Failure to Notify Correct Responsible Party of Room Change
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
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Notify Residents of Room Changes: The facility did not complete room change notifications for two residents whose rooms were changed, and no documentation of notice was found in the medical record. One resident with BIMS 15 said she was okay with the move but did not know until the day of the change. An LSW confirmed the notifications were not completed and could not show the resident was aware of the room change.
A facility failed to document whether room change notifications were made to residents and their representatives after a plumbing backflow and drainage water backup led to relocation of multiple residents from affected rooms. During record review, 4 of 9 resident charts lacked a completed Notification of Room Change evaluation, and the DON confirmed staff did not document whether the residents and their representatives were notified of the transfer.
A resident with cognitive impairment and Korean as her preferred language was moved multiple times for census needs, but the facility did not document that she received written notice of the room changes in a language she could understand. Records showed verbal approval from the guardian, while staff interviews confirmed the resident did not speak English well and that the SSD relied on the guardian rather than informing the resident directly.
The facility failed to provide written notice before changing the rooms of three residents. One resident had a family member listed as RP, and two residents were their own RPs. Records showed room changes for each resident, including one resident who moved to a different unit and another who had two room changes, but there was no evidence that written notice with the reason for the change was given before the moves. Social services staff confirmed the facility had no evidence of written notice.
Failure to Provide Written Notice Before Room Change: A cognitively intact resident was moved to another room without advance written notice or a documented reason for the change. The SW stated she only followed up after the move and had no documentation of notice, while the resident reported staff began packing her belongings without warning and gave no explanation. The NHA acknowledged the facility did not use its room-change notice form.
Failure to Provide Written Notice for Room and Roommate Changes: The facility did not ensure that two residents received required notice before room or roommate changes. One resident with dementia, schizophrenia, and severe cognitive impairment was given a roommate without advance notice to the family, and the roommate later moved after an altercation. Another resident with severe cognitive impairment and wandering behaviors was moved between rooms multiple times, with staff and family reporting that no prior notice was given and staff giving conflicting accounts of who was responsible for notification.
Failure to Notify Residents of Room Changes
Penalty
Summary
The facility failed to notify residents and their representatives of room changes for 2 of 3 residents reviewed for room change notifications during the complaint survey. Resident #60 had been in one room since admission and was moved to another room on 07/02/25, but no room change notification was found in the medical record. Resident #68 was admitted to one room on 03/10/26, moved to another room on 04/27/26, and then moved again on 06/16/26, and no room change notification was found in the medical record. During interview, a resident with BIMS of 15 stated that she was okay with her room change but did not know she was moving until the day of the move. The LSW stated that the room change notifications were not completed for the two residents and said she had a text conversation with Resident #68’s daughter about it, but could not show that the resident was aware of the room change. The facility policy titled Notification of Change states that the facility must inform the resident and, when applicable, consult with the physician and/or notify the resident’s family member or legal representative when there is a change requiring notification, including a change of room or roommate assignment.
Failure to Document Room Change Notifications
Penalty
Summary
The facility failed to document whether notification of a room change was made to residents and their representatives after 21 residents were relocated from Rooms 111 through 125 on the Magnolia Unit due to a plumbing backflow and drainage water backup. During review of 9 residents' records related to the room transfers, 4 residents did not have a completed Notification of Room Change evaluation in their medical records. The deficiency was identified during a complaint survey after the affected area was observed to be closed off for repairs, with contractors present to replace flooring and clean up the area. Facility documentation showed the residents were moved because of the drainage water backup in the hallway and shower drains affecting Rooms 111 through 125. The DON stated the Social Worker was supposed to ensure the Notification of Room Change was completed for all 21 residents, and also stated the Social Worker was on leave. On interview, the DON confirmed the facility staff failed to document whether the four residents and their representatives were notified of the room change that occurred when the residents were relocated.
