Failure to Investigate Resident Death Following Dialysis and Missing Interfacility Documentation
Summary
The deficiency involves the facility’s failure to investigate an alleged incident related to a resident’s death following a dialysis treatment, despite policies requiring thorough investigation of all occurrences not consistent with routine operations and care. Facility policy on Reporting and Investigating Resident Accident/Incidents required that all such occurrences, including those that may have caused physical injury or harm, be reported, reviewed, and thoroughly investigated, with completion of an Accident/Incident Report, review of the care plan and CNA profile, and appropriate notifications. The policy also referenced federal regulation 42 CFR 483.13 regarding injuries of unknown source and outlined that incidents with injury without known incident and where abuse or care plan violation could not be ruled out must be reported to the New York State Department of Health and to the Director of Investigations and Administrator. Despite these requirements, there was no documented evidence that the facility conducted any investigation into the circumstances surrounding the resident’s condition upon return from dialysis and subsequent death. The resident involved had chronic kidney disease on dialysis, cellulitis of the right lower leg, and malignant neoplasm of the endometrium, and was minimally cognitively impaired but able to understand and be understood. On the day in question, the resident left the facility around 11:00 AM for hemodialysis and was observed on video at noon leaving the facility in a wheelchair, upright, with an oxygen tank, and communicating with staff and the transport driver. A facility policy on Renal Dialysis required that residents be sent with a communication book containing an Interfacility Report completed prior to transport, and that the dialysis unit complete its section and a Dialysis Information Sheet before the resident’s return. However, the Dialysis Communication Sheet for that day, and for the prior dialysis visit, showed that the dialysis center’s section was left blank. Later that day, video showed the resident returning around 6:00 PM slumped to the left in the wheelchair, wrapped in a blanket, wearing a mask with oxygen tubing visible, and not interacting with the transport driver or the friend who met them. The friend’s written statement documented that the resident arrived at the dialysis center uncomfortable, crying, and disoriented but still able to state their name, address, and recognize the friend. The friend further documented that when they returned to pick the resident up, the resident appeared unconscious, was not moving, and did not respond, and that dialysis staff reported the resident had been crying and yelling and then fell asleep during treatment. Upon arrival back at the facility, the friend noted the resident was limp and drooling and brought them to the nursing station, where staff quickly attended to the resident. Multiple staff interviews confirmed that upon return from dialysis, the resident was unresponsive, with staff unable to obtain vital signs and a nurse confirming the resident was pulseless with blue lips and mottling of the hands and fingers. The resident was pronounced deceased shortly after arrival. Staff, including the ADON and an RN, attempted to call the dialysis center but were unable to reach anyone, and there was no other resident using that dialysis facility for comparison. The DON and Administrator both acknowledged that no facility investigation was conducted into what happened to the resident at dialysis or during transport, and there was no documentation of what items were sent with the resident or any checklist used. The DON stated that because the resident arrived with no pulse or respirations and had a Do Not Resuscitate order, there was nothing to investigate, and the Administrator stated that no investigation was done because it was believed the resident had died at dialysis. This lack of investigation into an unusual occurrence involving a resident’s death, in the context of missing dialysis documentation and unanswered calls to the dialysis center, constituted the cited deficiency under 10 NYCRR 415.4(b)(3).
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Investigate Allegation of Misappropriation: A resident with COPD, anxiety, and PTSD reported $1,600 missing and believed another resident had taken the money, but the SSD told him it was too late to investigate. The grievance record and reporting portal contained no misappropriation report for the resident, and the CNO recalled hearing about missing funds from a family member but did not follow up, while the CEO stated the allegation should have been reported and investigated.
The facility failed to complete a thorough investigation after a resident sustained a 7 cm penile laceration associated with a condom catheter. The resident had a stroke, contractures, cognitive communication deficit, and non-healing pressure ulcers, and the incident record lacked a full investigation or staff statements to determine the root cause and rule out abuse or neglect.
Incomplete Abuse Investigation: The DON investigated an allegation that a resident with dementia, depression, and a prior femur fracture was treated roughly during a shower, but only interviewed one CNA named on the abuse report. Another CNA was also assigned to the resident and documented providing the shower, yet was not interviewed, and no other residents cared for by either CNA were interviewed. The facility's abuse policy required thorough investigation, including staff and resident interviews, and the DON stated the policy was not followed.
