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.

THEDACARE REGIONAL MED CTR - NEENAH 130 2ND ST NEENAH, WI 54956 April 27, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, record review and interview, the facility failed to ensure patients are notified of their right to file a grievance and of their right to privacy, and failed to protect the patient's right to privacy for 12 of 12 inpatients (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12).

Findings include:

Patients are not provided notification of their right to file grievances. See tag A118.

The facility failed to document necessity of monitoring and failed to accurately disclose use of video monitoring for 12 of 12 patients. See
tag A143.

The cumulative effect of these deficiencies has the potential to affect all patients receiving inpatient behavioral health treatment at this facility.

Please see the following excerpt from a memo issued by the State of Wisconsin Department of Health Services titled "Patient Privacy During Inpatient Psychiatric Treatment" (OQA Memo 06-025): "Cameras in Bedrooms Under Individualized Conditions: Monitoring of patient bedrooms can be conducted under limited, individualized conditions when it is necessary to protect the health and safety of the patient. Each hospital should have policies and procedures to assure that when patient bedrooms are monitored (without film or tape), such visual or audio monitoring is done in accordance with individual patient need. ...Ongoing patient assessment is necessary to determine need for monitoring. ...Assessment of a need for monitoring in a patient's bedroom should be reflected in the patient's treatment plan. The patient should be aware of the monitoring. When it is possible, the patient's consent should be obtained. Monitoring should be discontinued when the need is no longer present. If the patient is in a double room with a roommate who does not require monitoring, staff should either obtain consent of the roommate for whom there is no documented need for monitoring, or relocate one of the patients."

A paper copy of this memo was discussed and provided to facility staff on 4/25/2017 at 12:45 PM.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record review and interview, the facility failed to provide patients information on external grievance procedures in 1 of 1 department reviewed (Behavioral Health). This has the potential to affect all patients admitted to the behavioral health unit.

Findings include:

During an interview on 4/25/2017 at 9:10 AM, Supervisor A stated all patients are provided an admission packet upon admission to the inpatient Behavioral Health unit.

Review of the packet includes a document titled "Patient Rights According to Wisconsin Law 51.61" stating: "Grievance Procedure. Step 4: If the problem remains unresolved after exhausting Steps 1, 2, and 3, follow Wisconsin State Grievance Procedure Stage 2."

Review of the State of Wisconsin Grievance Procedure does not include information that the patient is able to file a grievance directly with the State Agency along with the contact information (telephone number and address) in order to do so.

In an email communication received 4/27/2017 at 6:25 AM, Manager C and Supervisor A stated the facility "has a Hospital Guide for patients and families- however, our unit is not able to dispense this guide to our patients as it is made with staples. As you are aware, staples could be a weapon for our patients. In lieu of the guide/booklet, we do have a State of WI Client Rights for Inpatient Services poster that is posted in our patient care hallway. On that signage is the State Address and the phone number for the state."
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, record review and interview, the facility failed to provide written disclosure of the facility's use of continuous video surveillance in patient rooms for 12 of 12 patients (Patients #1 - #12); failed to have procedure in place for the use of video monitoring when used for medical necessity in 1 of 1 department (Behavioral Health); and failed to document evidence of individual need for video monitoring for safety and security reasons in 12 of 12 patients reviewed (Patients #1 - #12).


Findings include:

Facility policy "Camera Monitoring of Inpatient Behavioral Health Patient Rooms" dated 10/2016 states: "-Camera monitoring of patient's rooms is conducted to protect the health and safety of the patient. -Upon admission all patients are to be informed that cameras are monitoring all rooms and patient areas. Patient is to be informed that all bathrooms and shower rooms are not monitored by camera. -During a patient's physical exam, physical treatment or assisting a patient with bathing at bedside, patient's privacy should be upheld. This should be done by covering the individual camera screen located in the nurse's station. -Patients are video monitored only when medically necessary or in security situation." This is the policy in its entirety.

During an interview on 4/25/2017 at 9:10 AM, Supervisor A stated "there is video monitoring all the time in rooms [on the Behavioral Health unit], but they are not recorded." Per A, "nobody is monitoring them, and none of the bathrooms are visible. We use them if there is a code [security code], we can look to see where it's happening." When asked if the monitors are used for any medical purposes, Supervisor A stated "what we can do is if a patient is a 1:1 and we're not sure if someone has progressed to the point where it's needed we do 1:1 at a distance [using the video monitoring] and slowly progress down...we don't have many patients on 1:1." A stated the video monitors are for safety and security purposes, "not on to monitor someone." Supervisor A stated there are 2 sets of monitors on the unit, one in each nurses station. A stated staff are "not looking at other rooms, only looking at the patient being monitored."

During observations of the Behavioral Health unit on 4/25/2017 from 9:25 AM to 10:00 AM, a monitor on the wall of Nurses Station #1 showed video surveillance of all 13 patient rooms and the seclusion room on the unit. A stated "we have 19 beds and 13 rooms." A did not address how the facility protects the privacy rights of patients in a shared room when only one patient in the room requires monitoring.

Facility document "Patient Rights According to Wisconsin Law 51.61" states: "1. Patient Rights: ...o. The right to not be filmed or taped without consenting, except for security purposes. I understand that by seeking admission here, I may be video monitored when medically necessary." Per Supervisor A, this document is included in the admission packet for all patients admitted to the inpatient Behavioral Health unit. On 4/25/2017 at 9:15 AM, when asked if patients are aware of the continuous video monitoring, A stated "I thought there was something that talked about what we do" in the patient admission packet. The only information that addresses video monitoring in the admission packet is the "Patient Rights According to Wisconsin Law 51.61." This was confirmed with Supervisor A, Program Coordinator B and Manager C during review of the admission packet on 4/25/2017 at 9:20 AM. There is no written documentation disclosing to patients that the video monitors are on continuously, and what purpose they serve.

