Failure to Provide Written Notice Before Resident Room Change
Penalty
Summary
The facility failed to provide written notice to a resident and her responsible party (RP) prior to changing the resident’s room assignment. The resident, an elderly female with severe cognitive impairment (BIMS score of 3), multiple diagnoses including idiopathic normal pressure hydrocephalus, Alzheimer’s disease, and adult failure to thrive, was moved to a new room due to a non-functioning bathroom in her previous room. The move was discussed verbally with the RP by the Director of Nursing (DON) and Administrator (ADM), but no written notification was provided, and the RP did not have the opportunity to see the new room before the move occurred. Interviews with facility staff, including the social worker (SW), assistant director (AD), and licensed vocational nurse (LVN), confirmed that the facility’s practice was to notify residents and families of room changes verbally, not in writing. The SW and AD stated that verbal consent was documented in the electronic health record, and the SW was generally responsible for coordinating room changes. The ADM and DON both indicated that the urgency to move the resident was due to a directive from a state surveyor to ensure the resident had access to a working bathroom, but acknowledged that written notice was not provided as required. The facility’s policy and procedure for resident rights, as reviewed, did not specify the requirement for written notification prior to room changes, and staff interviews confirmed that written notice was not part of the facility’s standard process. The lack of written notice and documentation of the reason for the room change constituted a failure to honor the resident’s right to receive written notice before a change in room or roommate, as required by regulation.