F0609

J

Failure to Timely Report Witnessed Physical and Verbal Abuse by an LPN

New Orleans, Louisiana Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that witnessed physical and verbal abuse of a resident was reported to the administrator/designee and the state agency within the required 2-hour timeframe. On 02/17/2026 at approximately 4:00 PM, an LPN physically and verbally abused Resident #1 by repeatedly hitting him on the face, head, and shoulders with a closed fist, placing her knee on his neck, grasping his shirt and attempting to drag him across the floor, and yelling profanities at him, including, “b***h, don’t hit me” and “b***h, I’m tired of you.” This abuse was witnessed by two CNAs (S5 and S6) and another resident (Resident #2). The LPN further stated to the two CNAs, in front of Resident #1, “leave that b***h on the floor, don’t help him up.”

The immediate jeopardy situation continued when the two CNAs left Floor B for approximately 8 minutes, leaving Resident #1 and 20 other residents alone on the unit with the same LPN who had just committed the physical and verbal abuse. Later, at approximately 5:00 PM, the LPN instructed one of the CNAs, again in front of Resident #1, to “leave that b***h in his chair.” The CNA then left the LPN unmonitored and with access to all 21 residents on Floor B while she went in and out of rooms to complete her rounds. Despite witnessing the abuse and understanding that abuse should be reported immediately, the CNAs did not report the incident to the administrator or other administrative staff within 2 hours, and the LPN remained on duty until she clocked out at 11:20 PM.

Multiple staff interviews confirmed that the abuse was not reported in a timely manner and that there was confusion or lack of knowledge among some staff about how to contact administrative staff when they were not physically present in the facility. S5CNA acknowledged she did not report the abuse to any administrative staff or nurses until the morning of 02/18/2026 and stated she did not know how to reach them at the time of the incident. S6CNA similarly indicated that the abuse should have been reported immediately but was not reported until the next day, and that she did not know who to report to at the time. Another CNA (S7) reported that S5CNA told her about the abuse on 02/17/2026, but she also did not report it, despite having the phone numbers of the administrator and DON. The administrator and DON both indicated that the CNAs who witnessed or knew of the abuse should have reported it immediately. The administrator acknowledged that the physical and verbal abuse should have been reported to the state agency within 2 hours, which did not occur.

The facility’s abuse-related policies, including the Abuse Prevention policy, Abuse Recognition, Reporting, and Investigation policy, and Abuse Reporting and Investigation policy, required that any person who witnessed or suspected abuse immediately inform the house supervisor, who would notify the administrator or designee, and that the administrator or designee report all allegations of suspected or actual abuse through the state incident reporting system and to proper parties as required by state and federal law. Despite these policies, the witnessed abuse of Resident #1 by the LPN on 02/17/2026 was not reported to the administrator until approximately 10:30 AM on 02/18/2026, and thus was not reported to the state agency within the required 2-hour timeframe. This failure to follow established reporting procedures and to promptly notify the appropriate authorities constituted the cited deficiency.