Policy – Universal Masking Policy for Patients and Visitors

Developed by: Infection Prevention & Control / Occupational Health and Safety
Approved by: Executive Vice President, Patient Care Services

The purpose of this policy is to provide clear guidance on the application of medical mask use at Grand River Hospital (GRH) for patients and visitors. This policy has been developed to ensure the safety of patients, care partners, visitors, staff and other team members.

GRH takes steps to create safe environments for everyone. Universal masking is an effective way to help reduce the spread of COVID-19 and other infections. The general public wearing masks is a means to contain respiratory secretions.

The Region of Waterloo indoor public spaces masking bylaw does not apply to hospitals. However, the GRH policy on masking respects the intentions of the bylaw and sets the same expectations across all GRH locations. The concern of GRH is the risk associated with contact between unmasked persons and other patients, staff and visitors where physical distancing is not always possible.

All Patients, Care Providers and visitors are required to wear medical grade masks at all GRH sites when indoors or within two (2) meters of others outdoors, regardless of vaccination status.

Inclusion Criteria
All patients, care partners and visitors who attend GRH for clinical care or to support someone receiving care from GRH. All other vendors or persons who enter GRH.

Exclusion Criteria
Staff Masking Requirements are outlined in a separate policy, including any staff with medical mask exemptions.

Care Partners: Care Partners are individuals identified by patients or substitute decision makers as being essential to their well-being and providing direction in their care, and/or whose presence enhances their stay and contributes positively to their overall healing process.

COVID-19 Vaccinated: Anyone who received the full series of an approved COVID-19 vaccine or combination of COVID-19 vaccines approved by Health Canada (e.g., two doses of a two-dose vaccine series, does not need to be the same vaccine as long as 2 doses have been administered, or one dose of a single-dose vaccine series, or one or two doses of a COVID-19 vaccine not approved by Health Canada followed by one dose of a Health Canada approved COVID-19 vaccine) and having received the final dose of the COVID-19 vaccine at least two weeks prior to visit.

Hospital provided mask: A hospital provided mask includes all medical grade masks or otherwise provided to a patron by GRH.

Mask Exemption: A mask exemption excludes a patient or care partner (essential visitor) from mask-use for a medical reason and is proven through documentation from a health care provider.

Visitor: Visitors are those who want to provide well wishes.

General Statements

Medical grade masks are mandatory at all GRH sites when indoors or within two (2) meters of others outdoors, regardless of vaccination status. Any exception to mandatory masking is at the sole discretion of GRH based upon guidance of Infection Prevention and Control best practices and/or provided by government authorities.

While universal masking is mandatory, exceptions to the policy include:

  • Inpatients where masking impedes care as outlined below in patient procedures.
  • Outpatients, and on rare occasions essential caregivers/care partners, who have physician/NP documented medical conditions that preclude the use of masks for extended periods of time. They can be authorized for entry at the discretion of the clinical manager or their delegate with review of documentation and in consultation with IPAC.
  • People who require immediate medical intervention (i.e. Emergency room).
  • A face shield will be offered to assist with personal protective equipment (PPE) measures however, they are not considered a suitable substitution for a mask.

Patient procedure

Outpatients: A medical mask must always be worn. All patrons entering the hospital must replace any non-medical masks, including cloth masks, with a hospital-provided medical mask.

Inpatients: It is recommended that patients wear a mask whenever staff/physicians or visiting caregivers are within two (2) meters. If tolerated, masks can be worn over therapies (e.g. oxygen with nasal prongs). Patients are encouraged to practice hand hygiene before and after applying/removing their masks. Patients may need assistance from staff to apply and remove their mask at the bedside.

If wearing a mask impedes care (i.e. respiratory distress during therapy) then patients may remove their masks as long as staff are masked and two (2) meters distance is maintained from other patients. In a room with more than one patient, the curtains are pulled around the bed space.

Staff are protected with their own PPE (based on a personal risk assessment) when they are providing care to patients who are not masked (i.e. mouth care).

Patients also wear masks whenever they leave their rooms or bed space in a multi bedded room. If going outdoors, patients may remove the mask upon arrival to their destination but only if they remain two (2) meters away from other people at all times.

Note: Regulations differ between patients and care partners as the hospital is considered the patient’s home while admitted for care.

Care partner and visitor procedure:
All care partners must don a face mask in order to enter GRH. A medical mask must always be worn indoors and outdoors.

  • Care Partners are to maintain physical distancing from patients.
  • To avoid removal of masks, eating and drinking by care partners/visitors is not allowed in patient room or on units.
  • In multi bed rooms, privacy curtains must be drawn.
  • Essential Parents/Caregivers who are with children or developmentally challenged adults for continuous, extended periods of time, may remove their masks at the bedside of the private room when staff or physicians are not present.
  • For parents/care-givers who are required to stay for continuous, prolonged periods of time, they can eat in the patient’s room with an approved exception, respecting physical distancing from any other person in the room, and with privacy curtains drawn while mask is removed. If the patient is in additional precautions, they should NOT eat in the room.
  • Masks must be donned by the caregivers/parents whenever leaving the bedside.
  • Parents/caregivers are to be asked to don the mask when team members enter the room. In some circumstances this may not be appropriate (sleeping caregiver).
  • When not using the mask, the mask should be kept in a paper bag which can be obtained from the clinical unit.

