F0726

D

Failure to Ensure Staff Competence in Emergency Response, Fall Prevention, and Feeding Assistance for a High-Risk Resident

El Cajon, California Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that staff caring for a high fall‑risk resident were competent, informed, and trained to meet the resident’s safety and care needs. The resident had a history of intellectual developmental disability, severe cognitive deficits, and was rarely or never understood, with documentation indicating the resident did not have capacity to understand and make decisions. The resident’s fall risk assessment showed a high fall‑risk score, and hospital physical therapy records documented decreased awareness of the need for safety and assistance. Despite this, the resident’s fall care plan contained only general interventions such as reminding the resident to call for assistance, keeping the call light within reach, and keeping the resident within supervised view as much as possible, which the Director of Staff Development later acknowledged were not individualized to the resident’s cognitive and safety needs.

On the day of the incident, multiple CNAs and nurses described that the resident was confused, impulsive, and had poor safety awareness, with a history of sitting on the edge of the bed, attempting to stand or ambulate without assistance, and not reliably using the call light. One nurse supervisor stated he had verbally instructed CNAs to closely monitor the resident, perform visual checks every 30 minutes, and keep the resident under continuous supervision, including staying in the room if the resident was alone. However, the assigned CNA reported she was not informed that the resident was a fall risk and did not ask another staff member to supervise the resident when she left the area to use the restroom. A registry CNA also reported she was not instructed to monitor the resident. Other CNAs on the unit stated they were not told the resident was a fall risk or that close supervision was required. During this period, the resident remained seated in a wheelchair in the hallway, unsupervised, and later was found in his room lying face down on the floor with a bleeding head wound, unresponsive or minimally responsive, and with irregular breathing.

After the fall, several staff members described the resident as unresponsive or non‑responsive, with irregular or agonal breathing, twitching, and oxygen saturation not registering on the pulse oximeter. The nurse who responded confirmed the resident had a pulse but did not assess chest rise and fall to determine effective breathing and did not initiate rescue breaths, instead applying oxygen via a non‑rebreather mask and performing chest rubs. Multiple CNAs confirmed that no rescue breaths or chest compressions were provided, and the nurse later acknowledged that documentation indicating chest compressions had been done was inaccurate. The Director of Staff Development and the DON both stated that staff were expected to follow AHA BLS guidelines, which require rescue breathing for an unresponsive person with a pulse and abnormal or ineffective breathing, and that supplemental oxygen alone does not provide ventilation. In addition, the resident had a nutritional care plan and speech evaluation indicating severe swallowing impairment, aspiration risk, and a requirement for 1:1 feeding assistance, and the resident’s name appeared on the facility’s feeder list. Nonetheless, the assigned CNA reported she was unaware the resident required 1:1 feeding assistance and had placed the meal tray on a bedside table for the resident to eat independently while seated in a wheelchair in the hallway. The DSD and DON stated that staff were required to communicate resident‑specific risks, including fall risk and feeding assistance needs, through shift reports and huddles, and that failure to communicate these needs left staff unaware of the resident’s required level of care.