Failure to Provide Advance Notice and Monitor Roommate Compatibility
Penalty
Summary
The facility failed to provide advance written notice to a resident prior to assigning a new roommate, as required by policy. The resident was not informed in writing before another resident, who was known to have frequent outbursts and confusion, was moved into his room. Multiple staff members, including the Social Service Assistant, Assistant Director of Nurses, and Licensed Vocational Nurse, confirmed that there was no documented evidence of written notification or monitoring for compatibility following the room change. The facility's policy requires advance notice and monitoring for 72 hours to ensure compatibility, but these steps were not followed or documented. As a result of this failure, the resident experienced significant distress, including inability to sleep due to the new roommate's constant yelling and outbursts. The resident reported the issue to several staff members but stated that nothing was done to address his concerns. Staff interviews confirmed that the two residents were not compatible as roommates, and no monitoring for compatibility was documented in the clinical records. This led to a resident-to-resident altercation and a violation of the resident's rights.