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Based on observation, interview and record review the hospital failed to ensure the privacy of patient information for one of four patients reviewed for confidentiality, Patient 5. The hospital failed to ensure the property of Patient 5, labeled with patient confidential information, was not released to the wrong patient.

Findings Include:

Patient 1 and 2 were both patients at Overland Park Regional Medical Center. Patient 2 was admitted from 11/01/18 to 11/05/18, and her son, Patient 1, was in the Neonatal Intensive Care Unit (NICU) from 11/01/18 to 11/25/18. Patient 2 was pumping and storing her breast milk in the hospital's freezer until she returned home.

The 11/01/18 "Admission Summary" for Patient 1 identified he was admitted on 11/01/18 immediately following delivery. He was "delivered after mother presented with vaginal bleeding and admitted to the NICU for prematurity.

Review of the 11/25/18 Discharge Summary for Patient 1 diagnosis included: 24 day old with feeding problems, jaundice in preterm infant, breech presentation, large for gestational age, and hypoglycemia."

Review of the 12/20/18 "Patient Event Record" completed by the Director NICU and reported by Patient 2 identified the following information: "Patient 1 was admitted on 11/01/18, Event Code: Wrong medication; wrong breast milk went. Event date: 11/25/18, time: 1200. Event location: NICU Neonatal Intensive Care Unit; Exact location: Babies [baby's] home. Description of event: "Mother discovered breast milk with another babies [baby's] name on the bottles. Mother had already fed the milk. She discovered 16 other bottles of another patient [patient's milk] in her freezer. Pt [patient]/Family notified: Patient 2 on 12/20/18 at 8:37 AM, and Patient 5 on 12/20/18 at 8:38 AM by phone from the Director, NICU. Breakdown in process: did not follow process to double check milk."

On 02/19/19 at 12:05 PM observation of the NICU refrigerators and freezers that are used for storage of breast milk were found to have labels on the breast milk containers that included a scan bar, baby's name, pump date, time; and breast milk containers located in the freezer also included the thaw date. The front of plastic bins containing breast milk containers were labeled with the patient's name. Observed RN A administer breast milk, as described on the hospital procedures for "EMAR Labeling of Breast Milk."

On 02/19/19 at 12:10 PM interview with the Director NICU RN A revealed "if not paying attention, breast milk containers can accidentally be put in the wrong bin; that is why scanning is very important. Scan every time they give milk; that is what they are supposed to do."

During a telephone conversation with Patient 2 on 02/19/19 at 1:55 PM, she revealed that on 12/19/18 when she went to make Patient 1 a bottle of breast milk and found the label was for another woman's breast milk. She did not notice the label on the bottle until her son had completed the bottle. Patient 2 had counted 16 bottles of another person's breast milk that the hospital gave her by mistake when she left the hospital. All the breast milk bottles were labeled with another woman's name and her confidential information.

On 02/19/19 at 2:00 PM interview with Director Risk Management (RM) regarding the mother that went home with the wrong breast milk revealed, "we acknowledged the error; identified both mothers; mother was tested; rendered test results to the mother; and notified her by phone and in writing." She had a conversation with the Manager NICU; "wanted us to release PHI [Protected Health Information]; we only release what pertained to testing. She wanted additional testing, healthcare history and background from the other mom. We could not provide ... because of HIPAA violations. The nurse was gathering the breast milk and preparing the patient (Patient 1) for discharge. She pulled out the wrong batch of breast milk and that was how the mistake happened. The double verification process in place was not adhered to, hence the mistake."

On 02/19/19 at 2:40 PM interview and record review with the Director NICU, revealed systems and documents that were put in place since the event. "Since we had a mistake, we don't want it to happen again."

On 02/19/19 at 4:00 PM interview with the Manager of Infection Prevention (IP) revealed that she had conversations with Patient 2 to include "we did the appropriate blood work and informed that the blood work was negative; she (Patient 2) received a letter that stated the lab work was negative. She wanted us to take the breast milk that was in her home and test it. I told her that it was out of our custody and there was no way we could test it. We follow the CDC [Center for Disease Control and Prevention] guidelines with input from our physician."

On 02/20/19 at 10:00 AM during an interview with the Social Worker and Director NICU regarding patient rights and infection control, the Director NICU stated "we had yearly competency (training); nurses are to double check milk. Before, there was no written proof (ensuring accuracy of the name on the breast milk container matched the respective mother/baby), something we taught nurses to do. I don't know why she didn't double check."

Procedures for "EMAR [Electronic Medication Administration Record] Labeling of Breastmilk" (no date) included on the "Purpose: To implement EMAR labeling of expressed breast milk (EBM) at the time that it is pumped by the infant's mother, and to identify the process of scanning EBM at the bedside prior to administration to an infant."

"Guidelines for Storing and Defrosting Breastmilk" (no date) included procedures for the collection, storage, handling, and documentation; verification of the infant's name and medical record number on the container label and infant band by two personnel or electronic medication scanning system before preparation or administration of human milk.