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Based on medical record review, staff interview, and review of patient rights information and facility policies, the facility failed to ensure patients were fully informed of their visitation rights, including any restrictions or limitations, for 7 of 7 patients reviewed (#1, #2, #3, #4, #5, #6, #7). The findings were:

1. Review of the facility's policy "Visitation of Patients," revised 3/23, showed "All Patients (or their Support Person, where appropriate) shall have the right, subject to his or her consent, to receive visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend...Patient Visitation Rights shall not be restricted, limited, or otherwise denied on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability." Further, the visitation policy stated "...On the Adult Unit, visitation takes place on the weekends and must be arranged through the Therapy Department. Due to limited visitation space and the need to adequately monitor patients, patients will be limited to two (2) family members visiting at a time and will be allowed to visit for 15 minute intervals. A total of six (6) visitors may be visiting on the unit at a given time. Visitors to the Adult Unit must be 18 years or older...WBI may impose clinically appropriate limitations on patient visitation when visitation would interfere with the care of the patient, whether the reason for limiting or restricting visitation is infection control, disruptive behavior of visitors, or patient need for rest or privacy."

2. Review of the facility's "Patient Bill of Rights" given to patients showed only "Receive or refuse visitors."

3. Review of the admission packet given to patients showed only "Visitation. We encourage visitors to enhance positive relationships and communication skills among family members during a patient's course of treatment. Visiting hours vary by unit. Please ask the unit nurses for more information."

4. Review of the following patient records showed the patients were given the "Patient Bill of Rights" and the admission packet, which did not fully inform the patient of the facility's policy on visitation rights:
a. Patient #1 admitted 6/3/24.
b. Patient #2 admitted 6/3/24.
c. Patient #3 admitted 6/6/24.
d. Patient #4 admitted 5/30/24.
e. Patient #5 admitted 6/6/24.
f. Patient #6 admitted 4/12/24.
g. Patient #7 admitted 5/21/24.

5. During an interview on 6/11/24 at 12:01 PM the associate administrator stated there was no other documentation regarding visitation rights provided to patients.