Failure to Notify Resident and Emergency Contact of Room Change
Penalty
Summary
The facility failed to provide documented room change notifications to a resident and their emergency contact, as required by regulations. This deficiency was identified for one resident, who was admitted with multiple diagnoses including dementia, heart failure, and diabetes. The facility's policy on room changes, revised in January 2024, mandates that notifications be provided within a reasonable time and that social services coordinate room change requests. However, the resident's emergency contact reported not being informed of the room change from the second to the third floor, which was discovered during a visit when the resident was not found in their original room. Interviews with facility staff, including the Regional Nurse and the Nursing Home Administrator, revealed that the facility could not provide a consistent reason for the room change, citing various explanations such as the resident's long-term care status and the need for a more compatible roommate. Additionally, there was no evidence that the resident or their emergency contact received written prior notification of the room change, as required. The lack of proper documentation and communication regarding the room change led to the deficiency being cited.
Plan Of Correction
The facility can not retroactively correct the cited deficient practice for Resident R1. Current residents with room changes for the past 7 days were reviewed to verify notification to the resident, emergency contact, and roommate were provided. The Social Worker and nursing management team have been re-inserviced on the Room Changes policy. Residents with upcoming room changes are being reviewed during morning meetings to verify notification to the resident, emergency contact, and roommate are completed and documented. The Social Worker or designee will conduct audits of residents with room changes weekly x4 weeks, then monthly x2 months to verify notification to the resident, emergency contact, and roommate have been completed and documented. Results of the audits will be reported at the monthly Quality Assurance Improvement Meetings for review and recommendations.