Failure to Provide Written Notification and Obtain Consent for Room Changes
Penalty
Summary
The facility failed to provide timely written notification and obtain proper consent for room changes for one resident, as required by both facility policy and federal regulations. The policy states that residents or their representatives must be given written notice and the opportunity to consent or appeal before a room change occurs, except in cases of safety. However, documentation showed that the required written notifications were either missing or incomplete for two separate room changes involving the same resident. The resident in question, an 81-year-old with diagnoses including bipolar-type schizoaffective disorder, borderline personality disorder, and muscle weakness, was cognitively intact at the time of the incidents. On one occasion, the resident was moved following a physical altercation with a roommate, with the move documented as being for safety reasons. However, the room change notification form did not indicate that the resident was provided written notification, nor did it include the resident's signature. On another occasion, the resident was moved again, with the form stating the move was at the resident's request, but there was no documentation of consent or the resident's signature, and no supporting notes in the electronic medical record. Interviews with facility staff confirmed that the process for room changes should include obtaining the resident's or representative's signature on a notification form prior to the move, and that this was not done in these cases. Staff also acknowledged that the facility had recently changed its documentation process and was attempting to catch up on missing forms, but the required notifications and consents were not properly documented at the time of the room changes.