Failure to Honor Resident Room Change Preference and Support Self-Determination
Penalty
Summary
The facility failed to honor a resident's preference for a room change, as well as other expressed choices, for one resident with moderate cognitive impairment and diagnoses including diabetes, hypertension, and dementia. The resident reported dissatisfaction with their care, specifically noting lack of access to their clothes due to a locked closet, not being allowed to leave the locked unit or go outside for an extended period, and frequent intrusions by other residents into their room. The resident stated that requests for a room change were made to both the unit manager and their guardian, but these requests were not addressed. Staff interviews confirmed that the environment was overstimulating for the resident, affecting their participation in meals and activities, and that staff availability limited the resident's ability to leave the unit for activities such as visiting the vending machine. Observations included another resident entering the affected resident's room and using their belongings, which the resident indicated was a recurring issue. Review of the medical record showed no documented behaviors that would necessitate placement on a locked unit, and the director of nursing confirmed there was no specific criteria for such placement. The resident's care plan and progress notes did not document behaviors justifying the current room assignment. Additionally, a request for the facility's room change policy was made but no policy was provided by the end of the survey.