Failure to Act on Resident’s Room Change Request Related to Ongoing Noise Disturbance
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to request a room change and to provide appropriate notice and follow-through on that request. One male resident with multiple complex medical conditions, including heart failure, atrial fibrillation, diabetes mellitus, peripheral vascular disease, and general anxiety disorder, was admitted in November and had impaired cognition and dependence on staff for toileting and transfers per his MDS. This resident was housed across the hall from a female resident who had encephalopathy, delusional disorder, anxiety disorder, insomnia, bipolar disorder, chronic kidney disease, and other conditions, and who was known to yell and scream. The facility’s policy stated that room changes would be made when the facility deemed it necessary or when requested by the resident, with documentation in the medical record and involvement of Social Services for inquiries. According to interviews, the male resident and his family member reported that he had complained about the female resident’s constant yelling and screaming, which made it difficult for him to sleep. The family member stated that a supervisor was asked for a room change and responded that a room change was not possible because other residents needed to be closer to the nursing station. The resident himself stated that he had requested a room change about three weeks prior and that no one followed up with him. The LVN reported that multiple residents, including this resident, had complained about the yelling and that the resident requested a room change about two weeks earlier, with the family member calling about one week later to follow up. The LVN stated she informed the DON and the Director of Social Services of the room change request. In contrast, the Director of Social Services stated she was not aware of any complaints from the current room regarding the yelling and screaming and was not aware of any room change request from this resident. The DON stated that any staff member could receive a room change request and that such requests should be reported to the DON and Social Services, but the DON was not aware that this resident had complained or requested a room change. Observations on the survey date documented the female resident repeatedly yelling loudly from her room, sometimes with the door open and without the call light activated, while the male resident’s door was open or slightly open across the hall. The failure of the LVN and/or facility to ensure that the resident’s room change request was effectively communicated, acted upon, and documented resulted in the resident remaining in a room across from a resident who was frequently yelling, contrary to the facility’s room change and noise control policies and the resident’s right to request a room change.
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