Failure to Provide Written Notice and Obtain Agreement for Resident Room Change
Penalty
Summary
The facility failed to honor a resident’s right to be informed and to exercise self-determination regarding a room change. A resident with unspecified dementia of unspecified severity without behavioral disturbance and an anxiety diagnosis was admitted as his/her own responsible party, with no guardian or DPOA documented. The resident’s care plan noted dementia and documented that on 1/6/26 a room move was discussed and the resident agreed, and that on 1/7/26 staff were assisting with the move when the resident became upset and stated a desire to leave the facility. A quarterly MDS dated 1/8/26 showed the resident had severely impaired cognition and no wandering behavior. During a later interview, the resident reported not agreeing to the room move, becoming very upset and tearful, not understanding why he/she had been moved to a locked unit, and feeling trapped there, and was unable to state whether written notice of the room change had been received. Record review of the EMR showed the resident had no guardian or DPOA, was his/her own responsible party, and there was no signed agreement uploaded related to the room move. Multiple staff interviews (two CNAs and an agency LPN) confirmed that all residents were supposed to receive written notice of room moves and that all parties needed to agree before a room change, but they were unsure whether this resident had received written notice; the agency LPN reported the resident was upset and refused to move while being escorted down the hall. The DON confirmed the resident had not been notified in writing about the room move, was unsure why written notification had not been provided, and stated unawareness of the regulation, while acknowledging the resident should have been notified in writing. The facility’s own Resident Rights policy stated that information about resident rights and responsibilities would be given orally and in writing, but there was no documentation that written notice of the room change had been provided to this resident.
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