Failure to Notify and Obtain Consent for Resident Room Change
Penalty
Summary
Facility staff failed to notify a resident or their representative of a room change, as required by facility policy and regulatory standards. The resident was moved to a new room without being provided a room change consent form, and no signature was obtained to document agreement to the move. Interviews with the resident revealed initial confusion and reluctance about the move, which was later explained by staff as necessary for safety reasons. However, there was no documentation in the clinical record or facility paperwork to show that the resident or their representative was notified or that consent was obtained prior to the room change. Further review of facility documentation and interviews with staff, including the Social Worker Director, Administrator, and DON, confirmed that the standard process for room changes was not followed in this instance. The facility's own policy requires notification of the resident's legal representative at least twenty-four hours in advance, documentation of the reason for the change, and the resident's and roommate's reactions, none of which were completed. The only documentation found was a note indicating the resident's belongings had been moved, with no evidence of notification or consent.