Failure to Report Alleged Abuse to State Agency as Required
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse was reported to the State Agency as required by 42 CFR 483.12(c)(1) and the facility’s own abuse policy. The facility’s policy, dated 01/2020, required that suspicions of abuse be reported to law enforcement and the State Survey Agency within two hours if serious bodily injury was involved, or within 24 hours if not, and referenced New York Public Health Law 2803-d requiring reports of physical abuse, mistreatment, or neglect to the New York State Department of Health. Resident #1, admitted with schizophrenia, transient cerebral ischemic attack, and hypertension, had a Minimum Data Set dated 12/03/2024 documenting moderately impaired cognition. After discharge to a group home, Resident #1 reported that between 01/09/2025 and 01/16/2025, two unknown males and one female at the facility pulled their arm, causing pain. On 01/31/2025, the DON received a call from a detective at the Attorney General’s office stating that Resident #1 had complained about staff pulling their arm during the specified period. The facility completed an internal investigation, including interviewing staff assigned to the resident, and documented in a Summary of Accident/Incident Report dated 02/02/2025 that the investigation concluded abuse did not occur. Review of nursing, medical, and social work notes from 12/2024 through 01/13/2025 showed no documentation of reported abuse, bruising, redness, or injuries of unknown source. Despite the allegation and the facility’s investigation, there was no documented evidence that the facility reported the alleged abuse to the New York State Department of Health. The DON stated they believed it was not necessary to report because they were informed that the Department of Health already had the complaint, and the Administrator stated that, based on the information and the resident’s discharge status, it was not necessary to report the complaint to the Department of Health.
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