Failure to Notify Cognitively Intact Resident of Room Change During Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to receive notice before a room change. Facility policy titled “Oklahoma Resident Rights and Responsibilities,” dated 11/29/22, states that every resident has the right to receive notice before their room or roommate is changed and, if applicable, to be informed of any telephone charges incurred when moving. Record review showed that the census list documented the resident in one room on the date of discharge to the hospital and in a different room upon return. The admission assessment dated 12/02/25 documented that the resident was admitted with osteomyelitis and methicillin-susceptible staphylococcus infection and had intact cognition with a BIMS score of 14. A discharge assessment dated 12/15/25 showed the resident was discharged to the hospital for a short-term stay. During interview, the resident stated they were hospitalized and that their personal items were moved before they returned from the hospital, and they did not receive any notification that their room had been changed while they were away. An LPN confirmed that residents should be notified when their room is changed and stated that the resident’s room was changed during the hospitalization because the bed was needed for a resident of the opposite sex. The ADON stated that the facility followed resident rights regarding room changes and that all cognitively intact residents should have been notified before a room change, but acknowledged there was no documentation in the resident’s progress notes on the date of the room change showing the resident had been notified.
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