PURPOSE

The purpose of this policy and procedure is to outline the process by which all visitors to the organization are to appropriately present and remain accounted for.

POLICY STATEMENT

It is the policy of Lake Chelan Health to provide a safe environment of care for our patients, visitors, and staff, while respecting, protecting, and promoting patient rights.

Lake Chelan Health allows a family member, friend, or other individual to be present with the patient for emotional support during their course of care and/or stay. All campuses allow for the presence of a support individual of the patient’s choice, unless the individual presence infringes on others’ rights, safety, or is medically or therapeutically contraindicated. The individual may or may not be the patient surrogate decision-maker or legally authorized representative.

It is the policy of Lake Chelan Health that all visitors to any of the campuses belonging to Lake Chelan Health are required to check in with Patient Access upon arrival. Visitors will receive a visitor badge indicating whom they are visiting.

If a support person accompanies any patient in any department, it is the policy of Lake Chelan Health that they will also check in with Patient Access upon arrival to receive a visitor badge.

Staff from Columbia Valley Community Health (CVCH) are welcome at Lake Chelan Health; however, they are required to wear their CVCH employee badge and visible to any LCH staff.

Any person not readily or easily identifiable can be challenged and asked to sign in at Patient Access.

SCOPE

The scope of this policy applies to all LCH staff and all visitors to the facility.

ROLES & RESPONSIBILITIES

It is the responsibility of all LCH staff to ensure the safety and security of the facility, co-workers and patients. Should a staff member encounter an unidentified person, the LCH staff member should ask the person who they are and what their business at LCH is. The LCH staff member shall also route the unidentified person to Patient Access to check in and obtain a visitor badge.

DEFINITIONS

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PROCEDURE

GUIDELINES FOR GENERAL HOSPITAL AREAS: 

1. Inform each patient (or support person, where appropriate) of their visitation rights, including any clinical restriction or limitation on such rights.
2. Inform each patient (or support person, where appropriate) of the right, subject to their consent, to receive the visitors whom they designate, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and their right to withdraw or deny such consent at any time.
3. Lake Chelan Health will not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability.
4. Ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences.
5. Lake Chelan Health recognizes that should a patient be incapacitated, a support person will be required to make decisions on behalf of a patient regarding visitors.
6. Unless circumstances require otherwise, Lake Chelan Health shall accept a claim to be a patient support person at face value and shall not request documentation from a person claiming to be a support person.
7. When circumstances require, request written documentation of patient representation by a legal document. Examples of when documentation might be required are if there is a conflict between two visitors or if there is a dispute as to who the patient support person is. Lake Chelan Health shall follow RCW 7.70.065 in resolving conflicts among those claiming to be support persons.
8. In no case may Lake Chelan Health request documentation of status as a patient support person in a way that discriminates on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity, or disability. Legal and other authority: 42 CFR 482.13
9. Patients can expect the staff to encourage psychosocial support from family and significant others. Staff will maintain cultural awareness.
10. If necessary, staff may limit the number of visitors in the patient room, at any given time, in order to carry out their duties.
11. A relative or significant other may remain in the patient’s room overnight, if the patient desires, and if it is appropriate to their condition. Staff will provide one sleeper chair/couch per patient room to accommodate overnight visitors. In unusual circumstances, a second relative or significant other will be provided a sleeper chair/couch, if nursing judgment determines it appropriate. Exceptions may be made to this guideline when deemed appropriate by the nurse responsible for care (e.g., dying patient).
12. Visitors will be informed that the patient bathroom and shower are for patient use only and visitors will be directed to use public restrooms.
13. Visitors may not be restricted according to age, however, minors will be directly supervised by a non-employee adult at all times.
14. Visiting Hours;
    1. Visiting hours are from 8:00 a.m. – 8:00 p.m., unless otherwise stated later in this policy;
       1. Between the hours of 9:00 p.m. – 7:00 a.m., the nurse may consider asking any visitor who is not staying overnight to leave the premises if their presence is disruptive to the delivery of care and comfort of patients.
       2. Building access for visitors after 9 p.m.:
          1. Access after-hours will be limited to the Emergency Department
15. At any time, the House Supervisor or designee may ask any or all visitors to leave the premises if their behavior is deemed inappropriate or unacceptable for the hospital setting. Inappropriate behaviors include, but are not limited to:
    1. Loud talking or laughing which disturbs patient care
    2. Unattended minors
    3. Children who are crying loudly or otherwise creating a disturbance, or are running in hallways or rooms
    4. Drug or alcohol intoxication
    5. Excessive use of offensive language (e.g. profanity or racial slurs)
    6. Spitting
    7. Arguing with hospital personnel, or patient disrupting patient care
    8. Violent behavior or threatening violence
    9. Carrying weapons
    10. Offensive sexual behavior
    11. Rudeness, insolence, disrespectful or abusiveness
    12. Any behavior disturbing another patient
    13. Any behavior preventing the nurse or other staff from carrying out his/her duties
    14. Stealing
    15. Damaging property
    16. Any criminal act
16. If the House Supervisor or designee determines that a visitor(s) is behaving inappropriately, they will ask the visitor(s) to leave the premises. If the visitor(s) refuses to leave when asked, the House Supervisor/ designee will notify law enforcement and request assistance in removing the visitor(s) and appropriate action to obtain a no-trespassing order will be completed.
17. Patients/Visitors who have weapons on their person will be asked to store them in their vehicle. If the individual does not comply, staff will contact law enforcement.
18. If, at any time, any person feels threatened with violence, the House Supervisor or designee will notify patient access to page Code Gray and remove all bystanders from the immediate area.
19. Visitors are restricted from entering the Nutrition Room, private offices, storerooms, utility rooms, or other areas deemed inappropriate by the House Supervisor or designee.

