HospitalInspections.org

Based on observation, interview, record review, facility policy and procedure review, the critical access hospital (CAH) did not meet the Condition of Participation for Provision of Services by failing to ensure patients and support persons received notice of the current visitation policy and by failing to ensure all swing bed patients (regardless of location in the hospital) had the same visitation privileges.

The cumulative effect of these deficient practices has the potential to impact the emotional and psychosocial wellbeing of the swing bed patients at this CAH.

Findings Include:

1. The CAH failed to ensure swing bed patients and/or support persons were informed of the changes in the visitation policy due to COVID-19 restrictions. (Refer to C1056)

2. The CAH failed to ensure all swing bed patients had full and equal visitation privileges. (Refer to C1058)

Based on observation, interview and record review, the facility failed to ensure swing bed patients and/or support person were informed of the changes in the visitation policy for eight of eight swing bed patients (Patients 1, 2, 3, 4, 6, 7, 8, and 9). This failure could affect the emotional and psychosocial wellbeing of any of the swing bed patients currently admitted to the facility.

Findings Include:

Review of the "Ness County Hospital Patient Rights and Responsibilities," document revised 01/11, showed:
...24. have visitors that are not limited, restricted or otherwise denied based on race, color, national origin, sex, sexual orientation, gender identity, disability, age or religion.
25. be informed of any specific alteration in visitation rights when specific clinical situations warrant
26. consent to have visitors of their choice and the right to restrict or withdraw consent for an individual to visit." ...

Review of the current "Intermediate" Swing Bed (ISB) and "Skilled" Swing Bed (SSB) admission packets showed:
"Access and visitation rights.
(1) The patient has the right to immediate access from:
e. visitors that are not limited, restricted or otherwise denied visitation based on race, color, national origin, sex, sexual orientation, gender identity, disability, age or religion.
(1) Each patient has the right to restrict or withdraw consent for visitation by any person at anytime.
(2) Each patient has the right to be informed of any specific alteration in visitation rights when specific clinical situations warrant."

Review of the policy titled, "Access and Visitation Rights" for swing bed and intermediate swing beds, last revised 12/17, showed, "Statement of Purpose: It is the desire and intent of Ness County Hospital to ensure that our visitation and practices honor the resident's right to access key individuals in his or her life. Policy Interpretation and Implementation: The Hospital's visitation is not limited but staff request that visitation does not interfere with patient cares.We recognize the importance of visitation and social contact to the emotional and psychosocial well-being of a patient.We will honor the patient's requests to the best of our ability to immediate access to family and other relatives regardless of the hour of the day.Visitation will be under the discretion of the Doctor and nursing staff to best meet patient safety and patient needs.In the event of infection, the best interest for public safety will be considered when providing patient visitation. If it would violate the rights of other patients the Hospital will establish alternate areas in the Hospital for visiting. These areas could include the chapel, a suitable office area, a dining room or a porch or patio area."

During an interview on 04/19/21 at 3:40 PM, Registered Nurse (RN) A stated, "a Skilled Swing Bed [SSB - defined by the CAH as a swing bed patient located on the hospital hall] patient is allowed one visitor per day. The Intermediate Swing Bed [ISB - defined by the CAH as a swing bed patient located on the long term care unit hall] patient visitation policy is up at the long term care nurses' station, a sheet with a schedule on it. They [visitors] have to call in advance (24 hours or so) and are using the living area or the outside space, dependent on the [COVID] vaccine status is whether or not they [patient] are behind plexiglass. If not vaccinated they must stay behind the plexiglass." When asked if the SSB patient COVID vaccine status would change their visitation directions, RN A stated, "It doesn't matter, they can go in the SSB patient's room"

