Vaughan Regional Medical Center - Visitor Policy

UPDATED VISITATION GUIDELINES

Visitation Policy

POLICY:

Vaughan Regional Medical Center promotes and supports a patient and family centered approach to care. The purpose of this policy is to define and set expectations regarding persons visiting hospitalized patients and to recognize our commitment to provide visitation in accordance with our non-discrimination policy, which provides access without regard to age, race, color, national origin, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.  Visitors privileges will be full and equal, consistent with the preferences the patient or support person has expressed concerning visitors. The hospital reserves the right to limit visitation as it effects the welfare of the patient and/or interferes with hospital operations.

No food or drink will be allowed in any areas of patient treatment.

DEFINITIONS:

Support Person: The term support person is defined as a family member, friend, or other individual who is there to support the patient during the course of the hospital stay. This may include person(s) not legally related to the individual. Support person may include, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

Visitor: A "visitor" is defined as a guest of the patient. Family members are considered to be visitors as well. Visitors are encouraged to visit during the hospital visitation hours of 9 a.m. to 9 p.m. Due to the critical nature of certain units the visiting hours may be more restrictive.

Food and/or Drink: Any substance that is eaten, drunk, or otherwise taken into the body as nourishment, to provide energy, refreshment, provision, foodstuffs, edibles, liquids, etc.

Loitering: Anyone present on the property of VRMC who is not a patient, family, visitor (anyone not properly registered after hours), staff, vendors or anyone otherwise having business with the hospital. (See Page 4 - 11.G)

Backpacks or Other Large Packages: Any article designed to be worn on the body for storing and carrying large items or large volumes of items such as books, laptops, clothing etc. as are popular among school age students - any large bags or packages which can hold large volumes (anything larger than a normal medium sized woman's purse).

IDENTIFICATION OF INDIVIDUALS:

During normal business hours when the hospital is unlocked, visitors are permitted to come and go as indicated in this policy. Hospital staff will display I.D. issued by Human Resources. Patients will display I.D. wrist bands issued by the hospital. Physicians will wear identification badges issued by Human Resources on personalized lab coats with their name monogrammed for identification. Vendors, contractors and service or sales representatives will display I.D. provided by the hospital on a temporary basis. All other individuals will be considered visitors.

PROCEDURE:

1. Patients and/or support persons are informed of the right, subject to his or her consent, to receive the visitors whom he or she designated, including , but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.  
2. The hospital allows for the presence of a support individual of the patient's choice, unless the individual's presence infringes on others' rights, safety or is medically, therapeutically contraindicated or the patient withdraws or denies consent for support person. Hospital professionals will use their "best clinical judgment" to determine when visitation would interfere with the care of the patient and/or care of other patients.
   Clinically necessary or reasonable restrictions or limitations on visitation may be considered if any of the following apply:

1. Patient is undergoing care interventions;
2. Presence of infection control issues;
3. Visitation may interfere with the care of other patients;
4. Existence of court orders restricting contact (of which the hospital is aware);
5. Disruptive, threatening, or violent behavior of any kind;
6. Patient need for privacy or rest;
7. Need for limitation on the number of visitors during a specific time period;
8. Need for minimum age requirements for child visitors; and
9. Inpatient substance abuse treatment programs having protocol limiting visitation;
10. Space limitations in patient rooms. Only one adult of the same sex as the patient may stay overnight with a patient with a semi-private room. This is allowed only if the patient's condition warrants and with the knowledge and consent of the charge nurse.
11. Activation of hospital emergency operation plans and/or security concerns.

1. To help patients recover and to not overly tire patients, visitors should be brief, quiet and pleasant. The patient or patient's designated support person, in conjunction with the registered nurse and the healthcare team, may make additional limitations for family and visitors, especially in the intensive care units.
2. It will be at the discretion of the nursing staff to allow children under the age of 12 to visit under certain situations.
3. Visitation by children under the age of 12 is allowed in general areas but only under the direct and constant supervision of an adult (someone over age 18 and not the patient). To protect patient privacy and preserve patient health parents are required to keep children under control and not allow them to roam the building unattended.
4. All children under the age of 14 will be required to leave the hospital by 9 PM.
5. Pediatric patients age 10 and below, must have a responsible adult stay with them around the clock.
6. Visitors should not sit on patient beds, place personal items on the patients beds or use tobacco products.
7. Any time a visitor(s) creates a situation which is disruptive to the unit or interfering with patient care in any way, they will be asked to leave. If they fail to comply with the request to leave, the Nurse Manager/House Supervisor and/or Security will be notified.
8. The Security Department is responsible for safeguarding patients, physicians, employees, visitors, and the property and facilities of the medical center. In this regard, they will:

1. Inspect the building at the close of visiting hours daily (21:00 hours) to assure anyone remaining in the building is an employee, patient or visitor. Anyone found in the building not meeting this criterion will be informed that visiting hours are over and escorted out of the facility.
2. Refuse admittance to the Medical Center of any individual not displaying a photo I.D. after hours.

