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.
|HARTGROVE HOSPITAL||5730 W ROOSEVELT ROAD CHICAGO, IL 60644||May 30, 2019|
|VIOLATION: PATIENT RIGHTS||Tag No: A0115|
|Based on document review, videotape review and interview, it was determined that the Hospital failed to ensure personal privacy by conducting all of the body searches in a room (quiet room) with a camera and video recording the body searches on all patients. The use of video cameras during the body search has the potential for serious emotional and psychological harm for all patients admitted to the hospital. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights, was not in compliance.
The Hospital failed to ensure the patient's right to privacy by video recording the body search on admission. See deficiency at A - 143.
An immediate Jeopardy (IJ) was identified on 5/30/19 for the Hospital's failure to maintain all patients' personal privacy by video recording all of the body searches for contraband (weapons drugs or harmfull substances), thus placing all 146 current patients on census and future patients, at potential risk for serious emotional and psychological harm
The IJ was and announced on 5/30/19 at 2:00 PM, during a meeting with the Group Chief Executive Officer, Chief Clinical Officer and Director of Performance Improvement. The IJ was not removed by the survey exit date of 5/30/19.
|VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY||Tag No: A0143|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review, videotape review and interview, it was determined that for 2 of 3 Patients (Pt #1 and Pt #13), the Hospital failed to ensure the patients' right to privacy by video recording the body searches on admission. This failure has the potential to affect all future admissions, with the average monthly admissions of 351 patients.
1. On 5/28/19, the Hospital's Consent titled, "Universal Consent - Consent to Examination and Treatment" (5/2013) was reviewed and included "...the undersigned acknowledges and is hereby informed that the hospital uses real time video surveillance and recording equipment on its program units. This equipment is used solely for monitoring the patient areas for safety. Video surveillance and recording equipment is used in common areas and is never used in a patient's bedroom or bathroom..." The Hospital's Universal Consent does not include information regarding the use of video recording in the quiet room for body searches.
2. On 5/28/19, the Hospital's policy titled, "Photographs, Videotapes and Other Recordings of Patients" (10/26/2018) was reviewed and required "...Videotapes and other recordings may be used and disclosed as follows and if in compliance with applicable state laws...Treatment - Facilities may photograph, videotape or make other recordings of a patient for treatment purposes..."
3. On 5/28/19, the Hospital's policy titled, "Contraband Search and Disposal" (4/19) was reviewed and required "... Patients and their belongings will be searched for contraband on a routine basis: Upon admission, return from medical appointments, quiet room usage, post visitation...Patient is brought to a private area and is asked to remove all clothes...Nursing staff will ask the patient to perform range of motion including squatting and lifting arms to assess for a hidden contraband. Staff does not check body orifices (rectum and vagina) manually..." The policy did not include information regarding the body searches being recorded by video surveillance.
4. . On 5/29/19, the Hospital's policy titled, "Facility Surveillance Video Camera Recording" (10/2018) was reviewed and required "...If video footage is used for training of staff, the video footage in question will be reviewed in real time or within 30 days..."
5. On 5/29/19 at approximately 10:00 AM, the clinical record of Pt #1 was reviewed. Pt #1 was a [AGE] year old male who was admitted on [DATE] with the diagnosis of major depressive disorder and suicidal ideation. The clinical record included orders for a a body search dated 5/3/19.
6. On 5/29/19 at approximately 10:30 AM, the video surveillance recording from Pt #1's admission body search dated 5/3/19 was reviewed in the presence of the Director of Performance Improvement (E #1). The video recording noted the Program Specialist (E#6) conducting a body search on Pt #1 in the "cloud" room (private room). The video recording showed Pt #1's unclothed, upper body during the body search. A second staff, a Registered Nurse (E #8), was seen entering the room two times to check Pt #1's body, during the body search.
7. On 5/29/19 at approximately 11:00 AM, the clinical record of Pt #13 was reviewed. Pt #13 was a [AGE] year old female who was admitted on [DATE] with the diagnosis of major depressive disorder. The clinical record included an order for the body search on 5/27/19.
8. On 5/29/19 at 11:30 AM, the video surveillance recording from Pt #13's admission body search dated 5/27/19 was reviewed in the presence of E #1. The video recording noted Pt #13's breasts exposed on the video recording.
9. On 5/28/19 at 10:30 AM, an interview was conducted with the Charge Nurse (E #4). E #4 stated that on admission, the patient is taken into the quiet room for a body search. E #4 stated that there is a video camera in the quiet room. E #4 stated that the patient is naked and the patient is checked for bruises, marks, scars or contraband. E #4 stated that the patient is asked to squat and cough to check for hidden contraband (items not allowed).
10. On 5/28/19 at 11:10 AM, an interview was conducted with the Director of Performance Improvement (E #1 ). E #1 stated that the admission body search is done in a private room with a camera and the body search is video recorded. E #1 stated that the Hospital keeps the video recording for 2 weeks up to 45 days, which can be reviewed by the Director of Nursing, Director of Performance Improvement and the Group Chief Executive Officer.
11. On 5/28/19 at approximately 2:00 PM, the Chief Clinical Officer (E #5) was interviewed. E #5 stated, "The body searches are done in the quiet room. There is a video surveillance that records and is good (kept) for a few days. They (patients) could be naked during the search. We use the video surveillance because if we find a contraband a few days after admission, we can go back to see if the search was done correctly, and as a patient safety measure, if a patient makes an allegation, then we can review the tape for that. Only the Director of Performance Improvement sees the video recording to verify appropriate body searches, only if there is an allegation. This has been a hospital-wide practice since 2009." There was no signage posted in the Hospital about video camera usage during body searches. No changes have been made to ensure patient privacy.