COMMUNITY HOSPITAL OF SAN BERNARDINO

Report ID: RETC11.01, California Department of Public Health

Reported Entity: COMMUNITY HOSPITAL OF SAN BERNARDINO

Issue:

Based on interview and record review, a registered nurse (RN 1), did not follow facility policy and procedures for releasing "Patient Property", upon discharge from the facility. This resulted in RN 1 giving Patient B a "Patient's Valuables Envelope" belonging to Patient A.Findings:On July 31, 2014 at 8:10 AM. review of Patient B's face sheet indicated that Patient B was admitted to the facility on July 8, 2013, with a diagnosis of depression with psychotic features (a mental disorder in which a person has depression along with loss of touch with reality), and discharged on July 12, 2014 at 2:52 PM. A concurrent review of Patient A's face sheet indicated that Patient A was admitted to the facility's on July 9, 2013, with a diagnosis of schizoaffective disorder (a mental disorder characterized by abnormal thought processes and deregulated emotions), and discharged on July 13, 2013 at 2:00 PM.On July 31, 2014 at 8:50 AM, during a telephone interview with the Facility Privacy Officer (FPO), she stated, "Patient B was ready to go home from the behavioral health services unit and was very agitated and anxious to leave. RN 1 retrieved a "Patient's Valuables Envelope" from the safe and gave it to Patient B at the time of discharge. RN 1 did not verify that the name on the patient's valuables envelope was Patient B's. RN 1 did not verify that the contents of the envelope belonged to Patient B, and RN 1 did not sign the "Valuables Returned" portion of the patient's valuables envelope along with Patient B." The FPO further stated that RN 1 inadvertently gave a "Patient ' s Valuables Envelope" that contained the name and personal belonging items of Patient A to Patient B at the time Patient B was discharged from the facility."When asked if the items belonging to Patient A were retrieved from Patient B, the FPO stated, "No, we were unable to locate Patient B after discharge."The personal items which contained Patient A's PHI, included: Name, Account number, Medical Record number, date of birth, physician ' s name on the front of the envelope Cell Phone, Ear phone, 3, DS Players (portable game consul) (Name of College) Identification Card Driver's License containing name, address, photo, date of birthA review of the facility policy and procedure titled, "Patient Property", dated November 2001, indicated under the section titled, "4.0 Discharge":"4.3 Have patient verify all belongings are accounted for and obtain appropriate signatures from the patient. Should the patient be unable or unwilling to sign, the staff person will write "patient unable" or "patient unwilling" in the patient signature area and have two (2) staff sign as witnesses."The failure of RN 1 to follow facility policy and procedure related to patient property in the behavioral health services department, resulted in Patient A's personal belongings and PHI being released to Patient B, with the potential to expose Patient A to identity theft.

Outcome:

Deficiency cited by the California Department of Public Health: Nursing Service Policies and Procedures.

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: RETC11.02

2 other violations reported on the same date. Note that other citations may be about the same event: R4OB11.01, R4OB11.02