Failure to Notify Resident and Representative of Room Change
Penalty
Summary
The facility failed to notify a resident and the resident's representative in writing of a room change, as required by facility policy. Medical record review showed that the resident, who had impaired cognition and multiple diagnoses including hypoxic ischemic encephalopathy, cerebral infarction, CHF, hypertension, and schizoaffective disorder, was dependent on staff for medication administration, transfers, eating, and personal care. Progress notes did not document the room change, and interviews with the resident's representative and the Admissions Director confirmed that the representative was not informed of the move until after it had occurred. Facility policy required written notification in a language and manner understandable to the resident and representative, including the reason for the move, but this was not followed.