ST HELENA HOSPITAL-CLEARLAKE

Report ID: 7PTF11, California Department of Public Health

Reported Entity: ST HELENA HOSPITAL-CLEARLAKE

Issue:

Based on interview and record review, the facility failed to prevent unauthorized access and disclosure of three patients' (Patient 1, Patient 2, and Patient 3) medical information when: 1) Patient 1's and Patient 2's information were not updated upon registration; and 2) Patient 3's After Visit Summary was given to Patient 4. These failures allowed the unlawful or unauthorized access to protected health information.Findings: CA00364784The California Department of Public Health was notified on 8/6/13 that a breach of protected health information occurred on 5/24/13.During an interview on 8/13/13 at 3:45 p.m., Administrative Staff A stated that, on 7/30/13, she was notified by Management Staff B that Patient 1 was registered, on 5/24/13, and her demographics were not updated by Unlicensed Staff C.During an interview on 8/13/13 at 3:45 p.m., Administrative Staff A also stated that the breach had been discovered during an audit, on 7/30/13 and then reported to Management Staff B.Patient 1's protected health information included Patient 1's name, hospital record number, physician name, primary insurance name, service rendered, amount charged/paid, and amount due.During an interview on 8/13/13 at 3:45 p.m., Administrative Staff A further stated that it was an error, in not following policy and procedure, when Unlicensed Staff C did not update Patient 1's demographics upon admission and typed in, on her admission form, Patient 1's employer, in error, as her guarantor.CA00364791The California Department of Public Health was notified on 8/6/13 that a breach of protected health information occurred on 7/23/13.During an interview on 8/13/13 at 4:45 p.m., Administrative Staff A stated that, on 7/30/13, she was notified by Management Staff B that when Patient 2 was registered, on 5/24/13, Patient 2's demographics were not updated by Unlicensed Staff D.During an interview on 8/13/13 at 4:45 p.m., Administrative Staff A also stated that the breach had been discovered, on 7/30/13, when Patient 2's Employer called and spoke to Management Staff B.Patient 2's protected health information included Patient 2's name, hospital record number, physician name, primary insurance name, service rendered, amount charged/paid, and amount due.During an interview on 8/13/13 at 4:45 p.m., Administrative Staff A further stated that it was an error, in not following policy and procedure, when Unlicensed Staff D did not update Patient 2's demographics upon admission and typed in, on her admission form, Patient 2's employer, in error, as her guarantor.CA00364797The California Department of Public Health was notified on 8/6/13 that a breach of protected health information occurred on 7/23/13.During an interview on 8/13/13 at 4:15 p.m., Administrative Staff A stated that, on 7/25/13, she was notified, by Patient 4, that Unlicensed Staff F gave her Patient 3's Visit Summary after her clinic visit on 7/23/13. Patient 3's protected health information included her name, medical record number, age, gender, date of birth, provider name, vital signs, measurements, weight, medication list, diagnoses, and allergies. During an interview on 8/13/13 at 4:15 p.m., Administrative Staff A also stated that Patient 4 did not notice she had the wrong information until, 7/25/13. Patient 4 returned the visit summary, for Patient 3, to health information management on 7/31/13.During an interview on 8/13/13 at 4:15 p.m., Administrative Staff A further stated that currently there was no policy and procedure for handing out copies of visit summaries to patients. A review of the facility Policy and Procedure for "Patient Registration Operational Guidelines" (Sep 2004 ) reveals the following: "SUBJECT: Selecting a guarantor When registering a patient for a service at [the facility] it is important to correctly identify the guarantor on the account".

Outcome:

Deficiency cited by the California Department of Public Health: Health & Safety Code 1280