SANTA CLARA VALLEY MEDICAL CENTER

Report ID: 4WD111.01, California Department of Public Health

Reported Entity: SANTA CLARA VALLEY MEDICAL CENTER

Issue:

Based on observation and record review, the hospital failed to maintain patient rights for confidentiality of records when confidential information was in view and accessible to the public. Findings:1. On 9/24/12 at 9:40 a.m., during the tour of the transitional care unit, Patient 8's medical record was left open unattended on the counter at the nurse's station. The record disclosed Patient 8's name, medical record number, date of birth, and vital signs. 2. On 9/24/12 at 12 p.m., during the tour of the "four medical unit", Patient 15's medical record was left open and unattended by a hospital physician on the counter of the nurse's station. The record disclosed Patient 15's name, medical record, date of birth, and physician progress notes. 3. On 9/24/12 at 2:10 p.m., during the tour of the MICC B unit, a chart rack containing patient medical records was located in the main hallway, easily accessible to visitors or patients. At the time of the observation the chart rack contained medical records for Patients 18 and 19. 4. During an observation on 9/27/12 at 10:00 a.m. at the 4 Surgical nurse's station, a list of patient names, medical record numbers, and indications of need for a sitter (supervised care) was noted on the counter. The list was visible to the public.During a concurrent interview with the charge nurse, she stated the list should not have been placed where it was visible to the public. She further stated the patient names and other information should be covered. Review of the hospital's "security of protected health information" policy and procedures dated 3/23/09, indicated the hospital would "protect monitors/documents/faxes from public view".

Outcome:

Deficiency cited by the California Department of Public Health: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS