Failure to Timely Report Resident Abuse Involving Inappropriate Video
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and mistreatment were reported immediately, as required by regulation. Multiple staff members became aware of a video/photograph taken by a certified nurse aide that depicted a resident partially unclothed and exposed during incontinence care. This video was shown to several staff members, including other aides, LPNs, and the Assistant Director of Nursing. Despite witnessing or being informed about the video, staff did not report the incident to the Administrator or the Director of Nursing within the mandated two-hour timeframe. Some staff members expressed fear of retaliation from the Assistant Director of Nursing, who was related to the aide who took the video, and believed that the presence of supervisory staff absolved them of the responsibility to report the incident themselves. The incident involved a resident who was exposed in a video/photograph taken without consent, with the image being shared among staff. The video showed the resident unclothed from the waist down, with visible feces, while staff members were seen gagging and laughing during care. Several staff members, including LPNs and aides, either saw the video or were told about it, but did not take immediate action to report the abuse. Some staff members stated they did not report the incident because they assumed supervisory staff would handle it, while others cited intimidation and fear of retaliation as reasons for not reporting. The Administrator was not notified of the incident until nearly two weeks after staff first became aware of the video. Upon finally being informed, the Administrator and Director of Nursing initiated an investigation and recognized the situation as potential abuse that should have been reported to the state agency within two hours. The delay in reporting resulted in psychosocial harm to the resident and had the potential to affect all residents in the facility. The failure to report the abuse in a timely manner constituted substandard quality of care, as documented in the facility's policies and confirmed by interviews with staff and management.