Failure to Provide Adequate Written and Language-Appropriate Notice of Room Change
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and written notice of a room change, in accordance with its own policy and resident rights requirements, for one of five sampled residents. The facility’s policy on Room Change/Roommate Assignment, revised 3/2021, required that residents and their representatives receive at least one hour advance written notice of any room or roommate change, including the reason for the change and information to help them become acquainted with a new roommate. For this resident, who had been in a private room for five years and had a BIMS score of 9 indicating moderate cognitive impairment, the facility initiated a move from a private to a shared room because the private room was needed for an incoming resident requiring isolation. The Social Services Director (SSD) left a voicemail for the resident’s responsible party about the move but did not wait for a response before proceeding, and staff began moving the resident’s belongings despite the responsible party’s request for more time. The Notification of Room Change form for this resident was incomplete and did not contain the date of notification for either the resident or the responsible party, their approval status, or the required signatures and dates. The SSD stated that the purpose of the form was to notify all parties of the room change and inform them of their rights to appeal, but acknowledged that the form was not completed and that the move proceeded even though they had not actually spoken with the responsible party. Additionally, the resident’s facesheet identified a primary language other than English (Farsi), yet the SSD communicated the room change to the resident only in English and did not use a translator or translation service, despite the facility having access to a translator line or staff translators. The resident and responsible party reported that the rapid packing and moving of belongings was very distressing for the resident. The Admissions Director and Administrator both confirmed that the Notification of Room Change form was incomplete and that the resident spoke very little English, confirming the failures in written notification and communication in the resident’s primary language.
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