Failure to Provide Written Notification and Explanation for Room Changes
Penalty
Summary
The facility failed to update and implement its policy and procedure regarding room changes, affecting three residents who were moved without proper written notification or explanation. The facility's current policy required written notice for room or roommate changes, including the reason for the move, but this was not followed in practice. The Social Service Director confirmed that no written notifications were provided to the residents or their responsible parties, and the Director of Nursing acknowledged that the policy did not align with regulatory guidance requiring written explanations for such moves. Resident 1, who was blind and had type 2 diabetes mellitus, was moved from her room of over a year to a new location designated for isolation purposes. She reported not being oriented to the new room, experiencing difficulty navigating the space, and feeling that her needs were disregarded due to the room's location and size. Resident 2, with a diagnosis of cerebral infarction and dependent on staff for activities of daily living, stated that staff moved her without asking for her input or providing any documentation or explanation for the change, leaving her feeling disrespected and unable to exercise her rights. Resident 3, who had a urinary tract infection and required substantial assistance, was moved after complaining about a noisy roommate. She reported that staff informed her that the complainant would be the one moved, and she was not oriented to her new room or roommate. She felt forced to move and believed the process was unfair. The facility's governing body was found to be responsible for ensuring policies were updated and implemented, but failed to do so in accordance with regulatory requirements.