ST MARY MEDICAL CENTER

Report ID: NRKR11, California Department of Public Health

Reported Entity: ST MARY MEDICAL CENTER

Issue:

Based on interview and record review,the facility failed to ensure the confidential treatment of patient health information for Patient A when Patient B was discharged from the Emergency Department and received Patient A's discharge instructions. This resulted in the unauthorized release of Patient A's protected health information to Patient B.On March 6, 2015 at 2:30 PM, a phone interview was conducted with the Manager of Accreditation (MOA) regarding an entity reported incident of breach of personal health information for Patient which was identified on January 29, 2015.The (MOA) stated, Registered Nurse (RN1) brought Patient B back to the Emergency Department and the discharge instructions were retained. The type of information that was breached the physicians name, patients name, medical record number, account number, and diagnosis. Patient A was notified via certified mail on February 16, 2015. On March 10, 2015 at 11:00 AM, a phone interview was conducted with Interim Supervisor of The Emergency Department (ISOER) stated, The RN1 discharged Patient B instead of Patient A and asked Patient B's name and stated the Patient A's name. RN1 received training on patient confidentiality and HIPPA and was educated on the importance of using two patient identifiers.On March 10, 2015 at 11:10 AM, a phone interview was conducted with Registered Nurse (RN2) when asked, how she noticed the wrong patient was discharged and stated, RN1 and herself were printing the discharge paperwork. She notice the patient, that was walking out was not Patient A. Patient B was supposed to be transferred to Kaiser. RN1 got the paperwork from Patient B. RN2 stated; she wrote an incident report and notified the manager.On March 20, 2015 at 2:15 PM a phone interview with RN 1 stated, one of the nurses handed me a chart and printed the discharge instructions and told me if I can discharge Patient A. I asked Patient B for his name and he stated it was correct. I discontinue his Intravenous therapy (the infusion of liquid substances directing into a vein) and gave him his discharge instructions. RN2 noticed the patient being discharged wasn't the correct one. RN1 stated,"Next time I won't accept any documentation from another nurse and I will verify the Patient's name and date of birth before being discharged.A review of Patient A's discharge instructions given to Patient B included: Diagnosis, chest pain, patient's address, patient's phone number, and after care instructions.

Outcome:

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