CONTRA COSTA REGIONAL MEDICAL CENTER

Report ID: V56D11.04, California Department of Public Health

Reported Entity: CONTRA COSTA REGIONAL MEDICAL CENTER

Issue:

Based on interview and record review, the hospital failed to protect the confidential medical information of 10 patients {Patient18 and Patient19 (CA00316633) Patient 20 (CA00322695), Patient 25 (CA00318231), Patient23 (CA00318228), Patient26 (CA00322626), Patient27 (CA00322627), and Patient28 (CA00322629) } of 16 patients reviewed, as evidence by:1. Patient18 received an ID wristband pertaining to Patient19 and Patient19 received an ID wristband pertaining to Patient18 (CA00316633); 2. Patient21 received an x-ray requisition form pertaining to Patient20 (CA00322695);3. Patient 24 received 6 bottles of Patient25 ' s prescription medications when transferred to another hospital (CA00318231);4. Patient22 received a prescription slip pertaining to Patient23 (CA00318228);5. Patient26 complaining that when being registered in the Emergency Department the registration clerk yelled her name and address to verify her identity (CA00322626);6. Patient27 complaining that when having blood drawn at the clinic laboratory, the Lab tech yelled " I need help with a Hep C girl " (CA00322627);7. Patient29 submitted a formal grievance that when her daughter (Patient28) came to the clinic for a pregnancy test the nurse told another nurse that Patient28 was pregnant and the second nurse told several people in her neighborhood, one of whom told Patient29 that her Patient28 (17 year old daughter) was pregnant (CA00322629); These failures caused patients loss of dignity and privacy, and placed them at risk for identity theft. Findings:Review on 10/22/12 of facility policy "Confidentiality of Patient/Client Information", dated 12/1991and revised 6/2010, showed that the policy instructed staff that While individuals are patients/clients of the hospital it is each employee ' s obligation to contribute to the provision of care in an environment that protects the patient ' s/client ' s right to privacy, and to accomplish this all observations and or verbal, written, pictorial or photographic communications regarding patients/clients, in the absence appropriate authority to access or release that information, should be safeguarded as confidential. The policy instructed staff that each employee is responsible for keeping patient/client information confidential and that employees may not access, discuss or reveal any patient/client medical information without proper written authorization from the patient. The policy instructed staff that employees shall only have access to patient/client information as needed to carry out their specific job duties. The policy further instructed staff that employees will only discuss a patient ' s medical condition with those individuals authorized by the patient.Review on 10/22/12 of facility policy "Safeguarding Protected Health Information", dated 4/14/2003 and revised 7/1/2010, showed that the policy instructed staff that Health System Identification Cards contain the patient ' s name, date of birth, medical record number, phone number, the abbreviated name of the clinic where they receive services, and the name of their health care provider, and that this information is considered " confidential information " and is therefore subject to the same protections under Federal and State law as other health information.. The policy instructed staff that " Workforce members must take precautions to prevent the unauthorized access, use, or disclosure of health system identification card itself, any document embossed with this information, or any document with this information written on any part of it. " The policy further instructed staff that they " must be very careful to give the correct health system identification cards and paperwork to the proper patient. " The policy also instructed staff that Work force members must take reasonable steps (e.g. lowering voices, moving to more protected area, etc.) to protect the privacy of all verbal exchanges or discussions of confidential information. Review on 10/22/12 of facility policy "Accuracy of Information on Clinic Cards", dated 6/2004, showed that the policy instructed registration staff that when a patient presents a cranberry clinic card it is to be checked and if the information on the card differs from the information obtained during that day ' s registration, then a new card with corrected information must be printed and the old card recycled. The policy instructed registration staff to confirm all necessary patient information while registering a patient for a medical appointment or ancillary service and that a new card must be printed and the old card recycled specifically when: a. the name, DOB (date of birth) or gender is now different in the computer system because of a change or an error correction, b. the phone number has been changed as reported by the patient, c. the PCP (primary care provider) on the card does not match the PCP in the computer system, d. the financial class on the card does not match " today ' s financial class " . Review on 10/22/12 of facility policy "Patient Identification Process", dated 9/2011, showed that the policy instructed staff to protect and accurately identify each patient served, and that staff must reliably identify the individual as a person for whom the service or treatment is intended and must match the service or treatment to that