Failure to Notify Family of Resident Room Changes
Penalty
Summary
The facility failed to notify a resident's family member when the resident was moved to different rooms on two consecutive days. The resident, who had severe cognitive impairment and was totally dependent on staff for activities of daily living, was transferred without the knowledge or consent of her family member. The family member reported not being informed or consulted about the room changes, which resulted in the resident being placed in a three-bed room with limited space, making it difficult to use necessary equipment such as a Hoyer Lift and leaving the resident without a bedside table for personal belongings. Interviews and record reviews confirmed that there was no documentation of family notification regarding the room changes, as required by the facility's policies and procedures. The Social Services Director acknowledged that the facility is responsible for notifying family members or representatives of room transfers and confirmed that this did not occur in this instance. The facility's policies also require documentation of the room transfer and communication with the resident and their representatives, which was not completed.