Failure to Provide Written Notification of Room Change
Penalty
Summary
Facility staff failed to provide written notification of a room change to a resident prior to moving the resident to another room. The resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including malignant neoplasm of the frontal lobe and cervical spondylosis with radiculopathy, was moved to a different room for medical management. The clinical record showed that the resident's Power of Attorney was notified and gave consent for the change on the same day the move occurred, but there was no evidence that the resident received written notification prior to the move. A Room Change Notification form was completed by a social worker, who later admitted to marking that the resident and responsible party received a copy of the notification in error. The facility's policy required proper documentation and timely notification for internal room transfers, but in this instance, only verbal notification was provided. The deficiency was confirmed through staff interviews, clinical record review, and facility document review, with no additional information provided to the survey team before the exit conference.