individual and must secure their protected health information and medical record accuracy at all encounters. The policy instructed Registration Clerk staff that for patients presenting for services 18 years and over:Request to see a government issued photographic proof of identity, Compare the identification presented with the patient information in the registration system and the appointment documentation.After identifying the patient and completing the registration process, the registration clerk will place an identification wristband on the patient ' s limb. The policy further instructed clinical and ancillary staff to be responsible for verifying the patient ' s identity prior to rendering care, preforming diagnostic studies, giving medication and treatments by asking the patient to state his/her name and date of birth and comparing the wristband information to the verbal information provided by the patient.1. On 10/22/12, the CPO (Compliance/Privacy Officer) stated that on 6/25/12 RC-V (registration clerk) placed a medical ID (Identification) wristband onto Patient18 ' s wrist that belonged to Patient19, and that RC-W placed a medical ID (Identification) wristband onto Patient19 ' s wrist that belonged to Patient18. The PO explained that the error was discovered on the same day when before the patients left the clinic. The CPO explained that the medical ID wristband included the Patient ' s name, date of birth, medical record number, Patient account number, Primary Care Provider and date of service.Review on 10/22/12/11, of the " MPI Visit Selection " (a list of clinic appointments) for Patient18 showed an appointment on 6/25/12 at facility 646.Review on 10/22/11, of the " MPI Visit Selection " (a list of clinic appointments) for Patient19 showed an appointment on 6/25/12 at facility 646. 2. On 10/22/12, the CPO (Compliance/Privacy Officer) stated that on 6/28/12 staff gave Patient 21 a radiology requisition form and a lab requisition form embossed with Patient20 ' s medical ID (Identification) card after a clinic appointment. The PO explained that the error was discovered on 6/29/12 when Patient21 came to the clinic diagnostic imaging department for the exam and complained when they never called her name, at that point it was discovered that the orders/requisitions had been embossed with Patient20 ' s Medical ID card. The CPO stated that the Medical ID Card included the Patient ' s name, date of birth, phone number, medical record number and primary care physician ' s name and the radiology requisition form included information about Patient 8 ' s radiologic procedure.Review on 10/22/12, of the " MPI Visit Selection " (a list of clinic appointments) for Patient20 showed an appointment on 6/28/12 at facility 646.Review on 10/22/12, of the " MPI Visit Selection " (a list of clinic appointments) for Patient 21 showed an appointment on 6/28/12at facility 646.Review on 10/22/12, of the " Ultrasound Request " dated 6/28/12 showed an imprint of a medical ID card for patient20 in the upper right corner and hand written at the bottom of the page patient21 ' s name.Review on 10/22/12, of the " Out Patient Lab Order Sheet " dated 6/28/12 showed an imprint of a medical ID card for patient20 in the upper right corner.3. On 10/22/12, the CPO (Compliance/Privacy Officer) stated that on 7/10/12 a nurse from a different hospital called the CPO to inform that Patient24 had arrived as a transfer from the Emergency Department ' s PES unit (Psychiatric Emergency Stabilization) with six bottles of prescription medication belonging to Patient25 included in her possessions. The CPO explained that both patients (Patient24 and Patient25) had been seen in the PES on 7/8/12 and that the medication had been given returned to Patient24 instead of Patient25 when patient24 was transferred to another hospital for care. The CPO explained that the Prescription medication bottles had Patient25 ' s name, the name of the medication, and instructions for use of the medication. On 10/23/12, the PM (Program Manager of the PES) stated that when patients come into the PES they sometimes bring their prescription ' s so the doctor can see what they have been taking at home, and that when the patient is admitted the medications are placed in a numbered white bag that is sealed labeled with the patient ' s name and stored in the locked medication room on the PES unit. A corresponding numbered white tag is placed on the patients chart and the medications are returned to the patient on discharge. The PM explained that Patient25 came into the PES on 7/8/12 with the medication she takes at home and those were taken and placed in a white medication bag. But that when Patient24 was transferred to another hospital for care RN-A (registered Nurse) accidently gave the medications to the EMTs (emergency medical technicians) who transported Pateint24 to the other hospital. Review on 10/23/12, of a " Patient ' s Medication White Bag " showed an opaque white plastic bag with a peal and seal sticky closure that had printed on the front " Medicines Inventory and a six digit number with instructions to tear off and insert inside envelope followed by several lines to list the medications and a line for the patient ' s name and signature and a perforation line, then instruction to tear here. A second slip of plastic with a perforation line with instructions to tear here had the same six digit number and a place to write the Patient ' s address and for the patient to sign with instruction that this slip serves as a receipt for deposit. Then below that peroration line was listed the hospital name and address the same six digit number a space for the patient ' s name date of deposit, unit, medical record number, a line for received and sealed by, and a place for a signature of witness. Then " Instructions for using medicines envelope 1. List all medicines being deposited on the inventory sheet, if narcotics, list # of pills. 