HospitalInspections.org
Bringing transparency to federal inspections
SAN ANTONIO REGIONAL HOSPITAL
PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS
Tag No.: A0146
Based on interview and record review, the facility failed to maintain the confidentiality of Patient A's clinical record when a medical record request was inadvertently sent to an outside recipient. This was a breach of personal health information (PHI).
Findings
During an unannounced visit on 6/28/12, a breach of PHI for Patient A was investigated.
During an interview with the privacy officer on 6/28/12 at approximately 2:15 PM, he described the incident as follows:
"On 6/7/12, the unit secretary (US) monitor tech, faxed a medical record request form for Patient A to an outside certified public accountant (CPA) whose last four telephone digits were 9106. The form was supposed to be sent to an acute rehabilitation hospital whose last four digits were 9104. The unit secretary had not verified the fax number as per facility protocol".
During a review of the letter sent to the person whose PHI had been inadvertently released, the facility acknowledged that a breach had occurred.