Failure to Ensure 24-Hour Visitation Access
Penalty
Summary
The facility failed to ensure that residents had unrestricted access to visitors of their choosing at any time, as required by federal and state regulations and the facility's own policies. Specifically, one resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's Disease, vascular dementia, and major depressive disorder, was unable to receive visitors after 8:00PM because the front door was locked and staff did not respond to the doorbell. The resident's POA reported having to arrive before 8:00PM to visit and stated that repeated requests to facility leadership to address the issue were unsuccessful. The POA also attempted to alert staff through an electronic surveillance device in the resident's room, but staff did not respond to the front door. Interviews with the DON and Administrator revealed confusion and lack of implementation regarding after-hours visitor access. Although discussions had occurred about possible solutions, such as posting an on-call phone number or assigning a charge nurse to answer the door, no measures had been put into practice. Facility policies reviewed confirmed that residents are entitled to 24-hour visitation access, but these policies were not followed in practice, resulting in the resident's inability to receive visitors after regular hours.