Failure to Provide Required Advance Notice of Roommate Change
Penalty
Summary
The facility failed to honor a resident’s right to receive advance notice of a roommate change when a new roommate was assigned to Resident 2’s room. Resident 2 had been admitted with diagnoses including encounter for removal of an internal fixation device, anxiety disorder, and depression, and had an MDS BIMS score of 13, indicating intact cognition. Resident 2 initially shared a room with Resident 6 until Resident 6 was transferred to the hospital. On a later date, Resident 2 was given a new roommate without advance written notice, and only verbal notice was reportedly provided. During interviews, the ADON stated that the facility does not provide written notice when a resident acquires a new roommate and only provides written notice when a resident is moved to a new room. Review of the facility’s “Room or Roommate Change” policy, effective 6/27/22, showed that residents or their representatives are to receive timely advance notice before a room or roommate change, and that this notice can be verbal, written, or both. The ADON confirmed that when Resident 2 received a new roommate, only verbal notice was given and it was not documented in the clinical record, contrary to the facility’s policy. The report stated this failure had the potential to result in avoidable psychosocial distress.
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