F0609

F

Failure to Timely Report and Investigate Abuse Allegations and Injuries of Unknown Source

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report and investigate multiple allegations and incidents of abuse, neglect, and injuries of unknown source, and to notify the administrator and the State Survey Agency within required timeframes. Facility policy required that all alleged violations and injuries of unknown source be reported immediately, but not later than two hours if the events involved abuse or resulted in serious bodily injury, and not later than 24 hours if they did not involve abuse and did not result in serious bodily injury. The policy also required immediate notification of the nursing supervisor, DON, or administrator, initiation of an investigation, and reporting to the New York State Department of Health (NYSDOH). Surveyors found that these requirements were not followed for several residents.

For two residents involved in a resident-to-resident altercation, the facility did not ensure timely reporting or investigation. One resident with moderate cognitive impairment reported that another resident entered their room during the night, yelled at them, and dumped water from a refillable water bottle on them, leading the resident to call 911 when staff did not respond to their calls for help. The family later learned of the incident directly from the resident and filed a grievance. The grievance form lacked documentation of who received it, whether further investigation was required, and any investigation or follow-up details, although it noted the complainant was notified of actions taken. Nursing progress notes for the month did not document the altercation or any post-incident assessment, and the comprehensive care plans for both residents did not include interventions related to abuse or neglect. The facility could not provide an incident report or investigation, and there was no evidence the incident was reported to NYSDOH or that the administrator was notified at the time of occurrence.

For another resident, the facility failed to meet reporting requirements after an allegation of staff-to-resident abuse. This resident reported an allegation of abuse by a CNA on a specific evening. The allegation was not reported to the administrator within two hours as required for abuse allegations, and it was not reported to NYSDOH until approximately 24 hours after the allegation was made. Additionally, a resident who sustained an unwitnessed fall and was later found to have a hip fracture was not reported to NYSDOH, despite the serious injury. Another resident with dementia and severe cognitive impairment experienced two unwitnessed falls with head lacerations, was sent to the hospital, and later was found to have an acute left hip fracture of unknown source after returning to the facility and developing acute hip pain and functional decline. Staff interviews indicated that this resident had been ambulatory and independent with a walker before the fracture and experienced a significant decline afterward. The acting DON and administrator stated that injuries of unknown origin should be reported to NYSDOH, but there was no evidence that this fracture of unknown source was reported or that an investigation consistent with policy and regulatory requirements was completed.

Interviews with facility leadership and clinical staff confirmed that required notifications and investigations did not occur as expected. The assistant administrator reported they were not notified of the resident-to-resident incident and could not locate an incident report or investigation, and acknowledged the event was reportable and should have triggered a full investigation and assessments of both residents. The DON and administrator, who were not in their roles at the time of some incidents, stated their expectations that resident-to-resident altercations, abuse allegations, and injuries of unknown origin be immediately reported to them and to NYSDOH, and that thorough investigations be conducted. The medical director stated they were not always notified of reportable incidents and expected investigations for injuries of unknown origin. Overall, surveyors determined that for multiple residents, the facility did not ensure immediate reporting of alleged violations and injuries of unknown source to the administrator and appropriate authorities, and did not ensure that required investigations and documentation were completed in accordance with facility policy and 10 NYCRR 415.4(b)(2).