Failure to Notify Resident and Family of Room Changes
Penalty
Summary
Facility staff failed to provide advance notice or information regarding room changes for a resident with diagnoses including encephalopathy, Alzheimer's disease, and muscle weakness, who was dependent on staff for all activities of daily living. The resident's medical records showed multiple room changes on specific dates, but there was no documentation that the resident or his family were notified prior to these moves. Interviews with the resident's family member confirmed that they were not informed about the room changes, and facility staff, including the Social Services Director and Director of Nursing, acknowledged that notification and consent are required for such changes, even when moving a resident within the same room. Review of facility policy indicated that residents and their representatives must be given timely advance notice before any room or roommate change. Despite this policy, the lack of documentation and communication regarding the room changes for this resident was confirmed by both staff and family interviews. The deficiency was identified through interviews, record reviews, and policy examination, all of which demonstrated that the required notifications were not provided or documented as per facility protocol.