Failure to Timely Report Suspected Abuse and Investigation Results
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse and the results of related investigations to the New York State Department of Health for two out of three residents reviewed for abuse. In the first instance, a resident with diagnoses including metabolic encephalopathy, depression, and muscle weakness was found in bed with floor mats propped up against the bed and held in place by two wooden night tables, preventing the resident from exiting. The responsible certified nurse aide believed this would prevent the resident from rolling out of bed. Although the facility's investigation did not substantiate a breach in quality of care, the use of mats in this manner constituted a physical restraint. The incident was not reported to the Department of Health until the following day, and the 5-day investigative conclusion was not submitted until over a year later. In the second instance, a cognitively intact resident reported being struck twice on the chest/neck area by their roommate following a verbal disagreement. The incident was unwitnessed, and a full body and skin assessment revealed no injuries. However, the 5-day investigative conclusion for this incident was not submitted to the Department of Health until six days after the event. The facility's policy required immediate reporting of suspected abuse and submission of investigative results within five business days, but these requirements were not met in either case.