Failure to Notify Correct Responsible Party of Room Change
Penalty
Summary
The facility failed to ensure that the correct responsible party (RP) for a resident was accurately documented in the medical record and failed to notify the correct RP of a room change. The resident in question was admitted with diagnoses including cerebral palsy, altered mental status, and quadriplegia, and was determined to lack the capacity to make decisions. The resident required total assistance with activities of daily living and was dependent on staff for care. When the resident tested positive for COVID-19, a room change to the COVID-19 unit was required. Documentation showed that the facility notified an RP listed on the admission record, but did not verify that this was the correct RP. Interviews with facility staff confirmed that the standard procedure is to notify the resident or their RP of any room change, complete the necessary documentation, and inform the ombudsman. However, in this instance, the DON acknowledged that although a listed RP was contacted, staff did not confirm that this was the correct RP as documented in the admission record. The facility's policy requires advance written notice to all involved parties prior to a room or roommate change, but this was not properly followed in this case.
Plan Of Correction
F 559 CHOOSE/BE NOTIFIED OF ROOM/ROOMMATE CHANGE CFR(s): 483.10(e)(4)-(6) IMMEDIATE CORRECTIVE ACTION: Resident 1 was discharged on 1/3/25. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: All residents had the potential to be affected by this deficient practice. The Medical Records Director (MRD) reviewed five (5) residents with room change requests in the last 30 days, to check if written notice of room change was provided to the resident and/or resident's RP. No other residents were affected by this deficient practice. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The Director of Nursing Services (DON) conducted an in-service education with the licensed staff on 6/30/25, regarding facility policy on Room Change, ensuring that advance notice is provided to the resident and/or RP prior to room change. The Administrator conducted an in-service with Social Services department staff on 7/7/25, regarding facility policy on Room Change, ensuring that advance notice is provided to the resident and/or resident's RP prior to room change. Effective 7/7/25, the MRD or her designee will review weekly room change requests to ensure completion of the advance notice and notification of resident and/or resident's RP. The Social Services Director or the Social Services Designee will immediately correct any deficient practice identified in the audit. The DON and/or her designee and the MRD will randomly review five (5) resident charts weekly for the next 30 days to ensure residents' RPs were notified and documentation completed regarding room changes. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON will report findings to the Quality Assessment and Assurance Committee (QAA) regarding weekly random reviews for the next 30 days. The MRD will also report findings to the QAA regarding weekly random reviews for the next 30 days. The Administrator will monitor compliance through review of DON and MRD reports. CORRECTIVE ACTION COMPLETION: July 7, 2025 This page intentionally left blank