rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2017-10-20,280,D,0,1,5D9Q11,"Based on observations, staff interviews and electronic medical record (EMR) reviews, the facility failed to ensure that 1 of 16 residents (R #10) was consulted on personal preferences. Findings include: On 10/18/2017 at 2:19 PM R#10 was observed sleeping in bed. Staff #2 explained that staff were alert to resident's coughing as signal that assistance is needed and R#10 didn't want to use the soft call-light because often inadvertently triggered the call light by his/her head movements. Reviewed the resident's Care Plan (CP) which states Potential for Decrease in ADL, that interventions dated 8/24/15 included: I am to use a soft touch call light to call for assistance which is to be placed by my pillow near to my face. I will turn my head/face to touch the call bell. Discussed with Staff #2, that intervention of soft call-light still on ADL CP and there was no intervention that staff should listen for the resident's coughing as signal for assistance. Staff #2 went to ask R#10 if he/she wanted a soft call-light and R#10 responded, yes by nodding his/her head. The resident's sister came to visit at that time and Staff #2 explained to her that R#10 now wanted to use the soft call-light. Staff #2 called for the soft call-light to be re-installed. The facility did not explore care alternatives through a thorough care planning process in which the resident could participate.",2020-09-01
2,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2017-10-20,314,D,0,1,5D9Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and Electronic Medical Record (EMR) reviews, the facility failed to ensure that 1 of 16 residents (R #31) on the Stage 2 Sample Resident List was provided care to promote healing, pain control and prevent infection due to an existing pressure ulcer (PU). Finding include: During an EMR review on 10/17/2017 at 08:31 AM R #31 was admitted with a Stage 4 pressure ulcer to the right buttock and hip. There were no orders for wound vac dressing changes three times per week (Monday, Wednesday and Friday). During an interview on 10/18/2017 at 11:04 AM, Staff #2 stated that staff nurses do the daily wound care which includes the wound vac dressing changes. The wound nurse does weekly assessments once per week. Queried where wound nurse documentation would be located and Staff #2 looked at EMR under Notes but there was no wound nurse documentation for the once a week evaluation. Staff #2 explained that if wound healing, wound nurse wouldn't document because wound healing nicely. Pointed out documentation by Staff #47 written on 10/05/17 at 11:27 in Nurse Note, wound Right butt: no overall improvement noted in R butt wound status. Per Staff #52, (Wound Nurse), obtain surgical consult for R butt wound. Documentation of the EMR revealed inconsistent information regarding the wound characteristics. The wound measurement flowsheet stated the wound had undermining which was at 2 cm; the wound length got larger. Staff #2 stated the inconsistency is probably due to different nurses measuring the wound. Staff #2 further stated that goals were the same, maintain granulation tissue and get closer to surface then outside start to shrink. There was no infection, no redness or warmth around and no slough. Staff #47 documented odiferous on 10/16 and wound nurses both noted wound not odiferous during dressing change. On 10/19/2017 at 9:22 AM observed Wound nurses Staff #52 and #53 do dressing change to R #31's R buttock pressure wound. Staff #53 obtained wound dressing supplies and placed them on the resident's overbed table without sanitizing or covering the overbed table with a clean barrier. Staff #53 had put on clean gloves and started removing the soiled dressing while Staff #52 assisted by placing the opened wound supplies onto the resident's bed, left in the wrapper. With the same gloves Staff #53 was observed to remove the dirty dressing, clean the wound, apply skin prep and the wound vac drape; then she proceeded to measure the wound depth with the same gloves. Discussed observations with both wound nurses and queried about practice of using same gloves between dirty dressing and clean dressing. Staff #52 stated that gloves are usually changed at least 5 times during a dressing change although that was not observed. Also, informed wound nurses that didn't observe them wash hands before putting on clean gloves. Both stated that they used hand sanitizing gel when they entered the resident's room. Informed them that observed them handling the wound vac machine and tubing with the clean gloves on before starting the wound care. Staff #52 stated that they will be sure to wash hands and change gloves between dirty and clean dressing change. During the dressing change R #31 was observed to jerk. Staff #37 stated that last pain med ([MEDICATION NAME] mg) was given at 6 PM. The extended release pain meds are given 12 hrs apart. During the Interview with R #31, the resident stated that he experienced shooting pains during the dressing changes and currently rated pain at 8 on a zero to 10 pain scale. When asked R #31 said that he did not tell the MD about his pain due to not being able to tolerate the [MEDICATION NAME]. Currently the Resident is being weaned off of the [MEDICATION NAME]. The facility did not follow standards of practice for wound care for the resident's Stage 4 pressure ulcer that promotes healing and prevents infection.",2020-09-01
3,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2017-10-20,371,F,0,1,5D9Q11,"Based on observations and staff interviews the facility failed to ensure that residents eating utensils and food preparation dishes were being properly sanitized. Findings include: On 10/16/2017 at 10:19 AM during the initial kitchen tour, the dishwashing machine temperature log for (MONTH) documented temperatures for final rinse cycle were out of range and did not reach 180 degrees Fahrenheit for the final rinse cycle. According to Staff #54, when the staff take temperature and its wrong, it should be checked again. The procedure that the kitchen staff is to follow, is to attach a temperature strip to a coffee mug and run it through the dishwashing machine again. The temperature strip should have been attached to the log with low temperatures to show the correct temperature. During an interview, Staff #54 stated that the dishwasher was broken since (MONTH) and the final rinse temperature was not reaching 180 degrees Fahrenheit. The facility had called the Hobart representative in (MONTH) and was waiting to replace a part. On 10/17/2017 Staff #54 reported that the dishwasher repair was scheduled for 10/19/2017. The facility did not follow proper sanitation of the dishes, eating utensils and cookware to prevent the outbreak of foodborne illness.",2020-09-01
4,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2018-11-16,578,D,0,1,HKBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the resident with the provisions to formulate an advance directives for two residents (R)7 and R20 of 16 residents reviewed. This includes a written description of the facility's policies to implement advance directives and applicable State law. The residents record lacked documentation stating there was follow up to formulate the advanced directive. Findings include: 1. During the initial record review of R 7' s' electronic medical record (EMR) on 11/14/18 at 01:04 PM no advanced healthcare directives were found. 2. During the initial record review of R20's EMR, no advanced healthcare directives were found. During an interview with the Director of Nursing (DON) on 11/15/18 at 03:30 PM requested a copy of the advanced healthcare directives for both R7 and R20 and was provided only a copy of R20's physician's orders [REDACTED]. The policy on advanced directives/ POLST last revised 08/2018 was reviewed and stated .The POLST form is used by East Hawaii . Newly admitted residents may provide the facility with a previously completed copy of an Advanced Health Care Directives form (AD). The AD will be utilized for Legal Authorized Representative designation. H. If resident does not have an Advanced Health Care Directives and/ or POLST completed, staff will offer assistance in completing a POLST . During an interview with the Administrator on 11/16/18 at 9:47 who stated that the advanced healthcare directives used to be in place until a few years ago when we did away with them and started to formulate and require the POLST. While the POLST is a physician's orders [REDACTED].",2020-09-01
5,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2018-11-16,600,G,0,1,HKBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review facility failed to protect resident's right to be free from any type of abuse that results in, or had the likelihood to result in physical harm, verbal abuse, or mental anguish in four Resident's (R) 10, R20, R22, and R30 in the sample of 16. The facility failed to provide care planning interventions and supervision to prevent three incidents involving R30. An incident on 08/09/2018 resulted in R22 striking R30 after verbal confrontation with R30. On 11/04/2018, R30 and R20 had an abusive verbal confrontation that required staff to render a show of force to prevent a physical confrontation. On 11/12/2018, R10 was involved in a verbal confrontation with R30, when he felt R30 was loud and rude to staff. This deficient practice caused harm for R30 resulted in high potential to endanger the other 24 residents residing in the extended care facilitl section. Findings Include: During initial screening of residents on 11/13/2018, R25 expressed she would like to discuss concerns about R30. During a brief interview on 11/14/2018 at 10:50 AM, R25 stated, R30 upset the blind man (R22) to the point he went after him. He is verbally obnoxious. I give the staff credit as they are kind to him. During an interview with resident council members (R10, R22, R25, and R29) on 11/14/2018 at 10:45 AM R22 stated. There's a guy (R30) here who I got into it with. He talks all the time and goes on and on. A couple of months ago I was in the same room and got sick of it and punched him. R10 stated, He is bad to the staff how he talks to them and obnoxious. R29 stated, He was kicked out of bingo and has to know everything about everyone's business. R10 said, He has no respect for women. R25 stated, He (R30) asks one of the CNA's if she'll marry him. She told him she was married, and he tells her to divorce and marry me. When asked if the resident's present felt safe, they replied yes. R10 stated, He's not safe in our environment. When asked to explain, R22 said, Concerned someone will get upset with him because he's so obnoxious, always swearing and in everyone's business. Shared that R30 had been observed to be sitting alone in the dining room this morning. R10 responded. Staff have asked him to stay away, but he gets up and goes to the tables anyway and starts talking. During an interview with Director of Nursing (DON) and Administrator on 11/15/2018, about R30's behavior, AHA described him as Portuguese and very talkative. He is not offensive to everyone. Asked what interventions have been put in place to prevent further altercations involving R30, and AHA stated, We are working with them one to one to help them understand R30's communication style and separate them in the dining area. The residents committed to notify the staff if they feel frustrated with R30's conversation prior to addressing it directly with him. There has not been a second incident with these resident's (R10, R20 and R22). The concern regarding R30's safety discussed at Resident's Council interview was discussed. AHA stated, No one will be able to remain here if threats are made. Clarification made, and it was reiterated that the statements made were not made as a threat but interpreted as [MEDICATION NAME] concern that due to the ongoing verbal persistence of R30, any resident might unexpectedly react and harm R30. The level of frustration verbalized at Resident's Council interview revealed the interventions to date were not adequate and concern expressed for further occurrences. During a brief interview with AHA on 11/16/2018 , additional records were requested for care plans after the three incidents. AHA was asked if there was anything that could have alerted them or factors that could have been foreseen to prevent the incident on 08/09/2018 when R30 was struck. AHA replied, No, there was nothing. EMR reviewed R30 was known and identified on the baseline care plan as having difficult behavior, demanding and verbally abusive communication. On 08/09/2018 RN55 was made aware by R22 that he was upset with R30 and needed to talk. R30 and R22 were left in the room unsupervised resulting in a physical altercation. Interventions put in place after the incident were not effective in reducing behaviors resulting in a second and third incident involving R30. A behavioral contract was not developed with R30 until after the third incident on 11/19/18. On 08/09/2018 at 05:20 PM, an altercation occurred between R30 and R22. The incident report completed by RN55 documentation includes the following: R22 stating earlier that he wanted to talk to R30 about squealing to MSW (Master of Social Work). R22 states MSW talked to him and R10 during the day about complaints of them being mean to R30. Upset R30 went behind his back to talk to MSW instead of saying it to his face, stated he wanted this writer to be there as witness because R30 was lying to MSW. Notified R22 that he can talk to resident but not argue or do anything physical, to call this writer when he was ready to talk. R30 was sleeping when this writer left room at 