HospitalInspections.org

Based on staff interview and document review, it was determined the facility's patient visitation policy failed to address the use of behavior contracts (for visitors) to restrict visitation privileges.

Findings:

The surveyor reviewed three (3) medical records which detailed the use of behavioral contracts for visitors who were believed to be disruptive or pose a safety risk. These behavioral contracts limited the person's ability to visit with patients while in the facility. (Patient #2, #8, and #9).

During an interview on January 14, 2025, Staff Member #11 indicated that a Behavior Contract policy (for visitors with disruptive behavior) is in development currently, to address the usage of Behavior Contracts/Patient Care Agreements, but it has been difficult to nail a policy down. There are five (5) campuses that would be affected by this policy and the difficulty is making sure the language fits each of the sites.

The hospital did not have a written policy for the use of the behavior contracts outlined above to restrict visitation. Also, the hospital did not have a written policy that describes the content of these contracts and who could implement them.