Failure to Provide Written Notice Prior to Resident Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, to a resident and their responsible party prior to moving the resident to a different floor. According to the facility's policy, residents and their representatives must be notified in writing before any room change occurs. In this case, the clinical record review showed that the resident, who had a diagnosis of anxiety and muscle weakness and was assessed as moderately cognitively impaired with a BIMS score of 12, was transferred from the second to the third floor. The progress notes indicated the resident was not happy with the move but was willing to try the change. There was no documentation in the clinical record that the responsible party was notified of the room change before it occurred. Staff interviews confirmed that the move was made for safety reasons and that the responsible party was neither asked for input nor given options prior to the transfer. The Director of Nursing acknowledged that the required written notice, including the reason for the room change, was not provided to the resident or their representative in advance.