ST BERNARDINE MEDICAL CENTER

Report ID: 28DN11.01, California Department of Public Health

Reported Entity: ST BERNARDINE MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to protect Patient A's medical information. This breach caused Patient A's protected health care information to be released.Findings:The facility self reported that Employee B, a discharge planner, instructed Employee A, a nurse case manager with an incorrect room number (Room 506) to fax the H&P (History and Physical) and MAR (Medication Administration Record) to a hospice agency. Employee A had faxed the incorrect information to the hospice agency.The protected health information (PHI) for Patient A that was faxed in error consisted of:a. Name.b. Age. c. Room Number.d. Date of Birth.e. Sex.f. Physician name.g. Medical record number.h. Encounter number.i. History and Physical Report containing medical history and condition.j. Medication Administration Record containing list of all medications patient is receiving.During an interview with the health information officer on 3/28/12, she confirmed that both employees (Employee A & Employee B) had violated the facility's policy of safeguarding Patient A's health information.Review of the facility's policy and procedure: "Safeguarding PHI and Sensitive Information", with the effective date:1/5/09 indicated, "It is the policy ... to provide appropriate access to its information based on a need-to-know basis while preserving its confidentiality and integrity. The ... facility shall implement reasonable and appropriate administrative, technical, and physical safeguards ..."

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: 4N8L11.01