Failure to Provide Written Notice Before Resident Room Change
Penalty
Summary
The facility failed to provide a resident with written notice, including the reason for a room or roommate change, prior to moving the resident from a rehabilitation unit to a secure unit. Record review showed that the resident, who had severe cognitive impairment and was an elopement risk due to dementia, was transferred without documentation of notification or consent from either the resident or her emergency contact. The care plan was updated to reflect the new placement, but there was no evidence of written or verbal communication regarding the change. Interviews with the resident's family member and emergency contact revealed that they were not informed about the room change and did not provide authorization. The family member only learned of the move after visiting the facility and did not receive any explanation or notification from staff. Facility leadership, including the DON and Administrator, confirmed that there was no signed consent for the room change and were unsure if the family was notified. The facility's policy requires residents to be informed of their rights and involved in care planning, but this was not followed in this instance.