During an interview on 4/25/2017 at 9:40 AM, when asked about any privacy concerns on the unit, Patient #1 stated "my only concern is the video cameras in the rooms themselves...they explained that they're not recorded. They said they are to 'keep an eye on you'...I get it, it's just weird."

During an interview with Patient #2 on 4/25/2017 at 9:50 AM, when asked if Patient #2 had been informed of the video monitoring in the patient rooms, Patient #2 stated "no, they didn't tell me about it, but I saw it [the camera]."

Review of patient medical records on 4/25/2017 from 10:30 AM to 11:00 AM, reveal that all current inpatients have documented in their chart "Monitored patient with CCTV" under Standard Interventions BH. Inpatient medical records were reviewed with Registered Nurse E. E stated at the time of the review, "we document standard behavioral health interventions every shift, monitoring patients with CCTV [closed circuit television] is a standard intervention." There is no medical or security reasons documented in the medical record for the use of video monitoring as an intervention for 12 of 12 inpatient records reviewed (Patients #1-12). This standard documentation that all patients receive video monitoring as an intervention, without documentation of the reason for necessity, was confirmed on 4/25/2017 at 12:40 PM with Supervisor A, Program Coordinator B and Manager C.

During an interview on 4/25/2017 at 9:10 AM, when asked if there were any current inpatients that were currently on 1:1 monitoring, A stated "none on 1:1 right now" and stated there would be "daily documentation" to show if the monitoring is being used on patients for medical purposes. During observation of the video monitor in the nurses station on 4/25/2017 at 9:25 AM, the monitor had 2 sticky note 'flags' on the screen--one by room 461 (Patient #10) and the other by room 463 (Patient #5). When asked what the flags signified, Supervisor A stated those patients are "not a 1:1 but we've identified there is a potential [for high risk behavior]...someone put them there, that's who they were watching." Review of medical records for Patient #10 and Patient #5 contain no additional documentation of a medical or safety risk requiring the need for video monitoring.

During an interview on 4/25/2017 at 10:10 AM, Registered Nurse E stated "the cameras are used mostly for safety" and "yes, they are always on." E stated "we use them if we are worried about someone...if a patient gets upset and slams the door, we can go to the monitor and see them or if a patient is on 1:1 we wean them gradually. We use it more for 1:1, staff is assigned to watch [the patient] but if they are sleeping, we can watch them on camera." Registered Nurse E stated "when a patient is admitted , I always tell them about the cameras. And I tell them to change in the bathrooms." When asked how E ensures patient privacy, E stated "I take a chair or a stepladder into the room and tape a piece of paper over the camera...we can put a sticky note [over the patients room] on the monitor at the nurses station, but they can still be seen by the cameras in security." Registered Nurse E stated "there is no way to turn off cameras in some rooms and not others as far as I know."

During an interview on 4/25/2017 at 11:00 AM, when asked if the Behavioral Health patient rooms are monitored by security, Safety Specialist G stated "we do have a monitor in the security dispatch room, it's live only--not recorded. The purpose is for a code, if a code is called, they are directed to look and respond...it's not watched continuously."

The security dispatch room was observed on 4/25/2017 at 11:25 AM. The room included a staffed desk at which a number of screens with video surveillance were actively being monitored. On the wall on the left side of the desk was a large screen on which the Behavioral Heath rooms were noticeably visible and larger in size than other video surveillance which included parking lots, hospital entrances, public hallways, etc. During an interview on 4/25/2017 at 11:25 AM, Communication Dispatch Specialist H stated "I visually scan all the monitors every few seconds...looking for anything suspicious." When asked if the Behavioral Health inpatient room videos were included in that process, H stated "yes."

During a discussion about the use of the video monitoring on 4/25/2017 at 11:10 AM, Supervisor A stated "the intent is not for medical care." A stated "I didn't know the for sure the monitors were down in security." Staff I stated the cameras are "to protect all staff. For a patient to meet inpatient behavioral health criteria, there is a medical necessity [for the use of video monitoring]. The benefits of preventing injuries outweigh privacy concerns."

Security-related incidents and quality reports from 4/2016 to the present were reviewed on 4/25/2017 at 11:40 AM. There is no documented evidence that the use of the video monitoring in patients rooms had been evaluated as a necessary and valuable clinical tool for the safety and security of the facility's staff and patients.

Program Coordinator B stated at 11:50 AM, "we have them in place for safety and security for all staff and patients." Supervisor A stated "that is the use for it, and if there is a code, we need to see where it's at. Other than that, if a patient needs to be monitored from a distance, we can watch them on the monitor. Or if we need to locate where the patient is for a med pass or for a doctor visit, we can find them easily on the monitor."

When asked for any and all policies guiding the intent and requirements for use regarding the video monitoring on the Behavioral Health unit, Supervisor A stated "Camera Monitoring of Inpatient Behavioral Health Patient Rooms" (referenced above) was the only policy pertaining to it. The policy states: "-Patients are video monitored only when medically necessary or in security situation." The policy does not define "medically necessary" or "security situation." There are no policies addressing criteria to meet medical necessity or security necessity for use, no policies to guide staff in documentation requirements and no policies addressing patient notification or consent for video monitoring.

When asked if it is expected for staff to provide written documentation to justify the need for continuous video monitoring of patients for either medical or security reasons, Supervisor A stated "nurses should document that in their care plan." A went on to state that there is no policy or procedure to guide staff on documentation requirements for video monitoring based on individual need.

During an interview on 4/25/2017 at 12:10 PM, Program Coordinator B stated "Patient rights are reviewed as part of the admission process. I can see how we could expound on why we are using it explain it to the patient."