EISENHOWER MEDICAL CENTER

Report ID: GH7011.01, California Department of Public Health

Reported Entity: EISENHOWER MEDICAL CENTER

Issue:

Based on interview and facility document review, the facility failed to prevent unauthorized access and/or disclosure of Patient 1's medical information, when a lab order form was inadvertently given to a patient with a similar name.Findings:On February 22, 2013, at 10:30 a.m., the Director of Compliance (DC), was interviewed. The DC stated that on December 14, 2012, a Patient Admitting Specialist (PAS) at an outpatient clinic, printed a lab order for Patient 1 and gave it to Patient 2. The DC stated that the PAS located a lab order for Patient 1, who has the same name (different birthdate) as Patient 2. She stated that the PAS should have checked the birthdate to ensure it was the correct patient. The DC stated that Patient 2 presented to the lab on December 28, 2013, with Patient 1's lab order. The order was removed from Patient 2's possession and the facility notified of the breach.A copy of the lab order that was inadvertently given to the wrong patient was reviewed. In addition to the types of labs ordered, the form contained Patient 1's name, date of birth, social security number, and patient diagnoses.A review of the facility policy, "HIPPA - [Health Insurance Portability and Accountability Act] - Use and Disclosure of Protected Health Information (dated November 18, 2011)," was reviewed . The policy defined Protected Health Information (PHI) as, "Protected Health Information (PHI) - Individually identifiable health information transmitted or maintained in any form or medium, including oral, written and electronic...Information is considered PHI where there is a reasonable basis to believe the information can be sued to identify an individual." The policy indicated, "It is the policy of [ facility name] that the confidentiality of Protected Health Information contained in records and collected pursuant to treatment will be protected to the fullest extent possible. To maintain this confidentiality [facility] staff may not disseminate PHI unless it is pursuant to a valid request, a valid authorization or a legally recognized exception to this requirement."The facility policy titled, "Information Privacy (dated December 19, 2011)," was reviewed and indicated, "...Unauthorized of Unlawful Disclosure: is the release, transfer, provision of access to, or providing in any other manner of PHI outside of the organization, to parties without a treatment, payment or hospital administrative purpose..."The facility policy titled, "Department: Admitting and Registration...Patient Identity Verification (date May 1, 2009)," was reviewed. The policy indicated, "All admission/Registration staff will take steps to obtain and verify the identity of the person they are registering for service." The policy further indicated, "...Existing Patient/Account - In-Person Registration...Using the patient identifier information presented by the patient, the registrar will verify the patient's information including but not limited to: the patient's full name, date of birth, social security number, address and insurance information..."

Outcome:

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

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: 3QWE11.01