1700. Notified by Certified Nursing Assistant (CNA)16 at 17:20 that .R22 who was hitting . R30 during dinner. R22 said he brought up the issue of R30 squealing on him then R30 said used profanity. R22 states he lost it got up and started swinging his arms trying to hit R30 who was in bed. R22 is blind and states he just went toward R30's voice. RN55 told R22 he, should have called this writer like he promised. CNA16 states R22 was hitting the left side of R30's body, she pulled R22 away. R30 was moved to another room after the incident. Review of R30's Social Services notes by Social Worker (SW)1 include: On 08/10/2018 at 07:30 AM. R30 again stated he had no physical pain but said he was emotionally hurt. The SW responded the staff would keep him safe. On 08/10/2018 at 02:35 PM. At approximately 12:30 PM the resident said he did not feel safe, and felt restless and not normal. further describing the event as a trauma. The SW said to the degree he could, R30 should try to maintain a normal routine and be involved in activities within the group. R30 said, What if he comes in my room after me? The SW reassured R30 that R22 was not prone to this and, with the two men being in separate spaces, it was not at all likely to happen. On 08/10/2018 at 02:53 PM. R30 stated he felt safe but expressed anger at his former roommate who had hit him. On 08/13/2018 at 02:00 PM. R30 spoke several times with the SW throughout the day. He complained that his former roommates were being mean to him. He described looks and them whispering. The SW said he would attempt to address it with the other men but said the (sic) he needed to give that situation time since there had been overt conflict that previous week. Review of SW1 follow up notes for R22 include: On 08/10/2018 at 07:45 AM. R22 said he was upset the SW had spoken to him about R30's concerns with him (R22). Other residents reported that R22 shouted for R30 to shut up loudly in the dayroom on 8/8/18. R22 said I no care you kick me out of here. The resident (R22) said, I tell him you come to me if you got a problem with me. He said, Don't hide behind other people Brah. The SW also pointed out that three roommates had come and gone with R22 and the third roommate R10. The SW said that such physical attacks could not happen, as all residents needed to feel safe. On 08/24/2018 Subjective findings in R30's progress notes by Advanced Practice Registered Nurse (APRN) reviewed: We discussed the interpersonal challenges he has been having with peers and staff. He has been in 7 care homes. APRN's assessment included Borderline personality disorder-continues to have interpersonal problems, however willing to practice communication strategies with staff and distancing strategies with unfriendly peers. On 11/04/2018 an Office of Healthcare Assurance ([NAME]HA) report revealed a second incident involving R30. The event was described as follows: R20 was heard swearing at R30. Staff heard R20 state in a very loud voice, what! What!; As R20 was swearing, he was approaching R30. (Both men utilize front wheeled walkers for mobility assistance.) R30 was seated with other residents; facing the front of the .building, R30 was reacting to R20 and also began to curse at him. Staff approached both men and asked them to stop their behaviors. R20 appeared to be preparing to strike out at R30, as he was bringing his right hand backwards. However, staff was able to place themselves in a position to gain R20's attention and state, Stop. You need to go back to your room and calm down. R30 continued his taunt. R20 began to become more upset. He was becoming more difficult to redirect. Along with the staff aide, the activity aide, as well as the housekeeper was able to render a show of force, which successfully dc-escalated (sic) the situation. R20 returned to his room. R30 was advised not to approach or antagonize R20. The report documents, There were no issues prior to this event; as these residents had not associated with each other prior to this encounter. Causal factors identified by the facility were documented as: R30, had settled in to the facility; he continues to have a tendency to repeat self; making persistent verbal requests of others. R20, does have instances of verbal outburst that lends to his self-isolation. There were noted precipitating factors that could explain the incident. On 11/06/2018 an email From CNA26 was sent to the Director of Nursing (DON) which said R20 was only inches away from R30's back and ready to swing his hand on his back. R20 were about to turn around when R30 started to talk and teased him to fight. R20 got more upset and unable to redirect.' R20 had no plan to stop attacking R30. On 11/12/2018 a verbal altercation occurred between R30 and R10. The [NAME]HA initial report describes: R10 was trying to stop R30 from speaking loudly and rudely to the Recreational Aide. Survey team was on site 11/13/2018. RN56 nurses notes dated O7/24/2018 stated Resident's daily routine People say I talk too much and identified potential barriers to his discharge/ goals as: Hx difficult behavior, and demanding + verbally abusive. Comprehensive care plan dated 07/25/18 reviewed, no evidence of interventions to address identified difficult behavior and demanding, verbally abusive behavior noted. On 08/10/2018 at 10:34 AM, R30's comprehensive care plan revised after the incident on 08/09/2018, to include the following interventions: Please remind me if my verbal persistence is upsetting others. Let me know what good behaviors look like. Approach me in a gentle sensitive manner. Talk calmly. On 08/14/2018 Additional interventions include: Please ask me if I am upset. Offer me reassurances, but also encourage me to distract myself in places I feel safe, such as my new room or in common areas with staff. Allow me to vent over my feelings of frustration or anxiety, but direct me if I repeat themes after reassuring me this will not re-occur. My feelings get hurt if no one talks to me. On 09/17/2018 Please encourage me to resume my daily routine (out for activities, engaging others in conversation, out for meals etc. Remind me that others may not respond the way I expect them to. On 11/04/2018 After second incident, care plan revised to include: Changed to every 15 minute monitoring due to altercation. On 11/12/2018 after the third incident, care plan revised, I will be monitored so that another resident(s) I had a verbal altercation with will not be in the dayroom at thie(sic)same time as I am until further notice. On 11/16/2018 care plan revision, I will have 1:1 visit with my SW/LTC Administrator to verbalize my feelings and any concerns that I have. On 11/17/2018 care plan revision I am receiving 1:1 supervision due to verbal altercation I had with another resident (R10). 11 dc' d (discontinued) 11/20/2018. On 11/19/2018 NHA (Nursing Home Administrator) informed of behavioral contract developed and R30's agreement and signature provided.",2020-09-01
6,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2018-11-16,726,D,0,1,HKBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to properly date a Peripherally Inserted Central Catheter (PICC) line sterile transparent dressing (dressing) for R135. As a result of this deficient practice, the facility put R135 at risk for infection and/or other PICC line complications. Findings Include: During an observation of a PICC line for R135 on 11/13/18 at 12:30 PM, it was noted that the dressing was not dated. During staff interview with RN57 on 11/13/18 at 12:31 PM, RN57 acknowledged that the PICC line dressing was not dated and should have been. RN57 then stated that the PICC line would be immediately assessed and dressing would be changed and dated. A review of facility policy on Vascular Access Devices; PICCs, Appendix G; PICC, Site Care and Dressing Change stated Central PICC dressing change is a sterile procedure needing dressing kit. BioPatch and [MEDICATION NAME]. A sterile transparent dressing of appropriate size shall be used and changed every 7 days and PRN along with BioPatch and [MEDICATION NAME].",2020-09-01
7,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2018-11-16,761,D,0,1,HKBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to properly discard two medications that were stored in the Lehua Unit Medication Storage Cart. As a result of this deficient practice, two residents (Resident (R) 2, and R6) were at risk of being given an expired medication. Findings Include: 1. During an observation of the Lehua Unit Medication Storage Cart on [DATE] at 09:45 AM, an expired medication bottle of [MEDICATION NAME] was revealed in the storage drawer. This medication belonged to R6, and the label read [MEDICATION NAME] 160 mg/5 ml [MEDICATION NAME], discard after ,[DATE]. 2. During an observation of the Lehua Unit Medication Storage Cart, on [DATE] at 09:46 AM, an expired medication [MEDICATION NAME] was revealed in the storage drawer. This medication belonged to R2, and the label read [MEDICATION NAME] Oral Suspension 40 mg/5 ml, discard after [DATE]. On [DATE] at 09:45 AM, RN57 acknowledged that both medications were expired and should have been removed. According to facility policy on Outdated and Unusable Drugs, it stated All outdated drugs, contaminated drugs shall be returned to the Pharmacy Department for proper disposal.",2020-09-01
8,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2018-11-16,812,E,0,1,HKBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to monitor temperatures to ensure the refrigerators/freezer were in good working condition, and stored food beyond safe use by dates, in two kitchen refrigerators, one resident nourishment refrigerator, and a storage cabinet on the Long-term care unit. The deficiency compromised food safety for the residents. Findings Include: On [DATE] at 10:20 AM, during an interview with the Food Service Manager (FSM), the monthly refrigerator/freezer temperature logs were reviewed that revealed incomplete documentation of temperature monitoring. The FSM stated, They are to check them twice a day and document on the log. There was no evidence the kitchen storeroom refrigerator, or kitchen storeroom freezer temperature was monitored 12 out of 31 days in August, (YEAR). The log revealed the kitchen GC 14 Refer (Juices) refrigerator was not monitored 13 out of 31 days in August, (YEAR). Temperature documented on [DATE], [DATE], [DATE], and [DATE] was 52 degrees Fahrenheit (F), outside the safe range (41 degrees F, or less) for refrigeration with no evidence of corrective action taken after the deviation was noted. On [DATE], staff entered the comment, couldn't find thermometer. On [DATE] at 10:30 AM identified one container of tofu, and one container of sliced apples in a kitchen refrigerator with expired dates on the labels. The FSM confirmed the food, Needed to be thrown out. On [DATE] at 11:38 AM, inspection of the Long-term care nourishment room revealed one opened container of orange juice and a bowl of crystal light jello stored in the refrigerator with use by dates on the labels that had expired. In addition, there were eight unopened lemon water containers and two unopened orange juice containers stored in the cabinet that were beyond the use by dates.",2020-09-01
9,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2018-11-16,842,D,0,1,HKBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to accurately document the dates on a Physician Orders for Life-Sustaining Treatment (POLST) form for Resident (R) 23. As a result of this deficient practice, the POLST form would be invalid, and R23 may not have received the care as indicated on the prepared POLST form. Findings Include: During record review for R23, it was noted that the POLST form did not contain the two dates that was required on the form. These two dates were: 1. Date form prepared, and 2. Date of Physician Signature. The POLST form also stated Any section not completed implies full treatment for [REDACTED]. During staff interview with RN52 on 11/16/18 at 09:39 AM, RN52 acknowledged that the POLST form was not complete and missing the required dates. RN52 then stated that the issue would be followed up and presented to the physician. A review of the facility policy on Medical Record Documentation stated Each documentation entry or documents with multiple sections completed by multiple individuals in the medical record shall be immediately dated, timed and signed by the authorized personnel .",2020-09-01
10,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,640,D,0,1,P3CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to ensure a discharge assessment was transmitted within 14 days of completion. Findings include: On 12/19/19 at 11:46 AM, a record review was done for Resident (R)1. R1 was admitted to the facility on [DATE] from an acute hospital. On 07/18/19, R1 was discharged to the community. On 12/19/19 at 11:42 AM, the transmission receipt for R1's discharge assessment was requested of the Resident Assessment Coordinator (RAC). At 12:47 PM, the RAC reported the resident's assessment was batched with other resident's assessments and upon review of the transmission report confirmed R1's discharge assessment was not successfully transmitted.",2020-09-01
