HospitalInspections.org

Based on interview and document review, the hospital failed to ensure a patient (P)-1 was allowed visitors while admitted to the inpatient mental health unit. This had the potential to affect all patients who were admitted to the inpatient mental health behavioral units.

Findings include:

Guidance from the Centers for Medicare & Medicaid Services (CMS) revision date 9/26/22, in conjunction with the Centers for Disease Control and Prevention (CDC) reference QSO-21-08-NLTC pursuant to regulations such as 42 CFR 482.13(h), §483.420(a)(9), and §418.110(e), patients have a federal right to receive visitors at any time. We recognize that requirements for entering healthcare facilities (such as visitation restrictions and screening procedures) have been used throughout the COVID-19 PHE to mitigate the introduction of COVID-19 into facilities. While CMS guidance has focused on protecting patients and staff from COVID-19, we recognize that restricting visitation from family and other loved ones has taken a physical and emotional toll on patients. At this time, CMS is not issuing updated federal guidance on visitation.

On 2/8/23, at 10:30 a.m. during a tour of the inpatient mental health unit, registered nurse (RN)-A stated visitors and family members were not being allowed to visit patients per COVID restrictions. RN-A stated there were currently 16 patients on the unit. RN-A stated the risk of spreading COVID-19 had been greater due to multiple shared rooms, and patients being in close contact with each other. RN-A stated all patients being admitted to the inpatient mental health unit were tested for COVID-19.

On 2/8/23, at 10:45 a.m. P1 was interviewed and stated he had been on the mental health unit for a few weeks. P1 stated his family had wanted to come visit him, and he had wanted his family to visit, but they were not allowed to come and visit him.

On 2/8/23, at 11:05 a.m. mental health coordinator (MHC)-A was interviewed and verified patient had not been allowed visitors during their stay on the inpatient mental health unit. MCH-A stated patients had expressed concerns about not being allowed to have visitors.

On 2/8/23, at 11:10 a.m. RN-B was interviewed and verified patients had not been allowed visitors during their admission stay on the inpatient mental health unit. RN-B stated patients had expressed concerns about not being allowed to have visitors, and asked to be allowed to have visitors frequently.

On 2/8/23, at 11:15 a.m. (MHC)-B was interviewed and verified patient had not been allowed visitors during their admission stay on the inpatient mental health unit. MCH-B stated patients had been asking all the time to have visitors because they miss seeing family members.

On 2/8/23, at 12:01 p.m. family member (FM)-A was interviewed and stated P1 had not been allowed visitors during his admission stay on the inpatient mental health unit. FM-A stated both himself and P1's power of attorney (POA) had spoken via email numerous times to the inpatient social worker (SW)-A, as well as the patient liaison (PL)-A regarding the restricting of visitors. FM-A stated he had been aware of the lifting of restriction visors per CMS guidance, and had shared this with the facility. FM-A stated he believed not allowing P1 to have his family members visit during his stay was detrimental to his health, and had caused him to decompensate mentally.

On 2/8/23, at 1:23 p.m. the patient care manager (PCM)-A for the inpatient mental health unit was interviewed. PCM-A stated patients had not been allowed visitors during their admission stay on the inpatient mental health unit. PCA-M stated she had been aware of the guidance lifting restrictions for allowing patients to have visitors; however, the hospital still had restriction in place. PCM-A stated these restrictions included not allowing visitors for the patients on the inpatient mental health unit. PCM-A stated the she had been aware of the concerns P1's family member had expressed about not being allowed to visit P1; however, Abbott Northwestern Hospitals policy was still in place, and restricted any visitors on the inpatient mental health unit.

On 2/8/23, at 2:57 p.m. nurse practitioner (NP)-A was interviewed and stated visitor restrictions were still in place for the inpatient mental health units. NP-A stated P1's family member had expressed concerns with her related to not allowing visitors per CMS guidance; however, the facility visitation policy currently did not allow for any visitors on the inpatient mental health unit except for compassionate care giver visits, and P1 did not meet the criteria.

On 2/8/23, at 3:15 p.m. during a conference call with Safety & Quality Manager (SCM)-A, Safety & SCM-B, Vice President of Mental Health Services (VP of MHS), System Manager for Infection Prevention (SMIP), System Director of Occupational Health (SDOH), Risk Manager (RM), Director Mental Health (DMH), Manager Mental Health (DMH) and Vice President of Medical Affairs (VP of MA) present, VP of MA stated he had been aware of CMS guidance which came out on 9/22/22, which directed visitor restrictions were no longer indicated for acute care settings. VP of MA stated the decision to continue to restrict visitors for patients admitted to the inpatient mental health unit was based on high COVID-19 prevalence rate in the greater metro area. VP of MA further stated the decision to continue to restrict visitors in the mental health unit setting was to mitigate the risk of spreading COVID-19 on the mental health units, and prevent closure of the units which occurred when there were two or more positive COVID-19 cases.

The facility's COVID-19 Visitor policy effective date 1/23, indicated the primary purpose of the policy is to balance the goals of preventing the spread of COVID-19 with meeting the needs of our patients and the family, and support persons involved in their care, and supporting a safe environment for the delivery of patient care. The policy directed visitors will be allowed in facilities only when approved according to this policy.
The policy directed Mental Health Patients (Adult and Pediatric) Including Mental Health Outpatient Programs.
Infectious Disease Red Status
No visitors allowed EXCEPT for the following situations as conditions allow:
o Children and adolescents may have one parent/guardian
o Patients who require assistance from a support person due to underlying impairment or disability
Infectious Disease Yellow Status
One visitor allowed during scheduled unit visiting times per care team's discretion on adult and geriatric units. Children and adolescents may have two parents/guardians:
o Patients who require assistance from a support person due to underlying impairment or disability
Standard Visitor Status (Green)
Visitors allowed during scheduled unit visiting per care team's discretion.