Failure to Provide Proper Written Notice and Explanation Before Room Change
Penalty
Summary
The facility failed to honor a resident’s right to receive written notice and explanation before a room change when staff moved Resident #13 to a new room without properly completing the required written notification. The facility’s “Resident Room Changes & Roommate Rights” policy, revised 8/31/25, required that when a resident is moved at the request of facility staff, the resident, family, and/or representative must receive a written explanation of why the move is required and be given an opportunity to see the new location, meet the new roommate, and ask questions. Resident #13, who had multiple diagnoses including schizoaffective disorder, insomnia, anxiety, depression, and dementia, and was documented as cognitively intact on a quarterly MDS assessment, was re-admitted to the facility and later transferred from one room to another. The “Notice of Room-to-Room Transfer” form for this move, signed 11/13/25, listed only “POA Notified” as the rationale for the transfer, with no further written explanation of the reason for the move. During interview, the Social Services Manager acknowledged that the notification of room change was not filled out correctly and should have identified in writing why the resident was moving rooms. This deficient practice created the potential for psychosocial harm if Resident #13 was not provided an opportunity to see the new location, meet a new roommate, or have questions answered related to the move.
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