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Based on policy review, record reviews, document review, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The deficient practices identified below had the potential to affect the physical safety and emotional well-being for all 109 inpatients at this facility.

1. The hospital failed to ensure patients received care in a safe setting related to inspecting patient belongings for contraband, observing patients in accordance with physician orders, and ensuring the physical environment was free of ligature and suffocation risk. (see findings in tag A0144)

2. The hospital failed to ensure the Interdisciplinary Team (IDT) reviewed and modified the patient's plan of care (POC) after use of restraints for one of four medical records reviewed for restraint use (Patient (P)8. (see findings in tag A0166)

3. The hospital failed to ensure the Registered Nurse (RN) conducting the face-to-face assessment of the patient in restraints had the specialized training to conduct that assessment for four of four medical records reviewed for restraints (P7, P8, P9, and P10). (see findings in tag A0205)

4. The hospital failed to ensure patients placed in mechanical restraints were monitored for respiratory rate and/or (see findings in tag A0175)

5. The hospital failed to ensure patients maintained the right to receive visitors during their hospital stay. (see findings in tag A0215)

6. The hospital failed to ensure patients and families received written notification of the complete ban on visitation rights. (see findings in tag A0216)

Based on policy review, record reviews, observations, and interviews, the hospital failed to ensure (1) patient belongings brought into the hospital by visitors after admission were searched in accordance with hospital policy resulting in three patients (Patient (P)P1, P2, and P3) overdosing and the death of P3, (2) patients were observed in accordance with practitioner's orders for four of six patients (P3, P11, P12, and P13), and (3) patients on Unit A were free from environmental risk of potential ligature risk. The deficient practices resulted in one patient death and had the potential to affect the current 109 inpatients and any future patients admitted to the hospital for psychiatric services.

Findings include:

1. Review of the facility policy titled, "Patient Rights and Responsibilities Procedure," revised May 2017, indicated ". . . In order to respect, protect, and promote patient rights, [name of hospital] employees and members of the Medical Staff shall: . . . 21. Respect the patient's right to receive care in the least restrictive environment possible, consistent with patient safety. . ."

Review of the facility policy titled, "Potentially Harmful Items on the Inpatient Wing," revised October 2020, indicated "I. Policy: Potentially harmful items are either kept off the inpatient wing of the hospital entirely or else patient access to these items is controlled according to the procedures outlined. II. Purpose: To maintain a safe environment through limiting patient access to potentially harmful items and through regular documented safety rounds by nursing staff of inpatient units. . . B. Potentially dangerous items include . . . 6. Medications, alcoholic beverages and illegal drugs. . . Items being left by visitors for patients are searched. . . Items brought to patients by visitors are also checked. Potentially harmful objects are returned home per policy. . . If illegal drugs are discovered, staff notifies the administrator-on-call. The drugs are deposited in the overnight safe. . ." There was no documentation that the policy addressed whether additional belongings received after admission had to be added to the belongings list. Further review indicated the policy did not address that staff were to complete a belongings list of the items brought onto the unit at the time of admission.

Observation of a hospital-provided video recording on 05/11/22 of Unit A from 04/30/22, starting at 9:37 AM (time shown on the monitor screen), in the presence of Director of Quality Management (DQM) and Director of Nursing (DON) who both identified the staff and patients visible in the video, revealed at 9:37:58 AM, Behavioral Health Associate (BHA)1was seen carrying a white plastic grocery-type bag onto Unit A. At 9:38:26 AM, BHA1 was seen with the bag behind the BHA desk with P1, P2, P3 standing at the BHA desk. At 9:38:49 AM, BHA1 obtained a pair of latex gloves and carried the bag out of sight, alone. At 9:39:43 AM, BHA 1 handed the bag to P2. At 9:40:32 AM P2 was seen opening the bag and entering Room 56, identified as P2's room by DQM and DON. At 9:40:51 AM, P1 was seen entering Room 56, and at 9:40:58 P3 was seen entering Room 56.

