Failure to Provide Written Notice of Room Changes
Penalty
Summary
The facility failed to provide written notice of room changes to two residents out of a sample of five reviewed for notifications. For one resident with multiple complex diagnoses, including aftercare following circulatory surgery, type 2 diabetes with kidney complications, end stage renal disease, and encephalopathy, the record showed that a message was left for the resident's son and a friend was contacted regarding the room change. However, there was no documentation in the electronic medical record that written notice of the room change was provided to the resident or their representative. Similarly, another resident with diagnoses such as a displaced femur fracture, subluxation of the cervical vertebrae, Alzheimer's disease, and dementia was moved to a different room after the family was notified by phone and assisted with the move. Despite verbal communication, there was no evidence in the record that written notification of the room change was given to the resident or their representative. Staff interviews confirmed that the facility did not have a policy for resident room changes and that notifications were typically made by phone, without written documentation.