F0842

D

Inaccurate Emergency Event Documentation for Fall and Respiratory Distress

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate, complete, and reliable medical records that reflected the actual care provided to a resident during an emergency event. The resident had a history of intellectual developmental disability and an MDS indicating severe cognitive deficits, was rarely or never understood, and was unable to make decisions. On the evening of the incident, a CNA reported that she began her shift and observed the resident independently wheeling himself in the hallway, provided him a meal tray, and saw him eat independently. She stated she was not informed the resident was a fall risk and that he remained unsupervised in his wheelchair in the hallway until approximately 8 p.m., when she returned from a bathroom break and found nursing staff with the resident lying face down on the floor with a bleeding head wound. She reported that oxygen was applied and that the resident was minimally responsive, moving only his hand, and that CPR or chest compressions were not initiated because the resident had a pulse.

Multiple staff interviews consistently indicated that chest compressions were not performed, while the medical record documented that they were. LN 1 stated that the resident’s baseline was alert but not oriented x3 and non-verbal, and that during the event the resident had agonal breathing but a pulse. LN 1 reported that the only intervention provided was oxygen via non-rebreather and explicitly stated that what was documented in the medical record about chest compressions was not true. CNA 2 stated she assisted in placing the resident in a safe position, observed irregular breathing, and saw LN 2 administer oxygen via non-rebreather, confirming that CPR or chest compressions were not initiated because the resident had a pulse. CNA 3, a registry CNA, stated she had been informed by LNs at the start of the shift that the resident was a fall risk and had observed the resident in the hallway attempting to stand from his wheelchair and being impulsive and resistant to redirection. She reported that after the fall, oxygen via mask was applied and that she observed no rescue breaths or chest compressions, and that the resident did not regain consciousness and his body was twitching on the floor.

In contrast to these accounts, the resident’s EHR contained nursing notes and an IDT fall note documenting that chest compressions were initiated. A nurse’s note by LN 1 at 20:55, entered as a late entry, described the resident lying face down with agonal respirations and a bleeding laceration, oxygen via non-rebreather being applied, and stated that, as per the medication nurse, the carotid pulse was too faint to be identifiable and that compressions were briefly initiated and then stopped after breathing stabilized and a carotid pulse was noted. A separate nurse’s note by LN 2 at 21:00, also a late entry, documented that the resident was found on the floor unresponsive, with bleeding to the head and abrasions, and stated that “the chest compression initiated and oxygen with a non re-breather mask was given” and that 911 was called. The IDT fall note likewise stated that the resident was unresponsive and that chest compressions and oxygen with a non-rebreather mask were given. LN 2 later acknowledged that documentation indicating chest compressions were performed was inaccurate and that it should have reflected chest rubs only. The DSD and DON both stated that nursing documentation must be accurate, complete, objective, and reflect exactly what care was provided, and that documenting interventions that did not occur, such as chest compressions in this case, was not acceptable and could misrepresent the resident’s clinical status and negatively impact continuity of care during hospital transfer.