Failure to Provide Written Room Change Notifications
Penalty
Summary
The facility failed to provide written notification to residents and/or their responsible parties regarding room changes, as required. Three residents were affected by this deficiency. One resident, who was cognitively intact and had diagnoses including adult failure to thrive, diabetes, and spinal stenosis, was moved between rooms multiple times without receiving written notice. Another resident with cognitive impairment and diagnoses of ventricular fibrillation, dementia, and acute kidney failure was moved to a different room, with only a phone message left for the responsible party and no written notification provided. A third resident, also cognitively intact and diagnosed with heart failure, diabetes, and osteoarthritis, did not receive written notice when a new roommate was assigned to their room. Interviews with staff, including the Social Service Designee (SSD), Regional Nurse, floor nurses, Assistant Director of Nursing (ADON), and Director of Nursing (DON), revealed a lack of awareness and inconsistent practices regarding the requirement for written room change notifications. The SSD reported notifying residents verbally and documenting in the chart, but was unaware of the need for written notification. Nursing staff denied completing any notification forms, and there was confusion among leadership about who was responsible for the process. Review of the facility's policy on room transfers showed no mention of written notification, only documentation in the resident chart.