Failure to Provide Residents Access to State Abuse Hotline via Facility Phones
Penalty
Summary
The facility failed to ensure that residents had the ability to make confidential phone calls to the Missouri abuse and neglect hotline. Multiple observations and interviews revealed that the phones provided by the facility, including hand-held and desk phones accessible to residents, were unable to successfully connect to the hotline. When attempts were made to call the hotline from these facility phones, the calls would drop after a partial ring, and this issue persisted across several days and multiple devices within the facility. In contrast, calls made to the hotline from personal cell phones were successful, indicating the problem was specific to the facility's phone system. Three residents were directly affected by this deficiency. One resident, who was cognitively intact and independent in activities of daily living, reported being unable to use the facility phone to call the hotline and was not permitted to have a personal cell phone due to guardian restrictions. Another resident, with diagnoses including schizophrenia, bipolar disorder, and depression, also reported being unable to reach the hotline despite multiple attempts and expressed frustration, especially after an incident involving a broken knee. A third resident, with post-traumatic stress disorder and intact cognition, similarly reported being unable to use the facility phones to call for help and felt helpless as a result. All three residents had communicated these issues to staff, but no corrective action was taken prior to the survey. Facility leadership, including the Administrator, Assistant Director of Nursing, and Director of Nursing, attempted to use the facility phones to call the hotline during the survey and were also unsuccessful. Staff interviews confirmed that the issue had been reported by residents but not escalated appropriately. The facility's own policy stated that residents have the right to confidential communication and to voice grievances without interference, but the inability to access the hotline via facility phones directly contravened these rights.