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Based on interview, document review and video tape review, the hospital failed to ensure and promote patient privacy when the facility utilized both audio and video recording without patient knowledge in all 12-emergency department (ED) treatment rooms. In addition, the hospital failed to promote privacy for 2 of 2 patients (P7 & P15) reviewed when the patients presented to the emergency department (ED) for medical treatment and required care considered to be personal in nature that included exposing genitals and/or breasts. The facility videotaped via cameras, which recorded both audio and video, without their (P7 & P15) knowledge or consent. These deficient practices had the potential to affect all emergency department and hospital patients.

As a result of these failures, these deficient practices resulted in a condition-level deficiency and the hospital was found NOT in compliance with the Condition of Participation for Patient Rights at 42 C.F.R. § 485.614.

Findings include:

See C-2521; those findings apply here. Based on interview, document review and video tape review, the hospital failed to ensure and promote patient privacy when the facility utilized both audio and video recording without patient knowledge in all 12-emergency department (ED) treatment rooms. In addition, the hospital failed to promote privacy for 2 of 2 patients (P7 & P15) reviewed when the patients presented to the emergency department (ED) for medical treatment and required care considered to be personal in nature, that included exposing genitals and/or breasts. The facility videotaped via cameras, which recorded both audio and video, without their (P7 & P15) knowledge or consent. These deficient practices had the potential to affect all emergency department and hospital patients.

Based on interview, document review and video tape review, the hospital failed to ensure and promote patient privacy when the facility utilized both audio and video recording without patient knowledge in all 12-emergency department (ED) treatment rooms. In addition, the hospital failed to promote privacy for 2 of 2 patients (P7 & P15) that presented to the emergency department (ED) for medical treatment and required care that exposed genitals and/or breasts. The facility videotaped via cameras, recorded both audio and video, without (P7 & P15) knowledge or consent. These deficient practices had the potential to affect all emergency department and hospital patients.

As a result of these failures, these deficient practices resulted in a condition-level deficiency and the hospital was found NOT in compliance with the Condition of Participation for Patient Rights at 42 C.F.R. § 485.614.

Findings include:

On 2/18/25, in the morning during a initial tour of the physical environment of the ED area, it was noted that there was no signage in all 12 patient treatment rooms, including the one trauma bay to notify patients video and audio recording was used. A television screen for patient room monitoring with split screens for several patient rooms was visible behind the nursing desk in the central nursing station. This area was accessible and visible to all patient care staff working on the unit, which included medical providers, nursing staff, health unit coordinators (HUCs) and security staff.

On 2/18/25, at 11:48 a.m., during an interview emergency department (ED) manager verified video and audio cameras were actively being used routinely in all 12 patient treatment rooms, including the one trauma bay. ED manager verified no signage was posted in any of the patient rooms which would alert patients of the recordings. ED manager stated video can be turned off by staff, however audio cannot be turned off. ED manager stated video and audio recordings are retained by the facility for 30 days, however only leadership and security has access to the recordings.

On 2/18/25, at 12:53 p.m. during a follow-up tour of the physical environment of the ED area, it was noted that there was signage posted in the ED waiting area and triage room with information as follows, "For the safety of patients and staff this area is under video surveillance."

P7's Emergency Room Record dated 2/16/2025, identified P7, a 26-year-old female, who presented to the Emergency Department (ED) with symptoms of a chills, vision changes, and an increase in postpartum bleeding. P2 was admitted for treatment, which included Intravenous (IV) antibiotics.

On 2/18/25, during an interview at 1:59 p.m., P7 stated she came to the ED on 2/16/25, due to complications from her delivery. When asked if she was aware of the video cameras in the ED rooms, P7 stated, "No one told me, I had no idea whatsoever. I have been in the ED several times, and I would have wanted to know this." P7 then stated, "While I was in the ED, I was catheterized and completely undressed." Catheterization means a flexible tube is inserted into the bladder through the urethra to allow urine to drain from the bladder for collection. P7 stated, "I would want to know there were cameras on me" and "I do not like this at all."

P15's Emergency Room Record dated 2/18/2025, identified P15, a 35-year-old female who presented to the Emergency Department (ED) with symptoms of abdominal pain.

The hospital admission consent form (undated): indicated VIDEO AND AUDIO RECORDING. I understand that my stay at CentraCare will be subject to video and audio recording for the safety of patients, employees, and visitors.
P7 and P15 confirmed that, during the admission process, they were not informed of and did not consent to the use of video and audio recording while receiving care in patient rooms in the hospital's ED.

On 2/18/25, at 1:28 p.m. during an interview, P15 stated she came to the ED for severe abdominal pain, vomiting and tunnel vision. When asked if she was aware of the video camera in the ED room, P15 looked shocked and stated, "Now I am, that is weird, no one told me about the cameras." P15 further stated "This is concerning because I required a EKG which left my breasts exposed." P15 stated again, "I do not like that cameras were in the room, and at no time had staff notified me of there being cameras recording."

On 2/18/25, at 2:46 p.m. during an interview patient access specialist (PAS)-A, stated their role is to finish the registration when the patient has been seen by the provider in the ED. PAS-A, stated she has them sign the HIPPA, consent to treat, and authorization to bill. PAS-A stated all the documents are signed electronically. PAS-A stated, "I go over just the bare minimum not to hold up treatment."

