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.

Based on interview, record review, and review of the facility's policies, it was determined the hospital failed to have a procedure for ensuring the confidentiality of patient records in accordance with Federal or State Laws for one (1) of twelve (12) sampled patients (Patient #12). Patient #11 was provided with Patient #12's records at the time of discharge.

The findings include:

Review of the facility's "Patients' Rights and Responsibilities", ACORP-P-03, revised 07/02/15, revealed patients that received services at St. Elizabeth Healthcare had the right to confidentiality of personal health information, including financial and medical records, in accordance with applicable laws.

Review of the facility's "Release of Information", HIM-R-04, revised 07/12/16, revealed the medical center would fulfill its responsibility to protect the confidentiality of information contained in the medical record. Further review revealed the practices and procedures should be consistent with federal and state laws and regulations relating to release of information from patient health records.

Review of Patient #11's medical record revealed the patient was seen on 07/21/16 for a follow-up clinic visit at the Women's Wellness Center. Continued review of the record revealed an After Visit Summary (AVS) was printed on 07/21/16 at 7:14 PM.

Review of Patient #12's medical record revealed the patient was seen on 07/21/16 for a follow-up clinic visit at the Women's Wellness Center. Continued review of the record revealed an AVS was printed on 07/21/16 at 6:41 PM.

Review of the complaint intake information records submitted to this State Agency (SA) from Patient #11, revealed Patient #12's AVS was disseminated to Patient #11 at the time of discharge from the clinic visit.

Interview with the Mammography Technician, on 02/21/17 at 3:25 PM, revealed patients are supposed to sign the discharge instructions, as well be provided with the AVS at the time of discharge. Further interview revealed staff should review the patient's information in the Electronic Medical Record (EMR) to make sure the paperwork matched.

Interview with the Nurse Navigator, on 02/21/17 at 4:30 PM, revealed patients were provided with their AVS at the time of discharge. Further interview revealed the Nurse Navigators provided the patients with that portion of the medical record, as well as the discharge instructions, at the conclusion of the clinic visit. She further stated the AVS should be checked against the name and date of birth of the patient to ensure accuracy.

Interview with the Interim Nurse Manager, on 02/22/17 at 8:35 AM and 9:35 AM, revealed patients received an AVS at the time of discharge from either the Nurse Navigator or the secretary. Continued interview revealed it was probably the Nurse Navigator who provided Patient #11 with Patient #12's AVS based on the time of day both documents were printed.

Interview with the Patient Safety/Accreditation/Infection Control Nurse, on 02/22/17 at 9:15 AM, revealed staff printed the patient medical information using only one printer. Continued interview revealed the nurse should confirm accuracy of the printed documents against the patient's name and date of birth. She also stated the nurse "probably just ended up grabbing the wrong one, and did not check".

Interview with the Nurse Navigator that provided discharge instructions and the AVS to Patient #11 on 07/21/16, on 02/22/17 at 9:38 AM, revealed the department used the same printer to print patient paperwork. Continued interview revealed she was not aware she had provided another patient's medical information to Patient #11. She also stated it should have been caught at the time of discharge.

Phone interview with the Chief Nursing Officer (CNO), on 02/22/17 at 10:09 AM, revealed the facility did what they could to have a process in place to protect patient information. Continued interview revealed she expected the processes to include correctly identifying patient records.