HospitalInspections.org

Based on medical record review, staff interview and review of policies and patient rights information, the facility failed to ensure patients were fully informed of their visitation rights, including any restrictions or limitations, and the right to receive visitors whom s/he designates, including a spouse (including same-sex partner), another family member or friend for 6 of 6 sample patients reviewed (#11, #12, #13, #14, #15, #16). The findings were:

1. Review of the facility's policy "Visitors," revised 2/15/2023 showed "Banner Health (BH) will not restrict, limit, or otherwise deny visitation privileges on the basis or race, color, national origin, religion, language, socioeconomic status, sex, gender identity, sexual orientation, or disability...Patients shall be informed of their rights for visitation upon admission and prior to the start of care...Patients (or their Support Persons or legally authorized representatives in case of patient's inability to do so) may provide consent for visitation or withdrawal of that consent at any time during the hospital stay. ..BH has the right to designate clinically appropriate and reasonable restrictions or limits to visitation...General visiting hours are 6 a.m. to 10 p.m...two visitors are permitted at a time..." In addition, the policy addressed restrictions/limitations based on disruptive conduct, infection prevention, age restrictions, when visitation may interfere with the care of other patients, and for the health and privacy and any patient sharing a room with another.

2. Review of the "Patient & Visitor Guide," provided to patients, showed that patient rights included "...Have access to visitors and to communicate with persons outside the facility, except where restrictions are necessary because of patient safety/health concerns. If restrictions are necessary, they will be explained to you and your family." The information did not fully inform the patient of the facility's policy on visitation rights.

3. Review of the following patient records showed the patients indicated on the Condition of Admission and Treatment form they were given information on patient's rights (Patient & Visitor Guide), which did not fully inform the patient of the facility's policy on visitation rights:
a. Patient #11 who was admitted on 7/7/24.
b. Patient #12, who was admitted on 7/24/24.
c. Patient #13, who was admitted on 9/8/24.
d. Patient #14, who was admitted on 9/8/24.
e. Patient #15, who was admitted on 9/10/24.
f. Patient #16, who was admitted on 8/8/24.

4. During interviews on 9/11/24 at 1:34 PM and 2:14 PM the regulatory consultant stated patients signed the Condition of Admission and Treatment form once per year, which indicated they received the patient guide. They were given the patient guide on each visit. She stated there was no other documentation regarding visitation rights.

Based on medical record review, and staff and family interviews, the facility failed to ensure medications were administered in accordance with professional standards for 1 of 6 sample inpatients (#12). The findings were:

1. Review of the medical record showed patient #12 was admitted on 7/24/24 and discharged 7/29/24. Review of physician orders showed on 7/25/24 the physician ordered brimonidine 0.1%, 1 drop to both eyes, three times a day and dorzolamide 2%, 1 drop to both eyes, three times per day. Both orders stated "Patient own medication- Stored on floor for patient use. Please return to patient prior to discharge."

2. Review of the medication administration record (MAR) for July 2024 showed the patient did not receive the eye drops at all during the hospitalization. Documentation showed the drops were not given for the following reasons: not appropriate at this time, patient sleeping, unable to give, and patient refused. There lacked further explanation for "not appropriate at this time" and "unable to give." In addition, there lacked evidence the physician was notified that the medication was not given on multiple occasions.

2. During an interview on 9/12/24 at 9:10 AM the medical unit manager stated the family of the patient brought in eye drops for the patient to use during the hospitalization. When the patient was discharged, staff were unable to locate the eye drops. Eventually they were found in a personal belongings bag. She stated the patient had moved rooms, so she was not sure when the drops were placed in the personal belongings bag, but were definitely in the bag the entire time the patient was in room 550. She further stated the eye drops should have been locked in the medication room, but were not.

3. On 9/12/24 at 9:20 AM the medical unit manager, director of nursing (DON) and regulatory consultant stated the facility's expectation is that the physician should have been notified of the inability to administer the medications. Further, they stated there was no evidence the physician was notified.

4. On 9/12/24 at 10:30 AM a family member for patient #12 stated they brought in eye drops for glaucoma the day after admission because the facility was unable to provide them. She stated when the patient was discharged, staff were unable to locate the eye drops. She stated they were eventually found in a personal belongings bag in a room the patient was previously in (the patient had moved rooms during the hospitalization). Further, she stated she didn't think the patient received the eye drops during the stay because the facility did not know where the drops were.

Based on medical record review, staff and family interviews, and policy review, the facility failed to ensure medications were stored in a secure area for 1 of 6 sample inpatients (#12). The findings were:

1. Review of the medical record showed patient #12 was admitted on 7/24/24 and discharged 7/29/24. Review of physician orders showed on 7/25/24 the physician ordered brimonidine 0.1%, 1 drop to both eyes, three times a day and dorzolamide 2%, 1 drop to both eyes, three times per day. Both orders stated "Patient own medication- Stored on floor for patient use. Please return to patient prior to discharge."

2. During an interview on 9/12/24 at 9:10 AM the medical unit manager stated the family of the patient brought in eye drops for the patient to use during the hospitalization. When the patient was discharged, staff were unable to locate the eye drops. Eventually they were found in a personal belongings bag. She stated the patient had moved rooms, so she was not sure when the drops were placed in the personal belongings bag, but were definitely in the bag the entire time the patient was in room 550. She further stated the eye drops should have been locked in the medication room, but were not.

3. On 9/12/24 at 10:30 AM a family member for patient #12 stated they brought in eye drops for glaucoma the day after admission because the facility was unable to provide them. She stated when the patient was discharged, staff were unable to locate the eye drops. She stated they were eventually found in a personal belongings bag in a room the patient was previously in (the patient had moved rooms during the hospitalization).

4. Review of the facility's policy "Medications Brought in by the Patient," reviewed/revised 7/5/2023, showed "...Medications brought into the hospital by a patient should be sent home with a family member or a person designated by the patient if the medication if not needed for facility administration. If not sent home, medications will be stored in the Pharmacy (or a designated, pharmacy-controlled secure medication storage area for non-24-hour pharmacies), segregated from hospital stock...Any medications that are needed for facility administration should not be placed into the tamper-resistant package but should be sent separately to Pharmacy for identification and subsequent temporary storage and dispensation."