Failure to Timely Submit 5-Day Investigation Reports to State Authorities
Penalty
Summary
The facility failed to ensure that the results of investigations into suspected abuse, neglect, or theft were reported to the New York State Department of Health within five working days, as required by state law and facility policy. In three separate cases involving three different residents, the facility either delayed submission or did not provide documented evidence of submitting the required 5-day investigative conclusion report. The facility's policy clearly states that all findings of investigations must be documented and reported within five business days, but this was not followed in the cited incidents. In one incident, a resident with a history of psychosis and mood disorder struck another resident on the head with a therapy device. The incident was witnessed by two certified nurse aides, and the involved residents were separated, with one being sent for psychological evaluation. However, the 5-day investigative conclusion was not submitted to the Department of Health until six days after the incident, exceeding the required timeframe. In another case, a resident with severe cognitive impairment and no wander guard exited the facility unescorted and was found in a neighboring yard before being taken to the hospital. The investigation concluded there was no evidence of abuse or neglect, but there was no documented evidence that the 5-day investigative conclusion report was submitted to the Department of Health. Interviews with facility leadership confirmed awareness of the reporting requirements, but also revealed lapses in timely submission, particularly when incidents occurred over weekends.