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F0583
E

Privacy Breach Due to Unauthorized Video/Audio Monitoring

York, Pennsylvania Survey Completed on 01-30-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect the privacy of residents by using video/audio monitoring devices without proper consent or inclusion in the residents' care plans. Three residents, identified as Residents 16, 27, and 65, were subject to video/audio monitoring without their consent or the consent of their representatives. The facility's policy on resident rights was not adhered to, as it did not include a procedure for obtaining consent for video/audio monitoring or ensuring the privacy of residents. Resident 27, who had chronic kidney disease and a history of stroke, was observed to have a camera-like device on their bedside dresser. The device was used to monitor the resident at night due to a history of falls. However, the use of this monitoring device was not included in the resident's comprehensive care plan. Similarly, Resident 16, with peripheral vascular disease and type II diabetes, was monitored without a physician's order or inclusion in their care plan. The monitoring device transmitted both video and audio, which was not disclosed to the Nursing Home Administrator. Resident 65, diagnosed with epilepsy and dementia, also had a monitoring device in use without proper documentation in their care plan. The facility's Nursing Home Administrator admitted that there was no policy or procedure for the protection of residents' privacy with the use of video/audio monitors and that no consent was obtained from the residents or their representatives. The facility's failure to protect residents' privacy rights was a clear violation of the residents' rights to privacy and confidentiality.

Plan Of Correction

All video monitoring devices have been removed from resident rooms. All residents that had video monitoring removed will have their fall care plans reviewed and updated by IDT as needed. All staff will be educated on resident rights to privacy and confidentiality of their personal and medical records including accommodations, medical treatment, written and verbal communications, personal care, visits, and meetings of family and resident groups. Video monitoring will no longer be used in the facility; all staff have been notified, and all cameras have been removed. A QA tool has been developed to review 10% of residents weekly to ensure privacy and confidentiality of their personal and medical records including accommodations, medical treatment, written and verbal communications, personal care, visits, and meetings of family and resident groups. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.

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