Failure to Provide Written Notice of Room Changes
Penalty
Summary
The facility failed to provide written notification of room changes and roommate changes for one resident, who was admitted with diagnoses including anxiety disorder, depressive episodes, muscle weakness, a history of falling, and transient ischemic attack. The resident’s 4/22/26 MDS showed cognitive impairment with a BIMS score of 0 out of 15, and her preferred language was Korean. The communication care plan identified her as at risk for impaired cognitive function/dementia. Record review showed three room change notification forms documenting verbal approval from the resident’s guardian for room changes made for census needs, but there was no documentation in the resident’s EMR that she was provided written notice of the room changes in her preferred language. Staff interviews indicated the resident did not speak English well, that Google Translate was used or intended for communication, and that the SSD relied on the guardian to inform the resident. The SSD acknowledged she did not inform the resident directly of the room changes and said she should have attempted to do so using Google Translate.
Failure to Provide Written Notice Before Room Changes
Penalty
Summary
The facility failed to provide written notice before changing the rooms of three residents. For one resident, the clinical record showed admission to the facility and that a family member was listed as the responsible party. The resident’s room was changed to a different unit, and a progress note documented the resident’s agreement to move the following day; however, there was no evidence that the resident or responsible party received written notification, including the reason for the room change, before the move occurred. For two other residents, the clinical record showed that each was her own responsible party and that each had room changes during the stay. One resident’s room was changed twice, and the other resident’s room was changed once. In each case, there was no evidence that written notification, including the reason for the room change, was provided before the change occurred. Interviews with social services staff confirmed that the facility had no evidence that written notice was provided for the room changes noted above.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility did not ensure that a resident received written notice, including the reason for the change, before her room was changed. The resident, R8, was admitted to the facility and had a most recent MDS dated 6/23/26 showing a BIMS score of 14, indicating she was cognitively intact. On 6/26/26, the facility moved R8 from her room on one side of the building to the other side of the building without providing advance written notice or a documented reason for the move. During interview, the Social Worker stated she followed up with R8 after the move but did not give written notice or advance notice regarding the room change and had no documentation that notice or an explanation was provided. R8 stated that staff came into her room and started packing her belongings without prior notice and that she was given no reason for the move. The facility was unable to provide documentation showing preparation for the move or any written communication to R8 about the room change. The Nursing Home Administrator stated the facility did not provide written notice before room changes and acknowledged that a form existed to explain room changes and the reason for them, but it was not being used.
Failure to Provide Written Notice for Room and Roommate Changes
Penalty
Summary
The facility failed to ensure that residents received written notice, including the reason for the change, before a room or roommate assignment was changed for two residents reviewed for resident rights. The deficiency involved Resident #5 and Resident #24, both of whom were on the secure unit and had significant cognitive impairment and behavioral concerns documented in their records. Resident #5 was an elderly female admitted with diagnoses including unspecified dementia, paranoid schizophrenia, psychotic disorder with delusions, and major depressive disorder. Her quarterly MDS showed a BIMS score of 7, indicating severely impaired cognition, and her care plan noted agitation and anxiety related to dementia and delirium or an acute confusional episode. A family member stated that Resident #5 was given a roommate without advance notice to the family. The family member said she learned of the roommate only after asking CNAs on the hall and overheard staff discussing that the family had not been told. She also stated there was an altercation between Resident #5 and the roommate, during which the roommate pushed Resident #5, and then the roommate was moved to another room. Resident #24 was an elderly male admitted with diagnoses including unspecified dementia, psychotic disorder with delusions, hallucinations, and major depressive disorder. His admission MDS showed a BIMS score of 3, indicating severely impaired cognition, and he had behaviors including disrobing in public, rejecting care, and wandering. Staff observed him sleeping in an extra bed in a room that was not his, and CNA staff stated he often slept there because he did not like his roommate. Staff also reported that he had moved rooms multiple times and became confused about where his room was. His family member stated she was not informed of his room changes and found out only when she visited and he was no longer in the room she expected. Facility staff gave conflicting statements about who was responsible for notifying residents and families, and the DON stated she was unfamiliar with the facility policy on room and roommate changes. The facility policy required prompt written notice for room or roommate changes, including the reason for the change, and stated that notice should be given before a resident is relocated whenever possible.
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