Failure to Ensure Unrestricted Visitation Rights
Penalty
Summary
The facility failed to ensure unrestricted visitation rights for a resident who had a history of chronic kidney disease, type 2 diabetes, muscle weakness/paralysis, cognitive communication deficit, major depressive disorder, and a history of homelessness. The resident had varying cognitive assessments, with a BIMS score indicating moderate cognitive impairment at one point and a higher score at another. The resident's care plan addressed major depression but did not include interventions related to visitation or social support. A health care liaison from another facility attempted to visit the resident to complete an assessment following a transfer referral. Upon arrival, the liaison was directed to the resident's room by nursing staff but was soon interrupted by the DON, who asked her to come to the administration office. The liaison was then questioned by the Administrator about her presence and was ultimately escorted out by the Business Office Manager, despite having previously communicated with the BOM about the visit. Staff interviews revealed confusion about the process, with some staff stating that visitors were allowed at any time unless there was a safety issue or the resident refused, neither of which applied in this case. Facility policy and resident rights documents confirmed that residents are entitled to immediate access by individuals providing health or legal services, subject only to the resident's consent. The Social Worker confirmed that the transfer referral had not been withdrawn and that the liaison had not been told not to visit. Despite these policies and the resident's rights, the liaison was not allowed to complete the assessment, resulting in a failure to honor the resident's right to receive visitors of their choosing.