Failure to Notify Responsible Party of Roommate Change Resulting in Resident Injury
Penalty
Summary
The facility failed to notify the responsible party of a resident prior to a roommate change, which resulted in a new roommate being moved into the resident's room without prior notification. The resident involved had severe cognitive impairment, a legal guardian, and multiple medical diagnoses including vascular dementia, bipolar disorder, depression, schizophrenia, and bilateral lower limb amputation. Following the roommate change, the resident was observed with a black eye and facial bruising, and an incident report documented that the resident stated another resident made contact with his eye, while the other resident denied the action. Both residents involved had cognitive impairments, with one having a BIMS score indicating severe impairment and the other slight impairment. The Nursing Home Administrator acknowledged that there was no specific policy for bed or roommate changes and that the facility relied on regulatory guidance and interdisciplinary team meetings to make such decisions. The administrator admitted that the responsible party for the resident was not notified of the roommate change, which was a failure on the facility's part. Facility documentation and state guidance both require notification of the resident's representative prior to any room or roommate change, but this was not done, leading to the incident and subsequent injury.