ALL EYES ARE ON GRANNY CAMS.

Use of video monitoring equipment in residents' rooms has begun and is raising both hopes and hackles 

When you go to the bank, it's watching you. As you pump gas, it logs your every move. In fact, it might already be recording your interactions with residents. The use of video monitoring devices is becoming widespread throughout the country, and some are already being used in long-term care facilities, regardless of whether administrators consent to--or are even aware of--their presence.

"We [at one of the facilities I oversee] had one situation where a family member had a camera installed. It was installed on facility furniture, and the staff and administration were not advised it was there," says Judith Passerini, chair of the American College of Health Care Administrators and deputy secretary for Catholic Healthcare Services.

Often referred to as "granny cams," the possible types of video monitoring devices in long-term care facilities range from traditional video cameras and teleconferencing equipment to video telephones and Internet-based Web cams, although Passerini says that the granny cams she has seen or heard of have been videotape-based, not Web-based.

Not everyone likes the term "granny cam": "To me it sounds so degrading and disrespectful, and kind of frivolous," explains Barbara Hengstebeck, executive director of the Coalition to Protect America's Elders. Ana Rivas-Beck, a law and policy specialist at the National Citizens' Coalition for Nursing Home Reform, says the term fails to recognize that facilities also have young residents.

Whatever you call the devices, they could become a real presence in the long-term care field. "This technology is here," says Passerini, and Hengstebeck notes, "You can walk into any Office Depot and buy a Web cam to sit on top of your computer for $49 and the software to run it for $99." Hengstebeck adds that a simple VCR-based system with an infrared camera (to record images in the dark) can be purchased for $300 to 400. She acknowledges that these systems will still be expensive for some families, and this could result in a two-tier system in which some residents have video monitoring equipment and others don't.

Reasons vary as to why families choose to install monitoring equipment in residents' rooms. Rivas-Beck says they can be used for "virtual" visitation. Two-way communication is possible with devices such as video phones, teleconferencing equipment and Web cams. Or they can be used to ensure the safety and security of residents: "For family members, it means they can monitor the quality of care their loved one is receiving in the facility," says Rivas-Beck. "I think it's probably a valuable tool for those who can't see their loved one every day and sometimes suspect that he or she is being neglected or abused in some way and want to document it." However, Rivas-Beck notes that cameras mounted in rooms do not capture what happens in hallways, bathrooms and open areas, which she says are other places where abuse and neglect can occur.

Hengstebeck adds that even if every resident doesn't have a camera, using a camera to document the abuse of one resident will make the facility safer for all residents. Yet Suzanne Weiss, vice-president and counsel for public policy for the American Association of Homes and Services for the Aging (AAHSA), points out reservations from the standpoint of staff: "As a bottom line, nursing home staff shouldn't be doing anything they would be afraid to have filmed. On a perfectly practical level, though, even movie stars don't want their whole lives filmed." Robert Greenwood, associate director of public affairs at AAHSA, adds, "If you can imagine a nursing home where every resident was being monitored by a video camera, the caregivers basically would be on videotape all day long. I don't think any of us would like to work with a video camera trained on us all the time."

Even if a camera is installed in a resident's room, how the footage is interpreted can have profound implications, Greenwood says. He recalls seeing a TV segment a few years ago in which a reporter had a camera secretly placed in a nursing home. The camera recorded a resident transfer during which the resident moaned. The reporter cited the incident as evidence of "abuse," but Greenwood says that the reporter failed to realize that "many residents who are cognitively impaired do moan" and that the staff were not abusing the resident.

Staff considerations aside, equipping residents' rooms with video monitoring devices presents an issue for legal contention, considering that there is no federal law that specifically gives residents the right to have the devices in their rooms. Hengstebeck points out that advocates in some states, such as Maryland, Texas, Illinois and Michigan, are trying to convince their legislatures to pass laws that give residents this right; Jennifer Hilliard, a public policy attorney at AAHSA, has not been able to find any existing regulations on the issue. Nevertheless, Weiss says, "This is a residents' rights issue. A nursing facility is their home, and if they want cameras in their rooms, they have a right to have them...."

Joseph L. Bianculli, a partner in the law firm of Bianculli & Impink, PLC, which represents many of the largest long-term care providers, says there are, in fact, "several statutes and regulations that would bear upon their [granny cams'] use, the most obvious being privacy and residents' rights provisions."