11,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,684,D,0,1,P3CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with resident and staff member, the facility failed to provide a bowel regimen for a resident to address constipation related to the routine and pro re nata (prn) use of opioid medication for pain management for 1 (Resident 18) of 1 residents sampled. Findings include: On 12/17/19 at 02:07 PM, an interview was conducted with Resident (R)18. R18 was asked whether he/she has constipation, R18 responded that he/she takes pain medication which results in constipation. R18 confirmed that sometimes he/she will go without a bowel movement for more than three days. Initially, R18 reported that he/she fixes it on his/her own; however, later reported that medication is provided. On 12/18/19 at 02:58 PM, a record review was done. R18 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the annual Minimum Data Set with assessment reference date of 10/28/19 documents R18 yielded a score of 15 (cognitively intact) upon administration of the Brief Interview for Mental Status. R18 requires extensive assist with one personal physical assist for toilet use. The resident is continent of bowel and bladder. R18 was not coded for constipation. In the medication section, R18 was documented as receiving opioid medications for pain daily in the last seven days. A review of the physician's orders [REDACTED]. every morning; [MEDICATION NAME] powder, 17 gm every 48 hours as needed for constipation with a start date of 10/16/19; [MEDICATION NAME] HCI, 5 mg every four hours for pain, prn; [MEDICATION NAME] HCI, 10 mg every four hours for pain, prn; and routine [MEDICATION NAME] HCI 10 mg. twice a day at 08:00 AM and 05:00 PM. Further review of the facility's intake and output log found the tracking in the electronic health record (EHR) which documents the following: continent of bowel movement (#); incontinent of bowel movement (#); and bowel movements (#). The EHR documents R18 did not have bowel movement from 12/04/19 through 12/06/19. R18 was documented with 0 (zero) for continent of bowel movement and incontinent of bowel movement and no documentation for number of bowel movement. A request was made to review the resident's frequency of bowel movement. The facility provided a vertical report entitled Continent of BM (#). The review found R18 did not have bowel movement from 11/19/19 through 11/20/19; 11/28/19 through 11/29/19; and 12/09/19 through 12/10/19. This report did not indicate R18 did not have a bowel movement from 12/04/19 through 12/06/19, it is documented R18 was continent of bowel movement under the heading of result as 1 (one). The intake and output documented in the EHR did not match the filtered report provided by the facility. On 12/19/19 at 01:15 PM, an interview was conducted with Licensed Nurse (LN)6. Inquired when is the prn of [MEDICATION NAME] for constipation is provided. LN6 responded when the resident does not have a bowel movement on the second day. LN6 further clarified the nurses keep track of residents' bowel movement by shift reports. A review of the physician order [REDACTED]. On 12/19/19 at 02:53 PM, an interview was conducted with the Director of Nursing (DON) and Resident Assessment Coordinator (RAC). A review of the documentation provided by the facility confirmed the aforementioned time periods when the resident did not have a bowel movement. Requested documentation that a prn of [MEDICATION NAME] powder was provided. There was no documentation of administration of [MEDICATION NAME]. The RAC reported, the resident may have refused the prn. Further requested documentation of the refusal. The RAC confirmed there is no documentation of resident's refusal for prn of [MEDICATION NAME] during the aforementioned periods.",2020-09-01
12,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,686,D,0,1,P3CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure prevention of an avoidable facility-acquired pressure ulcer. Although the facility was conducting weekly skin assessments, the assessments did not identify skin issues prior to the emergence of a Stage 2 pressure ulcer to the coccyx. Also, the facility identified an abrasion to the right lateral knee as a result of a mechanical device, the interventions provided did not prevent the abrasion from progressing to a Stage 2 pressure ulcer. Findings include: On 12/18/19, a review of the facility's Resident Census and Conditions of Residents (CMS-672) found documentation of one resident with pressure ulcer (excluding Stage 1). The Facility Matrix provided by the facility on the morning of 12/17/19 did not document Resident (R)2 has pressure ulcer. R2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Observation of the resident during the initial tour of the facility on 12/17/19 found R2 asleep in bed with noted right below knee amputation. On 12/20/19 at 07:57 AM, a record review was done. A review of the physician's orders [REDACTED]. R2 has a care plan to maintain skin integrity, prevent skin breakdown. The following care plan revisions include: 11/07/19 - monitor for presence of [MEDICAL CONDITION]; 11/25/19 - use skin sleeves to bilateral arms for skin protection and do treatment to my right lateral knee; 12/09/19 - turn me very hour when in bed, continue to do skin check routinely, and notify physician/wound nurse of significant findings; and 12/09/19 - continue to encourage to increase fluid intake as tolerated and if not indicated. On 12/20/19, observation at 09:40 AM found R2 asleep in bed (air mattress), the resident was placed on his/her back with legs raised behind the knees. At 10:10 AM, resident was observed in bed, in the same position. The hospice worker was visiting the resident. A request was made for documentation of skin assessments. On 12/20/19 at 09:43 AM, the facility provided documentation of the progress notes related to the R2's pressure ulcers. The note for 10/30/19 documents R2 has a prosthesis for the right leg which he/she applies independently. A Stage 2 pressure ulcer developed as the resident was placing a sock on before applying the rubber cushion for the prosthesis. The skin and weight note dated 10/31/19 documents a pressure ulcer to right lateral knee measuring 1 cm x 1 cm. At this time Glucerna was ordered to increase R2's protein intake. Also, R2 was willing to add [MEDICATION NAME] (protein supplement) to his/her diet. Subsequent note on 11/07/19 documents no change to measurement of the wound. R2 was consuming the Glucerna and [MEDICATION NAME] to promote wound healing. R2 also documented with pneumonia. A nursing note on 11/09/19 notes wound bed is pink with contracted edges and minimal sanguineous draining with no signs and symptoms of infection. The use of duoderm was discontinued and [MEDICATION NAME] with kerrafoam dressing was initiated. The subsequent assessment notes on 11/13/19 a decrease in the wound from 1 cm x 1 cm to 1 cm x 0.8 cm. The note on 11/28/19 found R2 with recent decline in conjunction with changes in mental status (more confused and disoriented). The note on 12/03/19 documents an increase in measurement from 1.0 cm x 0.8 cm to 1.5 cm x 1.0 cm. An alert charting for 12/07/19 notes R2 with an open area to the coccyx measuring 1.2 cm x 0.8 cm. The wound was covered with foam dressing and sensicare was applied. The plan was to reposition every two hours and to get an order for [REDACTED]. On 12/20/19 at 10:13 AM, an interview was done with Licensed Nurse (LN)6. LN6 reported R2 has been experiencing a decline. LN6 also reported R2 was applying the prosthesis independently and upon discovering the application was wrong, the resident was re-educated. LN6 reported the injury to the right lateral knee started as a skin abrasion on 10/16/19 and was treated as an abrasion. Inquired whether weekly skin checks would find any changes to residents' skin to indicate possible skin breakdown. LN6 further explained R2 used to be very active and independent with hygiene care and recently has been more dependent on staff. LN6 responded the weekly skin check would indicate changes and maybe R2's skin breakdowns may have been identified before breaking down to a Stage 2 pressure ulcer. LN6 also reported R2 is being admitted to hospice. On 12/29/19 at 10:43 AM, an interview and concurrent record review was done with the Director of Nursing (DON). A review of the weekly skin assessments was done with the DON. The Stage 2 pressure ulcer to the right lateral knee was first documented on 10/09/19. The Advanced Practice Registered Nurse (APRN) was notified and ordered to apply [MEDICATION NAME] every day for four days. On 10/19/19, R2 went home for an overnight trip. Subsequently on 11/07/19, R2 was sent to the emergency department. The documentation up to 10/21/19 refers to the wound as an abrasion. A referral to the wound as a pressure injury was first documented on 10/31/19 as a Stage 2 pressure ulcer. A review of the weekly skin assessments in (MONTH) prior to the identification of a Stage 2 pressure ulcer to the coccyx (12/07/19) documents no skin issues. The DON reported R2 is declining and has been referred to hospice. The DON recalled prior to the breakdown of the coccyx (12/07/19), R2 went home from 11/01/19 through 11/03/19 for a visit.",2020-09-01
13,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,725,D,0,1,P3CE11,"Based on interviews with residents, the facility failed to ensure the provision of sufficient nursing staff to provide services to assure residents maintain their highest practicable physical and psychosocial well-being. Findings include: 1) On 12/18/19 at 10:00 AM, a confidential interview was done with ten resident council representatives that were invited to participate by the facility staff. The representatives reported staff members will respond to their call light right away; however, they are told they have to wait five to ten minutes as the staff member is providing care for another resident. Three residents reported there has been occasion where they had to wait for 30 minutes. One resident reported this usually occurs during the night shift. And another resident commented that he/she doesn't want to ask for help during the shift change. 2) On 12/17/19 at 01:55 PM, a confidential interview was done with a cognizant resident (the resident yielded a score of 15 on the Brief Interview for Mental Status, which indicates the resident is cognitively intact). The resident reported there are three shifts and identified the 03:00 PM to 11:00 PM as not having enough staff members to provide care. The resident shared that the call light is pressed, the staff member responds, turns off the light, tells you they are busy and will come back. The resident further reported, the call light is being pressed for assistance for repositioning, bathroom and transferring in and out of bed; however, acknowledged that the staff members are run down.",2020-09-01
14,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,726,D,0,1,P3CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to provide nursing professional standard of care for Resident (R)89's peripherally inserted central catheter (PICC). As a result of this deficiency, there is a potential risk for infection. Findings include: Resident (R)89, admitted on [DATE], was receiving intravenous (IV) antibiotic ([MEDICATION NAME] tazobactam) through a peripherally inserted central catheter (PICC). On 12/17/19 at 11:44 AM, licensed nurse (LN)5 prepared to administer intravenous medication for Resident (R)89. Observed the PICC dressing was not labeled, documenting the date, time, and staff that last changed the PICC dressing. LN5 confirmed the PICC dressing should have been labeled with the date, time, and staff initials. Additionally, LN5 confirmed there was no documentation in R89's medical record of the last date the PICC dressing was changed.",2020-09-01
15,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,761,D,0,1,P3CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to discard an expired medication on 1 of 3 medication carts. Findings include: On [DATE] at 12:55 PM, an inspection of the medication cart was done with Licensed Nurse (LN)6. The observation found one bottle of polyethylene [MEDICATION NAME] which was not labeled with an open date. LN6 found the pharmacy label which documented an expiry date of ,[DATE]. The licensed nurse reported this medication will be discarded.",2020-09-01
16,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,812,F,0,1,P3CE11,"Based on observations, staff interview, and review of records, the facility failed to 1. Maintain a safe refrigerated food storage, and 2. Maintain water temperature records for the manual dishwashing station. Findings Include: 1. During an initial tour of the kitchen on 12/17/19 at 09:50 AM, the walk-in refrigerator (GC14) was noted to have employee food stored on one of the shelves. The stored food was not labeled, not dated, and not being monitored. The Food Service Manager (FSM), who accompanied the initial tour, was queried about the stored food and acknowledged that the food was not labeled, not dated, and not being monitored. 2. During a follow up visit to the kitchen on 12/19/19 at 09:59 AM, FSM stated that their dishwashing machine had recently broken down and they were manually washing all the dishes. FSM explained the details of their manual washing process. However, upon review of records the facility had not recorded and/or maintained the water temperature for their washing since they started the manual washing process. On 12/19/19 at 11:00 AM, the FSM acknowledged that the facility had not recorded and/or maintained the water temperature for their manual washing process as previously mentioned. FSM actually created a new updated manual washing log which included the missing washing temperatures.",2020-09-01
