HospitalInspections.org

Based on interview and document review, it was determined the facility failed to protect each patients' right to personal privacy. Specifically, the hospital videorecorded patients in their NICU (neonatal intensive care unit) rooms without consent of the patient's representative in four (4) of four (4) medical records reviewed of patients in the NICU in the survey sample.

Findings:

The facility's policy, Photographing, Video Monitoring, Audio Monitoring/Recording, and/or Other Imaging of Patients, Visitors, Workforce Members, Non-employee Dependent Healthcare Professionals, Members of Medical staff was reviewed and reads in part: "The Conditions of Admission/Consent for Outpatient Services form (or the equivalent form in non-hospital settings) must contain language advising patients that photographs, video, and/or audio monitoring recording may be taken for patient care, security or for the purposes of health care operations (e.g., quality improvement or risk management activities)."

The medical record for Patient #6 contained a document, Conditions of Admission and Consent for Inpatient and/or Surgical Care dated 05/30/24. The document was signed by the patient and indicated the patient was signing for themselves and not as a representative signing on behalf of a minor child. The document contained the following language: "Consent to photographs, video, digital, and audio recordings I acknowledge that the facility's security, quality improvement, patient care, healthcare operations, and/or risk management activities may involve photographs, video, digital or audio recordings and/or other images of me, including telephone calls being recorded and consent to such images and recording." The document did not contain any language to indicate the patient was consenting to recording of their newborn (medical record #11). The medical record for the infant (medical record #11) failed to contain a consent for videorecording.

The medical record for Patient #7 contained a document, Conditions of Admission and Consent for Inpatient and/or Surgical Care dated 05/24/24. The document was signed by the patient and indicated the patient was signing for themselves and not as a representative signing on behalf of a minor child. The document contained the following language: "Consent to photographs, video, digital, and audio recordings I acknowledge that the facility's security, quality improvement, patient care, healthcare operations, and/or risk management activities may involve photographs, video, digital or audio recordings and/or other images of me, including telephone calls being recorded and consent to such images and recording." The document did not contain any language to indicate the patient was consenting to recording of their newborn (medical record #12). The medical record for the infant (medical record #12) failed to contain a consent for videorecording.

The medical record for Patient #8 contained a document, Conditions of Admission and Consent for Inpatient and/or Surgical Care dated 05/21/24. The document was signed by the patient and indicated the patient was signing for themselves and not as a representative signing on behalf of a minor child. The document contained the following language: "Consent to photographs, video, digital, and audio recordings I acknowledge that the facility's security, quality improvement, patient care, healthcare operations, and/or risk management activities may involve photographs, video, digital or audio recordings and/or other images of me, including telephone calls being recorded and consent to such images and recording." The document did not contain any language to indicate the patient was consenting to recording of their newborn (medical record #13). The medical record for the infant (medical record #13) failed to contain a consent for videorecording.

The medical record for Patient #9 contained a document, Conditions of Admission and Consent for Inpatient and/or Surgical Care dated 05/09/24. The document was signed by the patient and indicated the patient was signing for themselves and not as a representative signing on behalf of a minor child. The document contained the following language: "Consent to photographs, video, digital, and audio recordings I acknowledge that the facility's security, quality improvement, patient care, healthcare operations, and/or risk management activities may involve photographs, video, digital or audio recordings and/or other images of me, including telephone calls being recorded and consent to such images and recording." The document did not contain any language to indicate the patient was consenting to recording of their newborn (medical record #14). The medical record for the infant (medical record #14) failed to contain a consent for videorecording.

An interview was conducted with Staff Member #8 on June 24, 2024 who indicated that security cameras were recently placed in all NICU rooms, that the cameras were always recording, and that video footage was saved for 180 days. Staff member #8 has access to the cameras and has reviewed the recordings for patient care concerns and staff safety concerns. The infection control nurse also has access to the video recordings and utilizes them for infection control and handwashing audits. Additionally, members of the security team are able to view the recordings. Staff Member #8 stated that the no additional consent is obtained from the patients to record them and the Conditions of Admission covers videorecording consent. Staff Member #8 confirmed that nursing staff do not notify the parents (patient representatives) that they and/or their infants are being recorded when in patient rooms.

Based on interview and document review, it was determined that the facility staff failed to perform a Care Plan for four (4) out of four (4) patients sampled.

