Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide written notice to a resident regarding a room change, including the reasons for the move, as required by policy. The resident, who had diagnoses of End Stage Renal Disease, septic shock, and bilateral lower extremity cellulitis, and was assessed as having moderate cognitive impairment, was moved from one room to another within the facility. The resident reported that when they refused the move, staff insisted it was mandatory and stated that no reason needed to be given. The resident did not receive any written documentation explaining the reason for the room change. Multiple staff interviews confirmed that the facility does not provide written explanations to residents when room changes occur. Review of the resident's electronic health record showed no entries documenting written notice for the room change. The facility's own policy indicated that reasonable written notice should be given for transfers within the facility, but this was not followed in this instance. The resident expressed sadness and frustration as a result of the room change and the lack of communication.