17,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,880,D,0,1,P3CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to maintain a sanitary environment and failed to prevent the development and transmission of communicable diseases and infections as evidenced by the following: canister of [MEDICATION NAME] powder had a plastic measured cup (scoop cup) that was stored in the powder for multiple use; and a pad on the shower gurney had multiple tears and cracks, resulting in permeability of the plastic covering and allowing liquids/fluids to seep into the padding and resurface when weight is applied. Findings Include: 1) On 12/20/19 at 09:47 AM, during an observation of the medication cart on the North Wing, a 6-8 ounce canister of [MEDICATION NAME] powder was noted to have the scoop cup stored in the powder. Registered Nurse (RN) 23, who accompanied this observation, was asked about the scoop cup. RN23 stated that multiple hands would grab the scoop cup, but there was no procedure to ensure the cup was either sanitized or any procedure to prevent the spread of infections. RN23 further stated that the facility had most recently been using single use packets and wasn't sure when they switched to using the canister. 2) On 12/18/19 at 11:45 AM, observation of the shower room was done with Certified Nurse Aide (CNA)8. The observation found a shower gurney with a blue padding insert. The blue pad had cracks in the raised area under the head and around the drainage holes. Inquired how is the pad sanitized, CNA8 responded the pad is washed down after use and sprayed with a sanitizing solution. Initially CNA8 stated the residents are placed directly on the plastic padding; however, after discussion that the plastic covering was now permeable, the CNA reported a towel is placed on the padding.",2020-09-01
18,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,883,E,0,1,P3CE11,"Based on record review, staff interview, and review of policy, the facility failed to provide education regarding benefits and potential side effects for the Influenza Vaccination that was given to two Residents ((R) 15, 28) out of the seven residents reviewed. As a result of this deficient practice, the two residents and/or their representatives was not given the opportunity, or even the discussion, of minimizing the risk for acquiring, transmitting, or experiencing complications from the Influenza vaccination. Findings Include: 1. During a review of the immunization record for R15, it was noted that R15 received the Influenza vaccination on 10/10/19. However, after further record review, there was no documentation noted that the resident and/or resident's representative was provided education regarding the benefits and potential side effects of the influenza vaccination. On 12/20/19 at 12:30 PM, the Director of Nursing (DON) was queried and subsequently provided a consent form for R15 on the Influenza immunization. However, the consent form was for the previous flu season (YEAR)-2019. There was no consent form provided for the current year 2019-2020. 2. During a review of the immunization record for R28, it was noted that R28 received the Influenza vaccination on 10/04/19. However, after further record review, there was no documentation noted that the resident and/or resident's representative was provided education regarding the benefits and potential side effects of the influenza vaccination. On 12/20/19 at 12:30 PM, DON was queried and subsequently provided a consent form for R28 on the Influenza immunization. However, the consent form was for the previous flu season (YEAR)-2019. There was no consent form provided for the current year 2019-2020. A review of the facility policy titled Influenza and Pneumococcal Vaccination Protocol for Acute Care Inpatients and Long Term Care Residents stated the following: Policy, [NAME] Hilo Medical Center Registered Professional Nurses (RPNs) and Licensed Practical Nurses (LPNs) are authorized to give the influenza and/or pneumococcal vaccine to Hilo Medical Center patient and residents, who meet the criteria established by the Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP). B.the nurse screens the patient using the Vaccine Consent/Documentation Tool. Procedure, [NAME] Identify vaccine recipients with the criteria on the Vaccine Consent/Documentation Tool. The form lists the contraindications and timeframes for giving vaccine. As previously mentioned, there was no consent form provided for R15 and R28.",2020-09-01
19,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,157,D,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews, the facility failed to immediately notify the resident's representatives when there was a significant change in the resident's physical condition and health status for 1 of 23 residents (Resident #12) in the Stage 2 sample. Finding includes: During a confidential family interview on 04/11/2017 at 10:31 AM, a family member stated he/she is the person who would be notified of a change in condition involving Resident #12 (R #12). The family member stated there had been a recent change in R #12's health condition. The family member stated he/she had not been promptly notified by staff caring for R #12 of the laboratory tests and an electrocardiogram (EKG) that had been ordered. The family member further said the tests were ordered about a week ago on a Friday, and when he/she came to visit R #12 on Sunday, the resident was going through an exacerbation of her [MEDICAL CONDITIONS]. The family member stated the resident was also found to have swelling (edma) of her face and hands. During a follow-up confidential interview on 04/12/2017 at 9:02 AM, the family member said, I knew (the resident) was quite lethargic but not aware of the labs and EK[NAME] The family member also said there was a decline in the resident's condition and by that Sunday, 4/2/17, the on call physician was called to assess R #12. The family member stated although another family member is the primary contact (he/she) asked for me (this family member) to be contacted first due to a language barrier. The resident's clinical chart documents this family member to be the first person the facility is to call on the resident's contact list. The family member re-verified that no staff informed him/her of the labs and EKG and change in the resident's condition. On 04/13/2017 at 8:06 AM, an interview with Staff #58 was done. Staff #58 said R #12's [MEDICAL CONDITION] gets more complicated, but confirmed that when an EKG and labs are ordered, the family is to be notified. Staff #58 verified based on his chart review, there was no clinical documentation by Staff #100 to show that R #12's family member who is to be contacted first had been notified. Staff #58 said it was important that it be documented, but that it had not been done. The facility failed to immediately notify/contact the family member listed as the first person to contact regarding a change in the resident's condition and the ordered clinical tests.",2020-09-01
20,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,221,D,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with staff members, the facility failed to ensure a resident, Resident #63 was free from a physical restraint. Finding includes: On 4/10/17 at 11:30 [NAME]M. observed Resident #63 in the activity room. The resident was seated in a wheel chair with a gait belt looped through the bars on the sides of the wheelchair and buckled across her lap. Subsequent observation at 11:42 [NAME]M. found the gait belt still buckled across the resident's lap. At 12:21 P.M. Resident #63 was observed eating lunch at a table with the gait belt still affixed to her wheelchair. On the morning of 4/11/17 Resident #63 was observed eating her breakfast in the activity/dining room, the gait belt was affixed to her wheelchair. Subsequent observation at 10:06 [NAME]M. found the resident watching the entertainment. The resident was seated on a bench in the front row. On 4/11/17 at 2:22 P.M. observed Resident #63 asking Staff Member #110 to take her back to the room. Resident #63 was seated in a wheelchair and observed to be wearing a seat belt that was buckled in the front. Resident #63 was observed to self-propel the wheelchair with her feet. The seat belt was removed by the staff member, Resident #63 was observed to stand and walk to the bathroom independently. The resident stood in front of the toilet and started pulling her pants down, at this time, the staff member requested to have the door closed. Second observation at 3:06 P.M. found Resident #63 ambulating on the unit with the assistance of a staff member. Observation from 3:14 P.M. through 3:34 P.M. found Resident #63 propelling herself in the wheelchair around the unit. The seat belt was applied. On 4/12/17 at 8:03 [NAME]M. Resident #63 was observed eating breakfast in the activity/dining room, the seat belt was not applied and there was no gait belt looped across her lap. Subsequent observation at 9:04 [NAME]M. found the resident's seat belt was affixed. A record review done on the morning of 4/12/17 found a physician's orders [REDACTED]. The reason for the use of device is dementia with anxiety and left foot weakness secondary to TIA, gait instability. The form documents that the device is a restraint; however, the team checked that the front buckle belt is not a restraint because the: resident can ask to have it removed; resident can remove it on his/her own; and resident cannot get up on his/her own so is not being restrained. There is no documentation of an assessment for the use of a gait belt to be looped through the sides of the wheelchair as a possible restraint. A review of the Minimum Data Set for significant change with an assessment reference date of 1/9/17 codes daily use of trunk restraint. In Section [NAME] Activities of Daily Living Assistance, Resident #63 was coded as requiring extensive assistance with two person physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and walk in room and corridor as being totally dependent with one person physical assist. A review of the care plan for restraint was updated on 1/20/17 for the use of front buckle belt. The interventions included: when restraint in use, check q 1 hour and release q 2 hours and inspect skin, circulation and movement; release restraint during activities as appropriate; monitor resident's response to restraint; reposition q 2 hours and as needed; and ambulate with 2 person assistance as tolerated. On 4/12/17 at 1:31 P.M. an interview was conducted with Staff Member #155. The observation of the use of the gait belt looped through the side bars across the resident's lap was shared with the staff member. The staff member reviewed the physician order [REDACTED]. Subsequently an interview was conducted with Staff Member #85. The staff member reported the gait belt is not used to be looped over the resident's lap, the gait belt is kept in the resident's wheel chair for tactile purposes. The staff member further reported the gait belt is not to be used to loop across the resident's lap and the use of the gait belt is to assist the resident to ambulate. On 4/12/17 at 1:44 P.M. concurrent observation of the resident was done with Staff Member #155. The resident was asked to unbuckle the seat belt, the resident grabbed the buckle and stated that it was stuck. Resident #63 was unable to remove the front belt buckle. An interview was done with Staff Member #112 on 4/12/17 at 1:40 P.M. The observation of the use of the gait belt was shared with the staff member. The staff member commented that the gait belt was utilized as a restraint and it should not be used in that manner. An interview was conducted with the staff member providing direct care, Staff Member #28 on 4/11/17. The staff member reported the gait belt is not to be used across the resident's lap, the gait belt is kept in the wheel chair so the resident can play with it. The staff member denied applying the gait belt to the wheelchair and stated it may have been the night staff that applied the gait belt to the wheel chair. The facility failed to ensure Resident #63 was free of a physical restraint as evidenced by the use of a gait belt looped through the bars on the sides of the wheelchair and over the resident's lap without an assessment and plan of care.",2020-09-01
21,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,279,D,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure it developed and implemented a comprehensive, person-centered care plan for 1 of 23 residents (Resident #12), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment in the Stage 2 sample. Finding includes: Cross-reference to findings at F157. Resident #12 (R #12) was admitted to the facility from an acute setting as her cardiac status had stabilized. R #12's admission was for ongoing medical management and rehabilitation services (physical and occupational therapy) due to severe weakness related to her hospitalization . Some of her [DIAGNOSES REDACTED]. Observation of R #12 revealed the resident was arousable but lethargic. A family interview revealed the resident had a recent exacerbation of her [MEDICAL CONDITION] symptoms with noted [MEDICAL CONDITION] (swelling). A review of R #12's clinical chart found a 3/31/17 nursing note which documented upon assessment, the resident was noted to be diaphoretic and lethargic. Arousable but generalized lethargy .Noted increased irregular HR (heart rate) in the 120s and BP 110/79. The record revealed the attending physician was notified and ordered a stat EKG, which was done at 10:10 AM on 3/31/17. Per the attending physician's 3/31/17 note, she assessed the resident as having sinus [MEDICAL CONDITION] wheeze, questionable asthma as symptoms were recurrent, and ordered oxygen as needed. The physician also ordered a new inhalation medication ([MEDICATION NAME]) twice daily for 5 days and noted the resident's history of [MEDICAL CONDITION] and positive fluid retention, and consider checking of BNP . The lab tests drawn on 4/3/17 included a basic metabolic panel and a B-Natriuretic Peptide (BNP) level. The BNP was significantly elevated at 908 pg/mL (normal A 4/2/17 entry by the on-call physician found R #12 was assessed to have [MEDICAL CONDITION], [MEDICAL CONDITIONS] and mild [MEDICAL CONDITION]. Orders were given for a one time [MEDICATION NAME] dose and to increase the resident's routine daily [MEDICATION NAME] dose to 20 mg. Additional orders included increasing the oxygen to 2 Liters/min by nasal prong, to check the resident's oxygen saturation (O2 sat) level every shift and to report to the physician if the O2 sat was 90 or less. Daily weights x 5 days were also ordered and a 4/2/17 nursing entry stated R #12 had a weight gain of at least 2.5# (pounds) and observed with increased facial and bilateral hand [MEDICAL CONDITION]. A concurrent chart review of the resident's care plans was done with Staff #58 on 04/13/2017 at 8:06 AM. During the interview with Staff #58, he stated with regard to the resident's [MEDICAL CONDITION], the attending physician knew of the resident's BNP level and adjusted R #12's medications. He also acknowledged daily weights for five days were ordered. Staff #58 verified there was no care plan developed for the resident's [MEDICAL CONDITION] but that it was important to have one based on the resident's [DIAGNOSES REDACTED]. Staff #58 said, It is every nurse's responsibility to develop a care plan and affirmed a care plan for it was not done. The facility failed to develop a care plan for a resident with a known history of [MEDICAL CONDITION] and during a recent exacerbation of [MEDICAL CONDITION] symptoms.",2020-09-01
