Late Submission of Abuse Investigation Findings to State Authorities
Penalty
Summary
The facility failed to ensure that the results of all investigations into alleged abuse, neglect, exploitation, or mistreatment were reported to the administrator or their designee and to the appropriate state authorities within five working days, as required by both facility policy and state regulations. Specifically, an incident occurred in which one resident struck two other residents with a wheelchair footrest, resulting in injuries: one resident sustained an injury above the right eyebrow, and another developed a large swelling on the right arm. The facility conducted an investigation and determined that the incident did not meet the definition of abuse due to the absence of a prior pattern of aggression or clear intent to harm. However, the results of this investigation were not submitted to the New York State Department of Health within the mandated five-day period; instead, the findings were submitted three days late. The residents involved had varying medical histories, including end stage renal disease, diabetes mellitus, depression, hypertension, and cerebrovascular disease, with cognitive assessments ranging from moderately impaired to intact. Interviews with the DON and Administrator confirmed that both were aware of the reporting requirements and acknowledged the late submission of the five-day report. The Administrator could not provide a reason for the delay in submitting the investigation results to the state agency.