Search Privacy Violations, Breaches and Complaints
This database was last updated in December 2015 ago and should only be used as a historical snapshot. More recent data on breaches affecting 500 or more people is available at the U.S. Department of Health and Human Services’ Breach Portal.
ST MARY MEDICAL CENTER
Cited by the California Department of Public Health for a violation of California’s Health and Safety Code relating to medical privacy during an inspection that began on April 1, 2014. Also cited in 55 other reports.
Report ID: HG5X11.01, California Department of Public Health
Reported Entity: ST MARY MEDICAL CENTER
Issue:
Based on interview, and record review, the facility failed to ensure that the confidential treatment of protected health information (PHI) was maintained for Patient B, when the medication reconciliation record which was intended for Patient B, was given to Patient A upon discharge. This resulted in a breach (violation) of PHI for Patient B. The deficient practice had the potential for an unauthorized individual to use the disclosed information in a way not authorized by Patient B. In addition, the failure placed Patient A at risk of being misinformed about their discharge mediation teaching.Findings:On April 1, 2014 at 11:00 AM, a visit was made to the facility to investigate an entity reported incident of a breach of Patient B's PHI.During the interview conducted on April 1, 2014 at 11:20 AM, with the nurse manager, he described what happened as follows:" Every night the unit secretary prints the medication reconciliation form so it is available for the physician to sign. They are to put it in the patient's paper chart on the unit. The unit secretary placed the forms in the registered nurses' (RNs) boxes instead. RN 1 was assigned to both Patient A and B on March 8, 2014. Patient A's physician came in at 4:00 AM, and wrote all discharge orders, and filled out the medication reconciliation form RN 1 had filed in the charts. However, RN 1 had misfiled the medication reconciliation forms in the wrong charts. When RN 2 went to discharge Patient A in the morning, she failed to verify that all pages had the correct patient's name, and inadvertently gave Patient B's form to Patient A. On March 12, 2014 while scanning the paper portions into the electronic file, the clerk discovered the error."A review of the medication reconciliation and nursing discharge forms for both Patients A and B were reviewed with the Nurse Manager on April 1, 2014 at 12:00 PM. Based on the physician's discharge orders, and the nurses' discharge notes, Patient A had received the correct follow up instructions and prescriptions. Only the medication reconciliation form had the wrong Patient's name (Patient B).During a review of the facility policy and procedure titled, "Medication Management- Reconciliation of Medication Across the Continuum," dated, December 2012, the policy instructed the nurses to reconcile the discharge medications with the doctor's orders. The nurse was to review the medication reconciliation form with the patient at the time of discharge, and then both of them were to sign the form.The failure of the unit secretary to follow facility protocol related to medication reconciliation forms, coupled with RN 2 not verifying that the correct patient's name was on each page of paper instructions .resulted in a inadvertent release of PHI for Patient B.
Outcome:
Deficiency cited by the California Department of Public Health: Patients' Rights