EL CENTRO REGIONAL MEDICAL CENTER

Report ID: XX7811.02, California Department of Public Health

Reported Entity: EL CENTRO REGIONAL MEDICAL CENTER

Issue:

Based on interview and record review, the hospital failed to safeguard protected 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) from unauthorized person(s) in accordance with their policies and procedures, for 1 of 1 sampled patients (Patient 1). Patient 1's discharge instruction and prescription were inadvertently given to the wrong patient (Patient 2) at discharge.Findings: On 10/15/12 at 10:27 A.M., the hospital reported to the Department that an unauthorized disclosure of confidential patient information may have occurred when Patient 1's discharge instructions and prescription were inadvertently given to the wrong patient at discharge.A review of Patient 1's medical record was conducted beginning on 11/21/12 at 10:50 A.M. Patient 1 was admitted to the hospital's Emergency Department (ED) on 10/9/12, and discharged on the same day, per the facesheet. Patient 1's Discharge Instructions dated 10/9/12, contained the following confidential patient/health information: patient's name, physician name, medical record number, diagnoses, discharge instructions, medications and what they were for. A copy of Patient 1's prescription contained the following PHI: patient's name, physician's name, the 4 medications prescribed by the physician: Flagyl (antibiotic), Levaquin (antibiotic), Vicodin (pain medication), and Zofran (medication to treat nausea) prescribed by the physician and directions as to how to take them.A review of Patient 2's medical record was conducted beginning on 11/21/12 at 10:50 A.M. Patient 2 was admitted to the hospital's Emergency Department on 10/9/12 per the Discharge Instructions, dated 10/9/12.A telephone interview was conducted with Registered Nurse (RN 1) on 12/6/12 at 10:45 A.M. RN 1 stated that she did not recall discharging Patient 2. However, she stated that according Patient 2's medical record, her documentation indicated that she discharged the patient on 10/9/12. She explained that the hospital's process was to review and check each document at discharge to ensure that the correct discharge instructions and documents were given to the correct patient. She acknowledged that she was not aware that Patient 1's discharge instructions and prescription were given to Patient 2 (the patient she had discharged on 10/9/12).A review of the hospital's policy entitled "Access to and Maintenance of the Health Record," last review date of 7/21/11, was conducted. The policy stipulated that "All individuals engaged in the collection, handling or dissemination of patient health information should protect the confidentiality of patient data." Per the same policy, it indicated that "The collection of any data relative to a patient whether by interview, observation or review of documents shall be conducted in a setting, which provides maximum privacy and protects the information from being accessed by an unauthorized individual." A telephone interview with the Director of Emergency Services (DES) was conducted on 1/10/13 at 11:10 A.M. The DES stated that the nursing staff in the ED were expected to look at each sheet of the discharge documents to ensure that they were reviewed and given to the correct patient. He acknowledged that the hospital's policy was not followed when Patient 1's discharge instructions and prescription were given to the wrong patient (Patient 2) at discharge.

Outcome:

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

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: XX7811.01

1 other violation reported on the same date. Note that other citations may be about the same event: KF7D11.01