HospitalInspections.org

Based on a review of hospital policy and procedure, documents, medical records, and interview, the Department determined the hospital failed to ensure patients were allowed to have visitors during their admission at an inpatient psychiatric facility. This deficient practice poses the potential risk of violating a patient's right to visitors, an inability for family or friends to assess the patient's mental and physical health status and progress, having a detrimental effect on the patient's mental and physical health status and progress, and family and/or friends not being included in the patient's treatment plan.

Findings include:

Policy titled "Visitation," received 04/27/2022, revealed: " ...Visitation will not be held on a regular basis for patients ...."

Hospital document titled "Patient Acknowledgements and Consents," received 04/27/2022, and present and signed in six out of six medical records reviewed, revealed: "...All patients have a right to receive approved visitors and phone calls while you are a patient with Aurora Behavioral Health System ...."

Hospital document titled "Aurora Behavioral Health System Patient Handbook," received 04/27/2022, identified, " ...Due to the COVID-19 pandemic, and upon review of current hospital operations, in-person visitation will not be offered during your treatment ...Upon request, and when deemed appropriate by your treatment team, virtual visitations can be scheduled ...."

Hospital document on display at the front desk on 04/27/2022, revealed, " ...In a response to this everchanging pandemic, Aurora has assembled a team to review, monitor, and track all recommendations by the CDC, as well as local and State Health Departments ...Aurora will be eliminating visitations to our facility indefinitely ...."

Centers for Medicare and Medicaid Services (CMS) memorandum subject, "COVID-19 Focused Infection Control Survey Tool for Acute and Continuing Care Providers and Suppliers (REVISED)," revealed, " ...Visitation Restrictions: We recognize that requirements for entering healthcare facilities such as visitation restrictions were used to mitigate the introduction of COVID-19 into facilities. At this time, continued federal guidance regarding visitation restrictions for ACC facilities are no longer necessary ...."

Document titled "Termination of Emergency COVID-19," signed 03/30/2022, identified, " ...Now, therefore, I, Douglas A. Ducey, Governor of the State of Arizona ...do hereby terminate the COVID-19 emergency response operational period established by me on March, 11, 2020 ...."

Employee #1 confirmed during an interview conducted on 04/27/2022, that there is no log of patient visitors because patients have not been allowed to have visitations because of the COVID-19 pandemic. There have been no exceptions that he/she is aware of.

Employee #3 confirmed during an interview conducted on 04/27/2022, that the facility is not allowing visitors at this time because of the pandemic and they do not currently have staff to facilitate the supervision required for visitations. He/She stated that there are tablets available so the patients can have virtual visits. The virtual visits have to be scheduled through the social workers because they are the ones with access. If a patient were to want to see a family member or vice versa, they would have to call the social workers between the hours of 8:00 am and 5:00 pm, to schedule a visit using the tablet.

Employee #6 confirmed in an interview performed on 04/27/2022, that the patients, including adolescents, have not been able to have visitors, and he/she is not to sure why, though the management is saying it is because of the pandemic. He/she stated that they have not had virtual visits for families with the tablets because he/she just received access to the program the previous day before, so they have been unable to schedule any virtual visits. She/He also confirmed that as far as staff was told, the virtual visits were for therapy visits only and not family visitation. The social workers have the tablets used for the virtual visits, and they are only there from 8:00 am to 5:00 pm, not during visitation hours.