Failure to Establish Resident Rights Compliance Structure
Summary
The facility failed to establish a structure to comply with the residents' right to refuse transfers within the nursing home. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy did not include individualized mechanisms to ensure compliance with CMS Medicare requirements, and it was a 13-page document that consolidated all 483.10 resident rights statements into one policy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with mental health and seizure disorders, who had been placed in a private room for behavioral reasons, was moved to another room so that another resident with similar needs could have the private room. The transfer was made for facility convenience rather than the resident's needs, violating the resident's right to refuse non-requested transfers.
Surveyors found that several residents with cognitive deficits were moved between rooms multiple times without documentation of notification or explanation to their representatives, despite facility policy requiring such communication. Interviews and record reviews confirmed that families were not informed, and staff were unaware of the notification policy.
A resident who was cognitively intact and his own responsible party was moved from a private to a semi-private room despite repeatedly refusing the change. Staff proceeded with the move based on payer status and the need for the private room, but there was no documented clinical need or isolation requirement for another resident. The facility's actions did not align with its own policy, which allows residents to refuse certain room changes.
Facility staff did not inform a resident of the reason for a room transfer or document the notification, despite facility policy requiring both. The resident expressed dissatisfaction with the new room and was unaware of the reason for the move, which staff later attributed to a roommate conflict but failed to record.
Several ventilator-dependent residents and their representatives were not informed of or given the opportunity to refuse room transfers that were conducted for staff convenience. Communication about the moves did not include information about the right to refuse, and some residents or their POAs were not notified of the specific room changes until after they occurred. Staff confirmed that the option to refuse was not offered, despite knowing residents have this right.
A resident with hypertension and type 2 diabetes was moved to a new room without consent while hospitalized after a fall. The facility attempted to notify the resident via phone, but he was unable to respond. Upon return, the resident found his room changed and belongings moved, negatively affecting his sleep. The administrator denied the resident's request to return to his original room, confirming the move was for staff convenience.
Resident Rights Violation: Unwarranted Room Transfer for Staff Convenience
Penalty
Summary
A resident with diagnoses of schizophrenia, anxiety disorder, and seizure disorder was admitted to the facility and had been residing in a private room for an extended period due to behavioral reasons. According to the clinical record and census review, the resident occupied the private room from 6/21/24 to 7/10/25. Staff interviews revealed that the resident was moved out of the private room to accommodate another resident who also required a private room for behavioral reasons. The social worker confirmed that the decision to move the resident was based on facility needs rather than the resident's needs, and that the resident was not able to pay for the private room. The facility failed to ensure that the room change was not completed for staff convenience, as required by resident rights regulations. The social worker acknowledged that the move was made to meet facility needs and not the needs of the resident, despite being aware that both residents had similar behavioral concerns necessitating a private room. This action resulted in a deficiency related to the protection of the resident's right to refuse certain types of non-requested transfers within the facility.
Failure to Notify Residents or Representatives of Room Changes
Penalty
Summary
The facility failed to notify residents or their representatives of room changes or provide explanations for these changes for four residents with varying degrees of cognitive impairment. Observations, interviews, and record reviews revealed that residents with severe to moderate cognitive deficits were moved between rooms multiple times without documentation of family notification or explanation for the moves. In several cases, residents exhibited behaviors such as wandering, confusion, and verbal altercations, yet there was no evidence that families were informed or involved in care conferences regarding these changes. For example, one resident with a history of wandering and elopement risk was moved four times, and her family reported not being notified or invited to care conferences. Another resident, also with severe cognitive impairment and anxiety, was moved twice in a short period, with nursing notes indicating increased confusion and distress, but no documentation of family notification or rationale for the moves. Additionally, two other residents with moderate cognitive deficits and complex medical histories were moved between rooms without documented explanations or notifications to their families. The facility's policy required social services to complete a room change form and notify residents or their representatives, but staff interviews indicated a lack of awareness of this policy. The administrator acknowledged that the social worker was not aware of the notification policy and stated that she would expect staff to communicate with residents and their representatives prior to room changes. However, the records reviewed did not show that these procedures were followed.
