Failure to Report Allegation of Abuse Involving Resident Photography
Penalty
Summary
The facility failed to report an allegation of abuse through the required Electronic Event Reporting system (ERS) for one of three residents. Facility policy titled "Prohibition and Prevention of Resident Abuse, Neglect, Exploitation, Mistreatment, or Misappropriation of Resident Property" dated 12/9/25 states that all allegations of abuse must be reported initially through ERS, and defines emotional or psychological abuse to include taking or using photos or recordings in any manner that would demean or humiliate a resident. Resident R3 was admitted with diagnoses including a right humeral fracture, pain, and high blood pressure. Behavior Night Shift Documentation for 3/8/26 showed that Resident R3 called 911 and was attempting to take photos of other residents without their consent. During an interview, Resident R3 stated that everything was fine until the resident called the police, after which the facility "turned everything around" on the resident and removed the roommate, Resident R4, from the room. In a separate interview, the Director of Nursing (DON) reported that Resident R4's family had told Resident R3 to watch out for their loved one, and that Resident R3 took this too seriously and began photographing Resident R4, who was always fully clothed in the photos. Review of the facility's ERS reports showed no entry for this allegation of abuse, and in an interview the DON acknowledged that the facility did not realize the incident was reportable and therefore failed to report the allegation of abuse as required by policy and state regulations.
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