Failure to Provide Written Notice Prior to Facility-Initiated Room Changes
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, to residents and/or their representatives prior to facility-initiated room changes for three of eight residents reviewed. Clinical record reviews showed that residents were moved from their original rooms to different wings within the facility without any documented evidence that written notification or explanation was given in advance. This included one resident who was cognitively intact and another who was moderately cognitively impaired, as indicated by a BIMS score of 12. Both residents and their representatives were not informed in writing about the reason for the move, nor were they given the opportunity to refuse the room change or to be involved in the process as required by federal regulations. Interviews with the affected residents revealed that they were not told why their rooms were being changed and were not made aware of their right to refuse the move. One resident expressed frustration at being moved after over a year in the same room and stated that she would have refused the change if she had been informed of her rights. The Nursing Home Administrator was unable to provide any documentation showing that written explanations were given to the residents or their representatives prior to the room changes.