HospitalInspections.org

Based on a review of hospital policy and procedure, documents, medical records, and interview, the Department determined the hospital failed to ensure patients were allowed to have visitors during their admission at an inpatient psychiatric facility. This deficient practice poses the potential risk of violating a patient's right to visitors, an inability for family or friends to assess the patient's mental and physical health status and progress, having a detrimental effect on the patient's mental and physical health status and progress, and family and/or friends not being included in the patient's treatment plan.

Findings Include:

Policy titled "Visiting Hours," received 04/28/2022, revealed: " ...Hospital visiting hours are planned for each treatment program to enable patients to visit with family and significant others ...."

Hospital document titled "Patient Rights and Responsibilities" revealed: "...The patient has the right of access to people outside the hospital by means of visitors ...."

Hospital document titled "Visitation Policy," posted at the front entrance of the hospital revealed, " ...For Adolescence patients are permitted up to two visitors per visitation day, no switching allowed ...For Geriatric patents are permitted up to two visitors per visitation day, no switching allowed ...For Adult patients are permitted up to one visitor per visitation day, no switching allowed ...Due to COVID-19 social distancing protocols will allow only 14 patients to have visitors at a time. If full capacity, staff will call to reschedule for the following visitation day and placed first on the list to visit ...Please keep in mind that visitation is only 1 hour long and late arrivals will only be allowed to visit the remaining time left for visitation, no early departures ...."

Hospital website titled "QuailRunBehavioralHealth.com Latest Information on COVID-19 Precautions," identified, " ...We are actively monitoring and responding to all recommendations made by the Centers for Disease Control (CDC) and our local Health Authority ...In-person visitation has generally been suspended ...."

Centers for Medicare and Medicaid Services (CMS) memorandum subject, "COVID-19 Focused Infection Control Survey Tool for Acute and Continuing Care Providers and Suppliers (REVISED)," revealed, " ...Visitation Restrictions: We recognize that requirements for entering healthcare facilities such as visitation restrictions were used to mitigate the introduction of COVID-19 into facilities. At this time, continued federal guidance regarding visitation restrictions for ACC facilities are no longer necessary ...."

Document titled "Termination of Emergency COVID-19," signed 03/30/2022, identified, " ...Now, therefore, I, Douglas A. Ducey, Governor of the State of Arizona ...do hereby terminate the COVID-19 emergency response operational period established by me on March, 11, 2020 ...."

Employee #2 confirmed during an interview conducted on 04/28/2022, that the hospital started allowing visitors on Monday, 04/25/2022. S/He indicated that all patients and families were getting handouts explaining the visitation policy. When asked about current patients s/he stated s/he was sure they were notified of the hospital starting visitation, probably by social work.

Employee #5 verified during an interview conducted on 04/28/2022, that the hospital was only allowing adolescents to have visitors this week and would start allowing adults to have visitors the following week. S/he confirmed that they would be able to accommodate 20 patients to have visitors, not 14, as stated in the patient handouts. All incoming patients were being provided handouts on the new visitation policies. If there were more than 20 patients requesting visitors, then the visitor would be notified they would need to come on the following visitation day as they could not accommodate more visitors. Employee #5 stated on the first day they had visits open to adolescent families, there were about three or four visitors. S/He stated there were usually a lot more than 20 patients that received visitors during pre-pandemic visiting hours and their census is the same.

Employee #6 confirmed during an interview on 04/28/2022, that visitors were now being allowed for adolescent families. S/He also confirmed that there were computers available for virtual visits. S/He knew that new admissions were being notified of the visitation hours, but was unsure if current patient families were notified, although s/he was sure they were. Employee #6 went to the adolescent unit during the interview and reported back that the adolescent patients were asked if they were aware that visitors were now allowed in the hospital. Not all of the inpatients were aware of the change, and staff was currently working on notifying those families.