22,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,280,D,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's basic care plan for falls was revised for 1 of 23 residents (Resident #77) in the Stage 2 sample. Finding includes: Cross-reference to findings at F323. Resident #77 (R #77) was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R #77's 3/21/17 basic care plan was formulated by an interdisciplinary team (IDT) and included care plans for self care deficit, altered thought process, alteration in comfort and a risk for falls. During an interview with Staff #13 on 4/12/2017 at 2:04 PM, she acknowledged her 3/24/17 assessment of R #77 was not included in the basic care plan with regard to the resident's with left sided weakness, difficulty in communicating, confusion, and functional limitations in her mobility and transfer. Staff #13 said she understood where the handing off of communication may not have been in the basic care plan prior to the injury occurring. She said her entry on 3/24/17 was about therapy and the IDT care plan (on 4/4/17) included additional interventions, but that it was done after the resident's 3/25/17 fall injury occurred. On 04/12/2017 at 2:48 PM, interview with Staff #55 revealed the family stated the resident fell all the time at home. Staff #55 confirmed the resident sustained [REDACTED]. Staff #55 said she would have to look to see if she discussed it with the nurse manager at the time, but the nurse manager should have incorporated it into the resident's care plan. This was in relation to Staff #13's progress note entry of 3/24/17 that based on her assessment of the resident, the recommended plan was to support R #77's left upper extremity at all times, to respond as quickly as possible to her requests to toilet, provide two staff assistance for putting on briefs, and provide program and training for staff to maximize the resident's ADL safety, independence, mobility and quality of life. This was not found in the basic risk for falls care plan. R #77 then sustained a fall with a left shoulder subluxation (dislocation) injury on 3/25/17. Staff #55 acknowledged there should have been something more put in place and that Staff #13's assessment should have been part of it. She acknowledged as Staff #13 is also a licensed professional, her expectation was the staff speak in terms of a communication hand off and some of these things would have been added to the care plan. The facility failed to update/revise the resident's care plan following a therapist's assessment which may have prevented the fall injury from occurring.",2020-09-01
23,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,281,D,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to ensure the services being provided meet professional standards of quality according to accepted standards of clinical practice for 2 of 23 residents (Residents #43 and #76) in the Stage 2 sample. Finding includes: 1) During Resident #43 (R #43's) room observation on 4/10/17 at 2:42 PM, it was noted that she received enteral nutrition via [DEVICE] feedings (GTF). The enteral nutrition (EN) bag that was hanging on the IV pole but not being infused at the time was Fibersource HN. On the bag's label, it had the resident's handwritten name as initials. It was also dated 4/10/17 and 370 cc/hr written on it. There was no start time written on the label when the initial EN infusion began. R #43's physician's orders [REDACTED]. Review of the facility's policy on Enteral Tubes was provided on 4/12/17, but it did not address how the EN formula bags were to be labeled. On 04/13/2017 at 7:25 AM, a room observation was done with Staff #108 for R #43. The resident's EN bag that was hanging on the IV pole had the resident's handwritten name as initials, and 4/12 1300 on it. Staff #108 said, It's missing the feeding order. Staff #108 further said their policy says the EN bag should be labeled with the amount of the flow rate on it. Staff #108 stated, it's not acceptable, and also verified the way staff had labeled the EN bag per surveyor's 4/10/17 observation by omitting the start time was not acceptable. The State Agency references the American Society for [MEDICATION NAME] and Enteral Nutrition (ASPEN), The Journal of [MEDICATION NAME] and Enteral Nutritional Practice Recommendations, Bankhead, R., et al., [DATE], pp. 129-130: D. Labeling of Enteral Nutrition .Practice Recommendations .3. All EN labels in any healthcare environment shall express clearly and accurately what the patient is receiving at any time .4. The EN label should be compared with the EN order for accuracy and hang time or beyond-use date before administration. For R #43, there was a failure by staff to label the EN bag following acceptable standards of clinical practice as the labeling did not include the start times according to the physician's orders [REDACTED]. 2) On 4/20/2017 a record review found the following conflicting documentation for Resident #76: 12/14/2016 admission: Skin Assessment: superficial open area overlying coccyx; no surrounding [DIAGNOSES REDACTED] or discharge, excoriation and [DIAGNOSES REDACTED] in the coccyx 0.5 cm x 0.5 cm dry; 12/18/2016 EZ graph Stage 2, 1 cm x 1 cm to coccyx, open area red/flaky skin. physician notified obtained order for [MEDICATION NAME] boarder till physician can evaluate.; 12/21/2016 glueteal excoriation almost completely closed, physician order [REDACTED]. On 4/11/2017 at 3:15 PM interviewed Staff #14. Staff #14 was asked if Resident #76 was admitted with a pressure ulcer and if the ulcer had become a Stage 2 in 4 days then healed in 3 days. Staff #14 stated the doctor codes the ulcers, nurses are not trained to do the assessment. A concurrent record review was done with Staff # 14, who stated looks like Res #76 came in with an excoriation, a nurse assessed it and called it a Stage 2 then when the doctor came in he correctly called it a healed excoriation. This may have been an error on the staging by the nurse. A review of the facility guideline for staging found that nurses are able to do pressure ulcer assessment using the National Pressure Ulcer Advisor Panel, [DATE]th edition, found in the Clinical Nursing Skills Basic to Advanced Skills by [NAME] Duel, Martin. Incorrect pressure ulcer staging may potentially cause unnecessary treatment delivery to the resident.",2020-09-01
24,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,323,G,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure the resident environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance to prevent accidents for 1 of 23 residents (Resident #77) in the Stage 2 sample. Finding includes: A Stage 2 review was done based on an incident report (IR) involving a fall related injury sustained by Resident #77 (R #77). The facility's self-reported IR stated the resident's 3/25/17 fall appeared to have .more affected her shoulder which was already affected by the cva. She is forgetful at times and does not remember to use the call bell. She does not realize that the left side of her body does not support her anymore. What interventions were implemented after the incident/event to prevent further injury? Immediate measures: 1:1 supervision while in bed and visual supervision when out of bed. Toileting at least every 2 hours with the goal of working on promoting continence, PT/OT have done initial evaluations with resident on 3/23-24 and will be working with resident to increase physical capabilities which will help with all aspects of care and comfort. On site review found R #77 was admitted to the facility on [DATE] from the hospital with several [DIAGNOSES REDACTED]. The resident's chart review found her admission included rehabilitation services (physical and occupational therapy) and that she has confusion. The resident's unwitnessed fall occurred on 3/25/17 in her room, and at the time of the incident, she stated she wanted to go to the bathroom. As a result of the fall, R #77 sustained a left shoulder subluxation (dislocation) injury. The emergency department noted it was a difficult reduction of the shoulder injury and she was given a left arm sling to stay on for at least 7 days. Observation of the resident on 4/12/17 at 10:16 AM in the hallway found she still required the use of a sling. The resident was being assisted by nurses aides with Staff #13 instructing them how to apply a new cross-over type of sling to support her left shoulder/arm. The resident allowed the sling to be applied and spoke very few words to the staff in her native dialect. Chart review of the 3/24/17 therapy evaluation by Staff #13 found her assessment of the resident included, decreased mobility + ADL safety + independence, impaired cognition/safety awareness with impulsiveness and difficulty communicating. She remains aware of the need to toilet, sits for at least several minutes unsupported . Staff #13's plan was to recommend supporting R #77's left upper extremity at all times, to respond as quickly as possible to her requests to toilet, provide two staff assistance for putting on briefs, and provide program and training for staff to maximize the resident's ADL safety, independence, mobility and quality of life. On 04/12/2017 at 2:04 PM, an interview of Staff #13 was done regarding her 3/24/17 evaluation of the resident. She was asked how she communicated her plan to the line staff caring for the resident. Staff #13 replied that if things need to be known immediately, she went directly to a nurse's aide or the nurse. She said if they were not available, she would document it on a sheet for the next shift to get it communicated forward, or speak with the head nurse to communicate it as quickly as possible and do a care plan update. She acknowledged she could update the care plan as well. Staff #13 recalled speaking to a licensed staff about the toileting and transfer for this resident and how important it was for staff to stabilize the other side as she (the resident) really doesn't put any weight on the other side and her ankle on the left side is unstable and can't put weight on it to transfer. Staff #13 thought it may have been added or implemented to the basic care plan and said nursing typically would put it in right away and that the resident came in with a history of falls. Staff #13 acknowledged the resident sustained [REDACTED]. She also said she understood where the handing off of communication may not have been in the basic care plan prior to the injury occurring. Staff #13 was informed that her plan/recommendations were not found in the care plan, which could have potentially prevented an injurious fall from occurring. She said her entry on 3/24/17 was about therapy and the IDT care plan (on 4/4/17) included additional interventions, but acknowledged that it was done after the resident's 3/25/17 fall injury occurred. On 04/12/2017 at 2:48 PM, interview of Staff #55 was done. She affirmed she completed the IR because the DON was on leave. She said the family said R #77 fell all the time at home. She also said the emergency room physician said R #77's shoulder dislocation was a difficult reduction. Staff #55 said she would have to look to see if she discussed it with the nurse manager at the time, but the nurse manager should have incorporated it into the resident's care plan. Staff #55 acknowledged there should have been something more put in place and that Staff #13's assessment should have been part of it. She acknowledged as Staff #13 is also a licensed professional, her expectation was the staff speak in terms of a communication hand off and some of these things would have been added to the care plan. Further review of the post-fall investigation report revealed some of the contributing factors to R #77's fall included the resident's inability to ambulate by herself (stand/pivot), that she was non-English speaking with a lack of safety awareness, she had a condition (tumor excision) resulting in left sided weakness, neurological memory loss causing her to forget she has the left sided weakness, an inability to remember to use her call light, and, that her bed alarm although activated on the bed, had not been activated on the display board. It also noted a lack of staff guidance related to points of communication/exchange (i.e., handoffs/shift reports). In addition, this resident on admission was noted with a history of frequent falls and Staff #55 stated this in her interview. Yet, these assessments were not done until after R #77 suffered the injurious fall to her left shoulder, causing injury to an already weakened left side. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 04/13/2017 at 10:22 AM, the DON acknowledged that harm due to the resident's fall with injury, occurred for this resident. During an interview with the Medical Director on 4/21/17 at 8:30 AM, she stated the communication piece was something they are looking to improve, and mentioned the SBAR method as an example on how to improve communication amongst the staff. The facility failed to fully assess the resident's known pre-disposition to frequent falls concomitant with her clinical condition/status on admission. There was an additional failure in communicating Staff #13's plan/recommendations and failure to immediately implement interventions into the resident's care plan to assure staff would be alerted to the resident's care needs. This failure may have contributed to the resident's subsequent fall and left shoulder injury on 3/25/17.",2020-09-01
