Failure to Provide Written Notification Before Resident Room Change
Penalty
Summary
The facility failed to provide written notification to a resident or their Power of Attorney (POA) prior to a room change. Record review showed that the resident was moved to a new room to prevent falls, as decided by the Interdisciplinary Team (IDT) and the Director of Nursing (DON). The resident, who had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, reported having no knowledge of the move or the reason for it. The resident's belongings were packed and moved without their prior awareness. Interviews with facility staff revealed that the Social Services Director (SSD) was typically involved in room changes but was not familiar with this particular move. The DON stated that the resident was spoken to about the move and had agreed, but also described the resident as not alert and oriented, with hallucinations and delusions, and unable to make such decisions. The DON confirmed that the POA could not be reached and that no written notification was provided to either the resident or the POA. The SSD confirmed that a notification form, which includes information about the right to appeal, should have been provided but was not.