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Based on observation, medical record review, patient, interviews, staff interviews, and review of facility policy, the hospital failed to ensure all patients the right to personal privacy. (A-143). The cumulative effect of these systemic problems resulted in the facility's inability to ensure patients' rights to personal privacy.

Based on observation, medical record review, patient, interviews, staff interviews, and review of facility policy, the hospital failed to ensure all patients the right to personal privacy. This deficient practice affected three patients (Patient #4, Patient#6, and Patient #9) and had the potential to affect any patients placed in the facility's 12 camera equipped rooms (Room #111, #115, #117, #119, #121, #123, #124, #126, #128, #130, #132 and #134). The facility was a 76-patient bed facility with a current census of 30.

Findings include:

An observational tour conducted on 10/08/24 between 11:03 AM and 12:04 PM revealed the odd numbered rooms on the facility's West Hall (Room #111, #115, #117, #119, #121, and #123), and the even rooms on the South Hall (#124, #126, #128, #130, #132 and #134) were all equipped with hard wired fixed video cameras mounted in the ceiling above each patient bed. Observation of the monitor room revealed the room was equipped with two sets of monitors, one for a bank of cardiac telemonitors and a second with a bank of video monitors for the above referenced rooms. The monitor room was staffed with two monitor technicians. Observation of the color video monitors revealed patients could be seen laying their beds, sitting in bedside chairs, or interacting with various facility staff currently in the room. The monitor technicians could use audio to communicate with the patients. This was live monitoring only and the video footage could not be recorded.

Interview with Monitor Tech Staff C on 10/08/24 at 11:04 AM revealed the monitor room was staffed every day, 24 hours per day, seven days per week (24/7). All monitor technician staff were trained to monitor both the cardiac telemonitors as well as the patient room video cameras. Staff C verbalized the video cameras were always on and the facility had no way to disarm or shut off the cameras. The cameras were live feed only and not capable of recording. Staff C stated the video cameras were also equipped with a high-resolution zoom feature, which permitted monitor staff to view each of the 12 rooms simultaneously or to zoom in to each room individually with great clarity. Staff could verbally interact with the patients in all the rooms equipped with video cameras. Staff C demonstrated little pieces of construction paper that were cut out to resemble articles of clothing and could be stuck on the monitor screen with tape to cover patients' private areas for personal privacy. Staff C stated sometimes they put the construction paper clothing up when viewing the monitors.

Interview with Monitor Tech Staff D on 10/08/24 at 11:14 AM confirmed all patients in the video camera equipped rooms were monitored daily 24/7 and there was no way to turn the cameras off.

1. Review of the medical record revealed Patient #4 was admitted to the facility on 06/03/24. Diagnoses included iliopsoas abscess, lumbar osteomyelitis, and history of gastroparesis with history of Nissen Fundoplication procedure. The medical record revealed the patient was admitted to the facility's high observation area at admission. The patient's condition improved, and the patient was transferred to the facility's regular nursing room unit, Room #117, on 06/08/24. This room was a camera equipped room. Review of the medical record failed to contain any written documentation or explanation of the facility's camera equipped rooms or its 24/7 video surveillance of patients. The facility was unable to provide documentation Patient #4 was notified or consented to 24/7 video monitoring. There was no assessment of the need for video monitoring.

Interview with Patient #4 on 10/ 07/24 at 3:36 PM revealed she signed her own admission documentation, consent to treat forms, acknowledgment of the receipt of her Patient Rights and Responsibilities, and the facility handbook. Patient #4 verbalized she was never provided documentation of the facility's video surveillance policy nor was she asked to sign any consent for video monitoring by the facility. Patient #4 verbalized the audio-video monitoring "Was just creepy!"

2. Review of the medical record revealed Patient #6 was admitted to the facility on 09/12/24. Diagnoses included abdominal pain, acute kidney injury, abscess, and acute renal failure. The medical record failed to contain any written documentation or explanation of the facility's camera equipped rooms or its 24/7 video surveillance of patients. The facility was unable to provide documentation Patient #6 was notified or consented to 24/7 video monitoring. There was no assessment of the need for video monitoring.

Interview with Patient #6 on 10/09/24 at 1:58 PM revealed she observed the ceiling mounted video camera in the room when she admitted to the facility. Patient #6 verbalized she signed her own admission documentation, consent to treat, and receipt of her admission packet with Patient Rights and Responsibilities. Patient #6 verbalized she was not offered any document to sign that permitted the facility to video monitor her continually during her stay. Patient #6 stated, "I sort of expected that I would need to a sign consent for that."

3. Review of the medical record revealed Patient #9 was admitted to the facility on 07/24/24 and remained a current inpatient at the time of survey. Diagnoses included aneurysm of the ascending aorta, coronary arteriosclerosis, pressure ulcer to right hip and sacral area, nephrolithiasis, septic shock, seizures, traumatic rhabdomyolysis post fall, urinary tract infection and electrolyte imbalances. The patient slowly stabilized and was transferred to the long term acute care hospital (LTACH). Review of the medical record revealed the patient was unable to sign her admission documentation but was able to provide verbal consent for her admission documentation. There was no assessment of the need for video monitoring.

Review of the nurses' notes dated 08/18/24 at 5:46 PM documented the writer walked into Patient #9's room. The patient started yelling stating she was not dealing with telemetry watching her 24/7. The patient stated she does not have an order for a one on one (1:1) supervision and that's what the facility is doing. The patient stated she needs to see an order from a doctor that shows she needs to be a 1:1 supervision. The patient stated the facility was violating her Health Insurance Portability and Accountability Act (HIPAA) rights.

Observations on survey revealed Patient #9 resided in Room #123.

Review of the facility policy titled "Patient Rights," dated 10/01/23, revealed the policy purpose was to ensure each patient/family admitted to the hospital was aware of their guaranteed rights and their responsibilities. These rights were guaranteed and respected by the personnel of the hospital, but must also be adhered to by physicians, families, and visitors of the hospital. Each patient/family admitted to the hospital will receive a copy of the Patient Rights & Responsibilities policy upon admission. Under the heading "Patient Rights & Responsibilities" at Item #8 Privacy: "You have the right to expect staff to respect your privacy and conduct treatments with discretion, providing as much modesty as possible."

Interview with Administrative Staff A on 10/08/24 at 12:04 PM revealed the facility had 12 rooms equipped with video camera monitoring that were monitored 24/7. The facility had no way to turn them off, they were always on, and the monitor room was staffed 24/7. Staff A confirmed the facility had no policy related to these camera equipped rooms nor were patients required to sign consent.