VALLEY CHILDREN'S HOSPITAL

Report ID: 5JR911, California Department of Public Health

Reported Entity: CHILDRENS HOSPITAL CENTRAL CALIFORNIA

Issue:

Based on staff interview, clinical record, and administrative document review the facility failed to keep Protected Health Information (PHI) confidential when:1. Patient 1's Emergency Department visit notes and CT (computerized tomography, which is an X-ray that produces stereographic images) of head were sent by facsimile (fax) machine (transmitted a copy of printed matter electronically) to an incorrect fax machine. (CA00411372)2. Patient 2's discharge instructions were sent by fax machine to an incorrect fax machine. (CA00411348)These failures placed Patients 1 and 2's PHI at a potential risk for unauthorized use.Findings:CA004113721. On 10/31/14 at 10:30 a.m., during an interview, the Accreditation Coordinator (AC) stated the Health Information Management Technician II (HIMT) entered an incorrect receiving fax machine number into the sending fax machine when she attempted to send a fax to Patient 1's primary care physician. The AC stated the HIMT did not verify the receiving fax machine number was correct prior to sending the fax.The PHI disclosed included Patient 1's name, date of birth, medical record number, diagnosis, clinical findings, physician notes, and the CT scan findings.The facility policy and procedure titled, "Confidentiality" dated 9/14, indicated, "Policy: ... All information that is deemed confidential by [facility] and/or by specific legal statutes shall be kept confidential and shall not be copied, electronically accessed, transmitted or removed from Hospital premises under any circumstances whatsoever, without the prior written consent of Hospital Administration....The facility policy and procedure titled, "Facsimile Machines" dated 10/14, indicated, "...Policy: ...All individuals using a facsimile machine or desktop technology to transmit either patient or organizational information will be accountable for ensuring that the information is transmitted to the appropriate destination... Procedure... 2. Sending a Facsimile to External Parties. A... When confidential information is faxed to a destination number that is not pre-programmed, the fax machine operator shall be responsible for double checking the accuracy of the number in the machine's display before sending the fax..."CA004113482. On 10/31/2014 at 10:35 a.m., during an interview, the Accreditation Coordinator (AC) stated the Health Unit Coordinator (HUC) entered an incorrect receiving fax machine number into the sending fax machine when she attempted to send a fax to Patient 1's primary care physician. The AC stated the HUC did not verify the receiving fax machine number was correct prior to sending the fax.The PHI disclosed included Patient 2's name, date of birth, medical record number, diagnosis, clinical findings, physician notes, and lab results.The facility policy and procedure titled, "Confidentiality" dated 9/14, indicated, "Policy: ... All information that is deemed confidential by [facility] and/or by specific legal statutes shall be kept confidential and shall not be copied, electronically accessed, transmitted or removed from Hospital premises under any circumstances whatsoever, without the prior written consent of Hospital Administration....The facility policy and procedure titled, "Facsimile Machines" dated 10/14, indicated, "...Policy: ...All individuals using a facsimile machine or desktop technology to transmit either patient or organizational information will be accountable for ensuring that the information is transmitted to the appropriate destination... Procedure... 2. Sending a Facsimile to External Parties. A... When confidential information is faxed to a destination number that is not pre-programmed, the fax machine operator shall be responsible for double checking the accuracy of the number in the machine's display before sending the fax..."

Outcome:

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