A review of the schedule sheet at the LTCU's nurses' station referred to by Staff A, RN showed:
"Indoor/Outdoor Visitation Appointment Schedule"
-All visits will occur in the living room unless the rsd [resident] is on comfort care & cannot leave their room
-VISITS WILL BE SUPERVISED BY A STAFF MEMBER to assure proper PPE and social distancing are followed. (INSIDE will be monitored on camera system, OUTDOOR will have staff outside within visual range but space to allow for privacy) Outdoor visits are still considered to have the lowest risk of transmission of COVID-19 and are to be encouraged if weather permits.
-Pre -arranged times will be scheduled and maintained through the Charge Nurse
-Only one (1) resident with visitors at a time (1 visit/resident a day) and maximum of two (2) visitors for each resident.
-Visits to be 45 minutes long to allow time for staff to clean the chairs and other surfaces touched for all visits and UV light for indoor visits. (DO NOT WIPE THE PLEXI-GLASS WITH DISINFECTANT WIPES)
-All visitors will be screened at the ER door with questionnaire and temperature. Any visitor with 100.4°F or new onset of cough, nasal congestion or sore throat will be denied the visit.
-All parties will wear facemask unless resident is deemed unsafe to do so.
-Facility will provide masks for residents. FAMILIES must provide their own.
-A fully vaccinated resident may choose to have close contact (including touch) with their visitor while wearing a well-fitting face mask and performing hand-hygiene before and after. Regardless, visitors should physically distance from other residents and staff in the facility
-RM [list of four room numbers] are not fully vaccinated and must continue to visit with Plexi¿ Glass between them and their visitor.
-All parties are required to perform hand hygiene prior to entering the visitation room and periodically throughout visit."

During an interview on 04/21/21 at 1:05 PM, Patient 3 (SSB patient) stated he and his family were never given a visitor policy with the specific procedure now in place due to COVID-19 precautions.

During an interview on 04/21/21 at 1:30 PM, Patient 8 (SSB patient) stated she had not been given the visitation policy for COVID-19 restrictions at admission or any time during her stay.

During an interview on 04/20/21 at 1:00 PM, when asked if the facility advised him of the visitation policy upon admit, Patient 9 (ISB patient) stated, "Nope. I asked them this week"

During an interview on 04/21/21 at 1:24 PM, the Chief Nursing officer (CNO) stated patients are not given anything in writing other than the admission packet and that the visitation had changed due to COVID to one person per day. The CNO confirmed the current visitation policy was different than the visitation policy given to the patients on admission.

On 04/21/21 at 3:00 PM, the CNO provided a folder that each patient received in their room upon admission. In the folder was a "Welcome" page that showed on the lower half of the page:
"Visitors:
Visiting Hours
2:00 PM to 4:30 PM each afternoon
7:00 PM to 8:30 PM each evening"

On 04/21/21 at 3:00 PM when the CNO was asked if the listed visitation hours shown on the "Welcome" page in the folder provided to patients upon admission is what the current visitation hours are currently, the CNO replied, "No."

Based on observation, interview, and record review, the facility failed to ensure all swing bed (SB) patients had full and equal visitation privileges. This inequality has the potential to affect a swing bed patient's emotional and psychosocial wellbeing by not allowing the same visitor access to eight of eight SB patients (Patients 1, 2, 3, 4, 6, 7, 8, and 9).

Findings Include:

Review of the "Ness County Hospital Patient Rights and Responsibilities," document revised 01/11, showed:
...24. have visitors that are not limited, restricted or otherwise denied based on race, color, national origin, sex, sexual orientation, gender identity, disability, age or religion.
25. be informed of any specific alteration in visitation rights when specific clinical situations warrant
26. consent to have visitors of their choice and the right to restrict or withdraw consent for an individual to visit ...."

