SHARP CHULA VISTA MEDICAL CENTER

Report ID: KQD811.02, California Department of Public Health

Reported Entity: SHARP CHULA VISTA MEDICAL CENTER

Issue:

Based on interview and record review, the hospital failed to safeguard confidential patient information on a prescription medication from unauthorized person(s), for 1 of 1 sampled patient (Patient 1). Patient 1's respiratory medication (Advair Diskus- a controller asthma medication that combines two drugs into one inhaler) in a ziplock bag with a label that contained patient's full name, medication name, dose and instruction for use on it was found in Patient 2's room by unauthorized person(s).Finding:On 8/30/12 at 11:00 A.M., the hospital reported to the Department that respiratory therapist (RT 1) inadvertently left Patient 1's prescription medication (Advair Diskus) in Patient 2's room.A telephone interview with RT 1 was conducted on 9/7/12 at 10:00 A.M. RT 1 stated that she recalled providing respiratory care to Patient 1 on 8/24/12. She stated that Patient 1 had her aerosol therapy and then was given her Advair Diskus medication. She stated that after she administered Patient 1's respiratory treatment and medication, she went to Patient 2's room. She stated that she left Patient 1's Advair Diskus medication that was stored in a ziplock bag with a label on it that contained Patient 1's name, medication name, dose and instruction for use in Patient 2's room. She acknowledged that she should have returned Patient 1's Advair Diskus medication to the medication room prior to starting Patient 2's respiratory treatment.A telephone interview with the pulmonary department manager (PDM) was conducted on 9/7/12 at 10:20 A.M. The PDM stated that he was informed by the Patient Relations and Risk Management Department of the incident involving RT 1, Patient 1's Advair Diskus medication and Patient 2. He acknowledged that an unauthorized disclosure of confidential patient information occurred when RT 1 left Patient 1's Advair Diskus medication in Patient 2's room. He confirmed that Patient 1's Advair Diskus medication was stored in a ziplock bag which was labeled that contained Patient 1's name, medication name, dose and instructions for use. He stated that the hospital's policy was to safeguard confidential patient information.A review of Patient 1's medical record was conducted on 9/27/12 at 8:00 A.M. Patient 1 was admitted to the hospital on 8/15/12 with a diagnosis that included congestive heart failure per the facesheet. According to Physician's Order dated 8/21/12 at 7:18 P.M., Advair 250/50 BID (twice a day) was to be administered to Patient 1.A photocopy of the ziplock bag containing Patient 1's Advair Diskus and label was reviewed on 9/27/12. The label on the ziplock bag contained the following protected health information (PHI): Patient 1's name, medical record number, medication name, dose and instruction for use.A review of the hospital's policy entitled "Research and the HIPAA (Health Insurance Portability and Accountability Act- a law that was passed to protect patient's information) Privacy Rule", effective date of 8/11, was conducted on 9/27/12. The policy indicated that the hospital was prohibited from using or disclosing protected health information (PHI) without written authorization from the individual. PHI included patient names, date of birth, hospital admission, hospital discharge, patient postal addresses including city, state and zip code, telephone numbers, medical record numbers, etc...An exit conference with the PDM and the Director of Critical Care was conducted on 9/28/12 at 4:10 P.M. They both acknowledged that an unauthorized disclosure occurred when Patient 1's Advair Diskus was left behind in another patient's room by RT 1.

Outcome:

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

Related Reports:

The report containing this deficiency also includes information about 2 other violations. Note that these may be related to the same event: KQD811.01, KQD811.03