a. Review of Patient (P) 1's medical record indicated it was a closed record with no divider tabs. Review indicated P1 was admitted on 04/29/22 at 12:56 PM. Review of P1's "Admission Psychiatric Evaluation," dictated by Psychiatrist (Psych) 1 on 04/30/22 at 10:55 AM and electronically signed by Psych1 on 04/30/22 at 7:52 PM, indicated P1 was voluntarily admitted for opiate detoxification (detox). Further review indicated '. . . During this evaluation, the patient became obtunded [diminished responsiveness to stimuli, often due to a state of reduced consciousness], received Narcan twice. She admits that she was sharing unknown substances with two female patients on this unit. The patient was assessed and taken for medical evaluation to [name of Hospital A] by EMT [emergency medical technician] staff . . . Admitting Diagnoses: 1. Opiate use disorder, severe, with withdrawal. 2. Generalized anxiety disorder. 3. Cluster A and B personality disorder traits. 4. Rile out posttraumatic stress disorder. 5. Acute respiratory failure. Stressors: Severe. . . "

Review of P1's "Incident Report Form," documented by RN7 on 04/30/22 at 11:00 AM, indicated the approximate time of the incident was 10:15 AM on 04/30/22, the location of the incident was "Dayroom, RN Station," the type of incident was "Contraband" and "Other suspected overdose." Further review indicated witnesses included RN2 and Licensed Practical Nurse (LPN) 1. Review of "Facts Summary of Event" included "On 4/30/22 at approximately 10:15 am, on Unit A. Patient appeared overly sedated. Last medication taken was at 0900 which included Multivitamin, Folic acid, and Vitamin B1. Patient was then asked to sit down, vitals taken. Pulse ox immediately began to lower to 70's-80's, respiratory effected at 5 breaths per min, pale face, constricted pupils, and lost [sic] of conscious [sic]. Nurse assist called, 911 called, Sternal rub performed with no response. Patient Narcaned [sic] at 1017 am and again at 1020, bring [sic] patient respirations to 10 and pulse ox to 82%. Patient regained conscious [sic]. Sent to ED.

b. Review of P2's closed medical record with no divider tabs present indicated a nursing narrative note at 12:20 PM on 04/30/22, authored by RN2, that stated "Patient found unresponsive to voice but responsive to sternal (breastbone) rub. Patients [sic] pupils assessed found to be constricted. Narcan administered. Patient transferred to Room 57 by [Licensed Practical Nurse/LPN 2] and staff. 2nd Narcan administered. Patient became responsive to voice after 2 ml [milliliters] Narcan administered. EMTs [Emergency Medical Technicians] arrived and assumed care for the patient." The last physician's order noted was on 04/30/22 at 10:20 AM and read, "Send to ED [Emergency Department]."

c. Review of P3's "Incident Report Form," dated 04/30/22 at "1020" (10:20 AM) and completed by RN2, showed that under the type of incident "contraband" was circled, and under "other" was written, "suspected overdose." The "Facts Summary of Events," section dated 04/30/22 at "1400" (2:00 PM), stated that P3 was found in room by staff with no pulse, blue skin, and constricted pupils. Cardiopulmonary resuscitation (CPR) was started and 911was called. Narcan was administered "multiple times." P3 was intubated by EMTs (emergency medical technicians) and transported to the emergency room. Review of the "Discharge Summary" from Hospital A, dated 05/06/22, indicated P3 was diagnosed with "global anoxic brain injury" (occurs when the entire brain is deprived of oxygen causing significant damage) and expired on 05/06/22.

In an interview on 05/11/22 at 11:36 AM, RN6 stated he/she responded to a "Nurse Assist" overhead page to Unit A on 04/30/22. RN6 stated "We heard drugs came in with belongings brought in to [P2] and we'd heard [P2] had been antsy all morning, which is a red flag to us." RN6 stated he/she had a conversation that day with BHA1, and BHA1 admitted to searching the belongings bag brought in for P2, and also admitted that no additional items had been documented on the patient's belongings sheet.

