When mothers are leaving we fill out a lot of paperwork. The discharge instructions are three pages long, then we do education, and give a lot of pamphlets. We ask if they will need WIC, so we give them the form in the packet. The form contained the baby's birth weight and height, sex, delivery date and name of the hospital. The form also lists the mother's name, height and weight, hemoglobin and hematocrit (blood count to rule out anemia), and the name of the hospital. I don't now if I just picked it up, or [if] it was put in the wrong packet. My nurse manager had me get re-educated on HIPAA (Health insurance portability and accountability act)."The failure of RN 1 to match the name on each form she was giving to Patient B resulted in the unauthorized release of Patient A's PHI.

Outcome:

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