Incomplete Investigation of Alleged Staff-to-Resident Sexual Abuse: The facility failed to thoroughly investigate an allegation that a CNA raped a resident during incontinence care. The resident, who had intact cognition and significant medical diagnoses, reported genital and anal touching and later said embarrassment affected how they described the event. The record lacked a written or recorded resident statement, and the facility concluded abuse did not occur based on conflicting accounts rather than documenting a comprehensive investigation of all evidence.
The facility failed to thoroughly investigate two resident abuse allegations. In one case, an altercation with a scratch injury was recorded as an accident/incident, but the final report had no abuse conclusion and the Abuse Coordinator did not interview the residents, observe the injury, or document staff witness statements. In another case, the final report also lacked a conclusion, interview notes could not be produced, and CNAs who were present or witnessed the altercation were not interviewed despite progress notes showing CNA presence.
Failure to Thoroughly Investigate Allegations of Neglect and Possible Abuse: A resident with significant care needs alleged a CNA left her on a bedpan too long, spilled urine/feces in bed, and performed an unsafe hoyer transfer, while another resident was heard screaming during a one-person hoyer transfer. The facility did not complete a thorough abuse/neglect investigation because it did not interview the second resident, other potentially affected residents, or assess non-interviewable residents.
Failure to Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to ensure an allegation of misappropriation was investigated as required for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. Resident #23 stated that approximately two months earlier he reported $1,600.00 missing to the SSD and told the SSD he believed another resident had taken the money. He reported that when he explained the incident had occurred about one and a half months earlier, the SSD told him it had been too long ago to investigate. Review of the facility grievance records from February 2026 through June 2026 showed no documented allegation of misappropriation involving Resident #23, and review of the Long-Term Care Reporting Portal showed no report of misappropriation involving him. The CNO stated she recalled a family member mentioning Resident #23's missing funds but did not ask further questions, and the CEO stated the allegation should have been reported and investigated for potential misappropriation.
Incomplete Investigation of Penile Laceration
Penalty
Summary
The facility failed to conduct a thorough investigation to rule out the potential for abuse or neglect for one resident after a penile laceration was identified in connection with a condom catheter. The resident had diagnoses including stroke, contractures, cognitive communication deficit, and non-healing pressure ulcers of the buttocks and coccyx, and the condom catheter had been used to decrease moisture and help prevent worsening of the coccyx/buttocks wound healing. During review of the incident, the resident was found to have a 7 cm laceration of the penis from the condom catheter. The catheter had become dislodged during an assessment when the nurse aide noted low urine output, and the nurse supervisor later had an LPN reapply a new condom catheter. The facility’s incident documentation did not include a full investigation or staff statements to identify the root cause of the laceration and rule out abuse or neglect, and the Nursing Home Administrator confirmed that the investigation was not completed thoroughly.
Incomplete Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident who was admitted with diagnoses including a right femur fracture, difficulty walking, dementia, and depression. The resident reported that a CNA who assisted with her shower was "very rough," had "pushed me around," and became "nasty" when questioned. The allegation was documented in the facility's incident report and reported on the SOC 341 as suspected dependent adult/elder abuse. The DON stated she investigated the allegation and interviewed only CNA 1 because CNA 1 was named on the SOC 341 report and was believed to be involved based on staffing. However, the record showed CNA 2 was also assigned to the resident and documented that she showered the resident on the date of the alleged incident. CNA 2 was not interviewed, and no other residents cared for by CNA 1 or CNA 2 on that date were interviewed. The facility's policy required all allegations to be thoroughly investigated, including interviews with staff on all shifts who had contact with the resident and interviews with other residents cared for by the accused employee, and the DON stated the policy was not followed.
