NORTHBAY MEDICAL CENTER

Report ID: Z6GU11.01, California Department of Public Health

Reported Entity: NORTHBAY MEDICAL CENTER

Issue:

Based on interview and document review, the hospital failed to prevent unauthorized disclosure of one patient's protected health information.Findings: In interview on 10/8/12 at 2:30 pm, Staff A stated that CNA B went into Patient 1's electronic medical record (EMR) twice (9/10/12, and 9/14/12) when she should not have accessed it, because she was not involved in Patient 1's care. The first entry lasted one minute, and the second lasted three minutes. Staff A stated that CNA B wanted to find out where Patient 1 was in the hospital, because she had been raised since age three by Patient 1, her stepmother. Staff A stated that Patient 1's two blood daughters had agreed to palliative care for their mother's cancer. Staff A stated that CNA B researched the condition, talked to the family about it, and had tried to get her stepmother to get a second opinion about treatment. Staff A stated that CNA B talked to her stepmother and the family when she was off duty. Staff A stated that CNA B had received a written warning, but had not been fired.Review of Patient 1's medical record on 10/8/12, demonstrated that Patient 1 suffered from terminal cancer and was placed on DNR status on 9/13/12.In interview on 11/13/12, CNA B stated that she was 23-years-old and had been cared for by Patient 1, who had married CNA B's father, 20 years ago. She stated that Patient 1 had been admitted to the hospital on multiple occasions. She stated that she knew that Patient 1 had cancer and had been fighting it for years. She stated she heard what she thought was her stepmother's voice and checked the EMR 9/10/12, to see if she had been admitted. She stated that she did not go into the record to find out the diagnosis, just to verify that it was her stepmother's voice that she heard. She stated that she visited her stepmother during her break. Her stepmother was alone in the room. The next day she translated for one of the nurses and took her stepmother's vital signs (part of her duties). On 9/14/12, she went into the EMR again to find where her stepmother had been moved, when she was sent to the ICU; she went there during her break. Patient 1 told her that she had been trying to reach her. Other family members were in the room. Patient 1 stated that she was feeling better. CNA B stated that when her stepmother was transferred back to the floor, where CNA B worked, she was told by the lead RN that she was not allowed to enter her stepmother's room because of privacy issues. CNA B stated that she had no issues with the other family members. She stated that the other family members were older and had not lived with her, her father, or her stepmother, while she was growing up.

Outcome:

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

Related Reports:

2 other violations reported on the same date. Note that other citations may be about the same event: KWU611.01, KXYJ11.01