Failure to Provide Required Written Notice Before Room Change
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with written notice, including the reason, before changing the resident’s room. Resident 6, who had diagnoses including dysphagia and GERD, was observed residing in the locked dementia unit. Review of the admission MDS showed a BIMS score of 15, indicating normal thinking and memory. A progress note dated February 13, 2026, documented that the resident’s room was changed, and a subsequent note on February 14, 2026, recorded that the resident was upset and did not agree with the room change. During interview, the resident stated that he did not give consent to move rooms and was not provided with written notice of the room change. Staff interviews confirmed that the room change was initiated because staff reported the resident was talking about getting his money and car and leaving the facility, and he was considered an elopement risk. The social worker reported meeting with the resident and the resident’s POA and deciding to move the resident to the locked unit, noting that the resident already had a wander guard and that the facility had prior issues with residents leaving while wearing wander guards. The NHA stated that, because it was a late Friday afternoon and the resident was upset and wanted to leave, they decided to place him in the locked unit so he would not be able to leave. The facility was unable to provide any documentation showing that written room change notification was given to the resident prior to the move.
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