Policies

VISITING HOURS

MCP Number 00-04

VA Western New York Healthcare System Rescinded Document:

Buffalo, New York 14215 MCP 07-04 dated February 19, 2020

Signatory Authority: Effective Date:

Michael J. Swartz January 1, 2024

Responsible Owner: Recertification Date:

Director’s Office January 1, 2029

1. PURPOSE: To establish policy and procedures relating to patient/visitor control and access to VA Western New York Healthcare System (VAWNYHS). To ensure patients at our facilities are afforded the privilege of seeing family and friends during their admission; ensure that proper care can be provided to facilitate patient’s clinical needs; and to ensure a safe peaceful environment for all patients and employees.

2. POLICY: Person(s) other than scheduled duty employees and those persons(s) or groups specifically authorized by the Medical Center Director to be within facility buildings other than business hours (M – F 8:00am – 4:30pm) will be requested to present a valid reason for their presence.

3. RESPONSIBILITIES:

A. All employees are responsible for identifying unauthorized persons throughout the

health care facility to their supervisors or the VA Police. This includes both the Buffalo

and Batavia Medical Centers.

B. Unit personnel will designate appropriate visiting areas and respond to visitors on

the ward. Visitors accompanying patients off the wards are asked to notify the nursing staff for authorization before doing so.

C. VA Police Officers are responsible for intervening with identified unauthorized

persons.

D. Children (under the age of 16) must have permission of the attending physician,

nurse manager or charge nurse to visit patients. Once permission is granted, they must be accompanied and supervised by an adult.

E. VA Police will respond to all requests for assistance made by the wards/lodges

regarding visitors and for inappropriate behavior or lack of compliance with this policy and/or CFR Title 38 Section 1.218. This includes but is not limited to:

1) Loud and disruptive behavior.

2) Failure to comply with staff requests and direction.

3) All visitors, regardless of location, may have visitation privileges restricted.

4. PROCEDURES:

A. Establishment of Official Business Hours:

1. Official business hours at Buffalo and Batavia, are from 8:00am to 4:30pm,

Monday thru Friday, excluding legal holidays.

2. Outpatients and their escorts who are here after 8 pm need to check in with a staff

member on the unit.

B. Outpatient Clinic and Services:

a. Children accompanying Veterans to their outpatient appointments. On certain occasions, where a Veteran presents for an appointment with their child, the child can be permitted to accompany the Veteran to their appointment.

i. Children must be accompanied by the Veteran/Patient at all times.

ii. Facility staff can use discretion and reschedule the Veteran if the presence of the child interferes with the Veteran’s care or the care of others.

iii. Children are prohibited from accompanying the Veteran to their appointment if the Veteran is scheduled for: Surgery, Ambulatory procedures, Radiology appointments, Gynecological appointments and Emergency Room visits.

iv. VA staff on duty cannot care for minors.

C. Establishment of Official Visiting Hours:

1. Daily patient visiting hours for the Batavia and Buffalo campuses are from 11:00am – 8:00pm (unless indicated by ward listing below).

2. The Physician and/or Nurse in charge of any ward may alter visiting hours in the patient’s best interest or upon the patient’s request.

D. Access Control:

Buffalo Campus:

1. There will be signage at main entrances indicating visitors are required to

check in with staff on the unit upon entry to the facility. The signage will be displayed at the main entrance of the Medical Center, and entrances to the units.

2. Due to space considerations and respect for patient privacy, no more than

two (2) visitors at a time will be permitted at a time at the bedside of a patient.

3. At 7:45pm daily, an overhead announcement will be made announcing the

conclusion of visiting hours.

4. Outside groups meeting on VA property at either Batavia or Buffalo need to

receive prior approval to use VA space, and to be on property after hours. The group’s facilitator is responsible for the participants in the event of emergencies. Outside groups utilizing the premises are only authorized to occupy the assigned area.

5. Intensive Care Unit (ICU): Visiting Hours 2:00pm – 7:00pm. Hours may vary based on changes in medical care conditions; requires approval of medical care team.

· Two (2) visitors at a time (family member, caretaker, or responsible adult) over the age of 16 are permitted.

· Compassionate visitation exceptions (outside of visiting hours) for end-of-life care will be considered thru a request to the attending physician.

· Visitation may be delayed, or visitors may be asked to leave because of patient care activity in the unit.

· Overnight stays are not allowed.

5. ACUTE PSYCHIATRIC UNIT VISITATION PROCEDURE:

A. Unit 10A Inpatient Visitation Procedures: Visitation Hours M-F (6:00pm – 8:30pm), Sat/Sun/Holidays (10:30am – 12:30pm) and (6:00pm – 8:30pm).

· Visitation on this unit is by appointment only.

· Please call Monday-Friday (9:00am – 4:00pm) to schedule a visitation appointment.

· Two (2) visitors permitted (family member, caretaker, or responsible adult) over the age of 16.

6. Batavia Campus: Community Living Center (CLC) Visiting Hours 10:00am – 6:00pm.

· All visitors will check-in with clinical or clerical staff upon entry on any lodge area. Visitors will be advised of any special precautions which may need to be taken prior to a visit and will be directed to the designated visiting area as appropriate.

· Due to space considerations and respect for patient privacy, no more than two (2) visitors at a time will be permitted at a time at the bedside of a patient.

· Designated visiting areas are available for larger visiting groups and should be reserved.

· Visitation may be delayed, or visitors may be asked to leave because of patient care activity in the lodge.

· Visitation is subject to change based on any regulation changes that affect Community Living Center. Visitors will be advised of any special precautions prior to or at the time of visitation.

· Compassionate visitation exceptions for end-of-life care will be considered by the care team.

· Outside/exterior visitation will be held on the patio of building 4

· If visitors come on weekends, holidays or after hours and find the facility locked, call the Nursing Supervisor for admittance and resident check. The Nursing Supervisor’s phone number is posted on the wall near the entrance. The Nursing Supervisor can notify the ward and inform resident of visit.

· If the Nursing Supervisor feels any discomfort of admitting a visitor, he/she can notify the VA Police for escort.

· If for any reason the Nursing Supervisor feels that the visitation should not take place, visitors will be notified by the Nursing Supervisor and VA Police (if necessary).

7. REFERENCES: Medical Center Policy 11-16 Intensive Care Unit; VA Handbook 0730.

8. RESCISSION: Medical Center Policy 07-04, dated February 19, 2020

9. REVIEW: Review at minimum recertification including when there are changes to the governing document (for example, national policy or a healthcare accreditation body mandate).

10. RECERTIFICATION: This MCP is scheduled for recertification on or before the last working day of January 2029. This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.

11. SIGNATORY AUTHORITY:

//s//

Michael J. Swartz, FACHE

Executive Director

VA Western New York Healthcare System