In an interview on 05/11/22 at 4:32 PM, BHA1 stated BHA1, BHA2, and LPN1 were at the BHA desk when P2 asked if he/she could get his/her belongings that were dropped off the night before. BHA1 stated he/she asked the charge nurse (RN2) if he/she could get the belongings, and the charge nurse said yes. BHA1 stated around 8:30 AM, he/she asked the receptionist if there were belongings for Unit A. BHA1 stated the receptionist said yes, so he/she took the bag that had P2's name on it. BHA1 stated he/she got gloves and was going to search the belongings at the desk, but he/she went in the staff room to search. BHA1 stated he/she asked the other BHAs if there was a belonging sheet to chart, and they said no. BHA1 stated the bag had a top and bottom sweatsuit, socks, and a t-shirt. BHA1 stated he/she took the clothing out and searched them inside and out. BHA1 stated when he/she got out the break room, he/she handed the bag to P2. BHA1 stated P2 "really wanted that bag, [he'd/she'd] been asking about it." BHA1 stated P2 took the bag in his/her room. BHA1 stated he/she did not see any illegal substances when he/she searched the contents of the bag.

In an interview on 05/12/22 at 8:55 AM, DQM stated the hospital leadership suspect that something that was brought in the belongings bag for P2 was what caused the overdose of P1, P2, and P3. DQM confirmed the hospital policy for search of belongings did not include the need for the search to be done by two staff members and that the additional belongings needed to be added to list of the patient's belongings started at the time of admission.

In an interview on 05/12/22 at 9:32 AM, Administrator, when asked if Administrator suspected that something that was brought in the belongings bag for P2 was what caused the overdose of P1, P2, and P3, Administrator stated "absolutely!" Administrator stated, "I think it came into the belongings."

2. Review of the policy titled "Routine Observation of Inpatients," revised September 2020, indicated "Policy In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN [registered nurse] . . . The psychiatric practitioner will order one of three levels of observation at time of admission and as the patient's condition warrants a change: 15-minute (Q15) 5-minute (Q5) One-to-one (1:1) The psychiatric practitioner may also order a precaution level of observation for: Suicide Assault Elopement Seizure Fall Sexual Acting Out . . . Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following: Level of observation Precaution Location Behavior Activity Time Staff initial and Signature (legible with credentials) Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and or to back fill time frames that were not completed in a timely manner. . ."

a. Observation of the hospital-provided video recording of Unit A on 04/30/22 revealed BHA1 opened a crack in the door to Room 56 (P3's room) after listening at the door at 9:47:59 AM. The next observation was at 10:11:31 AM when BHA1 passed Room 56 and looked in the room through the opened door. There was 24 minutes with no observation of P3 who had physician orders for observations to be conducted every 15 minutes.

In an interview on 05/12/22 at 10:52 AM, DON stated he/she reviewed the video recording. DON confirmed BHA1 did not observe P3 every 15 minutes as ordered by P3's physician.

b. Review of the admission orders for P11, P12, and P13 indicated each patient had physician orders for every 15-minute observations, and each were ordered to be on suicide precautions.

Observation on 05/12/22 on Unit A at 12:08 PM revealed BHA3 was preparing boxed meals to be provided to the patients. While BHA3 continued to prepare patient meals at 12:25 PM (BHA3 remained at the BHA desk from 12:08 PM to 12:25 PM), P11, P12, and P13 were observed in their patient room. Continuous observation revealed no staff went down the hall where the rooms of P11, P12, and P13 were located to perform every 15-minute observations from 12:08 PM to 12:25 PM.

Observation on 05/12/22 at 12:26 PM revealed BHA3 went to observe P11, P12, and P13 who were in their rooms.

Observation of the "Patient Observation Record" for P11, P12, and P13 revealed BHA3 documented at 12:15 PM that P11 and P12 appeared asleep in their room, and P13 was sitting in his/her room.

In an interview on 05/12/22 at 12:30 PM, BHA3 confirmed he/she did observations of P11, P12, and P13 at 12:25 PM but documented the observation on each patient's observation record as being done at 12:15 PM. BHA3 confirmed every 15-minute observations were not done as ordered.

In an interview on 05/12/22 at 12:40 PM, BHA3 stated one BHA should have gone to make patient observations while the other BHA prepared the patients' lunches.

In an interview on 05/12/22 at 1:00 PM, RN1, the charge nurse on Unit A, stated "it's tough when we have two BHAs, but one BHA is supposed to stop [assisting with lunches] and do the [every 15-minute] checks."

