Failure to Provide Required Written Notice for Resident Room Changes
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, to a significant number of residents who were relocated within the facility. Documentation revealed that multiple residents experienced room changes without receiving the required written notification prior to the move. In several cases, forms either lacked the reason for the room change, the resident's signature, or any evidence that the resident was informed in advance. For example, one resident was moved to a different room on two occasions, with only one move documented as being at the resident's request and properly signed, while the other lacked any documentation of notification or reason. Interviews with facility staff, including the Administrator, DON, and LSW, confirmed that the process for notifying residents of room changes was not consistently followed. The DON acknowledged that the lack of room change notifications was a pervasive issue in the facility. In one instance, a resident reported being moved against their wishes after being told not to speak to their roommate, and there was no documentation of a room change notification for this event. The Medical Director explained that the move was prompted by privacy concerns and personality conflicts, but again, no written notice was provided to the resident. Facility policy requires that residents receive written notice, including the reason for the change, before any room relocation occurs. Despite this, the clinical records for 37 of 49 residents who were relocated, as well as one discharged resident, lacked the necessary documentation. The widespread nature of this deficiency was confirmed by the Administrator, who stated that all residents with a room change should have a notification with the reason documented, but this was not done for the affected residents.