Failure to Notify Resident Representative of Room Change
Penalty
Summary
The facility failed to promptly notify the resident representative of a room change for one resident. The resident, who had a history of left femur fracture, falls, hypertension, anemia, urine retention, and weakness, was assessed as moderately cognitively impaired. On one occasion, the resident was moved from one room to another, but there was no documentation in the progress notes or on the Room Change Notification form regarding this move. The Social Services Director (SSD) confirmed that the room change was not documented and stated that if she did not perform the move, someone else may have done so without completing the required notification. Further review showed that while a subsequent room change was properly documented, including notification to the resident and their representative, the initial room change lacked any record of notification or documentation. The facility's policy requires advance notice and documentation of room changes for residents and their representatives, but this was not followed for the room change in question.