Policy Purpose: The purpose of this policy is to create a supportive, healing environment for patients and to ensure that all visitors of patients enjoy equal visitation privileges according to the patient’s preferences or patient’s designated representative. Main Line Health hospitals (MLH) welcome visitors and encourage family members and friends of our patients to spend time with them. We recognize the opportunity to improve recovery and healing through visitation and offer an open/flexible visitation policy for our patients and their families.

Policy Statement: MLH patients are permitted to have visitors 24 hours per day, seven days a week, as long as it is not critically disruptive to their overall healing. Visitation will be individualized to meet the patient’s and family’s needs. MLH staff will support and facilitate this to the best of their ability whenever possible. MLH may need to limit or restrict visitors to better care for the patient or other patients and to protect their health, privacy and safety. The patient has the right to be made aware of any such clinical limitations or restrictions. The patient is informed of these rights in the Patient Guide Book.

Scope: This policy applies to all persons admitted to a bed at MLH or a service at MLH (such as Ambulatory Care), their families, support persons, and visitors. It applies to all staff and employees of MLH.

Procedure:

I. Visitor Definition: The patient has the right to decide whether he/she wants visitors or not during his/her stay here. The patient may designate those persons who can visit him/her during his/her stay. These individuals do not need to be legally related to him/her. They may include, for example, a spouse, domestic partner (including a same sex partner), another family member, or a friend. MLH will not restrict, limit or deny any visitor on the basis of race, color, national origin, religion, sex, gender identity or expression, sexual orientation or disability. Visitors should not visit a patient if the visitor is ill in order to limit exposure of the patient to risk of disease, except in unique situations such as imminent patient death.

II. Hours: Visitors are welcome and hours are not restricted to special times.

III. Exceptions

A. The patient or the patient’s designated representative may make visitation limitations. A hospital administrator, nursing administrator or designee may modify the open/flexible visitation for a specific patient or patient care area for special situations, i.e., patient is undergoing a procedure or intervention; patient condition; patient or patient’s roommate need rest or privacy, hospital-related extraordinary situations such as an external or internal disaster; disruptive, threatening or violent behavior on the part of visitor, and when visitation may interfere with the care of other patients.

B. In the event that a visitor exhibits behavior that is disruptive, challenging or disrespectful or compromises patient or staff safety, MLH staff is to notify Security, Nursing Supervisor and/or Nurse Manager for assistance. If a visitor interferes with patient care, the visitor will be asked to leave. MLH staff will explain the reason for any limitation and document in the patient’s record as indicated.

C. Visitors or family members with existing court order restricting contact will not be allowed to visit.

D. Visitors are limited to 6 PM to 8 PM on the inpatient Psychiatry Unit at BMH.

E. The MLH maternity departments support 24 hour/7 day a week visitation. In order to provide a safe environment the visitor guidelines include: In labor and delivery only two support people may be at the bedside. Children visiting the unit must be at least one year of age or over and need to be current with their chicken pox vaccine. One partner or family member age 16 years or older may stay overnight. Any visitors who are sick or not feeling well (cold, flu, fever, etc), including siblings, should not visit. Healthcare providers may modify visitation in order to support a healthy environment.

F. Parents of the NICU infant will receive, and acknowledge by signature, the Neonatal Intensive Care Unit, Visitation Information Sheet. This is a visitation guideline for parents, grandparents, and visitors.

IV. Access

A. Between the hours of 5 AM and 9 PM visitors may arrive through the main lobby and/or the Emergency Room.

B. Between the hours of 9 PM and 5 AM visitors may enter the hospital through the Emergency Department, a designated entrance controlled by Security or the main lobby (BMRH and LMC). During the hours between 9 PM and 5 AM, visitors will sign in with a Security Office or designee and receive a dated visitor bracelet that must be worn at all times while visiting.

C. Visitors in the building after 9:00 PM are expected to have a dated visitor bracelet and permission to be there.

D. The recommended process for a visitor staying after 9:00 PM who does not have a visitor bracelet, is to contact Security who will issue a bracelet.

V. Number of Visitors

A. The number of visitors is dependent on the needs and comfort of the patient and the needs and comfort of the patient’s roommate in semi-private rooms.

B. Nursing staff may limit the number of visitors if it is disruptive to the healing environment.

C. Overnight visitors are not permitted in semiprivate rooms. Alternative arrangements may be made if possible.

VI. Overnight Visitors

There is an option for visitors to stay overnight when circumstances on the unit permit. The visitor must be at least 18 years old. This individual does not need to be legally related to the patient. They may include for example, a spouse, domestic partner (including a same sex partner), another family member, or a friend.

  1. Overnight visitors are expected to bring their own personal care items. There will be no storage of food for guests in the patient refrigerator.
  2. A cot or sleep chair may be offered if one is available on a first come-first serve basis.
  3. Guests must be modestly dressed with hospital visitor bracelet in place at all times.
  4. Visitors are asked to limit their travel at night to their designated room and hallways in their respective patient care areas.
  5. Visitors may not stay overnight if they require care or are not capable of self determination or self care unless a second visitor is willing to assume that care, for example, visitors with dementia or who require toileting assistance.
  6. Infants may remain overnight at the patients request if another adult remains present and responsible for all care of the infant at all times. The infant may never be left alone with the patient.

VII. Visitor Guidelines

A. Between the hours of 5 AM and 9 PM visitors may arrive through available entrances.

B. Between the hours of 9 PM and 5 AM visitors may arrive through the Emergency Department Entrance, designated entrances controlled by Security, or the front lobby (BMRH or LMC).

C. Visitors are to follow all isolation guidelines as instructed by nursing staff and/or as designated by signage outside the room. Failure to adhere to isolation guidelines may result in prohibition from visiting.

D. Visitors should be mindful to the needs of the patient and other patients by keeping noise and disturbances to a minimum.

E. Disorderly or disruptive visitors will be asked to leave the area immediately, campus Security will be notified, and the action documented. Alcohol and drug use is prohibited.

F. Visitors may be asked to leave the room for treatments and personal care needs to respect the privacy of our patients.

G. Minors 13 and under are welcome to visit accompanied at all times by an adult.

H. The number of visitors that can be accommodated is dependent upon the patient’s location, and generally, will range between one and three visitors at a time.

I. Visitors may have access to the patient’s bathroom in private rooms within limitations of isolation protocols.

J. Visitors are asked not to come to the hospital with cold and flu symptoms, if they are feeling ill, or have recently been exposed to communicable diseases or infection.

References:
  1. CMS Condition of Participation-Patient Rights 482.13
  2. Administrative Policy & Procedure IV.1., Photographing or Videotaping Patients
  3. Administrative Policy & Procedure I.30 Weapons on Hospital/Facility Property

Revision Date: 11/01, 1/03, 11/05, 3/06, 11/06, 11/07, 11/08, 11/09, 3/10, 11/10, 3/11, 4/11, 11/11, 5/12, 9/14, 11/14, 1/16, 2/17, 1/18

Key Contact: Site Vice Presidents
Approved/Reviewed by MLH Medical Executive Committee