Failure to Provide Written Notification of Room Change to Resident's Representative
Penalty
Summary
The facility failed to provide written notification to a resident's representative prior to making room changes, as required. The resident, who had dementia, was moved twice within a short period—once for rehabilitation and again for long-term care—without the representative being notified in writing or given the opportunity to be present. The representative had specifically requested notice to assist the resident during the move, but this request was not honored. No documentation or signed consent forms regarding the room changes were found in the resident's electronic health record (EHR), and there were no progress notes addressing the room changes or the resident's adjustment to them. During interviews, the resident's representative expressed anger and concern over the lack of notification, stating that the moves caused the resident frustration and anxiety due to his dementia. A staff member acknowledged that she did not obtain written consent, mistakenly believing an email from the representative was sufficient, though the email only requested discussion about the move and did not provide consent. This oversight resulted in the resident being moved without proper notification or support from his representative.