Failure to Timely Honor Resident Request for Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with respect and dignity by not completing a requested room change in a timely manner. The resident was admitted with encephalopathy, depression, and dementia, and while a History and Physical documented capacity to understand and make decisions, a subsequent MDS showed severely impaired cognition and a need for moderate to maximal assistance with ADLs. The resident’s responsible party reported requesting a room change from Social Services on 1/8/2026 because the resident felt uncomfortable in the current room, and Social Services confirmed that a suitable room was available and agreed to the change. Social Services staff stated they informed the RN Supervisor of the room change request on the same day but were unsure why the transfer was not completed. The RN Supervisor acknowledged being informed of the request and stated the room change was not done because it was very busy during change of shift, and further acknowledged that the room change should have been completed as soon as possible. The DON confirmed that when a room change is requested, it is to be discussed with social services, the DON, and the admissions coordinator, and that a room was available for this resident at the time of the request and the change should have occurred as soon as possible. Review of facility policies on Resident Rights and Room Change/Roommate Assignment showed that residents are to be treated with kindness, respect, and dignity, and that room changes are to be made when the resident requests them, which did not occur in this case.
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