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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (#NY 591), the facility did not ensure the residents' right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. This was evidence for 1 (Resident #1) of 3 reviewed. Specifically, the facility changed Resident #1's rooms without providing the residents with advanced written notification. The findings are: The facility Policy entitled Room Change Policy and Procedure last reviewed 12/20/24, documented that the social worker will 2. Give the resident, designated representative/family member notification prior to changing their room. 7. Will document room changes and transfers in the resident's medical record. This Policy does not reflect that the resident has the right to receive written notification before being transferred to another room. Resident #1 was admitted with [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] documented the resident had a BIMS score of 15/15, indicating the resident was cognitively intact. A Review of the Facility Admission, Discharge and Transfer (ADT) Activity Detail Report revealed the following room changes for Resident #1: Bed Change 4/26/24 to Unit A Room A-20-A to Room A-11-A Bed Change 5/24/24 to Unit A Room A-11-A to Room A-26-A Bed Change 6/4/24 to Unit A Room A-26-A to A-26-B Bed Change 6/6/24 to Unit A Room A-26-b to Unit B-9-A There was no evidence that a written notice was provided to Resident #1 or their representative. During an interview on 1/17/25 at 9:51 AM, Resident #1 stated that staff would come into their room and just tell them they need to move to a different room. Resident #1 stated they could recollect at least 3 times when they their room was changed. Resident #1 denied signing or receiving any written documentation or being notified prior to the move. Resident #1 stated when they would ask the staff why they had to move they would ignore their questions or just say we need the room. Resident #1 stated they were never given the choice to agree to move or not. They would just be told you are moving. During an Interview on 1/17/25 at 10:21 PM, the Social Worker stated they spoke to the resident or the resident's family prior to moving rooms to see if they agree with the move. The Social Worker stated they will normally write a note regarding the agreement and move change in the resident's record. SW stated they do not provide residents with a written notice that she is aware of. SW stated if a resident or family does not agree with the move then they will bring it back to the interdisciplinary team and see if there are other options available. The Social Worker stated they were not employed at the time of the incident. During an Interview on 1/17/25 at 11:33AM, the Director of Nursing stated social services initiate room changes and then nursing is notified when it is acceptable to move the resident. The Director of Nursing stated the social workers and nurses are both expected to document any residents room changes in the residents' record. During a follow up interview conducted on 01/21/25, Resident #1 stated they never requested to move rooms, they were always told they had to move. 10 NYCRR 415. 5(e)(2) | Plan of Correction: ApprovedFebruary 12, 2025 Resident #1 is no longer in the facility, and was discharged home. Social Worker who was present a time of this deficiency is no longer employed at the facility. The current Director of Social Services was reeducated on the proper process for completing room changes. Specifically, that the resident has the right to receive written notice prior to the room being changed. An audit was completed for all residents in the past 30 days to ensure that a written Notice was provided prior to executing a room change. All negative findings were brought to the Administrators attention immediately. All residents have potential of being affected. The Policy and Procedure titled Room change policy and procedure was reviewed and updated. Specifically, that the resident has the right to receive written notice prior to the room being changed. Social Worker was educated by the Administrator to ensure that notice in writing is provided prior to making a room change, and room change is documented in the medical record. Additionally , the DON , ADON and all Nurse supervisors will be educated as well. Audits will be conducted by social worker to ensure that written notices are present for each room change prior to change being executed. Audits will be conducted weekly x 4 weeks, monthly x 2 months. All negative findings will be brought to the attention of the Administrator immediately. The results of all audits will be brought to the QAPI committee. Person responsible: Director of Social Work |