Failure to Provide Written Rationale for Room Transfers
Penalty
Summary
The facility failed to provide residents with prior written rationale regarding room changes, as required by its own Room to Room Transfer policy. The policy specifies that the facility must discuss transfers with residents and their families in advance, explain the rationale and rights, offer an opportunity to tour the new room, and introduce new roommates prior to the move. However, for two residents, these procedures were not followed. One resident, with a history of diabetes and a left leg amputation, was informed of his room transfer while outside and was not given a reason for the move. Documentation in his medical record did not include a rationale for the transfer, and he was not introduced to his new roommate beforehand. Additionally, after the move, he was unable to locate his prosthetic leg, which was later found in an inaccessible location. Another resident, with diagnoses including a cutaneous abscess and bipolar disorder, was also transferred to a different room without being provided a rationale. The room transfer notification in her medical record lacked any explanation for the move. Facility staff confirmed that an outdated room transfer document was used, which did not require documentation of the rationale for the transfer, resulting in the absence of required information for both residents.