GUIDELINES FOR PERI-OPERATIVE AREAS:

1. SURGERY DEPARTMENTS:
   1. During the preoperative phase of care: preoperative patients may, at their request, and if space is available, have one visitor sit at the patient’s bedside at the discretion of the attending registered nurse. Two support persons may be approved on a case-by-case basis.
   2. During the intraoperative phase of care, the visitors and/or family members shall be asked to wait in the waiting room. They will be kept informed of the patient’s progress and will be informed at the procedure’s end and may wait in the waiting area for the surgeon.
   3. During the recovery phase I of care: visitors are not allowed unless a special need has been identified and communicated to the Recovery Nurse prior to the completion of procedure/surgery, i.e. Down Syndrome, Dementia, Post Traumatic Stress, etc. The patient and their significant other will be located in a recovery bay spaced away from the other recovery patients with curtains pulled to maintain patient privacy.
   4. During the postoperative phase II of care: postoperative patients may, at their request, and if space is available, have one visitor or family member at their bedside at the discretion of the attending registered nurse.
      1. The curtain may be drawn around the patient’s bed to protect the privacy of other patients in the line of sight.
      2. The curtain’s position will be at the attending registered nurse’s discretion. They may feel a patient needs closer monitoring and may wish the curtain not be entirely closed.

INFECTION PRECAUTIONS

1. The presence of a suspected or diagnosed infectious condition may require restriction of visitors or that visitors follow specific infection control precautions consistent with those practiced by staff. The plan for the patient’s care will address management of visitors when precautions in addition to Standard Precautions are required. This plan will be based on Infection Control policies and procedures and consultation between the attending physician(s), nursing and Infection Control staff.
2. FOR COVID-19 SUSPECTED OR CONFIRMED PATIENTS IN ISOLATION:
   1. COVID-19 patients in isolation are permitted visitors only under the following circumstances:
      1. End of life COVID-19 patients still in isolation are limited to two visitors at a time with a maximum of six total visitors. “End of life” is defined as death being imminent within the next 24 hours. Those waiting their turn to visit the patient will not be permitted to congregate in hospital lobbies or waiting rooms.
      2. Goals of Care discussions with family and/or significant others should occur remotely utilizing video conferencing technology. At the discretion of the department manager, two family members or significant others may be in the patient’s room during goals of care discussions. “Goals of care discussions” specifically refers to instances where a patient’s clinical status deteriorated enough, despite our best efforts, that a frank discussion about anticipated best-case/worst-case outcome needs to occur to ensure we are respecting a patient’s and their families’ wishes and values in further medical care.
      3. Obstetrics COVID-19 patients may have visitors on a case-by-case basis as determined by department leadership based on the needs of the patient.
      4. Religious leaders may visit COVID-19 patients during normal visiting hours unless the patient status dictates otherwise or the presence of the religious leader disrupts patient care. Visits must be arranged through the House Supervisor.
      5. Visitors will be instructed to only visit the patient room and to minimize their time spent in other locations in the facility to minimize environmental contamination outside of the patient room.
      6. Visitors will be provided with instructions, before they enter the patient’s room on the following topics: the risks of an in-person visit, hand hygiene, limiting surfaces touched, and the use of personal protective equipment consistent with those practiced by staff.

SPECIAL CONDITIONS: 

Certain areas within the facility have been identified as higher risk inherent to their specific function and special applications will apply. The following areas include:

1. CAFÉ
   1. Will be open to the public from 7:00 a.m. to 4:00 p.m.
2. EMERGENCY DEPARTMENT:
   1. Visitors will be limited to two per patient. Visitors will be requested to stay in the appropriate patient room to maintain confidentiality of all patients. Visitors may rotate in to see a particular patient or more than two visitors can be allowed at the discretion of the RN. In the event that the patient is critical, or whose illness or condition warrants more family, the waiting room can be utilized to keep family together and enhance contact by the physician with the patient’s family.
3. OBSTETRICS:
   1. Post Partum: Visiting hours are from 8:00 a.m. – 8:00 p.m. The Father or designated support person may stay with the patient beyond visiting hours.
   2. Labor & Delivery: Special conditions may allow families to remain with the patient any hour of the day as approved by nursing staff.
   3. It is not recommended that infants or children visit, however, special arrangements may be permitted after consultation with Obstetrics staff.
4. END-OF-LIFE AND COMFORT CARE:
   1. Check with unit staff or the House Supervisor on the number of loved ones/visitors allowed for patients who are at the end of life or receiving comfort care.
5. INDIVIDUALS WITH DISABILITIES
   1. Individuals with disabilities may continue to request reasonable accommodation and modifications of policies, procedures and practices under the Americans with Disabilities Act, Section 504 of the Rehabilitation Act and Section 1557 of the Affordable Care Act.

REFERENCES

COP 42 CFR 482.13: Patient Rights

RCW 7.70.065: Informed Consent

ATTACHMENTS

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*Note: policy must be published on the Lake Chelan Health website as updates occur.

*This policy may be revised at any time without prior notice. All revisions supersede prior policy and are effective immediately upon approval.
*Any printed policy is not valid past the print date and should not be relied on for official purposes. Current versions of all policies can be found in PolicyStat.