Health inspection·August 2, 2021

California Code, Health and Safety Code, Section 1424 (f)(1) Any willful material falsification or willful material omission in the health record of a patient of a long-term health care facility is a violation. (f)(2) "Willful material falsification," as used in this section, means any entry in the patient health care record pertaining to the administration of medication, or treatments ordered for the patient, or pertaining to services for the prevention or treatment of decubitus ulcers or contractures, or pertaining to tests and measurements of vital signs, or notations of input and output of fluids, that was made with the knowledge that the records falsely reflect the condition of the patient or the care or services provided. The following citation is written as a result of findings during an anonymous complaint investigation for #CA00694517. An unannounced visit was made to the facility on 6/30/20 to investigate an allegation of falsified medical records. The Department determined the facility failed to: Maintain complete and accurate medical records for Patient 1 when a nurse's progress note was the result of willful material falsification of medical records. This failure resulted in a fabricated representation of facts surrounding Patient 1's change of condition, and death, after being found on the floor in his room bleeding from a head wound. During a record review of Patient 1's, "Progress Notes", dated 6/21/20, the note indicated, "Incorrect Documentation" and was struck through with a black line. The note read, at 10:00 p.m., licensed nurse (LN) 2 heard an alarm coming from Patient 1's room. The note read, "...Writer approached the room and found patient on the floor...appeared to have hit his right forehead on the bedside table and sustained a laceration...bed was in lowest position prior to fall. Assisted patient back to bed...forehead laceration cleaned...applied dressing. Patient 1 stated that he was okay and requested for some water. Was made comfortable...vital signs stable with no resp [respiratory] distress...encouraged patient to ask for assistance when needed..." At 10:15 p.m., LN 2 documented she entered Patient 1's room and he was found to have labored breathing and shortness of breath with an oxygen saturation (the amount of oxygen in the blood) of 86 percent on four liters (a unit of measurement) of oxygen. The note read Patient 1 was being, "Kept comfortable." At 10:30 p.m., LN 2 charted Patient 1, "...Was found unresponsive in bed with no respirations, no pulse, no heart or breath sounds...pupils fully fixed and dilated..." During an interview with LN 4 on 6/30/20, at 2:43 p.m., LN 4 confirmed he was called into Patient 1's room by LN 2 on the evening of the incident to help. LN 4 described how Patient 1 was on the floor in his room face down, bleeding from a head wound, and his chest tube (a tube placed in the chest that acts as a drain for blood, fluid, or air) had disconnected from the collection canister. LN 4 stated Patient 1 was rolled over and four staff members assisted him back to bed where his breathing was noted to be, "Very shallow." When LN 4 attempted to check Patient 1's pupils, they were unreactive and stated, "His eyes were wide open the whole time." LN 4 went on to say, "The fall was bad, he had two gashes to his head." LN 4 confirmed Patient 1's bed was raised, "To hip height" and stated Patient 1 always liked the bed raised to watch television. During an interview with LN 2 on 6/30/20, at 4:22 p.m., LN 2 confirmed she was Patient 1's nurse the evening of the incident. LN 2 stated she was sitting at the nurse's station when she heard an alarm sounding from Patient 1's room at approximately 10:25 p.m. When LN 2 entered Patient 1's room, she witnessed him face down on the floor, blinking his eyes, and breathing. LN 2 called for help and four staff members assisted Patient 1 back to bed and noted two lacerations on Patient 1's right side of his forehead. LN 2 stated when Patient 1 was put back to bed, he started gasping, and was deceased within minutes. LN 2 went on to say, "His death was expected, but not this way." LN 2 confirmed she corrected her documentation of the incident at the request of the director of nursing (DON) on 6/25/20. When LN 2 was asked why she initially falsely documented the incident for Patient 1, LN 2 explained she was a new nurse, there was no supervisor on duty the evening of the incident and asked LN 1 for assistance. To provide support, LN 1 called the DON for guidance. LN 2 indicated from the conversation LN 1 had with the DON, they thought he wanted us to, "Cover it up." During an interview with LN 1 on 7/1/20, at 3:05 p.m., LN 1 stated she went to Patient 1's room to help at the request of LN 2 on the evening of the incident at approximately 10:25 p.m. When LN 1 entered Patient 1's room, she witnessed him face down with his head resting on the feet of the over bed table. LN 1 stated when Patient 1 was turned over he was breathing and blinking, and noted two lacerations to the right side of his head, and bruising between his eyebrow and temple. LN 1 went on to say, within five minutes Patient 1 was deceased. LN 1 stated she texted the DON to report the incident at 10:56 p.m. and followed up with a phone call. LN 1 described her conversation with the DON and stated, "He kept cutting me off, trying to say he was dead when he fell...he kept saying he was dead when he fell." LN 1 went on to say, "We spent an hour deciding what to do, I encouraged [LN 1] to chart the truth. I was scared." During an interview with Patient 1's responsible party (RP) on 7/15/20, at 5:20 p.m., the RP was asked if the facility called to report the incident. The RP confirmed someone from the facility called her around 12:05 a.m., and explained to her, "As he [Patient 1] took his last breath, he flung himself out of bed." The RP went on to say she did not remember who she spoke with from the facility. During an interview with the DON on 7/16/20, at 8:50 a.m., the DON confirmed LN 1 texted him the evening of the incident at 10:56 p.m. and followed up with a phone call. The DON went on to say LN 1 told him Patient 1 received pain medication, fell, and passed away. The DON stated he told LN 1, "What are you asking me for?" and "She was alluding to something." The DON said he gave instructions to clean Patient 1 up, call the RP, and to be honest about the incident. When asked why LN 2 did not chart the truth, the DON stated, "What they told me and what they wrote were two different things. I don't know that the nurse told me what happened. Maybe they got nervous, scared. [LN1] blamed me for it." During a review of text messages between the DON and LN 1, not dated, the text messages included pictures of Patient 1's head injuries, the bloody floor next to his bed, and the legs of a bedside table. The text conversation revealed the DON told LN 1, "Seems like he fell because he was dead...he was DNR [do not resuscitate] expected to die about 1 week ago. Just notify his [RP] he passed and do as normal...the gash will raise suspicion...just be honest with [RP]...let her know he took his last breath and then he fell from low bed hitting his head on table" LN 1's text messages to the DON indicated she agreed the, "Gash" would raise suspicion, she confirmed she would call Patient 1's RP, and would instruct LN 2 how to chart the incident. During a review of the facilities policy and procedure (P&P) titled, "Charting and Documentation", revised 7/2017, the P&P indicated, "...Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate..." The Department determined the facility failed to: Maintain complete and accurate medical records for Patient 1 when a nurse's progress note supplied to the Department was the result of willful material falsification of medical records. "The above facts indicate that there was a willful material falsification in the medical record for the patient(s)."