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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: March 10, 2025
Citation Details None | 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 Administrator's 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 |