F0609

D

Failure to Timely Report Alleged Verbal Abuse to Administration and State Authorities

Brentwood, New York Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that an allegation of verbal abuse was reported to facility administration and the New York State Department of Health (NYSDOH) within the required two-hour timeframe. A cognitively intact resident with multiple fractures, including fractures of the left ulna, left humerus, and ribs, reported during the night shift that a staff member from the prior shift had threatened to further injure the resident’s already injured arm. The resident had a care plan for risk of abuse and neglect, and a separate care plan for behavioral symptoms related to fabrication/accusatory behavior, but the behavioral care plan did not document specific dates and events of prior accusatory behaviors. At approximately 2:00 AM, the resident told an LPN that someone wanted to hurt their arm; the LPN immediately reported this allegation to the RN supervisor.

The RN supervisor interviewed the resident, who stated that a staff member from the previous shift had verbally threatened to hurt the resident’s arm after an argument, but denied being physically hurt. The RN supervisor initiated an Accident and Incident report but did not immediately notify the Director of Nursing Services (DON) or Assistant Director of Nursing Services (ADON). Instead, the RN supervisor focused on the resident’s wellbeing and on ensuring that the alleged perpetrator was no longer assigned to the resident. The ADON was not informed of the allegation until the morning of the following day, more than 24 hours after the allegation was first reported to the RN supervisor. The facility’s Nursing Home Facility Incident Report shows that the abuse allegation was submitted to NYSDOH the day after the allegation was made, at 4:55 PM, well beyond the two-hour reporting requirement.

The facility’s written abuse policy defined verbal and mental abuse but did not include specific timeframes for reporting all reportable incidents, including allegations of abuse. Interviews with the ADON, DON, Administrator, and Medical Director revealed that the leadership involved in developing and reviewing the abuse policy were unaware that all alleged abuse must be reported to NYSDOH within two hours after the allegation is made, regardless of the presence or absence of physical injury. The ADON believed that only incidents resulting in serious harm required reporting within two hours and that other abuse/neglect incidents could be reported within four to 24 hours. The DON similarly believed that abuse or neglect with visible injury must be reported within an hour and those without injury within four to 24 hours, and acknowledged that the policy lacked required reporting timeframes. The Administrator and Medical Director also confirmed that the policy did not contain specific reporting timeframes, and the Medical Director did not know the exact required timeframe for reporting abuse allegations. Additionally, there was no documentation in the resident’s medical record regarding the abuse allegation, despite the incident and subsequent investigation.

Overall, the deficiency centers on the facility’s failure to ensure that covered individuals immediately, but not later than two hours, reported an allegation of verbal abuse to facility administration and NYSDOH, as required by 10 NYCRR 415.4(b)(2). The RN supervisor delayed reporting the allegation to administration for more than 24 hours, and the facility’s leadership and written policy did not reflect or communicate the correct mandatory reporting timeframes for all alleged abuse incidents.