2. Print patient ' s name and medical record number on bag. 3. Have patient sign signature line. 4. Unit staff depositing medicines must sign on appropriate line. 5. Have another staff person sign the witness line. 6. Place medicines and inventory list inside medicines bag. 7. Pull off liner and press to seal permanently. Take to inpatient pharmacy. The attached receipt must be presented and signed by the depositor when the envelope is delivered. The receipt must then be attached to medicines register as a permanent receipt for return of deposit intact. "Review on 10/23/12 of facility policy "Personal Property", dated 1992, and revised 5/2009, showed that the policy instructed staff that Upon admission the patient ' s property will be inventoried and documented on the " Patient ' s Personal Property Information Sheet " and Medication and narcotics are stored in the appropriate bag. The policy instructed staff to inventory and place medications in the " Medication (white) Bag " and sends it to the Pharmacy for storage, and that a copy of the itemized list is kept in the patients chart, attached to the personal Property Sheet. The Policy further instructed staff that all belongings will be returned to the patient upon discharge, and that all items should be checked as either present or not present. That as part of the discharge procedure, all valuables listed shall be returned to the patient, so noted, and both the patient and nursing staff must sign.Review on 10/23/12, of the "Patient Care Timeline" dated 7/8/12, 2:39p.m. to 7/9/12, 11:21a.m., showed that the nurse documented that Patient24 arrived to the PES at 2:39p.m., on an involuntary hold due to danger to self and others and " has been off medications for several weeks " and that Patient ' s valuables (purse) was placed in a locker at 3:02p.m. No documentation of medications brought in with Patient24 was found. Further review showed that RN-A documented at 11:21a.m., that Patient24 " departed with all personal belongings, personal medications and paperwork " , and " Report given to EMT from Ambulance. "4. On 10/22/12, the CPO (Compliance/Privacy Officer) stated that on 7/5/12 staff gave Patient22 prescription instructions with Patient23 ' s name printed on it. The error was discovered on 7/5/12 when Patient22 returned _ an hour later with the prescription intended for Patient23 saying " this is not mine. " The CPO explained that the only information the prescription had printed on it was Patient23 ' s name, the name of the medication, and directions for use.5. On 10/22/12, the CPO (Compliance/Privacy Officer) stated that on 8/13/12 Patient26 filed a formal grievance that when she was being registered for care in the ED (Emergency Department) that a registration clerk yelled her name across the room and then in the same loud voice yelled her address to confirm her identity. The CPO explained that when this was investigated the Manager of Registration for the ED reported that Patient26 was being registered by RC-2 (registration Clerk), when RC-1 offered to help and may have spoken loudly. The CPO explained that RC-2 had been on vacation and that RC-1overheard what she was asking Patient26 and started to explain the new process of patient identification to RC-2, when Patient26 became upset. 6. On 10/22/12, the CPO (Compliance/Privacy Officer) stated that on 8/14/12 Patient27 filed a formal grievance that when she was having her blood drawn at the clinic laboratory, Lab-Tech-Z yelled " I need help with a Hep C girl " causing her to feel very embarrassed and upset, that information about her hepatitis status was being yelled about for others to hear. The CPO explained that when this was investigated the Supervisor of the Clinical Lab reported that Lab-Tech-Z did yell for help but that she had yelled " I need help with a hard stick " , nothing about Patient26 ' s Hepatitis status was said. When asked if yelling is the appropriate way of dealing with this the Lab Supervisor explained that the lab tech and the patient were in a back room alone and no one would have heard them without the raised voice.7. On 10/22/12, the CPO (Compliance/Privacy Officer) stated that on 8/15/12 Patient29 filed a formal grievance that when her daughter (Patient28) was seen in the clinic for a pregnancy test clinic Nurse-X told Nurse-Y that Patient28 was pregnant and then Nurse-Y told several of her neighbors that Patient28 was pregnant one of whom told Patient29 that Patient28 (her 17 year old daughter) was pregnant. This caused Patient28 and Patient29 embarrassment and loss of privacy. The CPO explained that this was still being investigated and that Personnel Department was involved in interviewing the Nurses who participated in this malicious gossip.

Outcome:

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

Related Reports:

The report containing this deficiency also includes information about 3 other violations. Note that these may be related to the same event: V56D11.01, V56D11.02, V56D11.03