On 2/19/25, at 9:22 a.m. during an interview registered nurse (RN)-A stated there had always been cameras that record video and audio in the ED patient treatment rooms since the remodel in 2017. RN-A verified there is not signage posted that would inform patients of the cameras in the ED treatment rooms. RN-A stated the cameras are always running; however the video portion can be turned off for procedures that would be considered intimate such as catheterizing or a vaginal exam. When asked who has access to see the cameras, RN-A stated, "We all have access to the cameras, security, HUC, RN's, ED techs and medical providers."

On 2/19/25, at 9:42 a.m. during an interview RN-B stated, "Cameras are always running with video and audio." When asked who has access to see the cameras, RN-B stated, "We all have access to the cameras, security, HUCs, ED Tech, RN's and providers." RN-B further stated, there is a button outside the door that can disable the video for privacy reasons such as if someone is changing. RN-B stated, "I know I personally leave the camera on, it's protection for me and also the patient." RN-B was asked how patients are told there are cameras, RN-B stated, "I usually will try to point it out, but I don't know about others."

On 2/19/25, at 10:10 a.m. during an interview, ED-Tech-A stated all the rooms have cameras that are running with both video and audio. ED-Tech-A stated all staff in the ED have access to see the video cameras, however only security and ED managers are able to go back and view recordings.

On 2/19/25, at 10:41 a.m., during an interview security manager (SM)-A stated all ED rooms are equipped with cameras. SM-A stated the videos are kept for 30 days and only supervisors for security and supervisors for the ED have access to the recordings.

On 2/19/25, at 11:05 a.m., an archived video tape from 2/18/25 at approximately 12:13 p.m. of P15 while in an examination room in the ED was reviewed with the ED manager and surveyor for content. During the review, P15 was seen changing into a gown. P15 then was observed on the video having an EKG performed, exposing the right side of her breast. A unidentified PAS was seen entering P15's room at 1:38 p.m. and instructed P15 to sign the HIPPA privacy and consent to be seen, treated and exited P15's room at 1:39 p.m. ED manager verified the PAS did not mention the video camera or any other portion of the forms other than HIPPA, race and insurance. P15's entire ED visit was reviewed and it was confirmed the video camera was running and actively recording video and audio throughout the entire ED visit, which included P15 undressing and placing a gown on, EKG procedure, and P15 dressing back into her clothing.

On 2/19/25, at 11:05 a.m. review of an archived video tape of P7 while in the ED on 2/16/25, at approximately 8:29 p.m. while in the examination room, was reviewed with the ED manager and surveyor for content. During the review, P7 was seen removing her clothing and placing a gown on. At approximately 8:53 p.m., nursing staff entered P7's ED room and performed a catheterization which exposed P7s vaginal /peri area. P7's entire ED visit was reviewed and it confirmed the video camera was running and actively recording video and audio throughout the entire ED visit, which included P7 undressing and placing a gown on, and catheterization exposing P7's perineal area.

On 2/19/25, at 1:23 p.m. during an interview the ED-medical director (MD) stated the purpose of video monitoring patients in the ED rooms was for safety reasons. The ED-MD stated cameras are on at all times, however in his personal experience generally if he was to perform a genital urinary exam or have the patient exposed, that is not something that needed to be recorded. ED-MD stated he would expect nursing staff to do the same. ED-MD stated, "To my knowledge video recording only has to be the consent of one and that is the facility, the person running the camera." ED-MD further stated, "We are trying to watch people for the safety aspect of care." When asked how a patient who presented to the ED for a stomach pain and or post-partum complications presented as safety risk, ED-MD stated, "I can not give you an answer." When asked about signage informing the patients of the cameras which record video and audio, ED-MD stated, "There is signage in the waiting area." When asked how the average person would know that also means in the ED treatment rooms verses only the ED waiting area, ED-MD stated, " I don't know what the average person would assume, I know the signage is at a 5th grade level so sure an area can be defined as a very large area."

On 2/20/25, at 12:36 p.m. during an interview ED manager verified the policy related to use of video cameras outlines the following, "Cameras are used for purpose of audio/video surveillance, monitoring patient activity when deemed necessary, or for safety/security reasons. Audio/video surveillance may be turned off while providing cares for patient privacy. ED-manager verified during the video review that P7 and P15 showed no signs of aggression or violence throughout their entire ED visit. ED-manager verified that video cameras remained running and recording through both P7's and P15's entire ED treatment course even during treatment that left them exposed. ED- Manager verified cameras may be turned off for patient privacy while personal cares are being provided. ED-manager further stated, "I cannot say though if they should have been shut off or not but yes from what we observed they posed no safety risk to staff or the patients. And there was no aggression, no violence, and yes there was times they were on camera exposed."

The hospital's policy entitled, Digital Video/Audio Recordings in the Emergency Department, last revision date 08/2023, stated that "all persons entering the Emergency Department (ED) are subject to video/audio recording. Audio/video in entrances, hallways and patient rooms are recorded, and may be viewed in real time. Cameras are used for purpose of audio/video surveillance, monitoring patient activity when deemed necessary, or for safety/security reasons. Audio/video surveillance may be turned off while providing cares for patient privacy. Signs are posted informing people of audio/video surveillance. Data is stored on a secure server for 30 days".