F0609

K

Failure to Timely Report Multiple Abuse Allegations to State Authorities

West Islip, New York Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report multiple allegations of abuse and rough care to the New York State Department of Health (NYSDOH) within the required two-hour timeframe. Facility policy titled “Abuse Prohibition” dated August 2024 stated that all alleged cases of abuse, neglect, or mistreatment would be reported to the Department of Health or other appropriate agencies by the Administrator and/or the President of Clinical Services, and that alleged cases of abuse must be reported within five days, with confirmed cases reported immediately. Despite this, surveyors found no documented evidence that several specific allegations were reported to NYSDOH as required. The facility’s leadership, including the Administrator and Director of Nursing (DON), stated that they only reported allegations within two hours if they were substantiated or if they believed there was evidence of willful harm.

One resident with atrial fibrillation, respiratory failure, dementia, and a moderate cognitive impairment was the subject of an email grievance from their designated representative, who reported that the resident stated someone twisted my arm this morning. The email was sent to a social worker and forwarded to the Director of Social Work/Grievance Official and the RN Unit Manager. The Director of Social Work/Grievance Official, Social Worker, RN Unit Manager, DON, and Administrator all stated they interpreted the phrase someone twisted my arm as a figure of speech rather than a physical act, and therefore did not investigate it as an abuse allegation or report it to NYSDOH. The RN Unit Manager stated they interviewed the resident and the representative about other concerns in the email but did not document the interview and did not ask about the arm being twisted. There was no documented evidence that this allegation was reported to NYSDOH.

Another resident with cerebral infarction, hemiplegia/hemiparesis, and type 2 diabetes, and with intact cognition, reported via a grievance form that a CNA was rough and hurt them at times during care, left them unclothed for extended periods including in the presence of guests, and transferred them alone with a mechanical lift despite a requirement for a two-person transfer. An investigative summary dated the day after the grievance documented that there was credible evidence that this allegation was credible, that there was no evidence of abuse or mistreatment, and that the CNA would no longer be assigned to the resident. The DON later stated that the phrase there was credible evidence that this allegation was credible was written in error and should have read there was no credible evidence that this allegation was credible, and also stated they did not interview the resident. The DON further stated that at the time of the allegation, they only reported allegations of abuse to NYSDOH within two hours if they found evidence of willful harm. There was no documented evidence that this allegation was reported to NYSDOH.

A third resident with urinary tract infection, hereditary hemorrhagic telangiectasia, transient cerebral ischemic attack, and moderate cognitive impairment reported via a grievance form that a CNA was rough with me, tossed me around, and had a nasty disposition. The grievance investigation documented that the resident was interviewed and stated the CNA was rough removing their pants, that a statement was taken from the CNA, and that the CNA was removed from the assignment. There was no documented evidence that this allegation was reported to NYSDOH. The RN Unit Manager stated they did not report this alleged abuse to the Assistant DON or DON because they did not think the allegation was abuse. The Assistant DON stated that abuse was documented as a grievance, an investigation was completed, and if they felt abuse occurred then it was reported to NYSDOH within two hours. The DON and Administrator both stated that they reported allegations to NYSDOH within two hours only if they found evidence of willful harm or if the allegation was substantiated. The Medical Director stated they did not know the difference between a grievance and an allegation of abuse/incident and did not know if an allegation of abuse should be reported to NYSDOH. Immediate Jeopardy was identified related to these failures.