Failure to Timely Submit Investigation Findings for Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to report the results of all investigations of alleged abuse, neglect, or mistreatment to the administrator or their designated representative and to the appropriate state authorities within the required five working days. In one instance, a family member reported to an LPN that two CNAs were rough with a resident who had severely impaired cognition and multiple diagnoses, including depression and diabetes. The resident reported being held by the neck and having their feet pulled. The facility completed an investigation and determined the allegation was unsubstantiated, but the findings were not submitted to the New York State Department of Health within the mandated timeframe. In another case, two residents with intact cognition were involved in a verbal altercation in the dining room, during which one resident picked up a fork and threatened the other. Staff intervened immediately, and the incident was reported to the state health department. However, the facility did not submit the five-day investigation findings as required by regulation. Interviews with previous DONs revealed a lack of recall regarding the incidents and uncertainty about the reporting requirements for follow-up submissions. The facility's own policy required reporting to the Department of Health within two hours of any suspected abuse, neglect, or mistreatment, and completion of the investigation with findings reported within five days. Despite this, the required five-day reports were either delayed or not submitted for the incidents involving the three residents, resulting in noncompliance with state regulations.