3. Review of the policy titled "Potentially Harmful Items on the Inpatient Wing," revised October 2020, indicated ". . . General contraband: (not permitted on inpatient wing. . . 3. Electric cords (except as below under direct supervision) 4. . . plastic bags . . ."

Observation on Unit A on 05/10/22 from 9:30 AM to 10:30 AM revealed the following safety risks:
a. Staff lounge door was open with access to patients that had a microwave with an exposed electrical cord and two bathrooms that had toilet plumbing that was not contained and sink faucet handles that were ligature risks. The entrance door to the staff lounge had three hinges with spaces between each and the above-door hinge that were ligature risks.
b. At the end of the hall where the "Sharps Closet" and the "Clean Linen" closet were located, there was a shower chair that had a large plastic liner covering it that presented a suffocation risk.

The census on Unit A was 23, with all patients ordered to be on suicide precautions.

In an interview on 05/10/22 at 10:13AM, DQM confirmed the above-listed observed items were risks to patient safety. DQM stated the staff lounge door should remain closed and locked at all times.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure the Interdisciplinary Team (IDT) reviewed and modified the patient's plan of care (POC) after use of restraints for one of four medical records reviewed for restraint use (Patient (P)8. Failure to modify the patient's POC after the use of restraints could lead to inappropriate patient treatment decisions and interventions, with possible negative outcomes for all 109 inpatients receiving care at this facility.

Findings include:

Review of the "Psychiatric Evaluation" in the medical record of P8 revealed the patient was admitted on 03/17/22 for suicidal ideations and Major Depressive Disorder (MDD).

Review of the "Seclusion/Restraint Packet," dated 04/05/22, revealed P8 was placed in mechanical restraints from 12:00 PM to 2:30 PM for documented self-harming behaviors. In the section of the "Seclusion Restraint RN [Registered Nurse] Assessment," the question, "What revisions need to be made to the Treatment Plan? If no changes - why?" the documented entry was "N/A."

During an interview with the Director of Nursing (DON) on 05/12/22 at 3:35 PM, the above documentation was reviewed. The DON agreed the documentation showed no review or modification of P8's treatment plan was conducted.

Review of the facility policy titled, "Seclusion & Restraint," last revised 06/2020, revealed, "Treatment Planning Following the Intervention: At the Treatment Team meeting following the intervention, the patient's clinical status and treatment is reviewed and a written modification to his Treatment Plan is made to address the behaviors necessitating the intervention."

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure patients placed in mechanical restraints were monitored for respiratory rate and/or circulation checks for four of four patient (Patient (P)7, P8, P9, and P10) records reviewed for use of restraints. Failure to provide appropriate monitoring of patients in restraints had the potential to lead to negative outcomes for all 109 inpatients at this facility including injury or death.

Findings include:

1. Review of the "Seclusion/Restraint Packet," in the medical record of P7 revealed P7 was placed in mechanical restraints on 05/06/22 from 6:00 PM to 7:30 PM. Documentation in the "Physical/Medical Assessment" portion of the packet showed, "Document vitals and results of body system assessment, medical history, medication and lab review - note all results." In the vital signs portion of the form was the entry "Refused," and the section "R" for respiratory rate was blank. In the "Patient Monitoring" section of the packet, the entries at 6:00 PM, 6:30 PM, 7:00 PM and 7:30 PM, for vital signs was, "Refused," with no respiratory rate documented. There was no documentation of circulation checks for the assessments conducted every fifteen minutes throughout the restraint episode.

2. Review of the "Seclusion/Restraint Packet," in the medical record of P8 revealed P8 was placed in mechanical restraints on 04/05/22 from 12:00 PM to 2:30 PM. In the "Patient Monitoring" section of the packet, the entries every fifteen minutes showed no documentation of circulation checks for the assessments conducted every fifteen minutes throughout the restraint episode.

3. Review of the "Seclusion/Restraint Packet," in the medical record of P9 revealed P9 was placed in mechanical restraints on 04/04/22 from 4:30 PM to 5:45 PM. Documentation in the "Physical/Medical Assessment" portion of the packet showed, "Document vitals and results of body system assessment, medical history, medication and lab review - note all results." In the vital signs portion of the form was the entry "Refused," and the section "R" for respiratory rate was blank. In the "Patient Monitoring" section of the packet, the entries at 5:00 PM and 5:30 PM, for vital signs was, "Refused," with no respiratory rate documented. There was no documentation of circulation checks for the assessments conducted every fifteen minutes throughout the restraint episode.

