ST MARY MEDICAL CENTER

Report ID: OH6411, California Department of Public Health

Reported Entity: ST MARY MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to protect health information for Patient B, when the list of discharge medications was signed by Patient A's mother, due to the registered nurse (RN), not checking the patient's name against the medication list. This was a breach of protected health information (PHI) for Patient B.Findings:An unannounced visit was made to the facility on November 25, 2013 at 12:50 PM, to investigate an entity reported incident of a possible breach of PHI.During a review of the document titled, "Discharged Patient's Medication Reconciliation" dated October 30,2013 at 5:00 PM, Patient B's name is at the top, and Patient A's parental signature on the bottom. The form included Patient B's: name, date of birth, age, sex, height and weight, and medical record number.During an interview with the Director of Risk Management on November 25, 2013 at 1:10 PM, she stated, "[Used registered nurse's name- RN 1] was assigned to both Patient A and Patient B on the pediatric unit. Both were to be discharged on the same day. RN 1 was preparing the discharge paperwork in advance for both Patient A and Patient B. Patient A was discharged first, and the mother signed the paperwork provided on October 30, 2013. Medical records discovered the error during a routine audit on November 4, 2014, and informed me that the mother of Patient A had been given Patient B's paperwork to sign in error."During an interview with the Director of Risk Management on November 25, 2013 at 2:00 PM, she agreed that a breach of Patient B's PHI had occurred when Patient B's confidential medical information was released in error to Patient A. She stated, "We are now having the discharge paperwork verified by two employees and doing audits on this change.'

Outcome:

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