SHARP CHULA VISTA MEDICAL CENTER

Report ID: 65Q911.01, California Department of Public Health

Reported Entity: SHARP CHULA VISTA MEDICAL CENTER

Issue:

Based on interview, record and document review, the hospital failed to ensure that 1 of 2 sampled patient's (1) protected health information (PHI) was safeguarded. As a result, during Patient 2's discharge from the hospital, the patient was inadvertently given medical information which was intended for Patient 1. Findings:On 10/8/13 at 12:30 PM, Patient 1's PHI, which was not safeguarded, the Emergency Department's (ED) "Discharge Process" and the hospital's Policy and Procedure titled " Health information: Minimum Necessary Access, Use & Disclosure" dated 07/11, were reviewed with the Director of the Emergency Department (DED). The PHI included Patient 1's name, medical record number and multiple laboratory (lab) results, with the date of service for the lab draws. The ED Discharge Process indicated the following: Check all pages of the discharge instructions to make sure they belonged to the same patient. If an interruption occurred during the discharge process, the discharge process would stop and start over from the beginning. The Policy and Procedure indicated that employees shall limit each use and disclosure of patients' PHI to the minimum amount necessary and provide the information that is needed to be known.On 10/8/13 at 1:00 PM, an interview was conducted with the DED. During the interview, the DED stated that a Registered Nurse (RN) 1 did not follow the hospital's ED Discharge Process and Policy and Procedure. The DED acknowledged that as a result, Patient 1's PHI was not safeguarded when, Patient 2 was inadvertently given medical information which was intended for Patient 1.

Outcome:

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

Related Reports:

2 other violations reported on the same date. Note that other citations may be about the same event: PBI911.01, VSX011.01