Failure to Submit Investigation Results to State Agency Within Required Timeframe
Penalty
Summary
The facility failed to ensure that the results of an investigation into a resident incident were reported to the New York State Department of Health (NYSDOH) within five working days, as required by regulation. Specifically, after a resident with diagnoses including dementia, Alzheimer's disease, and Parkinson's disease fell during a transfer with a Hoyer lift and sustained a forehead laceration, the initial incident was reported to NYSDOH on the same day. However, there was no documented evidence that the results of the subsequent investigation were submitted to NYSDOH within the mandated five-day period. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that while the initial incident was reported promptly, the required five-day follow-up report containing the results of the investigation was not submitted. The facility's policies did not specify the requirement to submit the investigation results to the Department of Health within five working days, and staff could not provide an explanation for the omission during interviews.