Failure to Provide Advance Notice of Roommate Change
Penalty
Summary
The facility failed to provide advance written notice to a resident prior to a roommate change, as required by policy and resident rights. One resident, who was alert, oriented, and had intact cognition, was not informed in advance that a new roommate would be moving into her room. Documentation confirmed that while the incoming resident received notice of the room change, there was no evidence that the existing resident was notified. The resident only became aware of the change at the time of the new roommate's arrival, when staff inquired if she had been notified. This lack of notification was acknowledged by the Director of Nursing, who stated that the process had 'slipped through the cracks.' The affected resident reported that the new roommate was disruptive, which caused her significant distress, including a panic attack. Staff interviews confirmed that facility policy requires both the resident being moved and the resident receiving a new roommate to receive advance written notice, except in the case of new admissions. Review of the clinical record and facility policy further substantiated that the required notification and documentation were not completed for the resident who received the new roommate.