1. Security Officer ED Support:

1. The Security Officer will be available for assistance in the ER for unruly patients or visitors, arrival of any ambulance or a helicopter transfer when available and not involved in other duties. Assisting staff in the ER with unruly patients or visitors, or in any situation where potential violence may occur is a priority for the Security operation within the hospital. Security Officers will not become involved in clinical functions unless specifically directed by a Physician as a temporary life-saving incident.
2. The Security Officer may be needed to assist the ED admitting clerk if an unexpected high influx of patients occurs by obtaining basic information not clinically related. Information Security Officers will obtain will be limited to: Name, Time (use clock). Complaint only. Security Officers are not to get involved in the clinical functions of the hospital including the admitting process but will simply collect information that does not violate HIPPA and pass the information along to the admitting process. As soon as all patients basic information has been collected and passed along then the Security Officer is to return to normal duties.
3. If patient load is heavy and the receptionist is overwhelmed the Security Officer may be needed to provide access to allowed individuals into the admitting area and/or the ER treatment area. Officers are not to station themselves at the door to act as doormen or become involved in the clinical functions.
4. Security will enforce the visitation policies of VRMC regarding access to the treatment areas of the ED.
5. Security Officers have the authority to enforce this policy up to and including informing anyone they must leave the facility and campus for non-compliance with this policy. If the person is uncooperative and refuses to leave the Security Officer may contact the Selma Police for assistance. If the police are not adequately responsive in removing the uncooperative and disruptive individual from the property then the Security Officer may escort the individual off the property using reasonable force as is necessary and applicable to the situation.

Disruptive VisitorsCopy Link

Anyone who comes on campus as a visitor and creates a hostile or otherwise undesirable environment will be given the following options:

1. They may immediately alter their behavior to within acceptable parameters and be allowed to remain - otherwise their visitation rights will be affected in the following ways;
2. They will only be allowed on campus to seek treatment and/or visit family/friends who are hospitalized and only during normal visiting hours
3. They will only be allowed on campus if they remain in their vehicle and only if they are waiting to provide transportation to or from the hospital for family or friends.
4. They will not be allowed inside any buildings for any reason or allowed to loiter on campus at any time - otherwise they will be considered to be trespassing. Contrary to what some think Vaughan Regional Medical Center provides services to the community but is a privately owned business. Therefore to preserve the Patient Care environment for the benefit of our patients, to preserve patient information, to provide proper Security, reduce liability and to comply with regulatory guidelines - loitering is not permitted. Anyone who is found loitering on the property will be asked to leave for the above listed reasons. This includes;

1. Patients brought in by ambulance who have been medically evaluated and released,
2. Patients who come to the ED on their own who have been medically evaluated and released,
3. Anyone who has come to or been brought to the hospital who are not patients, family or currently visiting patients.
4. In the event unusual circumstances arise for someone who has been a patient and who have no means of leaving the property contact Case Management to have them evaluate the situation.
5. Anyone loitering on hospital property who refuses to leave are subject to removal by the Police.

1. If they are trespassing and refuse to leave when told to do so then the police will be called to remove them from the property
2. If while on campus for any of the above reasons they create further disruptions to hospital operations or hostilities toward any patient, visitor or staff, they will be banned from the property completely.
3. No backpacks or other large packages will be allowed in the ED Patient Treatment Areas to preserve Safety, Security and Patient Confidentiality. These items should be left in the patient or visitor's vehicle or at the registration desk during any visit to the Emergency Department. Items left at the registration desk will be located so that they are visible by the Security Camera Monitoring System at all times for liability concerns.

NORMAL VISITING TIMESCopy Link

1. INTENSIVE CARE UNITS (ICU)
   
   The Intensive Care Unit strives to provide the highest level of care to all patients and their families by creating a healing environment for the patients in our care. Part of this process is the importance of including the presence of family in the healing process when it is appropriate and beneficial. To achieve this the ICU has a flexible visitation policy that allows visitation at any time during hospital normal visiting hours, depending on the needs of the patients, family and the unit. (See After Hours Visitation section below).
2. ALL OTHER AREAS:
   
   9:00 AM to 9:00 PM
3. Number of Visitors
   
   Visitors will be limited to two (2) at a time. Other visitors who are present should wait in the general waiting areas. They may rotate their time in the patient's room.
4. General Waiting Rooms
   
   After 9 PM, if clinical conditions warrant and medical staff give permission, one (1) visitor may spend the night with the patient. The visitor must be able to safely stay alone and take care of their own needs and the visitor must meet the conditions of this policy.
5. Emergency Department
   
   Two visitors are allowed in the treatment area with each patient under normal circumstances. Special consideration is given for pediatric patients – both parents will be allowed and will have priority over other visitors. Clinical staff may determine variance to the visitation of visitors in the ED depending on the status of the patient. Visitors must obtain permission from clinical staff before being allowed to enter the patient care area past the registration desk at all times due to the potential disruptive nature of patient care.

