EISENHOWER MEDICAL CENTER

Report ID: 8QH111, 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 7). Patient 7's confidential information was facsimiled to a private physician's office, who was not the patient's physician, on September 10, 2014. This resulted in the unauthorized disclosure of Patient 7's protected health information (PHI).Findings:On September 23, 2014, at 8 a.m., an interview was conducted with the Deputy Information Privacy Officer (DIPO). She stated: a. On September 10, 2014, a Phlebotomy Technician (PT) facsimiled laboratory test results belonging to Patient 7 to a physician's office.b. On September 10, 2014, the physician's office in receipt of the laboratory test results belonging to Patient 7 informed the facility via a return facsimile that Patient 7 was not their patient and the physician, to whom the laboratory test results were intended, no longer worked at this office.c. On September 11, 2014, she verified with the incorrect physician's office that they had shredded the laboratory test results belonging to Patient 7.d. The PT had not used the "automatic fax system" to send the laboratory test results to the physician and had not verified the facsimile number prior to sending the laboratory test results to a physician. The incorrect physician's office personnel received and had an opportunity to view Patient 7's PHI, which included name, medical record number, financial number, date of birth, physician's name and laboratory test results.Patient 7 was informed of the disclosure of his protected health information (PHI) via a letter dated and mailed on September 17, 2014, to his last known address.The California Department of Public Health (CDPH) was notified via a facsimile received on September 17, 2014, and a letter dated and mailed on September 17, 2014, of the unauthorized access of Patient 7's PHI.The facility policy and procedure titled "Faxing Protected Health Information" reviewed/revised March 21, 2013, revealed "... Telephone the receiving facility to inform them that Protected Health Information is being faxed, confirm the fax number, and determine whether the fax number is located in a secured area. ... Automatic Fax Systems: Computer systems which automatically generate outgoing faxes containing Protected Health Information shall include a confidentiality statement on the first page whenever possible. In addition, all fax telephone numbers entered into such systems will be tested for accuracy prior to implementation."The facility policy and procedure titled "Information Privacy" reviewed/revised January 2, 2014, 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