4. Review of the "Seclusion/Restraint Packet," in the medical record of P9 revealed P9 was placed in mechanical restraints on 05/02/22 from 2:45 PM to 3:45 PM. In the "Patient Monitoring" section of the packet, the entries every fifteen minutes showed no documentation of circulation checks for the assessments conducted every fifteen minutes throughout the restraint episode.

During an interview with the Director of Nursing (DON) on 05/12/22 at 3:35 PM, the above documentation was reviewed. The DON agreed that even if a patient refused to allow the use of equipment to assess vital signs, the staff should count the patient's respiratory rate because this does not require the patient's compliance. The DON, upon review of the "Seclusion/Restraint Packet" agreed that the "Intervention" documentation codes provided state "Circulation Checks (Q [every] 15 min [minutes])." The DON agreed the four medical records reviewed showed no documentation of circulation checks were completed during the periods of restraint.

Review of the facility policy titled, "Seclusion & Restraint," last revised 06/2020, revealed, "Signs of physical injury or other medical concerns are reported immediately to the unit charge nurse or qualified designee ...If the patient is in mechanical restraints, circulation is checked on his extremities at least every thirty (30) minutes - every hour by a nurse and on the half-hour by the assigned staff member. Circulation checks are documented on the Seclusion/Restraint Record."

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure the Registered Nurse (RN) conducting the face-to-face assessment of the patient in restraints had the specialized training to conduct that assessment for four of four patient (Patient (P)7, P8, P9, and P10) medical records reviewed for restraints. Failure to ensure staff is adequately trained to conduct the medical and behavioral evaluation of patients in restraints had the potential to lead to negative outcomes for all 109 inpatients in this facility including injury and/or death.

Findings include:

1. Review of the "Seclusion/Restraint Packet," in the medical record of P7 revealed P7 was placed in mechanical restraints on 05/06/22 from 6:00 PM to 7:30 PM. Documentation in the "One Hour Face to Face Assessment" portion of the record, which includes sections on "Patients Immediate Situation/Reaction to Restraint; Physical/Medical Assessment; Behavioral Assessment; Need to Continue or Discontinue Restraint or Seclusion; and Treatment Recommendations Discussed with Medical Staff," was signed by RN10.

2. Review of the "Seclusion/Restraint Packet," in the medical record of P8 revealed P8 was placed in mechanical restraints on 04/05/22 from 12:00 PM to 2:30 PM. Documentation in the "One Hour Face to Face Assessment" portion of the record, which includes sections on "Patients Immediate Situation/Reaction to Restraint; Physical/Medical Assessment; Behavioral Assessment; Need to Continue or Discontinue Restraint or Seclusion; and Treatment Recommendations Discussed with Medical Staff," was signed by RN8.

3. Review of the "Seclusion/Restraint Packet," in the medical record of P9 revealed P9 was placed in mechanical restraints on 04/04/22 from 4:30 PM to 5:45 PM. Documentation in the "One Hour Face to Face Assessment" portion of the record, which includes sections on "Patients Immediate Situation/Reaction to Restraint; Physical/Medical Assessment; Behavioral Assessment; Need to Continue or Discontinue Restraint or Seclusion; and Treatment Recommendations Discussed with Medical Staff," was signed by RN10.

4. Review of the "Seclusion/Restraint Packet," in the medical record of P10 revealed P10 was placed in mechanical restraints on 05/02/22 from 2:58 PM to 5:20 PM. Documentation in the "One Hour Face to Face Assessment" portion of the record, which includes sections on "Patients Immediate Situation/Reaction to Restraint; Physical/Medical Assessment; Behavioral Assessment; Need to Continue or Discontinue Restraint or Seclusion; and Treatment Recommendations Discussed with Medical Staff," was signed by RN9.

