Failure to Timely Report and Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse were reported to the state survey agency within the required timeframes. Specifically, an incident occurred in which a resident with hemiplegia, epilepsy, and chronic obstructive pulmonary disease alleged that a registered nurse held their hands during a medication administration. The resident reported that the nurse attempted to force medication into their mouth, leading to the resident screaming and calling 911. Staff statements indicated that the nurse restrained the resident's arms in response to being hit. The incident was reported to facility administration shortly after it occurred. Despite facility policy requiring notification to the appropriate agencies within two hours of an abuse allegation and submission of a written investigative report within five working days, the facility reported the incident to the New York State Department of Health the following day, exceeding the two-hour requirement. Furthermore, the five-day investigative report was not submitted until 43 days after the incident. The Director of Nursing confirmed that both the initial and five-day reports were sent late and could not provide a reason for the delay.