A Critical Examination of State Agency Investigations into ...

CQC policy does not require further action by the investigator upon a finding ofinstitutional neglect of a child and the law does not require CQC to take any action aftermaking such a determination. CQC may, at its discretion, open a care and treatmentreview or other further inquiry in response to a finding of institutional neglect.An example of a report that would be classified as institutional neglect, accordingto Luhn, could be a situation in which a parent files an allegation with the State CentralRegister because “they see their child is not getting proper attention or that they heard orsaw they had a skinned knee and think that somebody might have abused them….If thesuspicion underlying the allegation is true, it might raise real concerns. But, in a lot ofcases, it’s possible to ascertain very quickly that, no, [the child] was playing with hisroommate and fell and skinned his knee and we took care of it in the infirmary….Verifythat with medical records and talk to a nurse and so on. Especially if the investigatorknows that facility and knows who they’re are dealing with and is satisfied with recordsthat they get. If within two or three or four days [they establish] that it’s not a credibleallegation of abuse or maltreatment they give it the so-called I.N. classification.”While it is true that a determination of institutional neglect by CQC (as opposedto a finding of abuse or neglect) is an “unfounded report” for the purposes of the StateCentral Register and, as with all unfounded reports, becomes a sealed record, it is unclearwhy, contrary to the plain language of the law and the stated legislative intent of theenacting statute, CQC considers a determination of institutional neglect simply anexpedient way to close cases.During its review of CQC’s January 2007 child abuse cases, the Inspector Generaldiscovered that CQC classified cases as unfounded that, in accordance with the plain214