Review of the facility policy titled, "Seclusion & Restraint," last revised 06/2020, revealed, "Trained Registered Nurse: Includes Nursing Coordinators and Nurse Administrators designated and trained to complete, in consultation with an LIP (Licensed Independent Practitioner), the face-to-face medical and behavioral Evaluation of a patient in seclusion or restraint. Training includes completion of the Crisis Prevention Institute (CPI)Nonviolent Crisis Intervention program ...An LIP, or trained Registered nurse in consultation with an LIP, completes an in-person face-to-face assessment within one (1) hour of the initiation of the intervention."

Based on observation, staff interview, Center for Disease Control and Prevention (CDC) visitation recommendations, and review of facility policies, the facility failed to ensure patients maintained the right to receive visitors during their hospital stay. Failure to provide a means for patients to receive visitors infringed on the rights of all 109 inpatients receiving care at this facility, with possible negative psychosocial effects on these patients.

Findings include:

Observation of the facility during a tour on 05/10/22 at 9:00 AM with the Director of Quality Management (DQM) revealed multiple outdoor courtyards with benches were utilized by staff and patients during the day as weather permitted.

During an interview with Registered Nurse (RN)4 on 05/11/22 at 11:09 AM, when asked about the facility visitation policy, RN4 stated, "We haven't had any since coronavirus." RN 4 stated that visitors are only allowed if approved by the facility Social Worker or by the patients' doctor. When asked if patients have asked for visitors, RN4 stated, "Yes, but we tell them 'No," and added he/she was not aware of any policy related to this restriction.

During an interview with RN6 on 05/11/22 at 11:36 AM, RN6 stated that there have been no visitors allowed, "since COVID." RN6 stated that patients and family members have asked about visitation and have been told, "No."

During an interview with Licensed Practical Nurse (LPN)1 on 05/11/22 at 12:06 PM, LPN1 stated that current visitation policy, as told to him/her by nursing supervisors, is, "No visitors are allowed due to COVID." LPN1 stated patients, "Ask all the time." When asked if patients and/or family had ever complained about lack of visitor privileges, LPN1 stated, "Yeah, maybe once every three months a patient says, 'I wish I could see my friends."

During an interview with RN3 on 05/11/22 at 12:33 PM, RN3 stated that no visitors are allowed in the facility. RN3 stated, "I've been here two years and there have been no visitors allowed. RN3 stated parents sometimes ask about visitation and, "I tell them we can't due to COVID." RN3 stated sometimes family members, "Get upset, because there is confusion between the Emergency Room, where they can visit, and here, where they can't."

During an interview with the DQM on 05/10/22 at 8:55 AM, the DQM stated there are currently no visitors allowed in the facility due to COVID and that the decision was made by the facility Administrator.

During an interview with the facility Administrator on 05/12/22 at 9:38 AM, the Administrator stated, "My decision was to end visitation at the start of COVID." The Administrator also stated that prior to this restriction the layout of the building made visitation difficult, and "More beds have been added but there was no decent visitation space. We had to bring visitors to the units, and this was difficult. " The Administrator stated, "Sometimes parents prepare to leave, the patient becomes upset and acts out, and we have a problem." When informed of the current low county transmission rate and current Centers for Disease Control and Prevention (CDC) guidelines which define mitigation strategies but do not advise complete restrictions of visitors to healthcare facilities, the Administrator replied, "We are using the CDC guidelines subjectively due to our staffing and our building." The Administrator stated, "I'm sure we've had complaints about lack of visitors." The Administrator stated, "We have geriatric patients at risk and we're waiting for no COVID in the building." The Administrator stated that the facility had not yet developed any mitigation strategies which would allow visitors and still protect at-risk patients. The Administrator denied having any current revised facility policy addressing the restrictions of visitation due to COVID-19.

Review of the "CDC COVID Data Tracker," website for May 3, 2022, through May 9, 2022, indicated the facility's county transmission rate was identified as "Low."

