EISENHOWER MEDICAL CENTER

Report ID: VSBC11, California Department of Public Health

Reported Entity: EISENHOWER MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to ensure all patient protected health information (PHI) was kept protected, which resulted in the unauthorized access of the patient's confidential information (Patient 5). Patient 5's confidential information was given to Patient 6 when Patient 6 was provided with discharge instructions by Physician 1 on October 1, 2013. This resulted in the unauthorized disclosure of Patient 5's protected health information (PHI).Findings:On October 16, 2013, at 4:40 p.m., an interview was conducted with the Compliance Specialist (CS). She stated: a. On September 30, 2013, Patient 5 was seen at the facility clinic by Physician 1, and during the process of providing Patient 5 with the "Office Visit Summary" the computer printer jammed.b. Sometime during the evening to the morning of October 1, 2013, the printer was unjammed and the "Office Visit Summary" for Patient 5 printed.c. On October 1, 2013, Patient 6 was seen at the facility clinic by Physician 1, and Patient 6 was given the "Office Visit Summary" that was on the printer.d. On October 1, 2013, Patient 6 called the facility clinic and stated he had received the wrong discharge instructions and was in receipt of Patient 5's "Office Visit Summary."e. On October 2, 2013, Patient 6 returned the "Office Visit Summary" for Patient 5 to the facility clinic.Patient 6 received and had an opportunity to view Patient 5's PHI, which included name, gender, date of birth, medical history, medications, preferred pharmacy, physician's assessment of Patient 5, plan of care, and return visit information.Patient 5 was informed of the disclosure of his protected health information (PHI) via a letter dated and mailed on October 8, 2013, to his last known address.The California Department of Public Health (CDPH) was notified via a facsimile received on October 8, 2013, and a letter dated and mailed on October 8, 2013, of the unauthorized access of Patient 5's PHI.The facility policy and procedure titled "Patient Identification Policy and Procedure" revised January 3, 2011, revealed "... Patient identification at (name of facility) must be performed utilizing at least two of the following patient identifiers prior to any examination, provision of services, communication, treatment or procedure. ..."The facility policy and procedure titled "Information Privacy" reviewed/revised December 19, 2011, revealed "... (facility name) will take all necessary steps to avoid unauthorized or unlawful access, use or disclosure of protected health information ... Whenever possible, the Information Privacy Officer will contact the individual or organization to whom the information was inappropriately or unlawfully accessed, used or released and requested that no further access, use or disclosure of the information is made and to return or destroy the information. The Information Privacy Officer will contact the Department of Public Health and report the breach within (5) five days of discovery. The Information Privacy Officer will contact the patient within (5) five days of discovery to inform him or her of the unauthorized access, use of disclosure and the plan or step's taken to mitigate it. ..."

Outcome:

Deficiency cited by the California Department of Public Health: Health & Safety Code 1280