F0609

D

Failure to Timely Report Allegation of Abuse Involving Inappropriate Resident Photograph

Sheldon, Iowa Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

Facility staff failed to timely report an allegation of abuse involving a cognitively impaired resident. The resident had diagnoses including depression, hypertension, and psychomotor defect following cerebral infarction, with a BIMS score of 8 indicating severe cognitive impairment. After the resident experienced a fall and was on the floor wearing a brief and T‑shirt, a CNA (Staff B) took a photo showing the resident on the floor with the brief down to the ankles and a pillow under the resident’s head, with Staff B visible in the background. Staff B then shared this photo in a staff work group chat. Another CNA (Staff A) later viewed the photo on Staff B’s phone in the hallway and questioned why Staff B had the photo; Staff B responded that it was in their work group chat.

Staff A did not immediately report the incident to administration, instead “sitting on it” for approximately a week before deciding to turn it in, acknowledging she knew it was not right for Staff B to have the photo. During this period, Staff A and another CNA (Staff D) discussed the photo with a third CNA (Staff C), describing the image but not showing it to her. Staff C, upon learning of the photo, immediately reported the matter to the DON. The DON confirmed that Staff A, Staff C, and Staff D informed her that about a week earlier Staff B had shown them the photo of the resident on the floor after the fall. The facility’s abuse and neglect policy required that alleged or suspected violations involving mistreatment, neglect, exploitation, or abuse be reported immediately to the administrator and to designated agencies not later than 2 hours after the allegation is made. The DON stated that staff should have reported the allegation to administration right away.