SAN ANTONIO REGIONAL HOSPITAL

Report ID: EKUQ11.01, California Department of Public Health

Reported Entity: SAN ANTONIO REGIONAL HOSPITAL

Issue:

Based on interview and record review, the facility failed to ensure their policy and procedures (P&P) for sending records via fax were followed when a CT Technologist (computerized tomography) (CT Tech) did not verify the phone number of the intended recipient on the fax cover sheet prior to sending medical records via fax for Patient A. This failure resulted in an unauthorized release of PHI for Patient A to a third party. Finding:On August 14, 2014 at 9:14 AM, a phone interview was conducted with the Director of Nursing Operations (DNO) regarding an entity reported incident of a breach of PHI for Patient A. The DNO stated, "The fax number should be verified before sending the fax, to make sure it is the right number for the intended party."During a review of the documentation faxed on July 23, 2009 to the third party in error, the documentation included Patient A's name, phone number, X-ray number and lab values.A review of the facility policy and procedure titled, "Confidentiality, Protecting Confidential Information," dated July, 2011, the policy indicated, "When faxing confidential information...validate intended recipient before sending the fax".The failure to ensure the fax number was correct by the CT Tech before faxing medical records resulted in the unauthorized release of Patient A's PHI to an unintended third party.

Outcome:

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

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: V31Q11.01