Visitation Policy

Purpose

To ensure that patients have a right to visitation from individuals of their choosing, free from unlawful discrimination, balanced by the health system's obligation to provide a safe and secure environment of care for all patients, staff and visitors. To set out processes for visitation hours management, in an effort to balance the above goals.

Policy

Patients of the health system may:

  • receive or deny visitors of their choosing, including spouses, domestic partners, other family members or friends.
  • designate a support person to help choose which visitors to receive or deny.

This right may be restricted for safety, security or infection prevention concerns identified by the health system, legal restrictions and court orders, and clinically necessary reasons, such as when healthcare professionals believe it's in the patient's best interest to limit visitation during clinical interventions, procedures or therapies.

The health system will not restrict, limit or otherwise deny visitation privileges on the basis on race, color, national origin, religion, gender or gender identity, sexual orientation or disability.

Working with nursing staff and Security personnel, the patient or patient's support person may request certain visitors be allowed full visitation, while others' visitation privileges are limited or denied. The health system will inform the patient or patient's support person the extent the request can be accommodated based on the resources available to control the visitor traffic and risk to Security operations overall.

The health system will maintain reasonable and effective processes to assure the safety and security of the facility while balancing the desire of patients to have visitors, especially outside the regular times of health system operation, generally considered to be 8am to 8pm.

In general, patients in police custody and/or correctional services custody will not be permitted to have visitors.

  • Minors in custody may be permitted to have a parent or guardian present depending upon the circumstances, taking into account safety issues and the discretion of law enforcement. 

Definitions

Support person – an individual designated by the patient, either orally or in writing (such as in an advance directive), who can exercise the patient's visitation rights on behalf of the patient. The support person may be a family member, friend or any other individual who supports the patient during the course of the health system care. The support person does not necessarily have to be the same person as the patient's representative who is legally responsible for making medical decisions on the patient's behalf. The health system must accept a patient's designation of support person, absent an indication of fraud or multiple, inconsistent designations.

Procedures

Notification of Rights

All patients and designated support persons shall be notified of their visitation rights noted above by means of the health system's Patient Rights and Responsibilities document. In addition, inpatients will have the visitation rights specifically highlighted in a separate document upon admission.

When

The Patient Rights and Responsibilities document will be provided to patients upon registration for any treatment encounter or in the case of a series of related encounters, the first encounter of the series. The document also will be displayed in various areas around the health system service areas in conjunction with other similar notices (e.g., Section 1557 of the Accountable Care Act Notice of Nondiscrimination, Notice of Privacy Practices, etc).

How

Patient acknowledgment of being offered the Patient Rights and Responsibilities will be captured by initialing the applicable section on the health system-Patient Services Agreement.

Inpatient Care

Patients who are admitted to the inpatient unit will receive a separate informational sheet about visitation in their inpatient packet.

Support Person

If the patient has designated a support person, that support person will receive the Patient Rights and Responsibilities document as well.

Support person is assigned when:

  • patient is incapacitated or otherwise unable to communicate his or her wishes,
  • there is no advance directive designating a representative on file,
  • no one has presented any documentation related to designation of a support person, AND
  • an individual presents themselves as a family member, domestic partner or close friend to the patient and claims that they are patient's support person, the health system shall consider that individual as the patient's support person without demanding any written supporting documentation. The health system will provide that individual with the Patient Rights and Responsibilities document and allow the individual to exercise the visitation rights on behalf of the patient. 
    • If there are multiple people who claim to be the patient's support person in a situation in which the patient lacks capacity, the health system will work through the analysis and process described in the policy "Patient Rights and Responsibilities – Notice and Posting" to determine who may exercise the patient's visitation rights. 

 

Possible Restrictions to Visitation

The health system will work with patients and their support persons to review any restrictions that are imposed based on reasonable safety and security concerns as well as clinical considerations. Restrictions are allowable when, for example (not an exclusive list):

  •  There may be infection prevention issues
  • Visitation may interfere with the care of other patients
  • The health system is aware that there is an existing court order restricting contact
  • Visitors engage in disruptive, threatening or violent behavior of any kind
  • The patient needs rest or privacy
  • The patient in undergoing care interventions and the healthcare professionals involved in providing those interventions in the exercise of their best clinical judgment determine that visitation is not appropriate. 

 

Visitation Restriction

While generally the health system will not unreasonably restrict the number of visitors that a patient has at one time, there are times when it will be appropriate to do so, especially during periods of heightened infection control protocols (e.g., during a pandemic) or when the number of visitors interferes with the care of other patients and the operations of the facility. Notice will be given to the patient or the patient's support person of the limitation and rationale.

