HospitalInspections.org

Based on review of documents, medical records and staff interview, it was determined the facility failed to provide documentation of patients' being provided with notice of current visitation policy, including any restrictions and reasons for the restrictions, prior to provision of care. This was noted for ten (10) of ten (10) patient records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10). This has the potential to infringe the visitation rights of all patients at this facility.

Findings include:

1. The facility policy entitled "Visitation Policy", last revised and approved 7/2013 was reviewed on 7/8/13. The policy states, in part, under the heading "Patients Right to Visitation: 1. To have patient and/or their support person (when appropriate) be informed of the visitation guidelines, including any clinical restriction or limitation of such rights."

2. The document entitled "Conditions of Admission and Authorization for Medical Treatment" was reviewed on 7/8/13. The document includes, in part, a section entitled "VII. Patient Rights and Responsibilities Acknowledgement: I acknowledge that I have received a copy of the Patient Rights and Responsibilities and have had an opportunity to ask questions". This document is signed by the patient or guardian/health care surrogate upon admission to the facility.

3. The facility Admission Packet, given to all patients admitted to the facility from any entry point, was reviewed on 7/8/13. This packet includes a document entitled "Patient Bill of Rights". The information regarding the facility visitation policy is not included in this document.

4. The medical records of patients #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10 were reviewed. None of the medical records revealed documentation of patients being provided with information regarding their rights to visitation.

5. An interview was conducted with Chief Nursing Officer on 7/8/13 at 1445. She reported the facility visitation policy was recently revised and approved. She stated the information included in the policy has not yet been included in the admission packet given to the patient, nor has it been included in the list of patient rights given in writing to patients at admission. She stated that currently, patients are advised of their visitation rights verbally by the receiving department staff. She agreed with the findings that there is no documentation in patient medical records of patients #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10, or their health care surrogates being informed of their visitation rights.