Failure to Provide Written Notice and Reasons for Resident Room Changes
Penalty
Summary
The facility failed to provide written notice, including the reasons for room changes, to three residents who experienced multiple room relocations. For each resident, record reviews showed no documentation of written notification or explanation for the room changes. Interviews with the residents and their representatives confirmed that they were either verbally informed or not informed at all about the moves, and none received written notice or reasons for the changes. The Social Services Director and Administrator both acknowledged that the process involved verbal discussions with residents or their representatives, but did not include providing written notice or documented reasons for the room changes. The residents involved had varying medical conditions, including broken heart syndrome, spina bifida, metabolic encephalopathy, malnutrition, respiratory failure, and muscle weakness. Assessments indicated that at least two of the residents were cognitively intact, while one had moderately impaired cognition. Despite their conditions and the frequency of room changes, there was no evidence that the facility provided the required written notifications, as confirmed by both documentation review and staff interviews.