Failure to Provide and Document Written Notice of Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide and document written notice to a resident before multiple room changes, contrary to its own policies on room and roommate transfers and notification guidelines. The facility’s policies required prompt written notification to the resident and, when applicable, to the resident’s representative for any change in room or roommate assignment, as well as advance notice of such transfers. Resident #1, admitted with a diagnosis including a fracture of the neck of the left femur and assessed as cognitively intact on the MDS, experienced several room changes between different halls. Registration records showed the resident was admitted to a room on the 100 hall, then transferred to the 200 hall, later moved back to the 100 hall for quality-of-care purposes, and then again transferred to the 200 hall. Record review showed only one room/roommate change notice form dated 04/18/25 for a move to the 100 hall, and no documented room/roommate change notices for the other room changes. The Social Service Director reported that staff typically call the family or speak with the resident regarding room changes, provide a room/roommate change request card, and do not move residents if they do not want to move, but she could not find documentation of notifications for the resident’s moves back to the 200 hall. CNA and nursing staff interviews indicated that social services are responsible for informing residents of room changes and that staff should document room changes and consent in progress notes, but such documentation was absent in this case. The DON and Administrator both stated that staff are expected to document room changes and resident/family notification in the progress notes, yet this was not done for Resident #1, resulting in noncompliance with the requirement to provide written notice before room changes.
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