BATON ROUGE, LA - Federal inspectors discovered that Jefferson Manor Nursing and Rehab Center staff completely abandoned an entire wing of residents for over four hours, during which time one resident died and was found in a kneeling position beside her bed.
Complete Care Abandonment Captured on Video
Surveillance footage from March revealed the shocking extent of the care abandonment at Jefferson Manor. Video evidence showed that from 12:00 a.m. until approximately 2:35 a.m., nursing staff provided no care whatsoever to residents on Hall A - a period lasting 4 hours and 35 minutes.
During this abandonment period, inspectors documented that a call light remained illuminated at 12:35 a.m., indicating a resident was requesting assistance that never came. The facility's administrator confirmed that the surveillance footage showed "no staff rounded on or provided care to any resident on Hall A" during this critical timeframe.
At 2:42 a.m., staff finally entered Resident #1's room and discovered her unresponsive on a fall mat in a kneeling position facing her bed. Despite immediate CPR efforts, the resident could not be revived, and the coroner was notified at 2:53 a.m.
Floor Maintenance Used as Justification
Multiple staff members told investigators that floor maintenance prevented them from accessing residents' rooms. The certified nursing assistant assigned to care for residents including the deceased stated she "was not able to provide care to her assigned residents on Hall A from 10:00 p.m. to 2:30 a.m., due to floor maintenance."
The licensed practical nurse responsible for the wing made an identical claim, stating she "did not provide care to her assigned residents on Hall A from 10:00 p.m. until 2:30 a.m. due to floor maintenance."
Two additional nursing assistants assigned to other rooms on the same hall confirmed they also provided no care due to the floor work, with one stating she "did not perform visual checks every two hours or provide care for her assigned residents from 10:00 p.m. until 2:30 a.m."
Federal Standards for Continuous Care
Nursing homes are required to provide continuous monitoring and care to residents, particularly those with mobility limitations and medical conditions requiring regular assessment. Federal regulations mandate that facilities ensure residents receive necessary care and services around the clock.
Visual safety checks must occur at minimum every two hours for most residents, with more frequent monitoring for those at higher risk. These checks serve multiple critical purposes: - Identifying medical emergencies requiring immediate intervention - Preventing falls and other injuries - Ensuring residents receive timely assistance with basic needs - Monitoring changes in condition that could indicate deteriorating health
The complete absence of any staff presence for over four hours represents a fundamental violation of basic nursing home care standards.
Medical Consequences of Care Abandonment
Extended periods without nursing supervision create multiple serious health risks for elderly residents with chronic conditions. During the documented abandonment period, residents faced potential dangers including:
Cardiac events can occur suddenly and require immediate recognition and response. Early CPR can significantly improve survival rates, but delays in discovery reduce the effectiveness of resuscitation efforts.
Falls and injuries pose constant risks for residents with mobility limitations. Immediate assessment and proper positioning are crucial to prevent complications from falls or prolonged time on the floor.
Medication-related emergencies can develop rapidly, particularly in elderly populations taking multiple prescriptions. Adverse drug reactions or missed doses can create life-threatening situations requiring prompt medical intervention.
Respiratory distress may occur due to underlying conditions or positioning issues. Regular monitoring allows staff to identify breathing problems before they become critical.
Bed Rail Safety Violations Compound Problems
Beyond the care abandonment, inspectors found the facility systematically violated bed rail safety requirements for multiple residents. The facility failed to conduct required entrapment risk assessments or obtain informed consent before installing mobility bars for four sampled residents.
One resident confirmed to inspectors: "she had not signed a consent for bedrails when the bedrails were implemented, and she used the bedrails for mobility."
Bed rail entrapment represents a well-documented safety hazard in nursing homes. The FDA has identified over 900 incidents of patients caught in bed rails, resulting in 480 deaths. Proper risk assessment must evaluate: - Body size and mobility limitations that could lead to entrapment - Cognitive status affecting ability to safely use rails - Alternative mobility aids that could provide assistance without entrapment risks
The Director of Nursing admitted to inspectors that "no staff was assigned to perform entrapment risk assessments or obtain informed consents for residents who had mobility bars ordered" and stated she "was unaware consents and entrapment risk assessments should be completed prior to installing mobility bars."
Industry Standards for Emergency Protocols
Professional nursing home management requires detailed protocols for handling maintenance activities that could interfere with resident care. Standard procedures include:
Phased maintenance that allows continuous access to resident rooms, typically working on small sections while maintaining normal operations in other areas.
Alternative care pathways ensuring staff can reach residents during maintenance activities, such as temporary relocation or modified access routes.
Enhanced monitoring during periods when normal care routines may be disrupted, including more frequent safety checks and clear communication protocols.
Administrative oversight to ensure maintenance activities never compromise resident safety or access to emergency care.
Reporting Requirements and Administrative Response
The facility's own policies required immediate reporting of neglect incidents to state authorities within two hours. However, the administrator did not report the incident until the following day, despite becoming aware at 4:00 a.m. that "the floor vendor impeded care by not allowing nursing staff to perform visual checks on residents."
Federal regulations classify the complete abandonment of resident care as neglect, defined in the facility's own policies as "failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness."
The administrator confirmed to investigators that "any allegations of neglect should be reported to the State Survey Agency within 2 hours" but failed to meet this requirement despite having clear knowledge of the care abandonment.
Facility Response and Ongoing Concerns
The violations occurred despite Jefferson Manor's written policies clearly outlining requirements for abuse and neglect prevention. The facility's own documentation stated that each resident "has the right to be free from mistreatment, neglect, and misappropriation of property."
The systematic nature of these violations - affecting multiple residents across an entire wing - suggests significant deficiencies in supervisory oversight and staff training. The fact that multiple staff members uniformly cited the same reason for abandoning residents indicates either inadequate emergency protocols or insufficient understanding of care priorities.
Federal inspectors classified these violations as having "minimal harm or potential for actual harm," though the death of one resident during the abandonment period raises questions about this assessment. The facility serves 51 residents, all of whom depend on continuous nursing care for their health and safety.
These violations highlight the critical importance of maintaining adequate staffing levels and clear protocols that prioritize resident safety above maintenance activities. The complete breakdown in care delivery documented at Jefferson Manor represents a fundamental failure in the basic mission of nursing home care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Jefferson Manor Nursing and Re from 2025-03-10 including all violations, facility responses, and corrective action plans.
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