Incomplete Investigation of Alleged Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of staff-to-resident abuse for 1 of 1 residents reviewed for abuse. The resident, who had diagnoses including obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction, was documented as having intact cognition. The allegation involved a CNA during incontinence care, and the resident reported that the CNA raped them and touched and rubbed their genital and anal area, causing them to feel unsafe in the facility. The facility’s investigative record did not include a written or recorded statement from the resident detailing the allegation, limiting the ability to objectively investigate the complaint. The facility’s accident/incident report documented that the resident told an LPN they had been raped, and an RN supervisor noted redness in the perineal area during assessment. However, the report also stated the facility concluded abuse did not occur because the resident gave conflicting statements, rather than documenting a comprehensive investigation of all available evidence. Additional statements in the record showed the resident later explained they felt embarrassed and ashamed when law enforcement and a male nursing supervisor were present, which affected how they described the event. The CNA stated they provided incontinence care and applied ointment, but denied doing anything beyond what was requested. The DON stated the facility obtained a statement from the resident, while the RN supervisor stated no statement was obtained or documented from the resident.
Incomplete Abuse Investigations and Missing Conclusions
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two separate resident altercations. For one incident involving two residents, the final Facility Reported Incident classified the event as an accident/incident rather than resident abuse, even though the report documented an alleged altercation and that one resident sustained a scratch on the right cheek requiring first aid. The final form did not include a conclusion stating whether abuse or assault did or did not occur. During review of the investigation file, the Administrator, who was also the Abuse Coordinator, could provide only the initial and final reports submitted to the state survey agency and could not provide additional evidence such as staff interviews, witness statements, or documentation of observations after the alleged abuse. She stated she did not interview either resident, did not observe the injured resident’s scratch, and only spoke with the ADON and an RN, both of whom said they did not witness the altercation. She also did not attempt to interview a CNA she believed may have pulled the injured resident from the other resident’s room, and there was no documentation showing staff interviews were completed. The injured resident’s EHR also did not show documentation of the scratch assessment, appearance, treatment orders, or any documentation that the abuse with injury occurred. A second altercation between two other residents was also not thoroughly investigated. The Administrator and DON provided only the initial and final reports and resident face sheets, and the final report did not include an investigation conclusion. Although the Administrator stated she had completed all interviews before submitting the final report, she could not produce handwritten interview notes or other investigation documentation. One resident said he discussed the incident with staff present at the time, while another resident could not recall the altercation. A CNA stated she was present during the incident and was never interviewed, and another CNA stated he witnessed the incident and reported it to the ADON but was never interviewed by the Administrator. Progress notes for both residents documented CNA presence during the altercation, yet the Administrator stated she did not interview any CNAs because she was told none were present. The facility policy required prompt and aggressive investigation of all abuse allegations, including interviews of the reporter, anyone with direct knowledge, and the resident if interviewable, and required the final report to contain a conclusion based on known facts.
Failure to Thoroughly Investigate Allegations of Neglect and Possible Abuse
Penalty
Summary
The facility did not thoroughly investigate allegations of abuse and neglect involving two residents. One resident, who had complex regional pain syndrome, mononeuropathy, muscle wasting and atrophy, pruritus, and required assistance with personal care, submitted a written grievance stating that a CNA left her on a bedpan for over an hour, questioned her about re-wearing a soiled brief, spilled the bedpan in bed, attempted a hoyer transfer without ensuring the sling was properly secured, and did not clean her skin after she had lain on a wet pad. The resident and her representative described the event as neglect, and the facility’s self-report also documented the allegation as neglect. A second resident, who had rheumatoid arthritis, polyneuropathy, non-[NAME] lymphoma, osteoarthritis, and dependence on enabling machines and devices, was heard screaming from behind a closed bedroom door while a CNA was transferring her alone with a hoyer lift. Staff reported hearing the resident yell, "Help me" and "Oww," and when they entered the room they found the resident in the lift and sling, leaning to one side, while the CNA was unhooking her. The resident’s care plan required two staff for bed mobility, toileting, and hoyer transfers. The facility’s investigation did not include a statement or interview from the second resident, did not include interviews of other residents cared for by the CNA during the shift, and did not include skin assessments of non-interviewable residents who may also have been affected. Facility leadership later stated the investigation was not thorough and should have included those interviews and assessments. The acting administrator also stated that hearing a resident screaming behind a closed door would make her suspicious of abuse, and that the incident should have been investigated as an additional allegation involving the same CNA.
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