Failure to Provide Written Notice Prior to Resident Room Change
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple complex medical diagnoses, including cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease, was moved to a different room without receiving written notification prior to the change. The resident, who was dependent on staff for all activities of daily living and received nutrition via tube feeding, was moved in April 2025 as part of a facility effort to consolidate beds. The medical record review confirmed there was no evidence of written notification provided to the resident or their representative before the room change. Interviews with staff revealed that the resident was unhappy with the new room assignment, particularly because the new bed placement did not allow the resident to look out the window as before. Admissions staff confirmed that neither the resident nor their representative was shown the new room or given written notice prior to the move, and acknowledged that the facility did not provide written notice for room changes. Review of the facility's policy indicated that notification is required for changes such as room or roommate changes, but this procedure was not followed in this instance.