Resident Phone Access and Dignity Violation During Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be treated with respect, dignity, and to communicate with family while in distress. The resident was an older female with multiple cardiac and mental health diagnoses, including unspecified diastolic CHF, essential hypertension, paroxysmal atrial fibrillation, generalized anxiety disorder, recurrent depressive disorder, and nonrheumatic aortic valve stenosis. Her Medicare MDS showed a BIMS score of 15, indicating intact cognition, and her care plan documented anxiety, depression, and use of antidepressant medication with interventions for psychosocial support. Video observation from the resident’s room on a specific morning showed the ADON telling the resident she was going to remove the resident’s phone from her chest while the resident was on a call with her son and in respiratory distress. The resident nodded her head no and held up her left hand, then became more frustrated as the ADON removed the phone and left the room. The phone was then placed on a rolling bedside table positioned approximately 10 feet away on the right side of the bed, toward the middle of the bed, where the resident could not reach it. During the period after the phone was removed, the resident attempted to reach the phone, and her hands were not shaking; she had been holding the phone in her left hand before laying it on her chest. Approximately eight minutes later, EMS entered the room, picked up the cell phone, and began talking to the resident’s son. In interviews, the ADON stated she believed the phone on the resident’s chest affected her breathing and that the resident was unable to hold the phone due to shaking hands, and she asserted the phone had been left within reach at the head of the bed. The DON and Administrator both stated that residents have the right to have their personal phones within reach and to speak with family at any time, and that staff should not remove a resident’s phone or place it out of reach while the resident is on a call. The facility’s resident rights policy stated that employees shall treat residents with kindness, respect, and dignity and that residents have the right to use a telephone in privacy and to exercise their rights to the fullest extent possible.
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