Review of the policy titled, "Access and Visitation Rights" for swing bed and intermediate swing beds, last revised 12/17, showed, "Statement of Purpose: It is the desire and intent of Ness County Hospital to ensure that our visitation and practices honor the resident's right to access key individuals in his or her life. Policy Interpretation and Implementation: The Hospital's visitation is not limited but staff request that visitation does not interfere with patient cares. We recognize the importance of visitation and social contact to the emotional and psychosocial well-being of a patient. We will honor the patient's requests to the best of our ability to immediate access to family and other relatives regardless of the hour of the day. Visitation will be under the discretion of the Doctor and nursing staff to best meet patient safety and patient needs. In the event of infection, the best interest for public safety will be considered when providing patient visitation. If it would violate the rights of other patients the Hospital will establish alternate areas in the Hospital for visiting. These areas could include the chapel, a suitable office area, a dining room or a porch or patio area."

During a facility tour on 04/19/21 at 1:00 PM, just past the coded exit/entrance double doors to the long term care area, a room was observed with couches and chairs. There was a vertical piece of Plexiglass dividing an area of the room. On the door side of the Plexiglass, there was an end table and chairs; on the table was a laminated sheet titled "Indoor Visitation," revised 03/15/21 that showed, "Cedar Village, [the CAH's attached Long Term Care Unit(LTCU)], will accommodate and support indoor visitation, including visits for reasons beyond compassionate care situations based on the following guidelines:
-There has been no new onset of the pandemic infection of staff or residents and we have completed one round of facility-wide COVID-19 testing with no new positive cases.
-Visitors must be able to adhere to the core principles of COVID-19 infection prevention and staff will provide monitoring for those who may have difficulty adhering to the core principles.
-Indoor visitation should be allowed at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission. These scenarios include limiting indoor visitation for:
-Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is > l0% and <70% of residents in the facility are fully vaccinated (fully vaccinated refers to a person who is> 2 weeks following receipt of the second dose in a 2-dose series, or > 2 weeks following receipt of on dose of a single-dose vaccine, per the CDC's Public Health Recommendations for Vaccinated Persons).
-Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the criteria to discontinue Transmission-Based Precautions; or
-Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine.
-The facility will limit the number of visitors per resident at one time to no more than two (2) visitors per resident.
-Each visit will be limited to 45 minutes with a minimum of 15 minutes between the next visit to provide time to disinfect high touch areas and no family visits will overlap with other resident family visits.
-The facility will limit the number of total visits to l resident visit appointment per day.
-The facility will limit the movement of visitors within the facility.
-Visitors will be directed to move through the facility only in the areas of the resident's room if compassionate care visit for a resident unable to leave their room or the designated visitation room for all other visits.
-Each visitor will be escorted by a staff member in the most direct route and the staff
member will instruct the visitor(s) on the most direct exit to be used at the end of the visit.
FAILURE TO FOLLOW THE VISITATION PROTOCOL AND PERSONAL PROTECTIVE EQUIPEMENT [sic] (PPE) REQUIREMENTS WILL RESULT IN LOSS OF VISITATION PRIVLEDGES [sic]!
Visitation Process: -Pre-arranged times will be scheduled and maintained through charge nurse/visit supervisor.
-Families will be asked to wait outside the entrance of the building until the scheduled visitation time to avoid overlap with previous visitations.
-Prior to visit, the assigned staff visit supervisor will discuss parameters with family members in which the visit can occur.
-All visitors will be required to complete the COVID screening assessment form and the form must be approved by the visit supervisor prior to entrance to the visitation areas.
-Once the visitor has successfully completed the screening assessment, the visitor will be screened for a temperature reading.
-Any person registering a reading of 100.4 degrees F will be denied the visit.
-All parties will wear face masks or face coverings.
-The facility will provide masks to the residents.
-Visitors are required to provide his/her own face mask if possible.
-The visitor(s) will be escorted by staff to the visitation area and seated in the designated area.
-Visitors will be instructed to not make physical contact with the resident and that they must maintain the recommended 6 feet distancing.
-The visit supervisor will require acknowledgement of understanding by each visitor including adult and child visitors.
-A fully vaccinated resident may choose to have close contact (including touch) with their visitor while wearing a well-fitting face mask and performing hand-hygiene before and after. Regardless, visitors should physically distance from other residents and staff in the facility.
-All parties are required to perform hand hygiene at the time of entrance to the building and will be instructed to perform hand hygiene periodically during the visit and at the time of ending the visitation.
-The facility is responsible for provision of the alcohol hand gel for all parties.
-Additional hand sanitizer will be provided in each visitation area.
-The assigned visit supervisor will monitor the visitation area periodically at a respectable distance to ensure privacy yet close enough to ensure social distancing and visitation protocols are maintained at all times during the visit.
-A laminated copy of this protocol will be placed on the visitation tables during each visit.
-The laminated protocol will be sanitized between each visit."


