EISENHOWER MEDICAL CENTER

Report ID: 493I11.03, California Department of Public Health

Reported Entity: EISENHOWER MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to ensure Patient 5 was informed in writing no later than five business days after the unauthorized disclosure of his protected health information (PHI)had been detected by the facility on February 1, 2013. This resulted in a delay in notification to Patient 5 of the unauthorized disclosure of his PHI. Findings:On April 24, 2013, at 10:25 a.m., an interview was conducted with the Director of Compliance (DC). She stated: a. On February 1, 2013, Patient 6 presented to the Emergency Department (ED) for treatment. Patient 6 was registered/admitted under Patient 5's date of birth, medical record number, and demographic data.b. Patient 6 was treated with medication, laboratory blood tests drawn and radiology tests were performed before a facility registration clerk identified that Patient 6 had been admitted and treated under Patient 5's name and medical record number.c. The ED Charge Nurse was made aware of Patient 6 being registered under Patient 5's medical record number and demographics on February 1, 2013, three hours after the initial registration.d. The DC was notified of the unauthorized disclosure of Patient 5's PHI on February 7, 2013.Patient 6 received and had an opportunity to view Patient 5's PHI, which included name, date of birth, medical record number, and account number.Patient 5 was informed of the disclosure of his protected health information (PHI) via a letter dated and mailed on February 11, 2013, to his last known address (three days after the initial five business days).The California Department of Public Health (CDPH) was notified via a facsimile dated February 11, 2013, of the unauthorized access of Patient 5's PHI (three days after the initial five business days).The facility policy and procedure titled "Information Privacy" reviewed/revised December 19, 2011, revealed "... (facility name) will take all necessary steps to avoid unauthorized or unlawful access, use or disclosure of protected health information ... Whenever possible, the Information Privacy Officer will contact the individual or organization to whom the information was inappropriately or unlawfully accessed, used or released and requested that no further access, use or disclosure of the information is made and to return or destroy the information. The Information Privacy Officer will contact the Department of Public Health and report the breach within (5) five days of discovery. The Information Privacy Officer will contact the patient within (5) five days of discovery to inform him or her of the unauthorized access, use of disclosure and the plan or step's taken to mitigate it. ..."

Outcome:

Deficiency cited by the California Department of Public Health: Medical Breach

Related Reports:

The report containing this deficiency also includes information about 2 other violations. Note that these may be related to the same event: 493I11.01, 493I11.02

2 other violations reported on the same date. Note that other citations may be about the same event: SW2M11.01, T07W11.01