Failure to Notify Residents or Representatives of Room Changes
Penalty
Summary
The facility failed to notify residents or their representatives of room changes or provide explanations for these changes for four residents with varying degrees of cognitive impairment. Observations, interviews, and record reviews revealed that residents with severe to moderate cognitive deficits were moved between rooms multiple times without documentation of family notification or explanation for the moves. In several cases, residents exhibited behaviors such as wandering, confusion, and verbal altercations, yet there was no evidence that families were informed or involved in care conferences regarding these changes. For example, one resident with a history of wandering and elopement risk was moved four times, and her family reported not being notified or invited to care conferences. Another resident, also with severe cognitive impairment and anxiety, was moved twice in a short period, with nursing notes indicating increased confusion and distress, but no documentation of family notification or rationale for the moves. Additionally, two other residents with moderate cognitive deficits and complex medical histories were moved between rooms without documented explanations or notifications to their families. The facility's policy required social services to complete a room change form and notify residents or their representatives, but staff interviews indicated a lack of awareness of this policy. The administrator acknowledged that the social worker was not aware of the notification policy and stated that she would expect staff to communicate with residents and their representatives prior to room changes. However, the records reviewed did not show that these procedures were followed.