Bianculli notes another issue: whether an incompetent resident can consent to the camera's placement. "Ordinarily, you can consent to waive some of your rights, but there is a question, I suppose, as to whether a surrogate can consent to waive the privacy rights of an incompetent person--whether Mrs. Jones' daughter could say, for example, 'I waive my mother's privacy rights, so therefore I'm going to stick a camera over her bed.'"

Also related to this issue are questions as to whether the privacy rights of the roommates might be violated if a camera is installed in a room and whether the resident can turn the camera on and off to keep moments of intimate care, such as bathing and toileting, private.

Not everyone believes, however, that privacy is an issue. "I really believe that the privacy issue is a red herring," says Hengstebeck. She indicates that video monitoring equipment can be focused on one resident, roommates can be asked to sign a document consenting to the camera's use and a device can be programmed to give a resident the ability to turn it off during private moments. Hengstebeck also believes that consent is not an issue because "there are many cognitively impaired residents in nursing homes who need their families to exercise their rights for them. This is an issue of choice. Families are already making those choices for cognitively impaired residents, and they just need to use their best judgment."

To prevent possible conflicts between facilities and residents/families, Passerini suggests that administrators create policies and procedures regarding the use of video monitoring equipment. If a facility decides to allow cameras, she says it could implement a fee structure, since there are several cost considerations to take into account. For example, the devices will probably need electricity to operate. Staff members' time (and subsequently facility funds) might be needed for maintenance and installation. There are possible financial responsibilities related to damage and theft. Further, residents who want video monitoring equipment might need private rooms to avoid roommate privacy issues.

Some fear, though, that if facilities allow installation of cameras, the technology could be exploited. "If you allow family members to bring cameras into a room, how can you prevent nursing facilities from providing 'virtual' care by using cameras?" wonders Rivas-Beck. She and Hengstebeck are concerned that long-term care providers could, for example, equip each room with a camera and then monitor residents from a central nursing station instead of attending to them personally. Hengstebeck further suggests that instead of directly answering a call bell, a nurse could check a monitor first before deciding whether to send a nurse to the room. "What you need," adds Rivas-Beck, "are nurses providing direct care. I mean, these aren't monkeys in a cage.

One facility is actually trying to use video monitoring equipment to its advantage. As of press time, Irvine Cottages, an Alzheimer's assisted living center in Irvine, California, had four resident rooms and several public areas equipped with cameras. According to Jacqueline DuPont, MD, CEO of DuPont Care, Inc., the facility's owner, the state of California determined that no other facility in the United States had a program like Irvine Cottages'. This state-sponsored pilot project actually ended in August, but Dr. DuPont is keeping the cameras rolling as she fights to have the project continued. The state, explains Dr. DuPont, wants to end the project because of concerns about the privacy and dignity of residents.

The tapes at Irvine Cottages are changed every six weeks. If a problem such as a skin tear, wound or allegation of abuse has occurred during that period, the tape is reviewed; otherwise, the tapes are reused. Only Dr. DuPont and the facility's administrator have access to the tapes, but nurses can watch the continuous live footage. Families, employees and residents (if capable) sign forms consenting to the cameras presence, and signs posted throughout the facility remind people that they are being monitored. However, residents and/or their families do have the ability to turn off the cameras at any time.

"The families absolutely love the cameras," says Dr. DuPont, noting, "I've never had a family that hasn't liked them." One reason, Dr. DuPont suggests, is that the video monitoring equipment can document episodes of abuse, which have occurred at Irvine Cottages. Because of the footage, one employee was fired for hitting a resident on the hand, and a Medicare-contracted home health nurse (who was not a facility employee) was terminated for hitting a resident with her jacket. Dr. DuPont dismisses concerns about "virtual care," noting that "cameras are only an aid" and do not take the place of direct care.

There is concern, however, that families could misuse the technology. Says Greenwood: "I know of nursing home staff that have expressed concern that [granny cam use] could take the place of personal visits, that families might not feel like they need to visit their loved ones as much if they can dial up the Internet site and watch them a couple of times a day. The downside is that it doesn't do the resident very much good to be watched on the Internet. They really need the interaction with their families."

The future of granny cams is not clear. Bianculli says that although they might sound appealing now, their use will not become widespread because their practical limitations will be quickly realized. Yet Hengstebeck believes that "it's inevitable that they become commonplace" because convenience stores, major intersections, hospital maternity wards and many other areas are already equipped with video monitoring devices.

One thing is certain, though: As technology continues to pervade our lives, long-term care facilities will continue to confront innovations and concepts that could challenge "business as usual" and redefine their caregiving relationships.

Douglas J. Edwards is an assistant editor for Nursing Homes/Long Term Care Management.