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  • Writer's pictureLeitner Varughese Warywoda

What type of Nursing Home "Incidents" are "Reportable Events" required by the Department of Health?

New York Nursing Home Incident Reporting

The Nursing Home Incident Reporting Manual for New York State is intended to give guidance to skilled nursing facility staff responsible for reporting allegations of mistreatment, neglect and abuse, resident injuries of unknown source, and misappropriation of resident property to NYS DOH. The manual explains what incidents should be reported and how they should be reported. The contents of this manual include different reporting requirements like investigation immediately upon discovery, reporting incidents via the HCS, a list of other specific incidents that should also be reported, and the facility's responsibility to report to other agencies. It includes the summary of all reporting requirements, time frames for reporting, and documents associated with the facility investigation.

Title: A Guide to Reporting Incidents in New York State Nursing Homes


Nursing homes are meant to be a safe haven for the elderly, providing them with quality care, companionship and happiness in their golden years. However, incidents of mistreatment, neglect, abuse, injuries of unknown origin, and misappropriation of resident property have been reported, which highlights the need for ensuring the safety of residents in nursing homes. It is why New York State has designed a set of regulations which necessitate stringent reporting of these incidents to the New York State Department of Health (NYS DOH) immediately. This blog post serves as a guide for the nursing home staff on how to report incidents in nursing homes within the state of New York.

Reporting Requirements:

The Nursing Home Incident Reporting Manual for New York State provides instructions for all skilled nursing facility staff responsible for reporting allegations of mistreatment, neglect and abuse, resident injuries of unknown source, and misappropriation of resident property to NYS DOH. The manual explains what incidents should be reported and how they should be reported.

According to Federal and State regulations, facilities are required to report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property, immediately to the facility's administrator. The report must be made to other officials in accordance with State law, including reporting to NYS DOH. The facility must also simultaneously initiate an investigation while the investigation is in progress, and it must prevent any further potential abuse. The incident report and the results of the investigation must be reported to the facility administrator and NYS DOH, if requested, within five working days of the incident. If the incident is verified, appropriate corrective action must be taken. The NYS DOH requires individuals in applicable long-term care facilities, such as nursing homes, to report any reasonable suspicion of a crime against a resident of the facility to at least one local law enforcement agency of jurisdiction and to NYS DOH.

Additional Details:

The law states that incidents resulting in serious bodily injury must be reported within two hours after forming the suspicion. All other incidents must be reported within 24 hours. Facilities must have policies and procedures that comply with this law. The law prohibits retaliation by a long-term care facility against individuals who make such reports and establishes distinct penalties, including a fine of up to $200,000, for the failure of an individual to report within the above-noted time frames (up to $300,000 if such failure exacerbates the harm to the victim of the crime).

In addition to the above, the Patient Abuse Reporting Law requires every nursing home employee, including administrators and operators, and all licensed professionals, whether or not employed by the nursing home, to report to NYS DOH when there is reasonable cause to believe that a resident has been physically abused, mistreated, or neglected. The law also outlines penalties for individuals who are found guilty of these acts and anyone who is required to report but fails to do so.


In conclusion, keeping residents of nursing homes safe and well-protected in their centers is not always the case. Although it is imperative to prevent, investigate and report incidents of mistreatment, neglect, abuse, and other related cases of abuse, it is also essential to provide quality companionship, social and physical activities to residents. If you are working in a nursing home in New York State, you must familiarize yourself with all the reporting requirements and regulations regarding abuse, neglect, mistreatment, misappropriation, and injuries of unknown source. By knowing them well and following the protocols mentioned, you will safeguard residents from abuse, mistreatment, and neglect. Finally, always remember that NYS DOH is there to help you, and you can always reach out for assistance in reporting incidents.

Answers to Common Questions:

Confidentiality is an essential consideration when it comes to incident reporting. Therefore, in the state of New York, all incident reports are submitted to the New York State Department of Health (NYSDOH) via a secure web site. It is crucial to note that all the information reported to the DOH Nursing Home Hotline is sensitive and confidential. In the event of an abuse, mistreatment, neglect, or misappropriation allegation, if it is investigated by the facility and not substantiated, it must still be reported to the Department if, at any time during the facility investigation, the reasonable cause threshold criteria are met.

Initial incident reports are to be submitted online within 24 hours of identifying the incident or if abuse, mistreatment or neglect appears to have occurred, once the reasonable cause threshold is met via the web reporting system. All facilities must ensure that they have internal reporting systems in place to meet these requirements. After the initial report is made, if the DOH requires additional information beyond the initial report, follow-up written reports should be completed and submitted upon request, within five working days of the incident. The initial report is submitted via the HCS, while the written report will be sent through conventional mail or fax.

If a facility has submitted a reportable incident to the Department via the web site, they do not have to call the hotline, but in the event that they cannot access the web site, they can call the toll-free line at 1-888-201-4563 or send an e-mail to Additional information that the facility wishes to submit after the initial report should be called to the toll-free hotline or e-mailed.

A series of events reported as incidents may trigger a survey if they are related to a specific area or standard of care. Critical factors that NYSDOH considers are whether the facility is doing all that it reasonably can to prevent incidents and whether the facility is completing appropriate investigations and follow-up when an incident is determined to be unavoidable. Verbal abuse constitutes any action that instills fear or psychological trauma for the resident, such as a threatening tone of voice, angry gesture, or any other action that creates fear, intimidation, or humiliation. It is essential to note that maintaining an acceptable investigation is crucial, and for this reason, it is advisable to refer to the educational PowerPoint on the Health Commerce System, and to ensure that all the questions on the Incident Reporting Form are thoroughly completed. If additional information is required, the investigator will contact the facility.

Any action that would typically be regarded as painful by a reasonable person, such as a slap that leaves no mark or any other action resulting in pain, is considered an injury, even if the resident cannot express or verbalize the pain, and is reportable.

To ascertain whether a staff person has been excluded from working in a nursing facility, members of the general public can access the New York State Nurse Aide Registry. Before employment, federal and state regulations require facilities to verify each nurse aide's certification status, as well as the status of all potential staff, with the Registry, which is available 24 hours a day, seven days a week at Additionally, a Criminal History Record Check (CHRC) is conducted on any unlicensed staff who have access to a resident or a resident's belongings. However, CHRC results are not available to the general public.

In summary, it is imperative for facilities to ensure that they have internal reporting systems in place to meet the NYSDOH's incident reporting requirements. Maintaining confidentiality is crucial throughout the entire investigation process. It is also crucial to understand the reasonable cause threshold criteria and to comply with the reporting timelines. Ultimately, the safety and well-being of nursing home residents must remain a top priority of every facility.


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