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Based on record review, interview and policy review, the facility failed to follow written policies and procedures regarding the visitation rights of patients (A0215).

Based on record review, interview and policy review, the facility failed to follow written policies and procedures regarding the visitation rights of patients for one of ten medical records reviewed (Patient #1). This could affect all patients receiving services from the facility. The census was 279 patients.

Findings include:

Review of the Inpatient Visitor Policy, updated 08/23/21, revealed the command center and physician leaders have decided to amend their inpatient visitor policy to allow one visitor per patient at a time in their hospitals, effective 08/23/21 to ensure the safety of their team members, physicians, patients, visitors and community. At the same time, they are committed to providing the most compassionate care possible to their patients and their families. Exceptions included End of Life (EOL). Two visitors plus one clergy member were allowed at EOL. Chaplains may assist the visitor and clergy member. Regardless of whether the visitors have been fully vaccinated or have recovered from having the virus, COVID-19 patients in isolation will not be allowed visitors, with the exception of EOL care.

Review of the Inpatient Visitor Policy, updated 01/06/22, revealed the command center and physician leaders have decided to amend their inpatient visitor policy to allow one visitor per patient as a time in their hospitals, effective 01/10/22. Exceptions included EOL. Two visitors plus one clergy member were allowed at EOL. Chaplains may assist the visitor and clergy member. Exceptions to the updated inpatient visitor policy revealed the newly revised inpatient visitor policy does not supersede existing policies in place for special circumstances. EOL is handled on a case by case basis at the local level.

Review of the medical record for Patient #1 revealed he drove himself to the emergency department (ED) on 01/01/22 because of increased shortness of breath. Review of the Emergency Department general note revealed he had coughing for three to four days, shortness of breath, body aches and fevers. He has not been vaccinated against COVID. He takes Flovent inhaler inhaler (for the long term management of asthma and chronic obstructive pulmonary disease) for a history of asthma. The patient's diagnosis was determined to be acute respiratory failure with hypoxia.

Patient #1 was a full code on arrival to the ED and was not interested in any advance directives or power of attorney. He was divorced and the medical record listed his daughter as his emergency contact person.

Review of the physician progress notes revealed on 01/05/22 the patient was coughing up mucus, had shortness of breath with minimal activity, no fever or chills. On 01/06/22 a computed tomography angiogram (an imaging test that looks at the arteries that supply blood to the heart) of the chest for pulmonary embolism was negative, and the physician discussed with the patient his increased oxygen requirement and that they may need to try BiPAP (machine that helps a person with chronic obstructive pulmonary disease to breathe. When using a BiPAP machine, a person takes in pressurized air through a mask to regulate their breathing pattern while they are asleep or when their symptoms flare) if not improved, discussed regarding proning, discussed with daughter and updated. On 01/07/22 the patient was anxious and started on an anti-anxiety medication. On 01/08/22 received therapy with high dose of steroids, progressive hypoxia today and on the floor to escalate care to progressive care unit (PCU) for further management, plan discussed with the patient and he agreed to intubation if warranted and long term mechanical ventilation also if needed, discussed there is no quick fix for COVID. On 01/08/22 the patient was anxious and started on BiPAP due to hypoxemia last night, discussed with patient in detail regarding the course of COVID and prognosis, discussed regarding transferring to ICU if hypoxemia persists for mechanical ventilation, discussed with sister overall care for about 25 minutes over the phone, pulmonary consult placed.

Review of a physician note dated 01/09/22 revealed the patient was with progressive hypoxia today on the floor to escalate care to progressive care unit for further management. Noted to have ST changes (changes to the heart observed on an electrocardiogram), went to catheterization lab, stent placed, vented the chest bilaterally due to worsening hypoxia. The patient wants aggressive care, full code, agreed to long term mechanical ventilation if needed. Discussed with daughter this morning the severity of illness and will continue with aggressive medical management.

Review of a physician medical surgical ICU note dated 01/11/22 revealed called by Patient #1's nurse to assess for acute tachycardia. On exam Patient #1's heart rate was around 160 to 170. The patient is on vasopressors (medcations) to maintain the blood pressure. Decision made to cardiovert Patient #1 given he was hemodynamically stable. Three attempts were made and the patient was started on an antiarrythmic. Patient #1 monitored for severe hypotension. Still on max pressors, less hypoxic, spent 45 minutes talking to the patient's daughter today about his clinical picture and she still wants the patient to be full code. She is aware the patient's prognosis is poor.

Interview with Staff A on 01/14/22 at 1:50 PM revealed the visitor contact tracing report for Patient #1 revealed from 01/03/22 to 01/09/22 documentation that stated "no visitors." On 01/09/22 at 9:54 AM there was documentation the patient's daughter was visiting and requested for her husband to come up. The nurse did not approve due to limited space and must meet her husband in the main lobby. On 01/11/22 at 7:31 AM it was documented that there were no visitors. Then again on 01/11/22 at 11:37 AM there was documentation the patient's daughter and son-in-law were allowed up to the waiting room per the doctor. Further interview with Staff A after reviewing the contact tracing report revealed because Patient #1 was COVID positive he was not allowed visitors until on 01/09/22 when Patient #1's daughter was called and was requested to come in. This tracing report showed on 01/09/22 and 01/11/22 that Patient #1 had visitors due to change of condition based on the 01/09/22 nurse's note and physician note.

