Failure to Notify Resident's Representative Prior to Room Change
Penalty
Summary
The facility failed to notify a resident's responsible party prior to moving the resident to a new room on a different unit. The resident, who had multiple diagnoses including Neurocognitive Disorder with Lewy Bodies, dementia, and other significant health conditions, was rarely or never understood and was unable to participate in a BIMS assessment. The resident's daughter was listed as Power of Attorney (POA) in the electronic health record (EHR). The resident was transferred from the first floor to the second floor, which is a dementia unit, but there was no documentation in the EHR indicating that the POA was notified about the room change or the reason for it prior to the move. The POA reported that she was not informed verbally or in writing about the transfer and only learned of the move when another family member could not locate the resident during a visit. The POA stated that she had called the facility after the move occurred and was not told about the transfer at that time. Staff interviews confirmed that the notification should have occurred prior to the move and should have been documented in the EHR, but this did not happen. A late entry was made in the EHR after the fact, but the POA maintained that no prior notification was given. Facility policy and state residents' rights documents require that residents and their representatives receive advance written notice and an explanation for any room change. The Notification of Room/Roommate Change form for the resident was incomplete, lacking documentation of notification to the representative, the date written notification was provided, and the reason for the change. Staff interviews further confirmed that the expected process was not followed, and the administrator acknowledged the oversight and improper documentation practices.