1. ED VISITATION PROCEDURE
2. Visitor badges will be controlled by the ED Receptionist at all times to track the number of visitors with patients in each room at any given time. Visitor badges will have the assigned room number and individual hanger location so when visitors request access and there are no passes for that room no additional visitors will be allowed until the current ones leave.
3. The Triage Nurse will obtain visitor passes as permitted when a patient is assigned a room in the treatment area and provide to the visitors for the duration of their visit. Visitor passes are to be surrendered to the ED Receptionist when they leave the ED. Minors accompanied by their parents will not be provided a visitor pass or be counted as one of the visitors unless they are not controlled by their parents and create a compromise to the care, treatment and safety of patients in the ED. Physicians and/or Nursing staff may determine at any time that a minor who is being disruptive will have to leave the ED treatment area. No minors will be allowed to visit the ED treatment are unless they are accompanied by an adult.

AFTER HOURS VISITATION:

1. To provide privacy, proper care and security for patients and staff, certain guidelines are required throughout the hospital. After hours visitation is by special permission only and is an exception; not a rule.

1. A list of approved visitors should be provided to the ED Admitting Representative from the visitor registration log after the end of regular visiting hours each evening by all patient care units that allow visitors to remain after hours.
   1. It is the responsibility of the patient care units to list and identify all individuals who are allowed to remain after normal visiting and make sure they have the proper visitor ID for that day clearly displayed at all times. This information is to be shared with Security every day.
2. Permission for patient visitors to remain, or additional visitation after hours should be approved by the Unit/Department at the discretion of the House Supervisor or Security Officer on duty, ensuring compliance with this policy/procedure.
3. Security will tour all areas of the building after visiting hours have ended and the building has been locked for the day. All individuals encountered who are not displaying the proper visitor I.D. listed in this policy will be asked to leave and escorted out of the building.
4. Nursing and Security staff will inform any visitors they find remaining after visiting hours are over that visiting hours are in fact over for the day and that special permission is required to remain. This permission may be obtained from the patient's nurse, Manager/House Supervisor or the Security Officer but is an exception and not the rule. All visitors who are allowed to stay after visiting hours should register at the nursing station in the patient area they are visiting as soon as regular visiting hours are over and obtain a temporary Visitors I.D. Pass. A list of all visitors and those patients they are allowed to visit will be sent to the ED Admitting Representative as soon as all visitors are registered.
5. All visitors arriving after visiting hours should only enter the hospital through the ED lobby and register as visitors at the Lobby Reception Desk. The ED Admitting Representative will be responsible for contacting the patient or patient's nurse, House Supervisor or Security Officer for approval before allowing visitors access to the building or the patient areas. The ED Admitting Representative will check identification of all after hours visitors and verify that the visitor log and pass are properly filled out and match the identification before admitting anyone into the building. Acceptable identification will be a driver's license or other form of identification issued by federal, state, or local authorities which contains a photo for identification verification. Security will support the after hours visitation registration process as needed to help make the process as smooth and trouble-free as possible. The ED Representative will provide properly identified and registered visitors with a Visitors I.D. Pass and then give access. Security may provide assistance in this process if necessary.
   1. In the event individuals and/or families arrive after hours in response to an emergency or after hours admission, and the proper pictured identification has not been brought by the individuals, staff will take the necessary steps to confirm identification and process the family members for after hours visitation in compliance with this policy.
6. Anyone who is found to be in the building beyond the ED waiting areas after hours without a visitors I.D. pass will be required to comply with this policy. All persons in the building after visiting hours are over should be hospital employees clearly displaying hospital issued I.D., patients displaying hospital issued arm bands or properly registered visitors displaying a visitor I.D. pass.

REGULATION OF THE POLICYCopy Link

It is the responsibility of all Vaughan employees to inform visitors of and assist in the enforcing of this policy. If problems occur, the Nursing Director/Supervisor should be notified. If further assistance is needed, the Security Officer and/or Administrator on Call should be notified.

1. The Director of Plant Operations is responsible for making sure Security and the Director of the ED is aware of this policy and the proper guidelines for enforcing this policy. The Patient Access Director is responsible for properly training ED Admitting Representative staff on the execution of this policy.
2. The Chief Nursing Officer is responsible for making sure all House Supervisors/Nursing Managers are aware of this policy.
3. All House Supervisors/Nursing Managers are responsible for informing their staff of their responsibilities for compliance with this policy which affects privacy, proper patient care and overall security of the hospital and the safety of its patients, visitors and employees.
4. Directors and Managers are responsible for overseeing employee/visitor activities in their departments including informing visitors when visiting hours are over and monitoring visitors remaining in patient rooms overnight.
5. Security provides assistance to supervisors and staff as required.
6. The Safety Committee is responsible for periodic review of this policy and updates, changes and amendments as becomes necessary.
7. Human Resources is responsible for informing all new employees at general employee orientation of this policy.
8. All employees must wear a hospital photo I.D. badge with picture and name clearly visible at all times.
9. Patients are issued arm bands and must wear them at all times.
10. Vendors are required to register in Materials Management on the Reptrak system and wear an issued I.D. badge any time they are in the building.
11. Anyone in the building at any time not displaying the identification listed in H, I or J are regarded as visitors in accordance with this and all related policies.