Failure to Timely Report Alleged Abuse, Neglect, and Serious Incidents
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, to the New York State Department of Health as required by federal and state regulations. Two residents, both with significant medical and cognitive conditions, were involved in separate incidents where the facility did not notify the appropriate authorities within the mandated timeframes. In the first incident, two residents went out on pass and did not return at the expected time. The facility did not report their absence to the Department of Health until several hours after they were located, exceeding the required two-hour reporting window. There was also no documented evidence that the police were notified when the residents did not return as scheduled. In the second incident, one of the same residents, who had dementia and a history of wandering, exited the building through a third-story window after removing an air conditioner and sustained multiple injuries requiring hospitalization. The facility did not report this serious incident to the Department of Health within the two-hour timeframe, as required for events involving serious bodily injury. The delay was attributed to the staff managing emergency services and conducting internal interviews, as well as lack of immediate computer access for reporting. Additionally, the facility lacked documentation showing that either resident was assessed for capacity to go out on pass, had a physician's order for the pass, or had a comprehensive care plan addressing outings. Interviews with the DON and Administrator confirmed awareness of the reporting requirements but acknowledged the incidents were not reported within the required timeframes. The facility's own policies required prompt notification to authorities, but these were not followed in the cited events.