Failure to Notify Representative of Room Change for Cognitively Impaired Resident
Penalty
Summary
The facility failed to notify a resident's representative of a room change, as required by its own policy and procedure for notification of change. On observation, a resident with severe cognitive impairment, as indicated by a BIMS score of 00 and diagnoses including heart failure, hypertension, cerebrovascular accident, and seizure disorder, was found to have been moved to another room. Review of clinical progress notes showed no documentation that the resident's representative was notified prior to the move. The facility's form for room or roommate change was incomplete, lacking a documented reason for the move and containing only a scribble mark for the resident's signature, with the nurse's printed name below it. The Director of Nursing confirmed that the resident was moved over the weekend to accommodate another resident's request due to a roommate issue, and acknowledged that notification should have been made and documented before the move. The resident's representative reported not being informed of the room change until after it had occurred, stating that the facility called them after the move had already taken place and did not seek their input beforehand.