Review of the CDC website page, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel [HCP] During the Coronavirus Disease 2019 (COVID-19) Pandemic Updated Feb. 2, 2022," revealed, under the heading, "Management of Visitors to Healthcare Facilities in the Context of COVID-19, Patient Visitation: 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic: Indoor visitation (in single-person rooms; in multi-person rooms, when roommates are not present; or in designated visitation areas when others are not present): The safest practice is for patients and visitors to wear source control [masks] and physically distance, particularly if either of them are at risk for severe disease or are unvaccinated. If the patient and all their visitor(s) are up to date with all recommended COVID-19 vaccine doses, they can choose not to wear source control and to have physical contact. Visitors should wear source control when around other residents or HCP, regardless of vaccination status. Outdoor Visitation: Patients and their visitors should follow the source control and physical distancing recommendations for outdoor settings described on the page addressing 'Your Guide to Masks."

Review of the facility policy titled, "Patient Rights and Responsibilities Procedure," last revised 05/2017, revealed, "Patient Rights: Allow family members, friend, or other individual to visit and communicate with the patient for emotional support during the course of stay."

Based on medical record review, staff interview, review of facility policies, and patient literature, the facility failed to ensure patients and families received written notification of the complete ban on visitation rights. Failure to provide information regarding visitation restrictions and the rationale for such restrictions infringed on the rights of all 109 inpatients and their support persons receiving care at this facility, with possible negative psychosocial effects on these patients.

Findings include:

During an interview with Registered Nurse (RN)4 on 05/11/22 at 11:09 AM, when asked about the facility visitation policy, RN 4 stated, "We haven't had any since coronavirus." RN 4 stated that visitors are only allowed if approved by the facility Social Worker or by the patients' doctor. When asked if patients have asked for visitors, RN4 stated, "Yes, but we tell them 'No," and added he/she was not aware of any policy related to this restriction.

During an interview with RN6 on 05/11/22 at 11:36 AM, RN6 stated that there have been no visitors allowed, "since COVID." RN6 stated that patients and family members have asked about visitation and have been told, "No."

During an interview with Licensed Practical Nurse (LPN)1 on 05/11/22 at 12:06 PM, LPN1 stated that current visitation policy, as told to him/her by nursing supervisors, is, "No visitors are allowed due to COVID." LPN1 stated patients, "Ask all the time." When asked if patients and/or family had ever complained about lack of visitor privileges, LPN1 stated, "Yeah, maybe once every three months a patient says, 'I wish I could see my friends."

During an interview with RN3 on 05/11/22 at 12:33 PM, RN3 stated that no visitors are allowed in the facility. RN3 stated, "I've been here two years and there have been no visitors allowed. RN3 stated parents sometimes ask about visitation and, "I tell them we can't due to COVID." RN3 stated sometimes family members, "Get upset, because there is confusion between the Emergency Room, where they can visit, and here, where they can't."

During an interview with the DQM on 05/10/22 at 8:55 AM, the DQM stated there are currently no visitors allowed in the facility due to COVID and that the decision was made by the facility Administrator. During a follow-up interview with the DQM on 05/11/22 at 12:55 PM, the DQM was asked how patients and family are notified of the current COVID visitation restriction. The DQM stated, "No information is given to the patients that I know of."

During an interview with the facility Administrator on 05/12/22 at 9:38 AM, the Administrator stated, "My decision was to end visitation at the start of COVID." When asked if written notice of the restriction was provided to patients and family members, the Administrator stated, "None at this time, they are just told by staff at the time of admission."

Patient medical records were reviewed for Patient (P)2, P7, P8, P9, and P10. In all cases, no written information related to visitation restrictions due to COVID-19 were located in the medical records. During the interview with the DQM on 05/11/22 at 12:55 PM noted above, the DQM confirmed no written notice was provided to the patients and no documentation was found of patients being verbally informed of this restriction.

Review of the facility policy titled, "Patient Rights and Responsibilities Procedure," last revised 05/2017, revealed, "Patient Rights: Allow family members, friend, or other individual to visit and communicate with the patient for emotional support during the course of stay."

Review of the facility policy titled, "Visitation," last revised 03/03/2020, revealed, "Each patient (or support person, where appropriate) will be provided written information regarding their visitation rights, including any clinical restrictions or limitations that may be imposed during the admission process."

Review of the document titled, "Adult Program Handbook," last revised 12/2016, revealed, "You have the right to see visitors during visiting hours, unless your physician decides that this would be harmful to you and your treatment."