Balancing Safety and Resident Choice in Nursing Home Visitation

Prior to COVID-19, much progress had been made to ensure the autonomy of the individual resident was honored. A national movement on person-centered care was created to ensure that the voice of the frail elderly was heard, and that their rights to continue living life to the fullest extent possible would be ingrained into the regulations, but also into the culture of aging care services. Part of the impetus of this movement was due to the outcomes seen in nursing homes – elders were not living. Their quality of life had been ignored and the sense of home, community, and even self was not factored into care delivery.

With the introduction of COVID-19, drastic measures were taken to prevent outbreaks in nursing homes with the main goal of saving lives. As a short-term response, these restrictions are ethical and warranted. But in the long-term, weight and serious consideration must be given to the unintended consequences of the harm caused by social isolation, as well as the liberties and autonomy of the individual resident. This virus could pose risks to frail elders living in nursing homes far beyond the length of time that the public experiences it. Therefore, it is not reasonable to expect residents to be separated from intimate contact with friends and family indefinitely, nor is it ethical and perhaps even legal. In short, there is a great risk that ageism is creeping in and clouding our perspective on how to approach visitation. I.e., because the population is old and at most risk, they are not allowed to make decisions because it’s too risky. Each of us makes decisions about the risk we take with COVID-19, whether it be strictly isolating or being in close contact with others. These residents are living in their home and we must remember this.

On Sept. 17, 2020, the Centers for Medicare & Medicaid Services (CMS) released the Quality, Safety, & Oversight memo, QSO-20-39-NH, Nursing Home Visitation – COVID-19, updating the visitation guidelines for nursing homes. Under the new guidance, CMS states, “Visitation can be conducted through different means based on a facility’s structure and residents’ needs, such as in resident rooms, dedicated visitation spaces, outdoors, and for circumstances beyond compassionate care situations.” AAPACN encourages facilities to review these new guidelines in full.

With these new guidelines, facility leaders can take measures now to provide visitation spaces for residents and their loved ones. The following are a few suggested actions nurse leaders can implement today to ensure resident safety and protect resident choice.

  • Decide on the location of indoor visitation rooms (a common room or extra office space) and have scheduled visits and cleaning in between.
  • Decide what procedures visitors will need to follow while in the facility, such as wearing masks and social distancing.
  • Offer virtual visits so residents can interact with family and friends remotely if they are still not able to visit in person. (CMS has provided nursing homes with the opportunity to apply for up to $3,000 in civil money penalty (CMP) funds for communication devices used for virtual visits. Nursing homes are limited to purchasing one device per 7-10 residents.)
  • Purchase awnings or tents along with plastic dividers to enhance safety and comfort. (Facilities may apply for an additional $3,000 in CMP funds for the purchase of tents for outdoor visitation and/or clear dividers (e.g., Plexiglas or similar product) to create a physical barrier to reduce the risk of transmission during in-person visits).
  • Have a procedure for limiting the number of visitors at one time which not only allows for better infection control practices but also for privacy, which is a requirement.
  • Establish outdoor visiting areas, such as a courtyard, patio, or parking lot, for when weather permits.
  • Educate staff, residents, and families on the facility’s visitation policy, and have a procedure for what will happen if the policy is not followed.

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