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MARSHFIELD MEDICAL CENTER 611 ST JOSEPH AVE MARSHFIELD, WI 54449 Feb. 5, 2013
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on complainant and staff interviews, pt. medical record reviews, and facility investigation report, the facility failed to prohibit disclosure of personal patient information to unauthorized persons for 1 of 10 pts. (Patients) sampled (Pt. #1). The facility failed to prevent unauthorized disclosure of name, date of hospital admission, hospital medical history number, home address, and date of birth for pt. #1. This has the potential to affect all pts. who receive services from this 21 bed alcohol and drug rehabilitation unit of the hospital.

Findings include:

Per interview with Complainant A beginning at 8:13 a.m. on 2/4/13, A stated that when pt. #1 was discharged from the hospital A&DR (Alcohol and Drug Rehab) unit on 1/10/13, in the personal belongings, the unit sent home for Pt. #1 with A, there were 2 bags with medications, one with Pt. #1's name and personal information on a pink slip of paper and one bag of medications with another patient's name (ID will be Pt. X) and personal information on it.

Per A, A kept the pink slips from both pt. #1 and Pt. X. A stated that there was information for Pt. X on the pink slip and on X's medication which included name, address, date of birth, and other hospital information.

During the onsite investigation at this hospital on the morning of 2/4/13, the following was revealed:

During staff interviews beginning at 10:30 a.m.,. Director of Risk Management AA verified that on 1/10/13 Pt. #1 received Pt. X's bag of personal medications which included personal identifying information. Per AA, it was, "Wrongful on the hospital's part."

Per interview with Performance Improvement Specialist BB, the Health unit Coordinator had called on the day of 1/10/13 to to let the pharmacy know that discharge medications were needed for 2 pts. who were being discharged . A transporter picked up the medications for both pts. (including that of Pt. #1) and took them to the A&DR unit. The nurse who was discharging Pt. #1, "Inadvertently put both pts.' bags of medications into ---(Pt. #1)'s bag of belongings." BB verified that Pt. #1 was given Pt. X's bag of medications upon discharge and #1 took them home.

Per interview with A&DR Program Manager CC, the bag of medications Pt. #1 received for Pt. X had a pink slip with the following information on it: The name of the hospital showing that pt. X had been at this hospital, X's name, address, hospital number, and date of birth. Included in the bag were the following bubble packs of medications which showed Pt. X's name and date of birth: Aspirin 81 mg, Levothyroxine (medication for thyroid), Lithium Carbonate 300 mg (antipsychotic for Bipolar Mood Disorder), Olanzapine 20 mg (antipsychotic used for schizophrenia/depression/bipolar), and Valacyclovir (primarily used for genital herpes or herpes zoster-shingles). Knowing the names of these medications could be used to look up the medications and find also medical diagnoses Pt. X may have by unauthorized user; therefore disclosing further personal medical information.

Per medical record review of Pt. #1 beginning on the afternoon of 2/4/13, Pt. #1 has had a history of drug abuse and suicidal ideations and 1 attempt by overdose of Valium (medication for treating anxiety) in October 2012. Pt. #1 has scheduled antianxiety, antidepressant, mood-anti-seizure medications as well as numerous pain medications. Pt. #1 having possession of these medications could pose a risk to potential medication abuse by #1.

Per review of the hospital investigation report, the hospital was made aware that another pt's. medications were sent home with Pt. #1 when Complainant A telephoned the hospital on the morning of 1/11/13, but A refused to disclose Pt. X's name as the name on the pink slip and bubble packs. Per documentation in the report by A&DR Manager CC, A said that the hospital needed to figure out what other pt's medications were sent home with Pt. #1. According to the report, A was not compliant in returning Pt. X's medications for verification that this incident occurred until hospital security staff drove to A's home on 1/30/13, at which time it was verified that the medications were those of Pt. X; however A refused to return the pink slip with X's personal information on as stated above.