Review of Patient 2's medical record showed admission to the facility to the "Intermediate Swing Bed (ISB) unit on 03/26/20. (The term ISB, used by the hospital, is defined as a swing bed patient under hospital swing bed regulations located on the LTCU hall). A nurse's note on 03/02/21 showed "resident was not patient with waiting for living [room] to become available to see wife verbally abusive [sic] flicked the finger at this RN open door to living [sic] which [staff] had not completed the cleaning process with assistance of CNA (certified nurse aide) was able to redirect and after procees [sic] completed is now visiting with wife."

Further review of Patient 2's medical record showed a nurse's note on 03/11/21 at 4:24 PM, "[Patient 2 name] wife came for a visit but was not on the list to do so. SSD [Social Service Director] went to visit with wife and explained to her that she needs to call morning of said visit. She stated that she has been told by other nurses different rules. SSD apologized for miscommunication. Wife shoved mail into SSD hands and stated "Tell [husbands name] that I left and to hell with you."

During an interview of Patient 2 on 04/19/21 at 1:36 PM, when asked if able to visit with anyone he desired, Patient 2 stated, "Yes, my wife is coming at 3:00 [PM]. My son was in the other day. I go to the visitation room [in the LTCU] or outside, depends on the weather."


Observation on 04/21/21 at 9:16 AM, Patient 4 (ISB patient) was out of his room, sitting in his wheelchair in the LTCU's activity room.

Review of Patient 4's medical record showed admission to an ISB on 01/13/20 after a hospitalization. Staff K, Advanced Practice Registered Nurse (APRN), placed Patient 4 on comfort care on 02/27/21.

Further review of Patient 4's record showed a nursing note written by Staff L, RN on 03/13/21 at 2:34 PM indicating the patient's granddaughter (Family Member(F) 1) came to visit around 10:00 AM. The nurse reminded F1 that she should call ahead for a visit and she could visit Patient 4 in the living room. F1 believed since Patient 4 was on comfort care that she could visit the patient in his room. The nurse apologized for the misunderstanding saying, "all pt's must have their visit either per window or family room unless they are unable to leave bed." F1 was upset and spoke to Staff N, LTC Director of Nursing (DON). F1 stated, "I'm going to fight for my grandfather, who is unable to speak for himself."


Observation of the LTCU living room area on 04/21/21 at 11:20 AM showed a non-sampled LTC resident and family member sitting on a couch together looking at memory box sitting shoulder to shoulder and wearing masks.


Observation on 04/19/21 at 3:15 PM showed Patient 3, assigned to a "Skilled" Swing Bed (SSB - the term SSB, used by the hospital, is defined as a swing bed patient under hospital swing bed regulations located on the hospital hall) in his room with a visitor. Patient 3 was not wearing a mask.

During an interview at that time, it was found the visitor was Patient 3's spouse. Patient 3 stated "One at a time, if there are more [visitors] you have to view them through the window."

Observation of the hospital swing bed hall on 04/21/21 at 2:53 PM showed SSB Patient 7 had a visitor in her room and the visitor wore a mask.

During an interview on 04/20/21 at 4:43 PM, Staff E, RN, stated the SSB patients could "have one visitor per day from 9:00 am to 4:00 pm, can be in the room but the visitor must wear a mask the whole time. The patient doesn't need a mask and we try to keep the door closed."

