Northwest Network (VISN 20)

Report ID: SPE000000081309, U.S. Department of Veterans Affairs

Reported Entity: VISN 20 Portland, OR

Issue:

A Veteran has reported that an unknown VA employee contacted his brother without authorization while he was an inpatient around the date of 10/04/12 and disclosed that the Veteran was an inpatient and upset with his brother. The Veteran says he was not upset with his brother and as a result of the phone call the brother has cancelled his cell phone and will no longer speak with him. The Veteran says he already questioned his providers about this and none of them admit to speaking with his brother. Update: 10/17/12: The Veteran suspects it was one of his mental health providers who called his brother but the Privacy Officer (PO) sees a reference to a telephone call with the brother in an 10/04/12 Audiology note. The Veteran has a 09/13/12 POA for health care scanned into his record naming the brother as a representative. It appears from the note that the provider was questioning his decision-making. Here is part of that provider's note: 10/04/12 Audiology note: M s/p L posterior temporal CVA who was referred by neurology for evaluation of aphasia on 9/28/12. Upon finishing this evaluation and a phone call with his brother, it was determined that he had been experiencing acute cognitive decline. Following the evaluation, he was unsure where to go because he could not remember where he lived. His psychiatrist, Dr. xxxxxxx, was notified of his cognitive decline. He was admitted to the ED and neurology was consulted. There were no neurological findings, therefore he was discharged to home. He was readmitted 10/2/12 through the ED after reporting that he thought he had taken too much clonazepam but couldn't remember. He endorsed having suicidal ideations. He was then transferred to the ICU, where he was monitored until being transferred to 5C 10/03/12 where he is currently located. The PO still has not tracked down the provider to confirm the phone call, the justification for it, and ask what information was exchanged. 10/22/12: The Veteran will receive a letter of notification.

Outcome:

A review of the Veteran\xe2\x80\x99s records shows his brother is listed as a Next-of-kin contact but there are no release authorizations on file permitting information to be disclosed to him. We do have an Advance Directive and Durable Power of Attorney for Health Care on file showing his brother as a designated Healthcare Agent but this can only be exercised if he did not have decision making capacity. The Privacy Officer plans to schedule additional training with the Mental Health staff to reinforce the requirements for disclosing information using an Advanced Directive on file as well as reviewing release authorization requirements.