The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

COMMUNITY HOSPITAL OF SAN BERNARDINO 1805 MEDICAL CENTER DRIVE SAN BERNARDINO, CA 92411 June 28, 2012
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
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.