Failure to Provide Written Notice Prior to Resident Room Change
Penalty
Summary
A deficiency occurred when a resident was moved to another room without receiving the required written notification prior to the change. The resident, who had an intact cognitive status as indicated by a perfect score on the Brief Interview of Mental Status (BIMS), reported being verbally informed by the wound care nurse on the night before the move but did not receive any paperwork or written notice regarding the room change. Review of the resident's records and interviews with staff, including a registered nurse and the Director of Nursing, confirmed that only verbal communication was provided and no written notification was documented or given to the resident. Further review of the facility's policy and procedure on room changes revealed that advance written notice is required for all parties involved prior to any room or roommate assignment changes. Staff interviews indicated a lack of awareness of this policy, and no documentation of written notice was found in the resident's electronic health record. The facility's census list also confirmed the room change, but there was no evidence that the resident received the mandated written notification in advance.