COMMUNITY HOSPITAL OF SAN BERNARDINO

Report ID: U5S111.01, California Department of Public Health

Reported Entity: COMMUNITY HOSPITAL OF SAN BERNARDINO

Issue:

Based on observation, interview, and record review, the facility failed to ensure that 10 patients' (Patients A, B, C, D, E,F, G, H, I and J), confidential medical information was protected, when empty vials of morphine (a narcotic) were found in the home of an employee. This resulted in a breach of protected health information for all 10 patients.Findings:On February 13, 2014 at 8:30 AM, an unannounced visit was made to the facility to investigate a self-report of a possible breach of PHI.An interview was conducted with the Director of Pharmacy on February 13, 2013 at 9:40 AM. She stated, "An EMT (EMT 1-emergency medical technician) who worked in our emergency room (ER) was found by the police to have in his possession a large number (over 100) empty vials of morphine, syringes and needles. These were found when the police went to investigate a report of a problem at his home. EMT 1 admitted that he had taken these out of the sharps containers in the ER, and would go home and see if there were any traces of the morphine left in the vial for him to use. We were able to find labels with patients' names and medical record numbers legible on 15 of those vials. Some dated back to 2009. Only ten of the 15 patients could be located within the medical record system at the facility. We notified the ones we could find in our system. We then addressed our system for securing medical waste, and the police addressed the legal implications."A review of the facility's investigative report dated, December 3, 2014, indicated, "The confiscated paraphernalia filled about three-quarters of a 33 gallon trash can. The paraphernalia was primarily empty drug vials, most of them without patient information...." After consulting hospital safety experts, hospital personnel determined that the mass of drug paraphernalia could not be inventoried safely by hand. Hospital personnel informed (name of government agency overseeing drugs) of its decision... Upon visually examining all items at the top of the drug paraphernalia, the Hospital Pharmacy Director was able to identify 15 patient labels on drug vials...only 5% of the vials had patients' names. The labels did not contain the hospital name, only the patient's name and medical record number (only ten could be located in the electronic records system)... EMT 1 was no longer employed..."An observation was conducted with the Director of Pharmacy on February 13, 2014 at 10:40 AM , of the contraband that had been removed from EMT 1's home. Observed in the locked Pharmacy office was a large (33 gallon) barrel with a lock on it. The lock was removed by the pharmacist so the contents could be viewed. Inside the barrel were socks, blood stained tissues, needles that were sticking out in all directions, syringes, and over 100 empty vials of morphine. Only the ten (10) bottles at the top of the pile contained patient labels on them that were legible. The other bottles that could be partially seen, could not be counted. The labels were torn or missing in a way that concealed the patients' identity.During a concurrent interview with the Director of Pharmacy, the Pharmacist stated, the Police had delivered the barrel to the pharmacy to dispose of the vials and the needles. Due to the risk of staff receiving a needle stick, the pharmacist said they looked at as many vials as they could do safely. The pharmacy staff found only ten of the 15 vials which had clear labels, had patient identities that could be traced in their electronic record system for the purpose of notification as required by regulations.During an interview with the Facility Privacy Officer (FPO) on February 13, 2014 at 10:00 AM, she stated, that this information was a breach of PHI for all these people (10 identified), and we have notified them."EMT 1's unauthorized access to used medication vials for the purpose of self-administering illegal drugs, resulted in the unauthorized release of protected health information for ten patients, contained on the labels of the vials.

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: C3DC11.01, C3DC11.02