Failure to Timely Report Suspected Abuse Involving Social Media Posts
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and mistreatment were reported immediately, but not later than two hours after the allegation was made, to the appropriate authorities, including the State Survey Agency and local law enforcement. This deficiency was identified for four residents, all of whom were depicted in photographs posted on social media by a Certified Nurse Aide. The photographs showed residents in various stages of undress, with their buttocks and genitalia exposed, and indicated that the residents had not received proper care. The social media post was publicly shared numerous times, and the incident was not initially reported by the facility. The residents involved had a range of medical and cognitive conditions, including generalized anxiety disorder, major depressive disorder, selective mutism, morbid obesity, chronic kidney disease, hypothyroidism, encephalopathy, polyneuropathy, anemia, cerebral infarction, hemiplegia, and hemiparesis. Some residents were cognitively intact, while others had severe cognitive impairment. The facility's own policy required immediate reporting of suspected abuse, but the Administrator and Director of Nursing did not recognize the incident as abuse at the time, instead viewing it as a dignity concern and beginning an internal investigation without notifying authorities. Despite being made aware of the social media post within an hour, the facility did not report the incident to the State Agency or law enforcement until several days later, after the recertification team brought the issue to their attention and questioned whether it constituted abuse. Interviews with staff confirmed that the images could be humiliating and degrading for the residents, and that such incidents should be reported as suspected abuse within the required timeframe.