Failure to Provide Written Notice of Room Changes
Penalty
Summary
The facility failed to provide written notice to residents or their responsible parties prior to making room changes, as required by both facility policy and federal regulation. This deficiency was identified through interviews, record reviews, and policy examination, affecting four residents who experienced multiple room changes. The facility's policy states that written notice, including the reason for the move, must be given in advance in a language and manner the resident and representative understand. However, documentation and interviews revealed that only verbal notifications or phone calls were made, and no written notifications were provided. Residents affected by this deficiency had varying medical histories, including end stage renal disease, congestive heart failure, schizophrenia, diabetes mellitus, and chronic obstructive pulmonary disease. Cognitive assessments showed that most residents had intact cognition, with one resident having moderate cognitive impairment. Despite their cognitive abilities, these residents were not given written notice or the opportunity to express their preferences regarding room changes. Progress notes and census reports confirmed multiple room changes for each resident without evidence of written notification. Staff interviews, including those with CNAs, LPNs, RNs, the Social Services Director, the DON, and the Administrator, consistently indicated that the process for room changes involved verbal communication and updates in the electronic health record, but not written notification. Staff were generally unaware that written notice was a regulatory requirement. Residents reported being moved without advance notice or written communication, and some expressed dissatisfaction with the lack of choice or information about the moves. The deficiency was systemic, as no staff member reported providing written notice for any room change.