25,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,334,F,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with staff members and review of the facility's policy and procedure, the facility failed to ensure 5 (Residents #70, #63, #34, #56 and #57) of 5 residents sampled for immunization had the opportunity to refuse the influenza vaccine. The resident's medical record does not include documentation that the resident or resident's representative was provided with education regarding the benefits and potential side effects of the influenza immunization and the resident received the immunization or refused the vaccination. Findings include: On 4/10/17 the facility provided a copy of the the policy and procedures for Vaccination Pneumococcal and Influenza Inpatient Protocol. The procedure includes if a resident is indicated for the vaccine, the facility will provide the :Vaccine Information Statement (VIS) and will review the appropriate VIS with the resident prior to the administration of the vaccine. The required documentation includes: patient/family education; the date of administration of the pneumococcal vaccine; amount and dosage given; the site of injection; the vaccine manufacturer; the lot number of the vaccine used; the expiration date of the vaccine; and signature of licensed nurse administering the vaccine. The policy did not include provision for the resident or resident's representative to refuse immunization. On 4/13/17 at 9:00 [NAME]M. an interview was conducted with the Director of Nursing (DON) and Staff Member #122. The staff members reported the process for immunizations include sending a letter to the resident or resident's representative to offer the vaccine with the VIS attached. The letters are sent out in (MONTH) and November. Staff Member #122 provided a sample of the immunization packet that is sent to the resident or resident's representative. The letter was reviewed during the interview which notifies the resident or resident's representative that All residents at (facility name) are scheduled to receive: flu vaccine annually; tetanus/[MEDICATION NAME] vaccine - given every [AGE] years, or as medically necessary; tetanus/[MEDICATION NAME]/peruses ([MEDICATION NAME]) - given one time for adults [AGE] years or older; and pneumococcal (a type of pneumonia) - given at age 65 with a second for those people aged 65 and older who got their first does under the age of 65 if five or more years have passed. The letter also documents that the physician has ordered these vaccines and will administer as ordered unless contraindicated. There was no information related to declination of the vaccines. Upon review of this letter, the DON stated the letter informs the recipient of the letter of the right to refuse the vaccines. Staff Member #122 reviewed the letter and confirmed there is no information regarding declining administration of the vaccines. Staff Member #122 reviewed the VIS documents in the packet and found the information statement for the [MEDICATION NAME] vaccine was dated 2/24/2015 which indicates the date when the form was updated, acknowledging the form may have been revised since (YEAR) and the facility may not be providing the most current information (VIS) related to vaccines. The inconsistent process for the five sampled residents was shared during this interview. The inconsistencies included letters that were not dated, letters that were dated and not signed, no documentation education was provided to the resident or resident's representative and no opportunity for the resident to refuse the immunization. Staff Member #122 commented the facility will definitely tighten the process for immunizing the residents. 1) On 4/11/17 an interview and concurrent record review was done for Resident #63 with Staff Member #155. Staff Member #155 confirmed the resident received the flu vaccine on 10/7/16 and the [MEDICATION NAME] on 6/18/16. The staff member reported the resident or representative is provided with information regarding the vaccine on admission then once a year the resident or representative is contacted. The staff member reported staff members are to document in the progress note that education was provided. The staff member referred to the Interdisciplinary Patient/Resident and Family Teaching Record form that documents education was provided to the resident or resident's representative. The staff member could not find documentation on the form that education was provided to the resident and/or representative. The staff member also reviewed the progress note and confirmed there was no documentation in the progress notes related to education and there was no documentation that the resident and/or representative had an opportunity to decline the vaccine. Further review found a letter dated 6/15/16 regarding vaccines informing residents that vaccines (annual influenza vaccine, tetanus/[MEDICATION NAME] and peruses and a pneumococcal vaccine) will be ordered by their physician. Also noted was an enclosed CDC Fact Sheets. This letter was not signed by the Acting DON. This letter was not the same letter that was included in the packet provided by the DON and Staff Member #122. There was documentation of a second letter dated 7/19/16 which was signed by the Acting DON. The letters sent to the resident or resident's representative did not include information to refuse vaccines. 2) On 4/12/17 at 8:52 [NAME]M. an interview and concurrent record review was done for Resident #34 with Staff Member #155. The review found a letter dated 6/15/16 regarding vaccines that will be ordered by the physician which was not signed by the Acting DON. There was another letter dated 7/19/16 which was signed by the Acting DON. The letter in the resident's medical record was not the same letter provided by the staff members during the interview. Subsequently, Staff Member #155 found the Interdisciplinary Patient/Resident and Family Teaching Record which documents on 6/30/16, 8/30/16 and 9/8/16 education was provided regarding vaccinations to the resident. The documentation on this form consisted of the staff member writing the number 8 for vaccinations in the topic/learning objectives column. There was no progress note to document the specifics of the education that was provided. A review of the physician's orders [REDACTED]. There was no documentation that the resident had an opportunity to refuse the vaccine. 3) A review of Resident #70's medical record on the morning of 4/11/17 at 2:55 P.M. revealed she received the Influenza vaccine for the (YEAR) flu season on 10/5/16. The documentation regarding the vaccine was incomplete and did not show how the facility discussed the risks and benefits with Resident #70's Power of Attorney (POA) for receiving the flu vaccine. An interview of the Nurse Manager on the afternoon of 4/11/17 at 2:55 P.M. revealed the facility did not educate the POA for the risks/benefits of the Influenza vaccine. 4) On 4/12/17, a chart review of Resident #56's (R #56) immunization status for influenza and pneumococcal vaccines was done. There was no clinical documentation to show the resident or the resident's representative received the vaccine information statements, including the benefits and risks of both immunizations, and the administration or the refusal of, or medical contraindications to the vaccines. In addition, the vaccine information statements (VIS) forms sent out were for the (YEAR) year, and not the current year for (YEAR). On 04/13/2017 at 7:21 AM, Staff #108 confirmed for R #56, she had received verbal consent from the resident's guardian to administer the vaccines. Staff #108 verified however, there was no documentation in the resident's progress notes about the verbal consent. Staff #108 also said the teaching record the facility used to chart when the VIS was sent out was a process being done on every unit. She acknowledged both the consent and/or declination had to be documented, but that it was not done. 5) In the morning of 4/15/2016 a concurrent record review was done with Staff #58 for Resident #57. Res #57 received an influenza vaccine in (YEAR). Staff #58 was asked to show evidence of the influenza vaccine education provided to resident #57 or POA prior to administration of the vaccine. Staff #58 showed a facility paper in the resident record with a checkmark to topic #8 verbal paperwork sent to family 7/20/16. When asked for evidence for consent for immunization. Staff #58 stated a telephone call was made to the resident's son around that time and the son agreed to the vaccine for the resident. There was no written evidence provided by staff for consent for vaccination or education on side effects and benefits of the vaccine. Failure to provide documented education on the vaccine side effects and benefits; and consent to vaccinate prior to vaccination potentially violates the resident's informed consent rights.",2020-09-01
26,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,353,F,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews, and facility policy reviews, the facility failed to provide sufficient nursing staff based on the staff's inability to provide the necessary care and services based on the resident assessments to ensure each resident is able to reach their highest practicable physical, mental and psychosocial well-being. Findings include: During the interview with the NHA and DON on 04/13/2017 at 10:22 AM, the NHA agreed they have had a staffing problem such that per the DON, the need for coverage was so great, due to the transition and sick calls. The DON also said they were often short 38% of their staff. The NHA said by not having a quality nurse position filled for about 1.5 years, they have seen doubling up of responsibilities with their remaining staff, which has led to a lack of identification of opportunities (for improvement) and they have become more reactive than proactive. The NHA also said it included the communication piece as well. The DON further stated with a 13 week turnover interval for the [MEDICATION NAME] (out of state travel nurses and nurses aides), there was less consistency in the delivery of care to their residents. She stated the real issues thus were not being addressed. The cumulative findings in the areas of Resident Rights, Resident Behavior and Facility Practice, Quality of Care, Quality of Life and Pharmacy Services demonstrates widespread concerns, including harm and substandard quality of care, which are interdisciplinary and includes nursing and administrative services. This deficiency is directly related to the lack of an effective quality assurance and assessment program, to which it is cross-referenced at F520. It is also evidenced and cross-referenced to the survey findings at F157, F221, F279, F280, F281, F323, F334, F371, F425, F431, F441 and F490.",2020-09-01
