Failure to Obtain Consent and Document Room Changes
Penalty
Summary
The facility failed to obtain written consent and provide proper documentation in the medical record prior to making room changes for a resident with intact cognition and multiple medical diagnoses, including type 2 diabetes mellitus, GERD, and muscle weakness. The resident experienced two room changes within the same month, and in both instances, there was no evidence in the clinical record that written notice was given or that the resident consented to the moves. The Room Change Forms indicated the moves occurred, but either lacked a documented reason or did not serve as a substitute for written consent or proper notification. Interviews with the resident revealed that he was not informed of the reasons for the room changes, was not asked for his consent, and was unaware that he could refuse the changes. The social worker acknowledged that it was her responsibility to obtain consent and document the process but admitted to forgetting to do so. The DON confirmed that the facility's process requires informing the resident or responsible party, obtaining consent, and providing notification prior to any room change, none of which were documented for this resident. The facility's policy also requires timely advance notice and documentation of room changes, which was not followed in these cases.