Failure to Protect Resident from Abuse Due to Inappropriate Photograph and Delayed Staff Action
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident with severely impaired decision-making abilities from abuse and neglect. The resident, who required substantial to maximal assistance with daily activities and had a history of behavioral symptoms, was photographed by a Certified Nurse Aide (CNA) while in a vulnerable state. The photograph, which included the resident in bed with an exposed peri area, was shared on social media. This act was in direct violation of the facility's policy prohibiting the taking and distribution of resident photographs. Despite being made aware of the allegation that a CNA had taken a photograph of the resident, facility staff allowed the CNA to continue working with the resident and other residents for an entire 8-hour shift. A Registered Nurse (RN) and CNA instructor, who was present at the facility, became aware of the incident but did not notify facility administration or remove the CNA from duty. The RN later acknowledged that she should have reported the incident and separated the CNA from residents but failed to do so at the time. The facility's own policy clearly prohibits staff from taking or distributing photographs of residents in any manner that could demean or humiliate them. The failure to immediately remove the CNA from resident care and notify appropriate facility leadership resulted in a lack of a supportive and safe environment for the resident involved, as well as for other residents in the facility.