EL CENTRO REGIONAL MEDICAL CENTER

Report ID: YMZ511, California Department of Public Health

Reported Entity: EL CENTRO REGIONAL MEDICAL CENTER

Issue:

Based on interview and document review the hospital failed to ensure that Patient 2's personal and protected health information (PHI) was kept confidential when a licensed health care employee gave Patient 2's discharge instructions to Patient 1. As a result of this failure, Patient 1 had access to Patient 2's personal information.Findings:An on site investigation of an entity reported privacy breach was initiated on 2/3/14. It was reported to the California Department of Public Health that, on 1/6/14 an unauthorized and inadvertent disclosure of Patient 2's demographic information was given to Patient 1 on discharge from the hospital.On 2/5/14 at 2:35 P.M., an interview was conducted with the Director of Quality Risk Management (DQRM). The DQRM stated that Patient 1 and Patient 2 were both on the medical/surgical floor and that, both were discharged on 1/6/14. The DQRM stated that the discharge instructions for Patient 1 were entered into the computer, but had Patient 2's demographics information. On 2/5/14 at 3:05 P.M., an interview was conducted with the Clinical Manager of the Medical/Surgical floor (CMMS). The CMMS stated that Registered Nurse (RN) 1, had "dismantled" Patient 1's medical chart and noticed that Patient 2's name was on the discharge paperwork. CMMS stated that during the discharge process two RNs were excepted to go into the patients room together, to check the armband to validate that it was the correct patient. The CMMS stated that when the correct patient was verified, the discharge paperwork was then signed by the patient, the discharging nurse and the second nurse.On 2/5/14 at 3:30 P.M., a review of the discharge instruction sheet given to Patient 1 was conducted. The discharge instruction sheet had Patient 2's name, patient ID number, date of birth, admit date, diagnosis, allergies, medical record number, account number, age, gender, attending physician, phone number, and education given related to the diagnosis. The bottom of the discharge instruction sheet had Patient 2's signature, RN signature and the second RN 's signature. On 6/3/14 at 8:50 A.M., an interview was conducted with RN 5. RN 5 stated that the discharge process for a patient included the following: a physician's order, discharge instructions were completed, and all pages were checked to ensure that each page had the correct patient name. RN 5 further stated that two RN's were to go into the patients room together to verify the correct patient name by the armband. RN 5 stated that he just signed the first page of the discharge instruction and did not go into Patient 1's room with RN 3.On 6/3/14 at 9:00 A.M., an interview was conducted with RN 3. RN 3 stated that she failed to ensure that she was in the right medical record when she filled out the discharge instructions for Patient 1. RN 3 stated she failed to check Patient 1's name was on the top of the discharge instruction sheet. RN 3 stated she failed to have a second RN go into Patient 1's room with her.On 6/3/14 at 9:16 A.M., an interview with the DQRM was conducted. The DQRM acknowledged that both, RN 3 and RN 5 failed to follow the discharge process.A review of the hospital's policy and procedure, entitled "Access to and Maintenance of the Health Record", dated 5/28/13, indicated "Procedure: Record Requests, Obtain written authorization from patient or legal representative prior to access, inspection or review of health information."The nursing staff's failure to validate that the correct name on the discharge instruction sheet, or to have a second RN go into the patients room for verification prior to releasing the discharge instructions to Patient 1, resulted in the inadvertent and unauthorized release of protected health record information. This was also in violation of the patient's right to confidentiality of all communications and record pertaining to health care received at the hospital.

Outcome:

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