HospitalInspections.org

Based on interview and record review, the facility failed to protect Patient A's protected health information (PHI) when her clinical record was sent to another patient. This had the potential to result in identity theft and was a breach of PHI.

Findings

On 6/26/12, an investigation was initiated into a possible breach of PHI for Patient A. A phone interview was conducted with the alternate privacy officer.

During the interview the alternate privacy officer, she stated they used an outside company to copy their medical records when they are requested. The staff used a cover sheet which had the correct information on it for Patient A. When the staff went to copy the next chart, they had not changed from Patient A's information and inadvertently sent her clinical record to the wrong person.

The PHI that was copied contained the patient's name, date of birth, phone number, social security number and dates of service with diagnoses.

A review of the letter sent to Patient A confirmed that a breach had occurred.