Failure to Document Staff Communication Regarding Roommate and Discharge
Penalty
Summary
The facility failed to ensure accurate documentation of staff communication with a resident regarding the admission of a new roommate. Medical record review showed that the resident was admitted for short-term rehabilitation and later left the facility against medical advice. There was no documentation in the medical record reflecting staff communication with the resident about the new roommate or the alternatives offered to the resident when concerns were raised about having a roommate. Interviews with staff revealed that the admission coordinator and other staff members communicated with the resident about the new roommate and discussed possible alternative arrangements, such as a private room. However, none of these communications were documented in the resident's medical record. The DON and the Nursing Home Administrator acknowledged the lack of documentation regarding these interactions and the resident's discharge against medical advice.