HospitalInspections.org

Based on interview and the hospital's policy and procedure, the hospital failed to correctly identify 1 (Patient #1) of 12 (#1 - 12) sampled behavioral health patients upon the patient's discharge by not verifying the patient's name and date of birth prior to handing the patient's discharge paperwork and medication to one patient that belonged to another patient. This deficient practice resulted in the disclosure of the name, age, and personal medical information of one patient (Patient #2) to someone else, thereby violating the right of Patient #2 to personal privacy. The findings are:

A. On 07/30/15 at 5:00 pm, during interview, the Nurse Manager of the Emergency Department who was working the evening of 07/21/15 stated that there were three patients being held in room #14. The three patients had already been medically screened, and were waiting for a Behavioral Clinical Liaison evaluation. Staff Member #1 (a behavioral health registered nurse (RN)) called Patient #2's first name, which sounded like Patient #1's first name, and Patient #1 responded, stating, "Yes, that's me." Without checking Patient #1's armband, or asking him to state his full name and/or date of birth, Staff Member #1 gave Patient #2's discharge paperwork (which identified Patient #2's name, age, and two medications, among other information) to Patient #1. Patient #1 departed from the hospital with two medications, sertraline (antidepressant medication) and lamotrigine (medication used to treat bipolar mental disorder), intended for Patient #2.

B. Record review of the hospital's policy and procedure titled "Patient Identification" effective date 05/30/14 revealed the following: "Purpose: To reliably identify the individual as the person for whom the service or treatment is intended, and to match the service or treatment to that individual. Policy: The following requirements represent a PDS [Name of hospital Delivery Service] Global Red Rule: Two patient identifiers that shall be used by all healthcare personnel to identify the patient, or verify the correct patient's identity when communicating or providing patient care, treatment, or services. The two patient identifiers that all healthcare personnel shall use are: 1) the patient's name, and 2) the patient's date of birth..."