HospitalInspections.org

Based on document review and interview, facility staff failed to allow a patient to receive a visitor for 1 of 10 medical records reviewed. (P1)

Findings include:

1. Facility policy titled, "Patient Rights and Responsibilities", PolicyStat ID 13517670, last revised 09/2021, indicated under PROCEDURE: You have the right to: 23. Designate visitors of your choice, if you have decision-making capacity, whether or not the visitor is related by blood or marriage, unless: a. No visitors are allowed. b. The facility reasonably determines that they presence of a particular visitor would endanger the health or the safety of a patient, a member of the health facility staff or other visitors to the health care facility, or would significantly disrupt the operations of the facility. c. Visitor restriction may also occur when clinically indicated. d. You have told the hospital staff that you no longer want a particular person to visit. e. The Hospital establishes reasonable restrictions upon visitation, including restrictions upon hours or visitation and number of visitors. f. Have your wishes considered, if you lack decision-making capacity, for the purpose of determining who may visit.

2. Review of P1's MR (medical record) indicated he/she was his/her own decision maker, had no POA (Power of Attorney), nor a documented HCR (Health Care Representative). Nursing Note documentation dated 10/13/2024 indicated P1 had visitation with C1 (Complainant) without issue. P1's MR lacked documentation of the need for visitor restriction on 10/14/2024.

3. In an interview on 11/27/24 at approximately 3:40 pm with R1 (Receptionist) confirmed the reason C1 was not allowed to visit P1 was d/t P1's confusion and inability to name C1 as a person he/she would like to visit with. R1 also confirmed that P1 refused to complete consent forms on 10/14/2024 but did complete his/her consent which included an access code and patient visitation rights forms on 10/16/2024. R1 did not feel comfortable letting C1 visit without a positive indication from P1 on 10/14/2024.

4. In an interview on 11/27/24 at approximately 4:30 pm with N1 (Registered Nurse) confirmed P1 received visitors on both 10/12/2024 and 10/13/2024 that included both family members (10/12/2024) and C1 (10/13/2024). On 10/13/2024 during the visitation C1 was concerned about P1 and the sudden decline in his/her health. N1 confirmed there was no reason P1 would not have been allowed to have visitors on 10/14/2024.

5. In an interview on 11/27/24 at approximately 4:45 pm with A1 (Chief Executive Officer) confirmed C1 was not allowed to visit P1 on 10/14/2024 but should have been.