Failure to Timely Report and Submit Abuse Investigation Conclusions
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or theft were reported immediately, and that the results of investigations were submitted to the New York State Department of Health within the required timeframe. Specifically, the facility did not report the investigative conclusions for three separate incidents involving three different residents, as required by state law and facility policy. The incidents included allegations of staff abuse, resident-to-resident sexual exposure, and concerns about a certified nurse aide's roughness and lack of empathy. In one case, a resident with chronic obstructive pulmonary disease, schizophrenia, and major depressive disorder reported to their representative that staff had physically abused them in the dining room. The administrator was not informed of the allegation until several days after the incident, and there was no documented evidence that the investigative conclusion was submitted to the Department of Health. In another case, a resident with dementia and schizoaffective disorder exposed themselves to another resident, causing distress, but again, the investigative conclusion was not reported to the Department of Health. A third incident involved a resident with muscle weakness, major depressive disorder, and anxiety, who complained that a certified nurse aide was rough and showed no empathy. The facility investigated and found no evidence of abuse, but did not submit the investigative conclusion to the Department of Health. Interviews with the Director of Nursing and the Administrator revealed a lack of awareness regarding the failure to submit the required reports, despite both being responsible for reporting and documentation.