Failure to Honor Resident's Right to Refuse Room Change
Penalty
Summary
Facility staff failed to honor a resident's right to refuse a room change, resulting in the involuntary relocation of a cognitively intact resident from a private to a semi-private room. The resident, who was his own responsible party and had no documented behaviors or clinical need for a private room, was actively involved in discharge planning to return to the community. Despite the resident's clear and repeated refusals to move, as documented in progress notes and staff interviews, the facility proceeded with the room change. On the day of the move, multiple staff members, including the social worker, director of admissions, and a CNA, entered the resident's room to assist with packing and moving. The resident became visibly upset, yelling at staff and demanding they leave his belongings alone. Despite his protests and physical resistance, staff continued to pack and relocate him to the new room. Staff interviews confirmed that the resident had not agreed to the move and that the facility's rationale was based on payer status and the need to use the private room for another resident, although documentation did not support an immediate clinical need for the private room. Facility policy states that residents have the right to refuse room changes if the move is solely for staff convenience or involves relocation between skilled and non-skilled units. In this case, the move was not supported by a documented clinical need or isolation requirement for another resident, and available room options were not fully explored or offered to the resident. The facility's actions were inconsistent with their own policy and the resident's rights, as evidenced by the lack of documentation supporting the necessity of the move and the resident's clear refusal.
Failure to Notify and Document Reason for Resident Room Change
Penalty
Summary
Facility staff failed to provide a resident with the reason for a room change and did not document the notification or rationale for the transfer. The resident, who had recently been moved to a new room, reported dissatisfaction with her current room and was unaware of the reason for the move. Review of the clinical record confirmed the room transfer but showed no evidence that the resident was informed of the reason. Staff interviews revealed that the move was due to a conflict with a roommate, but this was not documented in the resident's record. Facility policy requires that residents be notified of room or roommate changes, including the reason, and that this notification be documented, but this was not followed in this instance.
Failure to Honor Residents' Right to Refuse Non-Requested Room Transfers
Penalty
Summary
The facility failed to honor residents' rights to refuse non-requested room transfers when the moves were conducted for staff convenience. A reorganization plan was implemented, resulting in the relocation of ventilator-dependent and tracheostomy patients to different units and rooms. The facility sent a letter to residents and families outlining the plan, but the letter did not inform them of their right to refuse the room changes. Interviews and record reviews revealed that residents and their representatives were not given the option to refuse the transfers, and in some cases, were not even notified of the specific room changes until after they occurred. Four residents were specifically reviewed for this deficiency. One ventilator-dependent resident, who was responsible for their own decisions, was moved without prior notification or the opportunity to refuse, and only learned of the move after it happened. Another ventilator-dependent resident was informed of an impending room change and received a letter, but was ultimately moved to a different room than discussed, again without the option to refuse. A third resident, with an activated POA, was moved to a different room upon readmission from the hospital, and the POA was not notified until two days after the move. The fourth resident, also with an activated POA, was moved to a room different from what was communicated, and the POA was not given the option to refuse the move, expressing a preference that the resident not be moved due to familiarity with the previous room and staff. Staff interviews confirmed that the moves were made for the convenience of staffing and unit organization, particularly to consolidate ventilator-dependent residents for easier management by the respiratory therapist. The social worker acknowledged that residents were not given the option to refuse the moves, despite knowing that such a right exists. The administrator and DON were informed by the surveyor that the communication to residents and families did not include information about the right to refuse room changes, and that several residents and representatives were unaware of or not given a choice regarding the transfers.
Resident's Right to Refuse Room Change Violated
Penalty
Summary
The facility failed to ensure that a resident's room change was not completed for the purpose of staff convenience, violating the resident's right to refuse such a change. The resident, who had been admitted with diagnoses including hypertension and type 2 diabetes, was moved from Room A6 to Room B11 while he was at the hospital following a fall. The facility attempted to notify the resident of the room change by calling his phone three times and leaving messages, but the resident was unable to respond as he was in the hospital. Upon returning to the facility, the resident found that his room had been changed without his consent, and his belongings had been moved. The resident expressed dissatisfaction with the room change, stating that it negatively affected his sleep, and his request to return to his original room was denied. During an interview, the resident reported that the administrator dismissed his concerns, asserting authority over the decision. The Nursing Home Administrator confirmed that the facility did not afford the resident the right to refuse the room change, and the move was made for staff convenience, not considering the resident's rights.
Plan Of Correction
1. Resident #1 was offered a room change and declined. 2. A 14 day look back was completed of room changes. Any room change completed with the resident not present or RR not made aware will be re-offered a room change. Policy reviewed and revised. 3. Nurse educator will educate current social services and current LN's on revised room change policy. 4. DON/designee will audit all room changed during clinical stand up 5 x a week x 4 weeks to ensure policy is followed. Results to QAPI.
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