Failure to Provide Required Written Notice Prior to Resident Room Change
Penalty
Summary
The facility failed to provide a resident with written notice, including the reason for a room change, prior to relocating the resident to a different room. The resident, who had severe cognitive impairment and multiple complex medical diagnoses including Multiple Sclerosis, quadriplegia, Alzheimer's disease, and major depressive disorder, was dependent on staff for all activities of daily living and preferred to spend time in his room. Despite facility policy requiring a 30-day written notice to the resident or their representative before any room change, there was no documentation or notification provided to the resident's representative regarding the reason for the move. Interviews with the resident's family member and facility staff confirmed that no written or verbal explanation was given prior to the room change, and the family member only learned of the move after it occurred. The family member reported that the resident was comfortable with his previous roommate and struggled with the new room environment, which was too cold for him. Facility staff, including the Social Worker and DON, were unable to provide documentation or a clear reason for the room change, and acknowledged that the required notification process was not followed in this instance.