A Critical Examination of State Agency Investigations into ...

language of the statute, may have more appropriately been termed institutional neglect.Likewise, CQC classified cases as institutional neglect even where there was noindication of any fault on the part of the institution or the individual caretaker.In accordance with CQC policy, the decision to term a case as institutional neglector as unfounded depends primarily on whether the investigator could determine withinseven days that there was no injury of significance to the child. Even if the allegation iscompletely falsified, the case nonetheless may be designated by CQC as institutionalneglect. In its review, the Inspector General found such examples. For instance, in onecase the child recanted. In another case, CQC found no evidence of any injury to thechild and no credible evidence of a breach of duty by staff. Nonetheless, in each of thesetwo cases, the state certifying agency (OMRDD or OMH), the facility/institution wherethe child resided, and the child’s guardians were notified that there had been a finding ofinst itutional neglect. CQC performed no follow-up investigations or monitoring inrelation to any of the twelve cases designated as institutional neglect in January 2007.On the other hand, during the same time period, CQC designated cases as“unfounded” that may have been more appropriately termed “institutional neglect” inaccordance with the statutory language. For example, CQC investigated a case in whichit was alleged that three children with histories of sexual abuse engaged in sodomy whenthey were not being properly supervised. This was recommended as unfounded despiteCQC’s investigation determining that patient observation documentation was conflicting,one assigned staff member had not received proper training in providing supervision, thechildren involved had faulty admission assessments, and the children were not supervisedappropriately by staff when the incident was believed to have occurred. Additionally,215