F0550

D

Failure to Honor Resident’s Right to Personal Cellphone and Independent Communication

Tucson, Arizona Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a cognitively intact resident’s right to communication and personal possessions by not facilitating her access to a personal cellphone. The resident, who had diagnoses including type 2 diabetes mellitus, factitious disorder imposed on self, borderline personality disorder, major depressive disorder, anxiety disorder, and Huntington’s disease, was her own responsible party and had a BIMS score of 15, indicating she was cognitively intact. Her care plans identified risks for altered mood and psychosocial well-being related to panic disorder and emphasized encouraging alternative communication with visitors and family via phone or video calls, as well as promoting independence and assessing for lower levels of care as needed. Despite these documented needs and goals, the resident had been without a cellphone for several months after her previous phone broke, and she repeatedly expressed that she needed a cellphone.

Facility documentation and staff interviews showed that the resident had financial resources available and the cognitive ability to express her needs, yet her request for a replacement cellphone was not acted upon. A behavioral health note documented that the resident complained about her phone and asked staff to use their online account to buy her a new one, and she was told that the business office and social services would be notified. The business office manager confirmed that the resident had a trust fund balance of $543.00 and stated that the resident could verbalize her needs and had requested a cellphone, but the manager was waiting for the resident’s sister to decide because the resident had previously spent $1000.00 on food using her debit card via her cellphone. The business office manager also stated that she only handled the resident’s trust fund and that the resident’s finances were otherwise managed by a third party, with the sister acting as surrogate decision maker, even though the resident’s public fiduciary petition had been denied due to her intact cognition.

Additional interviews revealed that the resident did not know how to obtain another cellphone, did not have her sister’s contact number, and had not spoken with her sister since the previous year, while believing the facility had made her sister her power of attorney. The social service director acknowledged that everyone is allowed a cellphone but stated that this resident’s cellphone was considered a safety concern due to a hot phone charger, significant weight gain from ordering food, and related safety issues, and confirmed that the resident had not had a cellphone for several months. The director stated that the resident’s access to a phone was limited to using the facility phone at the nurses’ station or in the unit. The DON stated that residents with a BIMS score of 15 have the right to have their own phone and that social services and the business office should assist them in purchasing one with their own money. The facility’s Resident Rights policy affirmed residents’ rights to keep and use personal possessions and to have reasonable access to a telephone for private conversation, but the resident’s ongoing lack of a personal cellphone, despite her expressed wishes, available funds, and intact cognition, demonstrated the facility’s failure to honor her rights to communication and personal possessions as outlined in policy and regulation.

The facility’s own documentation further showed that the resident’s care plan interventions included encouraging alternative communication with visitors and family members via phone and other electronic means, and encouraging participation in supportive visits and activities important to the resident. However, the resident was observed sitting somewhat apart from other residents during an activity, interacting with staff who were showing her products on a cellphone, while she herself did not have a phone. Staff interviews indicated inconsistent awareness of the resident’s cellphone status, with one CNA stating that the resident’s phone had broken the previous month and an LPN stating she did not know if the resident had a cellphone. The combination of the resident’s documented need for communication to support her psychosocial well-being, her repeated verbal requests for a cellphone, her available personal funds, and the facility’s decision to defer to a sister who was not actively involved, resulted in the resident being without a personal cellphone and without independent access to persons and services outside the facility, contrary to her rights and the facility’s own policies.