Age Requirements

Children younger than 12 years old should always be accompanied by an adult other than the patient. Visits by children younger than 12 years old should be coordinated between the patient/ support person, the patient's nurse, and if applicable, Infection Prevention and Security personnel. Information about and access to the patient should be developmentally appropriate. These children may only visit if they are able to comply with all safety, security, isolation and/or infection prevention precautions.

Staff Guidance

Visitors shall be guided by staff to comply with the following reasonable safety, security and infection control protocols:

  • Family and visitors should check with staff before entering the unit.  
  • Family and visitors should always use the available hand sanitizer each time they enter and leave the patient room or unit.
  • Family and visitors should follow all isolation and/or infection control precautions as instructed by nursing staff.
  • Family and visitors should not come to the health system if they are feeling ill or have signs of, or have recently been exposed to, communicable illnesses or infections. health system personnel reserves the right to ask family and visitors to leave if they show signs of illness.
  • Neither staff nor patients are permitted to provide oversight to visitors who cannot care for themselves; all visitors should be able to care for themselves or be accompanied by a guest who can care for them.
  • Family and visitors should only enter the room of the patient that they are there to spend time with.
  • Family and visitors should avoid touching anything used to care for the patient, including but not limited to medical equipment and devices, supplies and medications in the patient's room.
  • Family and visitors should not bring any latex balloons into the facility; only mylar foil balloons are permitted.
  • Family and visitors should not congregate in the hallways, and instead use the available waiting rooms in the various patient care areas.
  • To facilitate the rest and recovery of all patients, family members and visitors should be mindful and sensitive to the needs of other patients and families by keeping noise and disturbances to a minimum.
  • Visitors should not bring food or beverages in for a patient unless approved by the doctor or nurse or clinical dietician, nor should any drugs be brought in for a patient without coordination between nursing, pharmacy and the patient.
  • Family or visitors may not consume alcohol or illegal drugs while on the health system campus, nor may family or visitors bring weapons on to the premises.
  • Family or visitors may not smoke while on the health system premises.

Visitor overnight rooming 

  • A family member over 15 years old or other mature visitor of the patient's or support person's designation may spend the night with the patient if the patient is in a single room, space is adequate, and the overnight stay will contribute to the wellbeing of the patient. The individual who is rooming in must be able to safely stay alone and take care of their own needs.
    • Overnight stays must be coordinated with the nursing staff and Security.
  • Children under 15 years old may not remain overnight in a patient room unless preapproved by nursing staff and accompanied by a responsible adult. 

Visitation Decision Records

Visitation decisions needing to be passed on between shifts shall be documented in the medical record. Any refusal by the health system to honor a patient's or support person's visitation request shall be documented in the medical record, along with the specific basis for the refusal. 

Visitation Security Guidelines

Security should be made aware of any visitors who are in the building anywhere other than in the Emergency Department, outside the hours of 0800am to 0800pm, Monday through Friday. Security personnel will identify and log these visitors as provided in the attachment to this policy. It is the obligation of all staff to report to Security any individuals who do not appear to have legitimate patient care or visitation purposes being on the health system premises. 

End-of-Life Care Accommodations

Special Considerations for Accommodating Visitation during End-of-Life Care 

Additional Visitors

End-of-Life care and the passing of a patient who was receiving End-of-Life care often is associated with an increase of visitors to support and honor the patient/ patient's family.

The number of visitors allowed at one time during End-of-Life care will be based on current health system infection prevention, safety and security policies, and such policies will typically address: 

  • Infection Prevention and safety rules
  • Number of visitors allowed in the patient's room at one time
  • Number of visitors allowed in the Spiritual Room at one time during the patient's care
  • Number of visitors allowed in the Spiritual Room in the event of the patient's passing
  • Any associated time restrictions 

 

Additional Space

The Spiritual Room is available and often requested by the patient and patient's family for this purpose, consistent with traditional practices.

If the Spiritual Room is being considered for patient and/or family use during End-of-Life care circumstances, nursing staff shall notify and collaborate with: 

  • Security
  • Nutrition and Food Services
  • Facilities
  • Environmental Services
  • Nurse Supervisor-on-call
  • Administrator-on-Call

Each area will have questions and provide directions to help make the use of the room a respectful and accommodating environment during this special time, while assuring safety and security for all.

Questions?

Questions regarding interpretation of this policy or the associated procedures may be directed to the Chief Nursing Officer, Chief Administrative Officer, Compliance and Risk Manager, Safety Officer or Director of the Environment of Care. 

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