Failure to Notify Resident Representative Prior to Room Change
Penalty
Summary
The facility failed to provide required written notice, including the reason for a room change, to a resident and the resident’s Resident Representative (RR) before moving the resident from one room and floor to another. The resident, a male with diagnoses of depression, anxiety, and dementia but assessed as cognitively intact on a recent Quarterly MDS, was not his own Responsible Party. The room change notification form was signed by the resident, not the RR, and indicated he was being moved from the third floor to a Medicaid room on the fourth floor. Admission documents showed the RR had previously signed as the party consenting to treatment and held medical power of attorney for the resident’s care decisions. The RR reported she was not informed by the facility of the room change and only learned of it when the resident called her, and she stated she should have been notified of any changes involving the resident. The resident stated staff “shoved” a form in his face telling him he was going to be moved to the fourth floor, that he felt coerced into signing because it was presented as if he had no choice, and that he was unsure why he was being moved. In interviews, the Administrator stated she had been trained that if a resident was of sound mind, staff could inform the resident and the resident could inform the RR, and that the RR would only be notified if the resident was not coherent. The Administrator and Chief Nursing Operator (CNO) stated the resident had the right to make decisions regarding his care, and the Administrator acknowledged that staff notified the resident of the room change and relied on him to notify the RR. The CNO stated they would change the RR designation to the resident to avoid contacting the current RR for care decisions, despite the facility’s policy stating that the facility treats the decisions of the resident representative as the decisions of the resident to the extent delegated or required by law.
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