Failure to Provide and Document Required Written Notice of Room Change
Penalty
Summary
Facility staff failed to provide required written notice of a room change for one resident. The resident had diagnoses including Alzheimer's disease, non-traumatic brain dysfunction, dementia with agitation/behaviors, diabetes, anxiety, and a history of stroke, and was assessed on the MDS as having severely impaired cognitive skills. The resident’s closed clinical record showed a room change occurred on 10/2/24, but there was no written notice to the resident’s representative prior to the move, and no documentation of the reason for the room change. Nursing notes contained no mention of the room change or any circumstances leading to it. During an interview, the DON confirmed there was no documentation of notification to the resident’s representative and no written notice explaining the reason for the room move, although she believed the move was related to the resident’s behaviors and thought verbal notification had been given. The facility’s policy on Room Change/Roommate Assignment required advance notice to residents and their representatives prior to room or roommate changes, including the reason for the change, and required documentation of the room change in the medical record. The lack of written notice and absence of documentation in the clinical record and nursing notes were inconsistent with this policy.
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