Failure to Notify Guardian of Resident Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, to a resident's guardian prior to moving the resident to a different room. The resident, an elderly male with diagnoses including vascular dementia, chronic obstructive pulmonary disease, and interstitial pulmonary disease, was rarely or never understood, had significant memory problems, and was severely impaired in daily decision making. The resident was at risk for injury due to wandering and resided in a secure unit. On the day of the room change, there was no documentation or notification to the resident's guardian regarding the reason for the move, nor was there any evidence of consent or the right to refuse being offered. Staff interviews revealed that the room change occurred after the resident pulled down a privacy curtain, damaging the curtain rail. Staff, including an LPN, HR, and the DON, believed the move was temporary and did not notify the guardian, as required by facility policy. The DON later confirmed that there was no documentation of guardian notification, and the guardian stated he did not recall being informed of the room change. Facility policy required prompt notification of the resident's representative when a room assignment change was needed, but this was not followed in this instance.