Failure to Provide Written Notification of Room Change
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident and their representative in writing prior to a room change. Record review showed that the resident, who had diagnoses including acute respiratory failure with hypoxia, heart failure, type 2 diabetes, and an amputation of the right lower leg, was admitted to the facility and had impaired cognition. There was no evidence in the medical record, including scanned documents, progress notes, or assessments, of any notification regarding the room change. The resident was unable to recall being notified about the transfer and did not know the date of the move, although she expressed comfort and no concerns with her care. Staff interviews confirmed that there was no documentation of notification to the resident or her Power of Attorney (POA) about the room change. The Social Services Designee (SSD) stated that while the POA was contacted by phone and text regarding the room change, there was no record of these communications or any written agreement from the POA. Facility policy requires written notification and documentation of room changes, but this was not followed in this instance. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for room changes.