LIBERTY — State inspectors cited the Sullivan County Adult Care Center for Immediate Jeopardy after finding the facility failed to properly investigate an allegation of verbal and physical abuse against a resident with dementia, assess the resident for harm, remove the accused certified nursing assistant from resident care or timely report the allegation to the state.

Inspectors classified the failure to investigate the allegation, assess Resident #1 and remove CNA #2 from access to residents as Immediate Jeopardy, finding that the failures created a likelihood of harm to Resident #1 and the potential for harm to other residents.

Immediate Jeopardy was called on May 26 and removed the designation on May 28 after the corrective measures were implemented.

According to the inspection report, a certified nursing assistant (CNA #1) reported on May 11 that they witnessed another CNA (CNA #2) forcibly grab a resident (Resident #1), push the resident into a wheelchair, position the wheelchair against a wall, use a dining room table as a barrier preventing the resident from getting out and repeatedly use profanities toward the resident. CNA #1 notified a licensed practical nurse (LPN) and registered nurse (RN) supervisor that night.

CNA #2 denied abusing the resident, telling inspectors that Resident #1 had been yelling and cursing and that they were attempting to redirect the resident. CNA #2 said the table was positioned between them and the resident and denied pinning the resident against a wall or blocking the resident with it.

According to the report, Resident #1 has dementia and is documented as having moderately impaired cognition. The resident’s care plan also noted that the resident could become verbally aggressive when frustrated or confused.

Despite the May 11 allegation, inspectors found CNA #2 remained routinely assigned to Resident #1 through May 21. Facility policy required a staff member suspected of abuse to be suspended or reassigned while the allegation was investigated. CNA #2 was not removed from resident care until May 21, while state inspectors were on site.

Two days earlier, CNA #1 had reported the alleged abuse to the New York State Department of Health (DOH) complaint unit.

Inspectors found no documented evidence that the facility had properly investigated the allegation, assessed the resident, made required medical notifications or updated the resident’s care plan.

The RN supervisor acknowledged that CNA #1 had reported allegations of verbal and physical abuse and said the Director of Nursing (DON) was notified. The supervisor also acknowledged that required assessments and an abuse investigation were not completed and that CNA #2 remained on the unit despite facility policy. The supervisor told inspectors they were overwhelmed and had “dropped the ball.”

The DON also acknowledged failures in the response. According to the report, no investigation or accident and incident report was initially opened because it was believed CNA #1 was fabricating the allegations. The DON later said the RN supervisor had been directed to investigate and that CNA #2 should have been removed pending completion of the investigation.

The report does not identify what evidence led facility staff to believe CNA #1 was fabricating the allegation.

Inspectors also documented a discrepancy in what information reached the Adult Care Center’s Administrator. The DON said the RN supervisor called on May 11 regarding allegations involving CNA #2’s treatment of Resident #1. The Administrator, however, told inspectors they were not made aware of the alleged verbal and physical abuse until contacted by the New York State Attorney General’s Office on May 21.

The Administrator said the May 11 statements had instead been presented as addressing CNA #1 becoming upset and leaving the shift. After learning of the allegation, the Administrator acknowledged that the incident should have been investigated and that the resident should have been assessed and referred for psychiatric or psychological services.

The facility also failed to make its required report to DOH within the regulatory timeframe. Although CNA #1 reported the alleged abuse to the DOH complaint unit on May 19, the facility itself did not report the allegation until May 21.

The inspection resulted in five deficiency citations, including failures to protect the resident from abuse, timely report suspected abuse, properly investigate and respond to the allegation, update the resident’s care plan and ensure required staff training.

Inspectors also found the facility could not document that CNA #1, an agency worker whose first day at the facility was May 11, had completed required orientation and training before being assigned resident care duties.

The resident’s behavior, psychosocial well-being and risk-of-victimization care plans also remained unrevised following the allegation. Inspectors found no documented evidence they had been updated when reviewed on May 29. The county’s corrective action plan states the interdisciplinary team revised the care plan that same day.

According to the report following the Immediate Jeopardy finding, the facility completed corrective measures including staff training and implementation of a tracking system for abuse and neglect allegations and investigations.