§483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.
§483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement.
§483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.
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Observations:
Based on facility policy review, clinical record review, and resident and staff interview, it was determined that the facility failed to provide written notice, including the reason for the change, prior to moving a resident to another room, for four of 12 sampled residents. (Residents 9, 10, 11, 12)
Findings include:
Review of the facility policy entitled "Room Change/Roommate Assignment," last reviewed Ocotber 30, 2023, revealed that prior to changing a room or roommate assignment residents and their representatives are given advanced written notice of the change. The advance notice would include why the change is being made and documention of the change would be recorded in the resident's medical record.
Clinical record review revealed that Resident 9 had a room change completed on May 24, 2024. There was no documented evidence that Resident 9 and their representative were given notice, including written notice, of the room change. In an interview on June 17, 2024, at 10:45 a.m., Resident 9 stated he did not know why or when he changes rooms, they just moved him.
Clinical record review revealed that Resident 10 had a room change completed on May 24, 2024. There was no documented evidence that Resident 10 and their representative were given notice, including written notice, of the room change.
Clinical record review revealed that Resident 11 had a room change completed on June 14, 2024. There was no documented evidence that Resident 11 and their representative were given notice, including written notice, of the room change.
Clinical record review revealed that Resident 12 had room changes completed on June 3 and 14, 2024. There was no documented evidence that Resident 12 and their representative were given notice, including written notice, of the room changes.
In an interview on June 17, 2024, at 12:22 p.m., the Director of Nursing confirmed there was no documented evidence that the residents and their representatives were notified of the room changes.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(5) Nursing services.
| | Plan of Correction - To be completed: 06/25/2024
No residents were affected by this deficient practice.
A facility wide audit will be completed to ensure all room changes within the past 10 days have been given advanced written notice of the change and documented of why the change is being made and documentation of the change would be recorded in the resident's medical record.
The social service director and staff have been in-service on the room change process. A paper notification has been developed to ensure compliancy for both the residents receiving the roommate and the resident moving to a new room.
Random weekly audit will be completed to ensure substantial compliance of written and/or verbal notification documentations for all room changes for both receiving roommate and the resident moving into a new room. The social service director will be responsible for overseeing the process.
The social service director will report results of the audits to QAPI monthly for 90 days to ensure going compliance. Weekly audit will be reviewed at QAPI for 90 days to ensure substantial compliance is achieved.
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