Failure to Notify Resident Representative Prior to Room Change
Penalty
Summary
The facility failed to follow its policy regarding notification of a resident representative prior to a room change for a cognitively impaired resident. The resident in question, an older adult male with multiple diagnoses including Type 2 diabetes, hypertensive heart disease, bipolar disorder, and moderate cognitive impairment (BIMS score of 11), was not responsible for his own decisions and had an assigned emergency contact. On the date of the room change, the Assistant Administrator moved the resident to a new room after the resident expressed a desire to change rooms. However, the resident's emergency contact was not notified of the change prior to it occurring, as required by facility policy. Interviews with facility staff confirmed that the standard procedure is for the DON or Social Service Director to notify the resident's emergency contact and document the notification in the electronic health record. In this instance, the Assistant Administrator acknowledged that the emergency contact was not informed on the day of the room change. The facility's policy specifies that both the resident and their representative must be provided with information about the room change prior to it taking place, which did not occur in this case.