EISENHOWER MEDICAL CENTER

Report ID: YK5011.01, 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 3). Patient 3's confidential information was given to Patient 4 when Patient 4 was registered at a facility Outpatient Center on January 28, 2014. This resulted in the unauthorized disclosure of Patient 3's protected health information (PHI).Findings:On February 5, 2014, at 11:20 a.m., an interview was conducted with the Information Privacy Officer (IPO). He stated: a. On January 23, 2014, Patient 4 was pre-registered over the telephone by an Admitting/Registration Clerk for an outpatient procedure at a facility Outpatient Center. Labels and a folder of documents were created for the patient through the pre-registration process.b. On January 28, 2014, Patient 4 presented to the facility Outpatient Center for his procedure and was registered by the Admitting/Registration Clerk as Patient 3. Patient 4 was given an arm band and "Conditions of Admission" consent.b. On January 28, 2014, when the nurse verified the patient's identity prior to the procedure, it was discovered Patient 4 had been incorrectly registered as Patient 3.c. The incorrect arm band and "Conditions of Admission" consent belonging to Patient 3 were destroyed, and Patient 4 was subsequently registered under the correct demographic information.Patient 4 received and had an opportunity to view Patient 3's PHI, which included name, date of birth, medical record number, account number, gender, and age.Patient 3 was informed of the disclosure of his protected health information (PHI) via a letter dated and mailed on February 4, 2014, to his last known address.The California Department of Public Health (CDPH) was notified via a facsimile received on February 4, 2014, and a letter dated and mailed on February 4, 2014, of the unauthorized access of Patient 3's PHI.The facility policy and procedure titled "Patient Identity Verification" dated May 1, 2009, revealed "... 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. ..."The facility policy and procedure titled "Information Privacy" reviewed/revised December 19, 2011, 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

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: LCXP11.01