Interview with Staff A on 01/14/22 at 2:40 PM revealed at end of life (EOL) for a COVID positive patient two visitors were allowed in the room. Whomever the power of attorney (POA) was could decide who could be in the room as a second person. If there was no POA the state law was followed. Further interview with Staff A revealed on 01/08/22 Patient #1 had a change in condition. Patient #1's daughter was at the window/door of Patient #1's room and the physician and/or nurse explained the patient's condition to the daughter. Once Patient #1 was at EOL two persons could be in the room.

Interview with Staff B on 01/19/22 at 10:19 AM for the 2300 critical care MSICU and PCU (progressive care unit)revealed she did not talk to any of Patient #1's family members that she could recall. She stated on 01/11/22 at 8:39 PM the registered nurse (RN) talked to the patient's daughter and updated her on his status. This was when the daughter decided to change the code status to Do Not Resuscitate Comfort Care - Arrest (DNRCC-Arrest - the patient would receive standard medical care until the time he or she experiences a cardiac or respiratory arrest). The nurse spoke with the doctor and made him aware the daughter wanted to change the code status. On 01/11/22 at 8:42 PM the order for the DNRCC-Arrest was placed by the physician. On 01/11/22 at 10:40 PM the physician pronounced that the patient expired. Further interview with Staff B on 01/19/22 revealed it was the hospital's goal to have family at the bedside with the patient at end of life (EOL). She stated it was not necessary that the DNRCC-Arrest be signed and it was always the goal that the family be at the bedside so the patient did not die alone. Staff B also revealed it was not the policy to tell a family member they could not go in the room unless the DNRCC-Arrest was signed. They did have restrictions related to COVID positive patients. There were two visitors allowed at EOL with a COVID patient.

Interview with Patient #1's daughter on 01/19/22 at 12:00 PM revealed she was allowed to observe the patient at the door/window to the room on 01/09/22 for about one minute and then she went back to the front entrance waiting room to be with her husband. Prior to her father going on the ventilator he made the decision to be a full code. Staff D met her the morning of 01/11/22 and made her aware of the patient's status and everything she had done. Staff D explained everything so she could understand it, but the daughter still wanted the patient to be a full code. Later that evening she spoke with a nurse who stated the patient barely had a heartbeat. The nurse explained the patient was declining rapidly and it was the end of life (EOL). The day shift nurse explained to the daughter the three different options for DNR and what they meant. She told the nurse at this time that she did not want to do anything. She stated she was not allowed in to see the patient until later that night and was able to be with the patient for two hours. The daughter revealed when she was on her way back to the hospital was when she made the decision to to make the patient a DNRCC-Arrest because his condition was not going to change and it was the right decision under the circumstances. When she arrived back to the hospital they were able to go in and see the patient.

Interview with Staff C on 01/19/22 at 12:31 PM revealed there were no visitors allowed for COVID patients except for EOL situations. The specifics were determined at a unit level. Patient #1 was allowed visitors at EOL which was on 01/11/22. If a patient was at EOL the code status did not matter.

Interview with the Staff D, the patient's physician, on 01/19/22 at 1:03 PM revealed she met with Patient #1's daughter around noon on 01/11/22 and the daughter wanted to keep the patient a full code even after she explained the critical condition and that he was not going to make it. She talked to the daughter every day and called her the day before the patient expired and made her aware he was not making much progress. The daughter made the comment that she knew he was not going to survive. She made the daughter aware that cardiopulmonary resuscitation (CPR) was futile. The daughter stated that she was not comfortable changing the code status. Staff D revealed she had told her for CPR to be functionable they needed to have a reversible cause and something more to act on but the daughter was not comfortable. Staff D explained to the daughter that the patient was getting all the pressors and drips he could get and there was nothing else that could be done for him. Further interview with Staff D revealed from what she heard the daughter made the patient a DNRCC-Arrest the night he passed away. Staff D added that it had been her practice that they did not let any visitor in the actively dying patient's room unless they had a change in code status from a full code to DNRCC-Arrest. She told the daughter since he was still a full code it was her understanding the patient could not have any visitors. He was maxed out on pressors and on mechanical ventilation since 01/08/22 at 11:30 PM for three days and that he would have died three days before but the ventilator and aggressive treatment was keeping him alive and they had nothing else to offer the patient. She tried to encourage the daughter to make the patient a DNRCC-Arrest and she said no. A full code meant they had to continue full aggressive treatment and continue aggressive medical care as any other full code patient would get. The patient did not have a reversible condition to be able to do CPR to be successful and CPR would be futile.

Review of an email received from the leadership team on 01/21/22 at 8:32 AM revealed End of life was considered when the trajectory of a patient's progress or stability is unable to be sustained with aggressive measures. It was based on the physical and physiological findings (i.e., changes in respiration, failure to respond to medication, inability to oxygenate, loss or decrease in cardiac function or neurological status or the ability to sustain such). It was a clinical evaluation based on the opinion that continued aggressive measures cannot reverse or further support bodily functions and this determination can be different for each patient. This term was also sometimes used in patients who remained full code and DNRCC but the patient continues to deteriorate despite maximal medical therapy and death was expected in next 24 to 48 hrs.

Interview 01/21/22 at 11:34 AM with Staff A revealed the patient's ventilator settings, treatment and medications remained the same, everything remained the same after the patient became a DNRCC-Arrest.

This deficiency substantiates Substantial Allegation OH00129158.