A resident with dementia, immunodeficiency, SLE, and RA was moved from a Medicare bed to an LTC room without prior written notice or explanation. The resident said she was not told why she was moved and learned of it only when it happened, and her family member reported receiving no written or verbal notice. The DON said the family was not notified because she forgot and the move occurred when a Medicaid bed became available.
Failure to Provide Written Notice Before Room Changes: A resident with diabetes, AKF, and dementia was moved between rooms multiple times, but the resident and family member said no written notice was provided. Staff said room changes were handled by the DON and communicated by phone or in person, and the record contained no documentation of the room changes. The facility policy required prior notification and written notice with the reason, effective date, and new room before relocation.
Failure to Notify RP Before Room Change: A resident with neurological conditions, cerebral palsy, and seizure disorder was moved closer to the nurses' station for safety-related reasons, but the RP was not given written notice or a clear explanation before the room change. The RP later found the resident had been moved and had to ask staff where he was located, while the LVN, SW, ADON, and DON could not confirm that prior notification had been provided.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room for contact isolation without prior verbal or written notice to the responsible party, despite facility policy requiring such notification. An LVN documented the room change but did not notify the family and later acknowledged it was her responsibility. The resident’s representative reported learning of the move only upon visiting and finding the resident in a different room. The DON and Interim ADM confirmed that nurses are trained and expected to notify residents or their representatives of room changes but could not explain why notification did not occur in this case.
A resident with depression, anxiety, and dementia, but assessed as cognitively intact, was moved from one floor to another Medicaid-designated room without the facility providing written notice or the reason for the move to the resident’s designated Resident Representative (RR), who held medical power of attorney. Staff had the resident sign a room change notification form, even though he was not his own Responsible Party, and he reported feeling coerced and not understanding why he was being moved. The RR stated she only learned of the move when the resident called her and that the facility did not notify her. The Administrator and CNO reported they believed informing the resident alone was sufficient if the resident was coherent and indicated they relied on the resident to notify the RR, despite facility policy stating that RR decisions are treated as the resident’s decisions.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room after damaging a privacy curtain, but the guardian was not notified in writing or given the reason for the change. Staff believed the move was temporary and did not follow facility policy requiring notification and consent from the resident's representative.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room due to a non-functioning bathroom, but neither the resident nor her responsible party received written notice of the change. Facility staff confirmed that room changes were communicated verbally and not in writing, and the facility's policy did not require written notification. This resulted in a failure to honor the resident's right to receive written notice before a room or roommate change.
A resident with severe cognitive impairment and dementia was moved from a rehabilitation unit to a secure unit without receiving written notice or explanation, and without notification or consent from her emergency contact. Facility leadership confirmed there was no signed consent or clear documentation of family notification, despite policy requiring resident and representative involvement in such decisions.
Failure to Provide Written Notice Before Room Changes: The facility did not ensure that residents received written notice, including the reason, before room changes were made. Records showed cognitively intact residents with multiple medical diagnoses were moved to other rooms, but documentation of written notice was absent, and one resident stated she was never given written notice when her room changed.
A resident was not allowed to share a room with their spouse or roommate of choice, and did not receive written notice before a change in room assignment was made, violating their rights.
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