Failure to Provide Required Written Notices for Resident Room Changes
Penalty
Summary
Surveyors found that the facility failed to provide required written notification of room changes for two cognitively intact residents who were moved between the back and front halls of the building. Facility policy stated that residents and their representatives must receive advance written notice of any room or roommate change, including the reasons for the move, and that Social Services (SS) would assist with adjustment by informing residents and families as soon as possible. For one resident admitted in November, the annual MDS showed the resident had clear speech, adequate vision and hearing, and was cognitively intact, originally residing on the back hall. Observation later showed the resident living in a front hall room, but the medical record contained no written room change notice. The resident reported moving to the back unit to be with a roommate who later went to the hospital and did not return, after which staff moved the resident back to the front. The resident stated they were not given written notice of the room change, though they had spoken with SS about it. SS confirmed that no written room change notice was provided for this resident, explaining that the prior management company had not used written notices and that the new company, which took over in October, did have a room change form. SS stated the resident had been back on the front hall for about six weeks and that the resident had been told verbally that a move back to the front would occur if the roommate left the facility. In a second case, another cognitively intact resident with adequate vision, hearing, and clear speech was documented on a quarterly MDS as residing on the back hall, but observation showed the resident in a front hall room, and the medical record contained no room change notice. This resident reported being moved from the back to the front a couple of weeks earlier due to renovation and stated no written notice was given. The DON and Administrator stated they would have expected written notification for these room changes and initially suggested notices might be awaiting scanning into the electronic record, but as of the survey date no such notices had been produced.
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