F0600

D

Failure to Protect Residents From Abuse, Neglect, and Inadequate Incident Response

Rensselaer, New York Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from abuse and neglect and to respond appropriately to allegations and incidents involving two residents. One resident with moderate cognitive impairment reported that another resident with severe cognitive impairment entered their room during the night, verbally harassed them, and poured water from a refillable water bottle onto them. The resident yelled for help, but no staff responded, and the resident ultimately called 911. The 911 dispatcher then contacted the facility, prompting staff to enter the room. The resident later told a family member they felt shaky, scared, and remained afraid when they saw the other resident. The family member filed a grievance describing the incident and requesting that the aggressor be moved to another unit.

The grievance form documenting this incident was incomplete. The section identifying the staff member who received the grievance was left blank, as were the sections indicating whether the grievance required further investigation and the investigation/follow-up to the complaint. Although the form noted that the complainant was notified of actions taken and was satisfied, there was no documented evidence of an investigation of the incident, no nursing progress notes describing the altercation or post-incident assessments for either resident, and no care plan interventions to prevent recurrence of abuse for either resident. The facility was unable to provide documentation that the incident was reported to the state health department. Key leadership staff, including the assistant administrator, current administrator, and current director of nursing, reported they were not notified of the incident and could not locate an incident report or investigation.

The second deficiency concerns a different resident who had a history of a left femur fracture, malignant neoplasm of the cerebral meninges, and anxiety, and who was independent in decision-making. An incident report documented that this resident was found on the floor during rounds and stated they had fallen while trying to close their door; a licensed nurse assessed the resident, who reportedly denied pain and head injury, had stable vital signs, and the family was notified. However, the resident later told staff they believed they had re-fractured their hip and called their family to request hospital evaluation. The family member reported receiving multiple calls from the resident stating no one was attending to them, that the resident had lain on the floor for about an hour before being put back to bed, and that when the family called the nurses’ station, an unnamed staff member said the resident was lying and hung up. The family member further reported that staff then entered the resident’s room and yelled at the resident for calling their family and lying about falling, after which the family called 911 for hospital transfer.

Communication and reporting failures contributed to the neglect finding for this second resident. The LPN on the night shift stated they were not informed by the prior-shift LPN that the resident had fallen, and only heard from CNAs that the resident “had fallen” without clear confirmation. When the family member called about the fall, the night-shift LPN did not know what they were referring to because they had not been told of the incident. The on-call provider was not notified before the resident’s transfer to the emergency department, and there was no documented evidence that the medical director was made aware of the resident’s experience. The DON stated that, in the event of a fall, they would expect a thorough investigation, completion of an incident report, documentation in the electronic health record, and family notification, and that such events should be reviewed in morning report. The administrator acknowledged there were issues with documentation and staff understanding of processes for adverse events and reporting, underscoring the facility’s failure to ensure the resident was free from neglect.