Failure to Notify Responsible Party of Resident Room Change
Penalty
Summary
The facility failed to ensure a resident’s responsible party received notice of a room change prior to the move, as required by resident rights and facility policy. A female resident with hemiplegia, peripheral vascular disease, major depressive disorder, and severe cognitive impairment (BIMS score of 4) was moved to another room for contact isolation precautions. A progress note dated 12/11/25 by LVN A documented that the resident was moved to a different room for contact isolation and that the resident was aware, but there was no documentation that the resident’s responsible party was notified. The facility’s policy, revised April 2025, stated that a nurse will notify the resident’s representative when there is a need to change the resident’s room assignment. During interviews, LVN A stated she was the nurse who moved the resident in December 2025 and did not remember contacting the family about the room change. She reported that the DON had said she would contact the family but did not, and acknowledged it was ultimately her responsibility to contact the family. The resident’s responsible party stated she did not receive a call about the room change and only learned of it when family members visited and found the resident in a different room. The DON and Interim Administrator both stated that nurses were trained and expected to notify the resident or responsible party of room changes and could not explain why the family was not contacted prior to the move.
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