A Critical Examination of State Agency Investigations into ...

In the following sections the Inspector General identifies problems with CQC’sapplication of Social Services Law § 412 in general and in the 32 cases reviewed.Questionable Interpretation of “Risk” CriteriaThe Inspector General found that CQC improperly has used the standard of“imminent risk” of physical injury in determining whether a child has been a victim ofabuse or neglect. The term “imminent” does not appear in the Social Services Lawdefinitions of abuse and neglect of children in residential care. In addition, in its review,the Inspector General identified one instance in which CQC appeared to have improperlyapplied the statutory criteria for finding risk.In its review of investigations from January 2007, the Inspector General identifiedone case in which CQC’s determination could be questioned. It was alleged that a staffmember had “roughly pulled and turned [a resident’s] face while giving him hismedication,” “pushed [his] head against the back of his wheelchair using excessiveforce,” “jabbed an eye-dropper into [his] eyeballs” and “verbally threatened” him duringthe process. Two staff members witnessed the treatment of this profoundly mentallydisabled resident and provided investigators with corroborating testimony, and thesubject admitted to having “lost it” while administering the medication. A registerednurse who examined the child within hours of the incident reported that there were nounusual marks to the head, no swelling/redness to the eyes, and the child gave noindications of pain or discomfort. However, a licensed practical nurse at the facility, whowas queried by CQC about the resident’s risk of harm, reported that the child “would beat risk of corneal damage, corneal scratching, corneal abrasions, or general eye irritation”if he were to “head butt or move his head while receiving eye drops.” CQC’s202