Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to honor a resident's right to receive written notice before a room change, as required by regulations. This deficiency was identified during an abbreviated survey, where it was found that a resident was moved multiple times without receiving any written notification. The facility's policy on room changes did not include the requirement for written notification, which contributed to the oversight. The resident, who was cognitively intact with a BIMS score of 15/15, reported that they were moved several times without prior notice or consent, and their inquiries about the reasons for the moves were ignored by staff. Interviews with facility staff revealed that the social worker typically communicated room changes verbally to residents or their families and documented the changes in the resident's record. However, there was no evidence of written notices being provided. The social worker and the Director of Nursing both confirmed that the process involved verbal communication and documentation in the resident's record, but not written notification. The social worker also mentioned that if a resident or family disagreed with a move, the issue would be brought to the interdisciplinary team for further discussion, although this did not occur in the case of the resident in question.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 Resident #1 is no longer in the facility and was discharged home. The Social Worker who was present at the time of this deficiency is no longer employed at the facility. The current Director of Social Services was reeducated on the proper process for completing room changes. Specifically, that the resident has the right to receive written notice prior to the room being changed. An audit was completed for all residents in the past 30 days to ensure that a written Notice was provided prior to executing a room change. All negative findings were brought to the Administrator’s attention immediately. All residents have the potential of being affected. The Policy and Procedure titled Room Change Policy and Procedure was reviewed and updated. Specifically, that the resident has the right to receive written notice prior to the room being changed. The Social Worker was educated by the Administrator to ensure that notice in writing is provided prior to making a room change, and room change is documented in the medical record. Additionally, the DON, ADON, and all Nurse Supervisors will be educated as well. Audits will be conducted by the Social Worker to ensure that written notices are present for each room change prior to the change being executed. Audits will be conducted weekly for 4 weeks and monthly for 2 months. All negative findings will be brought to the attention of the Administrator immediately. The results of all audits will be brought to the QAPI committee. Person responsible: Director of Social Work