Failure to Provide Required Written Notice Before Resident Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, before changing a resident's room. Facility policy titled "Change of Room or Roommate" stated that, prior to making a room change or roommate assignment, all persons involved, such as the resident and their representative, would be given advance notice of the change, and that parties could be notified in person, via telephone, or in writing. For one resident with Parkinson's disease and dementia, clinical record review showed a progress note indicating that on January 6, 2026, the Social Services Coordinator informed the resident's wife that the resident would be moved from a private room to a semiprivate room because a B bed was available. Further review of the resident's clinical record did not reveal any documentation that the resident or the resident's representative received written notice of the room change or the reason for the change. During an interview, the DON and the Social Services Coordinator stated that the representative had been notified approximately six months earlier that the resident would be moved to a semiprivate room once a B bed became available, and that the Social Services Coordinator had spoken with the representative the morning of the move and obtained agreement. They reported that the representative later became upset that the move occurred while they were out of the building and felt it would negatively affect the resident due to his cognitive level. The Social Services Coordinator acknowledged that no written notice had been provided and that she typically relied on verbal conversations to obtain consent for room moves.
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