SHARP CHULA VISTA MEDICAL CENTER

Report ID: P0RY11, California Department of Public Health

Reported Entity: SHARP CHULA VISTA MEDICAL CENTER

Issue:

Based on observation, interview and document review, the hospital failed to ensure that patient's personal health information (PHI- is any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) was safeguarded for one randomly observed patient (20).Patient 20's PHI was discussed by a Licensed Vocational Nurse (LN) 15, while another patient (21) and two visitors were present in an egress pathway (exit pathway out of the hospital) in the Emergency Department (ED). The hospital's policy related to HIPPA (Health Insurance Portability and Accountability Act) was not followed when Patient 20's HPI was not safeguarded. Findings:On 9/15/14 at 4:20 P.M., a tour of the ED was conducted with the Cardiac Program Manager (CPM) and Registered Nurse (RN) 14. An egress pathway in the ED was observed to have an illuminated green exit sign. One end of the pathway led back into the main ED, the other end of the pathway led to the ED waiting room. On 9/15/14 at 4:25 P.M., three chairs with barrier screens were observed in the egress pathway. The barrier screens folded around the back and sides of the chairs. Patient 20 and two visitors were observed in the first chair space. The second chair space was not occupied; however, the third chair space was occupied by Patient 21. In addition, there were two visitors leaning against the wall in the egress pathway. On 9/15/14 at 4:30 P.M., a Licensed Vocational Nurse (LN) 15 was observed in the egress pathway. LN 15 had a computer on wheels in front of her, while she talked to Patient 20's two visitors and entered information into the computer. The PHI that was entered into the computer by LN 15 had been discussed in front of Patient 21 and the two visitors who leaned against the wall. LN 15 was approached by another hospital staff and was told to take Patient 20 and Patient 20's visitors out of the pathway to another area of the ED to finish the "discharge process." On 9/18/14 at 11:52 A.M., an interview was conducted with LN 15. LN 15 stated that she was going over the discharge paperwork with Patient 20 in the egress pathway. LN 15 stated that another hospital staff had asked her to take the computer, Patient 20 and Patient 20's visitors into another area. LN 15 further stated she was asked to continue the discharge process in a private location. LN 15 and the Director of Critical Care (DCC) acknowledged that patients being discharged in the egress pathway did not ensure that their PHI was safeguarded, in accordance with their policy and procedure. The hospitals policy and procedure titled "Notice of Privacy Practices", dated 3/14, included the hospital's requirement to maintain the privacy of protected health information. This policy was not implemented when Patient 20's PHI was discussed in a public egress pathway.

Outcome:

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