27,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,371,E,0,1,1M3411,"Based on observations, staff interviews and facility policy review, the facility failed to maintain a walk in refrigerator and walk in freezer to ensure proper food storage. Findings include: An initial tour of the kitchen on the morning of 4/10/17 at approximately 9:30 [NAME]M. found a walk-in refrigerator and the walk in freezer both of which didn't latch when the door was left to shut on it's own. When shutting the door, the door did not completely shut until a staff member pressed it against the door frame. The top edge of the refrigerator door appeared uneven, sloping downward from left to right. At the top of the door, the space between the left side of the walk in refrigerator door and the refrigerator door frame had a gap of approximately 2 inches and narrowed toward the bottom to approximately 0.75 inches. The temperatures for the walk in refrigerator were maintained at or below 41 degrees. However, the possibility for the temperature to rise above 41 degrees was high based on the necessity for the the staff to push the door shut. In addition to the walk in refrigerator, the walk in freezer also did not latch when the the door was left to shut on it's own. A sign was taped to the freezer door to remind staff to push the door shut. When shutting the freezer door, the door did not completely shut until a staff member pressed it against the door frame. The edge of the freezer door appeared uneven, sloping downward from left to right. At the top of the door, the space between the left side of the walk in freezer door and the freezer door frame had a gap of approximately 2 inches and narrowed toward the bottom to approximately 1 inch. A gray strip around the freezer door was loose at the corner. The Maintenance staff re-glued the gray strip until it was permanently fixed. Additionally, the floor was wet under the door to the walk in freezer. Staff #12 reported that she thought the wetness was from condensation. The temperatures for the walk in freezer were maintained at or below 0 degrees. However, the possibility for the temperature to rise above 0 degrees was high based on the necessity for the staff to push the door shut. A review of the walk in refrigerator and walk in freezer temperature logs on the morning of 4/13/17 revealed the temperature levels for (MONTH) and (MONTH) (YEAR) were maintained within acceptable ranges. The foods in the freezer were frozen solid without any thaw. An interview of Staff #12 on the morning of 4/12/17 revealed the facility was aware that the walk in refrigerator and walk in freezer doors were not working properly. Staff #12 further noted the kitchen staff taped a sign to the walk in freezer door indicating the door was malfunctioning for an unspecified amount of time. As of survey date, 4/13/17, the facility had not contracted a vendor to assess the doors of the walk in refrigerator and walk in freezer. A review of the facility's policy titled, Food Storage and Preparation with revision date of 10/2015 revealed, (11) Preventive refrigerator, freezer, and ice machine maintenance to be provided routinely and as needed by contacting food service supervisor. The facility failed to maintain the doors for one of the walk in refrigerators and the walk in freezer.",2020-09-01
28,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,425,F,0,1,1M3411,"Based on observations, interviews, and policy reviews the facility failed to utilize the pharmacy for consultation services on all aspects of the provision of pharmacy services in the facility. Findings includes: Cross to F 431 1) On 4/12/2017 at 10:40 AM interviewed Staff #116 regarding the procedure for discarding discontinued narcotics. Staff #116 stated that liquid narcotics are disposed into the drain and the controlled pills are discarded into the sharps container. The policy for disposal of discontinued narcotics was provided by Staff #116 and reviewed. The policy dated 12/12 stated: 1. The director of nursing and the consultant pharmacist will monitor for compliance with federal and state laws and regulations regarding the disposal of medications. The nursing care center should maintain approved containers to separate and securely store different types of pharmaceutical waste until it is scheduled for pick up. b. Authorized personnel who have access to medications should deposit pharmaceutical waste in the appropriately labeled container. Each container used to collect, separate and store each type of pharmaceutical waste will be labeled with the type of waste to be stored in the container. 2. Controlled Substances listed in Schedules II, III, IV and V remaining in the nursing care center after the order has been discontinued are retained in the nursing care center - until destroyed as outlined by state regulation. a. Transfer to a container for release to a pharmaceutical waste contractor, was checked off on the policy. At 1:36 PM the same day interviewed the DON regarding nursing practice for disposal of discontinued resident narcotics. The DON shared the policy for disposal of controlled drugs used on the nursing floors dated 12/12 is old, a new policy dated 5/16 is on line but has not been changed in the PharMerica policy binders used by the nursing staff. At 1:41 PM the same day interviewed Staff #108 regarding disposal of narcotics procedure. Staff #108 stated the narcotics are popped out of the blister pack and thrown into the sharps container, sometimes the pills are crushed. The liquid narcotics are poured onto a paper towel and discarded. Later that afternoon contacted the pharmacist consult (Staff #181) for the facility. When asked the recommendation and policy for disposal of controlled medications at the facility Staff #181 shared, the pharmacist does not have a role in narcotics disposal, once the medication leaves the pharmacy it belongs to the resident, nothing is returned to the pharmacy. Upon request from the facility pharmacy can advise the facility on discarding controlled medication. When informed about the practice of throwing away discontinued narcotics in the sharps containers or down the drain Staff #181 stated, we don't look at that; we are more concerned with out of date drugs. A review of the pharmacy contract titled 'Hawaii Health Systems Corporation Agreement for Goods or Services Based Upon Competitive Sealed Proposals states 2.12 Provide experienced, trained Geriatric Consultant Pharmacist to perform the following services: As per CMS requirements provide assistance with tracking, destroying; and reconciling unused controlled substances. Failure to provide pharmacy consultative services for discontinued controlled substances may potentially provide opportunity for misuse of controlled discontinued substances. 2) On 4/12/2017 at 10:40 AM reviewed the temperature log on the 3rd floor of the facility. The log titled MEDS Refrigerator/Freezer Temperature Log was printed REFRIGERATOR STANDARD: 33 degrees - 40 degrees FAHRENHEIT. The recorded refrigerator temperatures for (MONTH) (YEAR) was found to be documented at 34 degrees on (MONTH) 7 and (MONTH) 8, and at 35 degrees on (MONTH) 12, (YEAR). The refrigerator contained some of the following medications and amounts: Calcitonin Salmon Nasal Solution 1 box; Cathflor Activase a 2 mg vial; Biscodyl Suppository 13 packets; Acetaminophen Suppository 10 packets; Octreotide 50 mcg one box; Ativan vials, 4 bags with 5, 3, 5, and 5 vials per bag. The printed manufacturers label recommended temperature storage at 36 - 46 degrees for the Octreotide, Calcitonin Salmon Nasal Solution and Ativan. The temperature log was concurrently reviewed with Staff #116. Staff #116 provided a printed copy of the facility policy titled, Refrigerator/Freezer Temperature control and Maintenance. The policy stated: Refrigerator standard range if 33 degrees to 40 degrees Fahrenheit. On the same day at approximately 11:06 AM the temperature logs for the 4th and 2nd floors were reviewed. Observed that all the units were using the same standard log with the incorrect temperature range of 33 to 40 degrees Fahrenheit. The refrigerator on the second floor was observed to have the following medications and amounts: pneumococcal vaccine premeasured syringes one box; Calcitonin Salmon Nasal Spray 1 box; Influenza premeasured syringes 1 box; Tetanus 2 vials, and Ativan 3 vials. On 4/12/2017 at 1:49 PM pharmacy consultant (Staff #181) was interviewed by phone and asked about the effect of the drug temperature being at 35 degrees when the manufacturers recommendation is at 36 degrees. Staff #181 stated, one degree is not going to matter, even if the package says 36 degrees, it is OK. When asked if the manufacturer could be consulted for the medications found on the 2nd and 3rd floors stored below the manufacturers recommendation, Staff #181 stated a call would be made to the manufacturer but a response would not be available for a few days due to the time zones. Later that afternoon interviewed the DON regarding the discrepancy on the facility medication temperature log, the facility policy for refrigerated medications for storage range of 33 - 40 degrees versus the manufactures recommendation for refrigerated medications to be stored at 36 - 46 degrees. Also the concern for the efficacy of the medications stored out of temperature range. The DON shared the policy and logs were revised on 12/2016. Requested copies of the temperature logs for the past 4 months from (MONTH) (YEAR) to (MONTH) (YEAR) from all the nursing units for review. On 4/13/2017 at 3:49 AM contacted the drug manufacturers Merck, for the pneumococcal vaccine; Phizer for the Ativan vials; and Sagent Pharmaceuticals for the Octreotide vial. Each manufacturer interviewed was asked about the efficacy of the drug when stored below the recommended 36 - 46 degrees. Ativan stored below 36 degrees had no information or recommendations of use. The Octreotide drug stability studies indicated the drug was stable up to 3 months under the accelerated conditions. Accelerated conditions are described as below 36 degrees. The pneumococcal vaccine efficacy was determined by the total number of hours kept below the manufacturers recommended temperature. On 4/13/2017 at 7:30 AM obtained from the DON the collection of medication refrigerator temperature logs from (MONTH) (YEAR) to (MONTH) (YEAR) for the entire facility, which had been requested from the DON on 4/12/2017. The following temp logs provided were missing: 4 North - missing (MONTH) (YEAR) and (MONTH) (YEAR); 3rd floor - missing (MONTH) (YEAR). Review of the 2nd floor refrigerator log found that the pneumococcal vaccine had been stored below 36 degrees for 216 hours from Jan - (MONTH) (YEAR). At 7:48 AM spoke to the Merck manufacturer consultant by phone regarding the 216 hours the pneumococcal vaccine was stored below 36 degrees. Per the manufacturers recommendation, given the number of hours kept below 36 degrees the recommendation was not to administer the vaccine to any patients and remove the vaccine from inventory. The manufactures advise was shared with Staff #108 and the DON. Review of the facility policy for potency of medications titled Refrigerator/Freezer Temperature control and Maintenance date effective 12/2016 found that the policy was not signed as approved and reviewed by a PharMerica consultant. Review of the contract agreement between HHSC and the Pharmacy Corporation of America states: 2.0 Contractor Requirements. The contractor shall provide Long Term Care Pharmacy services pursuant to the provisions specified below: 2.1 Provide the facility with a comprehensive range of professional pharmaceutical services related to the use, storage, distribution and administration of medicines. Inconsistency of nursing staff practice in the proper disposal of controlled drugs; failure to update the PharMerica binder used on the floors by nursing staff on the disposal of controlled drugs; and failure to provide consultative pharmaceutical service for policy development and review in the area of medications stored in refrigerator/freezer has the potential for pharmaceutical errors.",2020-09-01
29,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,431,F,0,1,1M3411,"Based on observation, interviews, and policy review the facility failed to provide pharmaceutical services to meet the needs of each resident. Findings include: Cross reference to F 425 1) On 4/10/2017 at 11:50 AM observed an IV bag hanging for Resident #44. The IV bag was not labeled with a resident's name or dated. At 12:00 PM interviewed Staff #116 regarding the unlabeled IV bag. Staff #116 agreed the bag hanging should be labeled. Staff #116 shared Resident #44 receives TPN nourishment through her PICC line and after the TPN is infused an IV bag is hung until the line is flushed. Staff #116 brought out an unopened IV bag to show that the pharmacy label is attached to the outside plastic wrap of the IV bag, when the bags are opened the pharmacy label is discarded. Unlabeled medications has the potential for medication errors. 2) On 4/12/2017 at 8:13 AM observed an unlocked treatment cart with one drawer pulled out resting in the hall outside of the dining hall. The opened drawer contained ointments. There was no staff seen near or around the opened cart. Shortly after observed Staff # 116 came out of the dining room. Staff #116 was asked about the unattended, unlocked treatment cart with the treatment drawer opened. Staff #116 stated she went to check a resident and had left the cart unlocked. Staff #116 agreed the cart should have been locked. Unlocked treatment carts has the potential for medication loss and misuse. 3) On 4/12/2017 at 10:40 AM interviewed Staff #116 regarding the procedure for discarding discontinued narcotics. Staff #116 stated that liquid narcotics are disposed into the drain and the controlled pills are discarded into the sharps container. The policy for disposal of discontinued narcotics was provided by Staff #116 and reviewed. The policy dated 12/12 stated: 1. The director of nursing and the consultant pharmacist will monitor for compliance with federal and state laws and regulations regarding the disposal of medications. The nursing care center should maintain approved containers to separate and securely store different types of pharmaceutical waste until it is scheduled for pick up. b. Authorized personnel who have access to medications should deposit pharmaceutical waste in the appropriately labeled container. Each container used to collect, separate and store each type of pharmaceutical waste will be labeled with the type of waste to be stored in the container. 