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Tag No.: A0143
Based on record review and interview, the hospital failed to ensure the patient right to personal privacy as evidenced by failing to ensure patients received a copy of the hospital video and audio surveillance protocol for 3 (#1, #2, #3) of 3 sampled patients.
Findings:
Review of the hospital Video Surveillance Policy #: EC-0002, Revised: 03/08/2024 revealed, in part:
Policy: It is the policy of Northlake Behavioral Health System (NBHS) to ensure that the facility balances the security and safety derived from the use of video surveillance with the privacy rights of the individual. The video surveillance policy provides detailed direction concerning the context, procedures and protocols within which the facility installs and operates surveillance cameras.
Notice of Use of Video Systems: The use of video/audio monitoring is noted on NBHS Consent for Treatment forms.
Review of Northlake Behavioral Health System patient admit packet revealed, in part:
This packet contains the following documents: Patient Rights and Responsibilities, NBHS Health Insurance Portability & Accountability Act (HIPAA) Including Video Surveillance Guidelines and NBHS Grievance Procedure. Further review of this packet revealed no evidence it contained video surveillance guidelines.
Review of Patient #1, Patient #2, and Patient #3's medical records revealed acknowledgment forms that read, in part: Acknowledgment of Receipt of Video & Audio Surveillance Protocol. I acknowledge that I have received a copy of the Notice of Privacy Practices, Patient Rights and Responsibilities including Video Surveillance Protocol, and Grievance Procedures of NBHS this date. Further review of Patient #1, Patient #2, and Patient #3's medical record revealed no evidence the patients received a copy of the Video & Audio Surveillance Protocol.
In an interview on 06/10/2024 at 1:13 p.m., S3Risk Manager (RM) confirmed the admit packet provided to patients did not contain a copy of the hospital video and audio surveillance protocol. S3RM confirmed this information needed to be added to the patient admit packet. S3RM confirmed there was no evidence Patient #1, Patient #2, and Patient #3 received a copy of the hospital video and audio surveillance protocol.