Failure to Timely Report and Submit Investigation Results for Abuse and Injury Incidents
Penalty
Summary
The facility failed to report the results of all investigations of suspected abuse, neglect, or theft to the administrator or their designated representative and to other officials, including the State Survey Agency, within five working days as required by regulation. In two cases, the facility did not submit timely follow-up investigation reports to the New York State Department of Health and, in one instance, did not notify local law enforcement as required. One resident with a history of morbid obesity and spina bifida experienced an incident during transport where they slid forward in their wheelchair. The incident was not immediately reported by the Certified Nursing Assistant involved. The resident later reported the event to a Registered Nurse Supervisor, who assessed the resident and found no initial injuries. However, several days later, the resident developed symptoms and was found to have acute fractures in both knees. The facility did not report the incident to the State Department of Health in a timely manner and failed to submit the required follow-up investigation within five days. In another case, a resident with thyroid disorder, bipolar disorder, and depression alleged being attacked by staff, resulting in a scratch on the cheek. The allegation was reported to the State Department of Health the following day, but not within the required two-hour window, and local law enforcement was not notified. The facility's investigation could not substantiate the claim due to inconsistencies and lack of surveillance evidence. Interviews with staff revealed a lack of awareness regarding the timely submission of investigation reports and proper notification procedures.