Code of Conduct for Patients and Visitors

Overview Statement

This policy applies to the Allegheny Health Network (AHN) entities and individuals outlined in the policy applicability section below.

AHN is committed to providing a safe and healing environment for patients, visitors and employees.  As part of that commitment, AHN has established a “code of conduct” for its patients and visitors.

While AHN understands that being hospitalized and receiving health care services can be stressful, AHN will not tolerate inappropriate, disrespectful or unsafe behavior (collectively, misconduct) from patients or visitors. The purpose of this policy is to establish a set of expectations for behaviors that promote a safe and therapeutic environment and to establish a mechanism to manage patient and visitor misconduct.

Terms and Definitions

Misconduct:

1. The use of profanity, racist or culturally offensive remarks, sexual language or behavior directed at others
2. Attempting to intimidate or harass others
3. Physical assault or the threat of physical violence
4. The use of raised and hostile tone of voice or the use of menacing gestures
5. Interfering with patient care and patient care equipment
6. Possession of firearms or any weapons
7. Using alcohol, illegal drugs or tobacco on the premises
8. Engaging in unlawful or inappropriate behavior, including, but not limited to purchasing or selling illegal drugs, having sexual relations on the premises, theft, or destroying property
9. Using any device to take photos or videos without permission, including any member of AHN staff/employee, facilities, equipment or PHI

Administration

A. Expectations of Security/Highmark Health Police Officer and Staff

1. Violations of the code of conduct are to be reported to security and/or Highmark Health police. Consider the need for and activate “Security Alert, Crisis Response Team” when indicated.
2. Security and/or Highmark Health police will respond, assess the situation and attempt to minimize the disruption.  Security and/or Highmark Health Police will address all potentially and/or actual criminal activities or behaviors and will engage local law enforcement as appropriate. The appropriate security and police reports will be completed describing the situation and actions taken.
3. AHN may escort anyone from its premises upon reasonable suspicion that the person has engaged in unlawful conduct on its premises or otherwise engaged in misconduct as described above.  Those escorted from the premises may not return to the facility until they receive permission from facility administration and/or security/Highmark Health Police unless they are seeking emergency care. Those who return without receiving permission, and who are not seeking emergency care, will be considered trespassers and security/Highmark Health Police are to be notified.

B. Patient Misconduct

1. When a patient violates the “Patient and Visitor Code of Conduct”, the following options may be initiated to resolve the situation:
   • Department leader or designee will inform the patient that he/she is engaging in behavior that is interfering with his/her care or that of others. Discuss behavior expectations, review the “Patient’s Rights and Responsibilities, and notify the attending physician.
   • If the misconduct persists or escalates, contact security/Highmark Health Police and/or call “Security Alert, Crisis Response Team”. Consider using AHN behavioral care contract to reinforce behavioral expectations. 
   • If the patient disruption rises to the level where law enforcement action is warranted, refer to the AHN policy entitled Private Police/Special Officers for Highmark Health.
   • If the physician/hospital determines that termination of relationship is necessary, follow policy for “Termination of Physician-Patient or Hospital-Patient Relationship.”

C. Visitor Misconduct

1. If a visitor violates the “Patient and Visitor code of Conduct” and refuses to correct that behavior when requested, the following procedure should be initiated:
   • The staff member or designee will notify security/Highmark Health Police for assistance or will initiate “Security Alert, Crisis Response Team” if indicated.
   • The security/Highmark Health Police Officer, along with department leader or designee, will inform the visitor that he/she has violated the visitor code of conduct and will discuss behavior expectations. The code of conduct documentation form should be utilized. 
2. Refusal to sign or abide by the code of conduct will result in visitation privileges being revoked.
3. The signed copy of the visitor code of conduct form will be provided to the security/Highmark Health police officer that is present for enforcement of any violations.
4. If the visitor continues to violate the code of conduct, the visitor will be escorted from the AHN facility by the security/Highmark Health police officer and advised that returning to the facility may result in criminal charges of Defiant Trespass being filed unless the visitor is seeking emergency care.

D. Medical Records Documentation

1. Any actions taken under this policy, including behavioral contracts, should be reported to leadership and documented in the patient's medical record. Staff will complete an RL6 occurrence report. Incident reports will be filed by Security and the Highmark Health Police Officer involved.