The findings include:

The facility's policy entitled, "Clinical Nursing Documentation," policy # 1436307, with a last revised date of 09/2023 reads, in part:
"... D. Assessment and Reassessment
... For inpatients, the initial systems assessment is completed within the time frame determined per unit...."
In a chart within this document, under the heading "Routine Plan of Care Documentation:"
"... Documentation must be completed by an RN within the patients first 2 hours on the unit."

Patient #1 arrived at the ED on 01/01/2024 at 3:01 p.m. and was admitted to the telemetry unit at 9:03 p.m. on 01/01/2024, but held in the ED awaiting bed availability on the unit. The patient was discharged at 1:39 p.m. on 01/02/2024. There was no documentation that Patient #1 had a Care Plan performed per policy while on hold.

Patient #2 arrived at the ED on 12/31/2023 at 11:59 p.m. The patient was first admitted to the Intensive Care unit (ICU) and placed on a hold in the ED at 12:59 p.m. on 12/31/2023. The unit assignment was later changed to general inpatient care (GIP) and the patient continued to be held in the ED at 12:13 p.m. on 01/01/2024. The patient was deceased at 2:40 p.m. on 01/01/2024. There was no documentation that Patient #2 had a Care Plan performed per policy while on hold.

Patient #3 arrived at the ED on 01/01/2024 at 12:28 p.m. At 6:58 p.m. on 01/01/2024, the patient was admitted to the telemetry unit but held in the ED awaiting bed availability on the unit. The patient was discharged from the facility at 11:28 a.m. on 01/02/2024. There was no documentation that Patient #3 had a Care Plan performed per policy while on hold.

Patient #5 arrived at the ED on 12/31/2023 at 1:03 a.m. At 7:51 a.m. on 12/31/2023, the patient was admitted as an inpatient, but held in the ED awaiting bed availability on the unit. The patient discharged at 3:31 p.m. on 01/01/2024. There was no documentation that Patient #5 had a Care Plan performed per policy while on hold.

Staff Members 1, 2, 7 and 11 confirmed at interview that the unit nurses should be performing Care Plans within two (2) hours of admission to the unit, even if the patient is being held in the ED, pending a bed assignment to the unit.

The above findings were discussed at the exit interview on 06/25/2024 at 1:45 p.m.

Based on interview and document review, it was determined that the facility failed to administer medications in a timely manner, per facility policy, in four (4) out of four (4) patients sampled.

The findings:

The facility's policy titled, "Standard Administration Times and Critical Medications," last revised 08/2022, states, in part:
... "Policy:
... 3. ...STAT orders:
a. STAT orders should be reviewed, verified and administered within 15 minutes from the time the order is electronically prescribed or written.
... c. ROUTINE orders should be reviewed, verified and administered within 120 minutes from the time the order is electronically prescribed or written.

Patient #1 had a STAT order for Lokelma from Staff Member #14. A notation of the STAT order appears in the Staff Member's notes of 01/01/2024 at 9:13 p.m. The order was entered into the system at 8:55 p.m. The medication was given at 10:35 p.m.

Patient #2 had an order for Methylprednisolone entered into the system at 2:35 p.m. on 12/31/2024. The medication was administered to the patient at 9:47 p.m. Patient #2 also had an order entered for Doxycycline [antibiotic] entered at 2:35 p.m. on 12/31/2024. That medication was administered to the patient at 4:57 p.m.

Patient #3 had an order for Doxycycline [antibiotic] entered at 7:14 p.m. on 01/01/2024. The medication was administered to the patient at 10:39 p.m. At 7:28 p.m. on 01/01/2024, Tessalon Perles were ordered for this patient. This medication was administered to the patient at 10:39 p.m.

Patient #5 had an order for Potassium Chloride ordered at 7:32 a.m. on 12/31/2024. The medication was administered to the patient at 10:58 a.m. At 7:33 a.m. on 12/31/2024, Doxycycline [antibiotic] was ordered. The medication was administered to the patient at 10:56 a.m.

In interviews with Staff Members #1 and #2 on 06/24/2024 and 06/25/2024, there was discussion concerning appropriate administration times compared to order entry times. All were in agreement that non-critical medications should be administered within one to two hours, at the maximum.

The above findings were discussed at the exit interview on 06/25/2024 at 1:45 p.m.