F0610

D

Failure to Thoroughly Investigate Multiple Abuse and Rough-Handling Allegations

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of abuse, mistreatment, or neglect reported through its grievance process. For one resident with atrial fibrillation, respiratory failure, and dementia, a designated representative emailed the social work staff stating the resident reported that someone twisted their arm that morning. The email was forwarded to the Director of Social Work/Grievance Official and the DON. The only documented investigation attached to this grievance addressed skin tears sustained on the same date, with no separate or specific investigation into the allegation that the resident’s arm had been twisted. The Director of Social Work stated they did not recall seeing the twisting allegation, and the DON stated they interpreted the phrase about twisting the arm as a figure of speech and therefore did not investigate it as a possible physical abuse incident.

Another deficiency component concerns a resident with a history of cerebral infarction, hemiplegia/hemiparesis, and diabetes, who required extensive assistance of two staff via mechanical lift for transfers. This resident reported to therapy staff that a CNA was rough during care, hurt them at times, left them unclothed for extended periods in the presence of guests, and transferred them without the required second staff person and mechanical lift support. A grievance form documented these concerns, and a social worker’s interview note recorded that the resident did not want to report anything but acknowledged being left exposed. The investigative summary stated there was credible evidence that the allegation was credible but concluded there was no evidence of abuse or mistreatment, and it did not address the allegation of transfers being done without a second person as required by the care plan. The CNA’s written statement denied leaving the resident exposed or causing harm and described using the mechanical lift, but did not address the specific allegation of performing one-person transfers. The DON later stated that the wording in the investigative summary about credible evidence was a typo, acknowledged not documenting the telephone interview with the CNA, and confirmed that no documentation addressed the allegation of not following the transfer plan of care or included interviews with other residents cared for by the CNA.

A third component involves a resident with urinary tract infection, hereditary hemorrhagic telangiectasia, and a history of transient cerebral ischemic attack, who had moderate cognitive impairment and was dependent on staff for bed mobility and transfers. This resident filed a grievance stating that a CNA was rough, tossed them around, and had a nasty disposition. The grievance investigation form documented that the resident was interviewed, the CNA provided a statement denying rough treatment or attitude, and the CNA was removed from the assignment. A nurse’s progress note on the same date documented that the resident was a two-person approach due to accusatory behavior. The RN Unit Manager reported that no other interviews were conducted beyond the resident and the accused CNA. Facility leadership, including the Administrator, DON, ADON, and Medical Director, described handling such concerns as grievances, often limiting investigations to interviews with the resident and the accused staff member, without routinely performing physical assessments, notifying the physician in the absence of visible injury, or interviewing other residents cared for by the accused staff. The Medical Director stated they did not know the difference between a grievance and an allegation of abuse/incident and were unsure if rough handling constituted abuse, and the DON confirmed that interviewing other residents cared for the accused staff was not part of their investigative process.

Across these three residents, the surveyors found no documented evidence that the facility conducted thorough investigations into the specific abuse-related allegations, including physical mistreatment (arm twisting, rough handling, being tossed around), dignity violations (being left unclothed in front of guests), and failure to follow the plan of care for transfers. The facility’s own policy required investigation of allegations of abuse, neglect, or mistreatment, yet the documentation and staff interviews showed that key allegations were either not investigated at all or were investigated in a limited manner that did not address all components of the complaints. This pattern of incomplete or absent investigation of alleged abuse and mistreatment formed the basis of the cited deficiency under 10 NYCRR 415.4(b).