LAC/HARBOR-UCLA MED CENTER

Report ID: 4WSM11, California Department of Public Health

Reported Entity: LAC/HARBOR-UCLA MED CENTER

Issue:

Title 22, 70707(b)(8)(d) Patients' Rights(b) A list of these patients' rights shall be posted in both Spanish and English in appropriate places within the hospital so that such rights may be read by patients. This list shall include but not be limited to the patients' rights to:(8) Confidential treatment of all communications and records pertaining to the care and the stay in the hospital. Written permission shall be obtained before the medical records can be made available to anyone not directly concerned with the care.(d) All hospital personnel shall observe these patients' rights.The above statute and regulation were NOT MET as evidenced by:Based on interview and review of the medical record and the hospital ' s P&P (policy and procedure), the hospital failed to protect confidential patient information for 246 patients when the filing staff of the Medical Records Department, who was not properly supervised, inappropriately disposed of 246 patient medical records at the bus terminal trash cans off the hospital campus.Findings:On 10/1/12, a visit was conducted to the hospital to investigate a breach detected on 9/7/12, and reported to the California Department of Public Health on 9/13/12. Review of the county's health services' P&P on breaches of protected health information (PHI) showed protection of privacy and security of PHI remained the policy of the Los Angeles County Department of Health Services (DHS) to which the hospital belonged. Workforce members who violated state or federal patient privacy laws, and/or DHS ' s P&P would be subjected to appropriate corrective action up to and including discharge.Review of the hospital's P&P titled Medical Records Services - Filing Correspondence showed the Correspondence Filing Unit was responsible for filing incoming correspondence. Each member of the Unit was assigned to a specific section which contained specific number of terminals. Each individual piece of correspondence was to be processed in a timely and accurate manner to ensure that these documents were incorporated in the correct medical record as soon as possible. The procedure noted that the worst thing that could happen was to file correspondence in the wrong patient's chart.On 10/2/12 at 1145 hours, interview with the Assistant Hospital Administrators 1 and 2 showed a contracted janitor of the Metropolitan Transit Authority (MTA) called the hospital on 9/7/12, and reported that he had discovered 3-4 inch stacks of medical documents bounded by rubber bands in two trash cans at Artesia Transit Center, an MTA bus terminal. The medical documents were identified as belonging to the hospital. Staff from the hospital ' s Health Information Management (HIM) and Facilities Management was dispatched to retrieve the medical documents. Some of the medical documents contained patient names, medical record numbers, addresses, telephone numbers, dates of birth, social security numbers, courses of treatments, and diagnoses. On that same day, the terminal digit numbers of the documents were identified and the involved Medical Records Staff 1 was reassigned to an area where there was no contact with patient or any other confidential information. Review of the hospital ' s documents showed HIM's inventory had identified 246 patients who were affected by the incident. On 10/3/12 at 0830 hours, interview with the police detective agent assigned to the case showed the involved Medical Records Staff 1 was identified by the documents' terminal digit number and coincided to the staff's bus route as the main mean of transportation to work. The Medical Records Staff 1 had no previous criminal record. "Mainly laziness" was the rationale why the patients ' medical documents were disposed of inappropriately.On 10/3/12 at 0950 hours, during an interview of the Medical Records Manager, she stated the involved Medical Records Staff 1 was a transfer from another county hospital and had been working in the Medical Records Department for one month. She further stated the Medical Records Staff 1 ' s normal filing production was an inch of correspondence in 45 minutes. The Medical Records Staff 1 was filing 3 inches in an hour. However, the Medical Records Manager said it never crossed her mind that the Medical Records Staff 1 was not doing her job. The investigation led to finding more patient medical documents hidden in the employee's working area.

Outcome:

Fine imposed and deficiency cited by the California Department of Public Health: Patients' Rights