During an interview on 04/19/21 at 3:40 PM, Staff A, Registered Nurse (RN), stated that, SSB patients are allowed one visitor per day. ISB patient visitation rules are up [posted] at the long term care nurses' station, a sheet with a schedule on it. "A visitor has to call in advance (24 hours or so)." She stated that they are using the living area of the LTCU or outside, dependent on the [COVID] vaccine status as to whether the patient is required to be behind plexiglass. "If patient is not vaccinated, they must stay behind the plexiglass." When asked if the SSB patient's COVID vaccine status changed the procedure for patient visitation, Staff A, RN stated, "It doesn't matter, they can go in the room." Staff A, RN was asked to clarify the statement and verified it didn't matter if the SSB patient was vaccinated or not, they could have in room visits.

A review of the schedule sheet at the LTCU's nurses' station referred to by Staff A, RN showed:
"Indoor/Outdoor Visitation Appointment Schedule"
-All visits will occur in the living room unless the rsd [resident] is on comfort care & cannot leave their room
-VISITS WILL BE SUPERVISED BY A STAFF MEMBER to assure proper PPE and social distancing are followed. (INSIDE will be monitored on camera system, OUTDOOR will have staff outside within visual range but space to allow for privacy) Outdoor visits are still considered to have the lowest risk of transmission of COVID-19 and are to be encouraged if weather permits.
-Pre -arranged times will be scheduled and maintained through the Charge Nurse
-Only one (1) resident with visitors at a time (1 visit/resident a day) and maximum of two (2) visitors for each resident.
-Visits to be 45 minutes long to allow time for staff to clean the chairs and other surfaces touched for all visits and UV light for indoor visits. (DO NOT WIPE THE PLEXI-GLASS WITH DISINFECTANT WIPES)
-All visitors will be screened at the ER door with questionnaire and temperature. Any visitor with 100.4°F or new onset of cough, nasal congestion or sore throat will be denied the visit.
-All parties will wear facemask unless resident is deemed unsafe to do so.
-Facility will provide masks for residents. FAMILIES must provide their own.
-A fully vaccinated resident may choose to have close contact (including touch) with their visitor while wearing a well-fitting face mask and performing hand-hygiene before and after. Regardless, visitors should physically distance from other residents and staff in the facility
-RM [list of four room numbers] are not fully vaccinated and must continue to visit with Plexi¿ Glass between them and their visitor.
-All parties are required to perform hand hygiene prior to entering the visitation room and periodically throughout visit."

During an interview on 04/21/21 at 11:00 AM, Staff N, Long Term Care Director of Nursing (LTC DON), regarding the visitation practices for the ISB patients on the long term care unit hall and the different visitation practices for SSB patients stated, "Correct. They [ISB patients] have to follow the Cedar Village [LTCU] visitation policy. It's their understanding when admitted they are being admitted to the nursing home. Staff N further stated that the cost is the same and the only difference between the ISB patients and the long term care residents is that no Minimum Data Set (MDS) assessment is needed to be completed for the ISB patients.


Review of five patient records (Patients 1, 2, 4, 6, and 9) showed their rooms are located on the long term care hall and they are considered ISB patients by the hospital. The five patients do not have the same rights to visitation in their rooms as the patients designated as SSB patients (Patients 3, 7, and 8) and are limited to a 45 minute visit in the living room area as directed by the LTC visitation policy. The SSB patients on the hospital side are allowed to have one visitor per day in their room during reasonable hours, without a time restriction, regardless of vaccination status.

During an interview on 04/21/21 at 11:48 AM, Staff M, CNO stated that regarding the difference between the SSB and ISB visitation practices, Staff M confirmed the ISB patients on the long term care unit hall were following LTCU visitation rules, even though all swing bed patients "should be under our [hospital] jurisdiction, however, Staff N, LTC DON disagrees"