Mask Exemptions
Ideally, a medical mask exemption is known prior to the patient’s appointment. This should be communicated by the patient or family physician when booking the appointment. If known ahead of time, arrangements are made with the clinical unit in consultation with Infection Prevention and Control (IPAC) and as outlined below.

When a patient has a medical exemption for wearing a mask, with applicable documentation signed by their healthcare provider, the GRH clinical team will work with the patient to maintain appropriate protocols to ensure safety. This may include but not limited to use of a face shield or allowing a personal mask choice (i.e. cloth mask).

Note: GRH staff are permitted to ask for documentation identifying a medical exemption, however, they are NOT permitted to ask the reason behind the exemption. The care team would be privy to this information during care.

If the exemption is not known ahead of the patient’s arrival:
The following process will apply to patients/care partners/visitors who refuse to comply with the universal masking policy and/or indicate they meet the exception criteria above.

Visitors who refuse to wear a mask are not permitted to enter. If the individual agrees to wear the mask into the hospital and later removes the mask or chooses to partially cover the mouth and nose, then the individual can be asked by any of the team members to reapply properly and if they refuse, will be directed to leave the site (follow the refusal to comply process below).

Outpatients and/or care partners/parents
Outpatients and/or care partners/parents who are required to accompany a vulnerable patient and are unable or refuse to wear a medical mask to scheduled clinic visit will be:

  • Asked to wear a medical mask to travel to the appointment area. If the patient or care partner is unable to wear a medical mask on route to the clinic, then the staff should discuss a face shield as an option. If this is not feasible, the clinic should arrange an escort to the designated room. Escorts and receiving area staff in contact with the unmasked patient or care partner, are to don eye protection in addition to the mask and other PPE based on a personal risk assessment.
  • Avoid crowded areas and do not share an elevator. Minimize the number of unmasked care partners/parent to 1.
  • The screening staff will call clinics advising of inability to wear a mask so the clinical staff can prepare to receive the patient and care partner. If the clinic is unable to accommodate and the appointment is safe to do so, the appointment will be rescheduled to a later time.
  • Upon arrival to the clinic, the clinical teams will discuss the concerns related to masking with the patient/care partner and attempt to find solutions. Based on this information the clinic will:
    • Sequester the patient/care partner to alternate space to facilitate physical distancing;
    • If necessary, reschedule or offer virtual visits;
    • Following the appointment, the patient/care partner is escorted out, taking care to maintain safe physical distancing in accordance with the process followed on arrival; and
    • Ask the patient to advise of any mask exemption prior to any future scheduled appointment.
  • For future appointments:
    • Explore the possibilities of an alternative care partner to attend if the patient is able to mask and care partner unable to.
    • Consider booking at the beginning or end of the day to avoid crowded waiting rooms.
    • Offer virtual/phone visits.

Emergency Department
Patients who present to the Emergency Department (ED) who are unable or refuse to wear a medical mask or face shield will be sequestered to an isolated area in the waiting room and care area. A room assignment in the main care area is recommended for all patients with a mask exemption. A parent accompanying a dependent child (under 18 years) in ED who refuses a medical mask will be handled as if an extension of the pediatric ED patient.

If the patient is referred directly to a clinic from ED, the process for outpatients above should be followed.

Refusal to comply with masking policy

  1. In instances where the patient/care partner refuses to comply with GRH universal masking policy, staff should refer to this policy and educate the patient / care partner on the ongoing evidence supporting universal masking.
  2. Should a care partner/visitor’s behaviour escalate and/or the care partner begins recording the interaction, staff should:
    • Remind the patient/care partner that video recording is strictly prohibited.
    • Politely ask the patient/care partner to leave the hospital.
    • Contact security for assistance, and if escalation occurs, activate Code White as necessary. Such event shall be documented in the incident management system (SafetyNet).
    • Contact appropriate management support (admin on call).

Related Documents
Care partner/Visitor Guidelines and Virtual Visit Support

Incident reporting: patient and visitor ADM-B-9050

Code white policy

Photography, video recording and audio recording policy

Public Health Ontario. Masks for Source Control

Public Health Ontario. ENVIRONMENTAL SCAN. Type of Mask Required or Recommended for the Public to Control Transmission of SARS-CoV-2 with Consideration of Variants of Concern: Rapid Environmental Scan

Kitchener/Waterloo face covering by law

Grand River Hospital Intranet – Univeral Masking Policy for Patients and Visitors

Any PRINTED version of this document is only accurate up to the date printed. Always refer to the intranet Policies and Procedures for the most current version of the document.
This material was prepared solely for use at Grand River Hospital (GRH). GRH accepts no responsibility for use of this material by any person or organization not associated with GRH. No part of this document may be reproduced in any form for publication without permission of GRH.