Failure to Notify Residents and Complete Room Transfer Assessment
Summary
The facility failed to notify two residents of a room change and failed to complete a room transfer assessment after moving Resident 127 into Resident 32's room. Resident 127 was admitted with diagnoses including Type II diabetes with neuropathy and asthma, and her record showed she had capacity to understand choices and make health care decisions, with a BIMS score of 14 out of 15 indicating intact cognition. During interview, Resident 127 stated she was moved from her previous room without a clear explanation, was told only that the room needed cleaning and she would return afterward, and said she did not want to move. She also stated nursing staff and CNAs did not provide additional information, and she was later told the room had been reassigned for short-term residents. The ADON stated residents must consent before being moved and must be informed of the reason for any transfer, but she was unaware of the reason for Resident 127's room change. The SSD confirmed Resident 127 was relocated and that the room change assessment section was not completed, with no documentation of the reason for the transfer or evidence of consent, and she could not identify who initiated the move. Resident 32, who had diagnoses including epilepsy and Type II diabetes, stated she remembered Resident 127 moving into her room and was not informed by staff. The SSD verified there was no documentation that Resident 32's RP was notified, no record that Resident 32 was informed of the transfer, and the transfer form had not been initiated. The ADM confirmed the transfer occurred but could not provide who authorized it or why it happened.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with aphasia, vascular dementia, hallucinations, altered mental status, and a feeding tube was moved to the MCU due to wandering. The DON, Administrator, and SS stated the family was notified by phone, but the resident’s daughter said she did not receive written notice of the room change before leaving the facility.
A resident with multiple medical conditions was moved to a new room due to bed bugs, but the resident's representative was not notified in advance as required by facility policy. Staff interviews revealed that the responsibility for notification was not clearly executed, and the resident's family only learned of the change after the fact.
Three residents, each with significant medical conditions, were moved to different rooms without receiving the required written notification. Staff confirmed that only verbal discussions occurred and that no policy existed for written room move notifications, resulting in non-compliance.
A resident with cognitive impairment and multiple medical conditions underwent several room changes without proper documentation of the reasons or written notification to the resident and their representative. Staff interviews and record reviews confirmed the absence of required notifications and documentation.
A resident with moderate cognitive impairment and multiple medical conditions underwent several room changes, but the facility did not notify the resident's representative prior to all moves as required. Documentation of notification was delayed, and interviews confirmed that the representative was only informed of one of the recent room changes, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room without receiving written notification prior to the change. Staff interviews confirmed that neither the resident nor their representative was shown the new room or given written notice, and the facility did not follow its own policy requiring notification for room changes.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to provide written notification before changing a resident’s room. Resident #95 was admitted with aphasia, vascular dementia, hallucinations, altered mental status, and esophageal obstruction, and the admission MDS showed impaired cognition with a BIMS score of 07 and dependence with all care; the resident also had a feeding tube. The care plan documented vascular dementia with mood disturbance, psychotic disturbance, and anxiety. Review of the resident’s progress notes showed no documentation that the resident was moved to another room, no family notification, and no written notice of the room change. During interviews, the DON and Administrator stated the facility decided to move the resident to the Memory Care Unit due to wandering, Social Services stated the family was notified by phone early in the morning, and the resident’s daughter stated she was notified by phone that the resident was moving to the MCU but had not received written notification before leaving the facility.
Failure to Notify Resident Representative of Room Change
Penalty
Summary
The facility failed to ensure that a resident's representative was notified in writing prior to a room change, as required by policy. A resident with diagnoses including acute kidney failure, dementia, and unspecified psychosis, who resided on a secured memory care unit and was assessed as having intact cognition, was moved to a different room due to the presence of bed bugs. Documentation in the medical record confirmed the room change, but there was no evidence that the resident's representative was notified of this change. Interviews with facility staff, including the prior DON and an LPN, revealed that the responsibility for notifying the family was assumed to have been handled by the DON, but no notification was actually provided. The resident's son confirmed he was not informed of the room change and only learned about it after being contacted by facility staff the following day. The facility's policy required that all parties, including residents and their representatives, receive at least a day's notice prior to any room or roommate assignment changes, which was not followed in this instance.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notification to residents prior to room changes, as required. Three residents were affected by this deficiency. One resident with dementia, CHF, and hypertension requested a room move, but there was no evidence of written notification in the medical record. Another resident with Parkinson's disease, COPD, and dementia agreed to a room move after a discussion with social services, but again, no written notice was documented. A third resident with CKD, osteoporosis, and atrial fibrillation was moved to accommodate another resident requiring isolation, with agreement from the emergency contact, but no written notification was found in the record. Interviews with facility staff confirmed that room moves were discussed verbally with residents or their representatives, but written notifications were not provided. Additionally, the facility did not have a policy in place regarding room moves. This lack of written notification and policy resulted in non-compliance with regulations regarding residents' rights to receive written notice before a room change.
Failure to Notify Resident and Representative of Room Changes
Penalty
Summary
The facility failed to properly notify a resident and the resident’s representative of multiple room changes, as required. Medical record review for a resident with diagnoses including dementia, spinal stenosis, cervical spine injury, neuromuscular dysfunction, bipolar disorder, and a history of opioid and alcohol abuse, revealed that the resident was cognitively impaired and dependent on staff for activities of daily living. The resident experienced room changes on three separate occasions, but there was no documentation in the medical record regarding the reasons for these moves or evidence that the resident or their representative had been notified in writing prior to the changes. Interviews with the facility Administrator and Social Services Director confirmed the absence of documentation for both the reasons for the room changes and the required notifications. Additionally, the resident’s representative confirmed that she had not been informed of the room changes. This lack of notification and documentation was identified during a complaint investigation and affected one of three residents reviewed for room changes.
Failure to Notify Resident Representative Prior to Room Change
Penalty
Summary
The facility failed to ensure that a resident's representative was notified prior to room changes, as required by both resident rights and facility policy. Medical record review showed that a resident with moderate cognitive impairment and multiple diagnoses, including dementia and depression, experienced several room moves. Documentation indicated that notification to the resident's representative was either delayed or not completed prior to the moves. Specifically, nurses' notes included late entries documenting notification after the fact, and the Director of Nursing confirmed that documentation of room changes was not made until a later date. Interviews revealed that the resident's representative was only notified of one of the recent room changes, despite multiple moves occurring. Facility policy requires that residents and their families be informed of room changes and that this information be documented in the medical record, including details such as the date and time of the move, who assisted, and how the resident tolerated the move. The failure to notify and properly document notification to the resident's representative prior to room changes led to the identified deficiency.
Failure to Provide Written Notice Prior to Resident Room Change
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple complex medical diagnoses, including cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease, was moved to a different room without receiving written notification prior to the change. The resident, who was dependent on staff for all activities of daily living and received nutrition via tube feeding, was moved in April 2025 as part of a facility effort to consolidate beds. The medical record review confirmed there was no evidence of written notification provided to the resident or their representative before the room change. Interviews with staff revealed that the resident was unhappy with the new room assignment, particularly because the new bed placement did not allow the resident to look out the window as before. Admissions staff confirmed that neither the resident nor their representative was shown the new room or given written notice prior to the move, and acknowledged that the facility did not provide written notice for room changes. Review of the facility's policy indicated that notification is required for changes such as room or roommate changes, but this procedure was not followed in this instance.
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