Kulana Malama: Medical Records Deficiency - HI
That is what federal inspectors found when they investigated a complaint at Kulana Malama, a nursing home on Oahu's western shore. The incident happened on June 18, 2025. The resident, identified in inspection records only as R25, experienced a decannulation, meaning her tracheostomy tube became dislodged. Staff yelled for help. Respiratory therapist RT16 responded and put the tube back in.
RT16 told inspectors he could not remember whether R25's oxygen saturation dropped during the incident. He said there was no color change and that she tolerates a quick decannulation okay. Then he said something that became the center of the inspection finding: he did not believe it was expected of him to document what happened in the resident's electronic health record.
He had not charted it. He had not flagged it. As far as the medical record was concerned, the incident had not occurred.
The Director of Nursing told inspectors the opposite when asked directly. The nurse who responds to an incident like this, the DON said, would document it in the resident's chart. The facility's own nursing documentation policy states that nursing staff are required to document care provided in the medical record, and that documentation serves as a means of communication and coordination with other healthcare providers.
RT16's account and the DON's account do not match. One of them describes a facility where a tracheostomy dislodgement gets noted and communicated. The other describes what actually happened on June 18.
Inspectors cited the facility under F0842, which covers medical record accuracy and completeness. The level of harm was rated as minimal harm or potential for actual harm.
R25's tracheostomy incident, the moment her airway device came free and a therapist rushed to replace it, exists now only because inspectors asked about it. It was never part of her medical record. Any provider who treated her afterward had no way of knowing it had happened at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kulana Malama from 2025-09-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 7, 2026 · Our methodology
Kulana Malama in EWA BEACH, HI was cited for violations during a health inspection on September 26, 2025.
That is what federal inspectors found when they investigated a complaint at Kulana Malama, a nursing home on Oahu's western shore.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.