2. Controlled Substances listed in Schedules II, III, IV and V remaining in the nursing care center after the order has been discontinued are retained in the nursing care center - until destroyed as outlined by state regulation. a. Transfer to a container for release to a pharmaceutical waste contractor, was checked off on the policy. At 1:36 PM the same day interviewed the DON regarding nursing practice for disposal of discontinued resident narcotics. The DON shared the policy for disposal of controlled drugs used on the nursing floors dated 12/12 is old, a new policy dated 5/16 is on line but has not been changed in the PharMerica policy binders used by the nursing staff. At 1:41 PM the same day interviewed Staff #108 regarding disposal of narcotics procedure. Staff #108 stated the narcotics are popped out of the blister pack and thrown into the sharps container, sometimes the pills are crushed. The liquid narcotics are poured onto a paper towel and discarded. Later that afternoon contacted the pharmacist consult (Staff #181) for the facility. When asked the recommendation and policy for disposal of controlled medications at the facility Staff #181 shared, the pharmacist does not have a role in narcotics disposal, once the medication leaves the pharmacy it belongs to the resident, nothing is returned to the pharmacy. Upon request from the facility pharmacy can advise the facility on discarding controlled medication. When informed about the practice of throwing away discontinued narcotics in the sharps containers or down the drain Staff #181 stated, we don't look at that; we are more concerned with out of date drugs. A review of the pharmacy contract titled 'Hawaii Health Systems Corporation Agreement for Goods or Services Based Upon Competitive Sealed Proposals states 2.12 Provide experienced, trained Geriatric Consultant Pharmacist to perform the following services: As per CMS requirements provide assistance with tracking, destroying; and reconciling unused controlled substances. Failure to provide pharmacy consultative services for discontinued controlled substances may potentially provide opportunity for misuse of controlled discontinued substances. 4) On 4/12/2017 at 10:40 AM reviewed the temperature log on the 3rd floor of the facility. The log titled MEDS Refrigerator/Freezer Temperature Log was printed REFRIGERATOR STANDARD: 33 degrees - 40 degrees FAHRENHEIT. The recorded refrigerator temperatures for (MONTH) (YEAR) was found to be documented at 34 degrees on (MONTH) 7 and (MONTH) 8, and at 35 degrees on (MONTH) 12, (YEAR). The refrigerator contained some of the following medications and amounts: Calcitonin Salmon Nasal Solution 1 box; Cathflor Activase a 2 mg vial; Biscodyl Suppository 13 packets; Acetaminophen Suppository 10 packets; Octreotide 50 mcg one box; Ativan vials, 4 bags with 5, 3, 5, and 5 vials per bag. The printed manufacturers label recommended temperature storage at 36 - 46 degrees for the Octreotide, Calcitonin Salmon Nasal Solution and Ativan. The temperature log was concurrently reviewed with Staff #116. Staff #116 provided a printed copy of the facility policy titled, Refrigerator/Freezer Temperature control and Maintenance. Purpose: To maintain proper temperatures for food safety and potency of medications. The policy stated: Refrigerator standard range if 33 degrees to 40 degrees Fahrenheit. On the same day at approximately 11:06 AM the temperature logs for the 4th and 2nd floors were reviewed. Observed that all the units were using the same standard log with the incorrect temperature range of 33 to 40 degrees Fahrenheit. The refrigerator on the second floor was observed to have the following medications and amounts: Pneumococcal vaccine premeasured syringes one box; Calcitonin Salmon Nasal Spray 1 box; Influenza premeasured syringes 1 box; Tetanus 2 vials, and Ativan 3 vials. On 4/12/2017 at 1:49 PM pharmacy consultant (Staff #181) was interviewed by phone and asked about the effect of the drug temperature being at 35 degrees when the manufacturers recommendation is at 36 degrees. Staff #181 stated, one degree is not going to matter, even if the package says 36 degrees, it is OK. When asked if the manufacturer could be consulted for the medications found on the 2nd and 3rd floors stored below the manufacturers recommendation, Staff #181 stated a call would be made to the manufacturer but a response would not be available for a few days due to the time zones. Later that afternoon interviewed the DON regarding the discrepancy on the facility medication temperature log, the facility policy for refrigerated medications for storage range of 33 - 40 degrees versus the manufactures recommendation for refrigerated medications to be stored at 36 - 46 degrees. Also the concern for the efficacy of the medications stored out of temperature range. The DON shared the policy and logs were revised on 12/2016. Requested copies of the temperature logs for the past 4 months from (MONTH) (YEAR) to (MONTH) (YEAR) from all the nursing units for review. On 4/13/2017 at 3:49 AM contacted the drug manufactuers Merck, for the Pneumococcal vaccine; Phizer for the Ativan vials; and Sagent Pharmaceuticals for the Octreotide vial. Each manufacturer interviewed was asked about the efficacy of the drug when stored below the recommended 36 - 46 degrees. Ativan stored below 36 degrees had no information or recommendations of use. The Octreotide drug stability studies indicated the drug was stable up to 3 months under the accelerated conditions. Accelerated conditions are described as below 36 degrees. The Pneumococcal vaccine efficacy was determined by the total number of hours kept below the manufacturers recommended temperature. On 4/13/2017 at 7:30 AM obtained from the DON the collection of medication refrigerator temperature logs from (MONTH) (YEAR) to (MONTH) (YEAR) for the entire facility, which had been requested from the DON on 4/12/2017. The following temp logs provided were missing: 4 North - missing (MONTH) (YEAR) and (MONTH) (YEAR); 3rd floor - missing (MONTH) (YEAR). Review of the 2nd floor refrigerator log found that the Pneumococcal vaccine had been stored below 36 degrees for 216 hours from Jan - (MONTH) (YEAR). At 7:48 AM spoke to the Merck manufacturer consultant by phone regarding the 216 hours the Pneumococal vaccine was stored below 36 degrees. Per the manufacturers recommendation, given the number of hours kept below 36 degrees the recommendation was not to administer the vaccine to any patients and remove the vaccine from inventory. The manufactures advise was shared with Staff #108 and the DON. Review of the facility policy for potency of medications titled Refrigerator/Freezer Temperature control and Maintenance date effective 12/2016 found that the policy was not signed as approved and reviewed by a PharMerica consultant. Review of the contract agreement between HHSC and the Pharmacy Corporation of America states: 2.0 Contractor Requirements. The contractor shall provide Long Term Care Pharmacy services pursuant to the provisions specified below: 2.1 Provide the facility with a comprehensive range of professional pharmaceutical services related to the use, storage, distribution and administration of medicines. Failure to properly label medication; failure to secure and lock treatment cart inventory; inconsistency of nursing staff practice in the proper disposal of controlled drugs; failure to update the pharmMerica binder used on the floors by nursing staff on the disposal of controlled drugs; and failure to provide consultative pharmaceutical service for policy development and review in the area of medications stored in refrigerator/freezer has the potential for pharmaceutical errors.",2020-09-01
30,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,441,F,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with staff member, the facility failed to establish and maintain an effective infection prevention and control program including the tracking and analyzing of outbreaks of infection. Findings include: 1) On 4/13/17 at 9:00 [NAME]M. an interview was conducted with the Director of Nursing (DON) and Staff Member #122. The staff members were asked how they collect, trend and analyze their data related to infection control. Staff Member #122 reported the nurses will submit infection surveillance forms to report any concerns regarding infections as well as discuss infection issues in daily rounds. This information is collected for data and reviewed for trends. The staff member also reported the infection program also tracks the immunization process. The DON and Staff Member #122 confirmed the facility had an outbreak of Norovirus in (MONTH) (YEAR). The Norovirus reportedly was isolated to the 4th floor; however, a resident on the 3rd floor also had Norovirus. Further queried whether the facility determined the source of the Norovirus outbreak. Staff Member #122 responded it's impossible to figure it out; however, the facility makes note if a cruise ship was in the port and possibly the Norovirus may have come from the children visiting from the school or a staff member being infected from their child. The data and trends collected by the facility were not specific enough to identify the origin of the Norovirus. A request was made to review their infection log/data. The facility provided data from (MONTH) (YEAR) through (MONTH) 6, (YEAR). The data included the resident's name, medical record number, room number, type of infection, culture, antibiotic and comment. The staff members were queried whether the infection control program determines whether infections were hospital or community acquired. The response was they did not think this is part of the policy to track whether infections are hospital or community acquired. Further discussion confirmed the facility does not perform root cause analysis of infections. The facility did not develop an infection prevention and control program which includes analysis of outbreaks of infection (root cause analysis) to formulate corrective action and plan for continued prevention. 2) On 4/12/2016 at 8:40 AM observed Staff #180 prepare 2 prefilled syringes of normal saline and 2 prefilled syringes of [MEDICATION NAME] to do a PICC line flush for Resident #44. Staff #116 was present orientating Staff #180. Staff #180 opened the individual packaging of each syringe and placed all of the syringes on top of the resident's bed with no protective barrier between the bedding and the syringes. Staff #116 picked up all of the syringes on the bed and failing to wipe the table or use a protective barrier, placed the syringes on the resident's over bed table. Observed Staff #180 use each syringe to do the PICC line flush. After the procedure an interview was held with Staff #116 and Staff #180, regarding use of a protective barrier for the clean syringes. Staff #116 agreed a protective barrier should have been used for infection control practice. Failure to maintain a clean working environment when administering medications has the potential for development and transmission of infection. 3) On 4/12/2016 at 9:04 AM observed Staff #180 do a PICC line flush for Resident #44. Staff #116 was present orientating Staff #180. The PICC line had two ports. Staff #180 opened one line, did an alcohol wipe to the needleless hub, inserted the normal saline syringe tip into the hub, and pushed the normal saline flush through the PICC line. Staff #180 then disconnected the normal saline syringe and without doing an alcohol wipe to the hub connected a [MEDICATION NAME] syringe tip and pushed the [MEDICATION NAME] solution through the PICC line. Staff #180 then opened the second PICC line, wiped the PICC port with alcohol, connected the normal saline syringe and pushed the normal saline into the line. Staff #180 then disconnected the syringe and without doing an alcohol wipe connected a [MEDICATION NAME] syringe into the hub and pushed the [MEDICATION NAME] solution into the line. After the observation interviewed Staff #116 on the observation. Staff #116 was asked if an alcohol wipe should have been done prior to the [MEDICATION NAME] flush for each line. Staff #180 stated, no need to do the wipe because the port is still clean. A concurrent review of the facility policy was done with Staff #180. The policy for IV Site Care and Maintenance. Procedure 4. states, Scrub needleless injection cap prior to each entry with alcohol. Failure to do the recommended alcohol cleanse prior to each entry into the needleless IV port has the potential for development and transmission of infection. 4) On 04/10/2017 at 12:46 PM, during observation of the second floor nursing unit's lunch service, Staff #140 was observed sitting next to Resident #4 (R #4). Staff #140 was feeding the resident while she sat in bed. This resident had a contact isolation sign posted at the entrance to her room. The sign stated, Stop Check with nurse before entering room .Wear Gloves for all contacts, Wear Yellow Gown within 3 feet, If splashing possible wear face shield . The Nursing Home Administrator (NHA) was standing in the hallway with the surveyor and confirmed surveyor's observation that Staff #140 was not wearing any personal protective equipment (PPE), such as a disposable gown and gloves while assisting the resident to eat. The NHA asked the staff to stop feeding the resident and to wash her hands and come out of the room to wear the appropriate PPEs. Surveyor queried Staff #140 and asked why she was not wearing any PPEs. Staff #140 replied, I think when you're feeding, not supposed to. All I hear is we use iso gowns, gloves, mask when we doing patient care. The NHA told Staff #140 that it includes feeding this resident, and asked the staff to wear the appropriate PPEs before returning to the resident's bedside. On 04/10/2017 at 12:51 PM, the Staff #108 stated there was a new order from R #4's attending physician that said staff was to gown only for peri-care, but acknowledged the signage did not reflect that. Staff #108 also said the attending physician wanted to ensure the family who visits daily during dinner would be able visit without wearing the PPEs as a quality of life matter for this [AGE] year old resident. The NHA pointed out this was inconsistent for the staff as to what they are supposed to be following for contact isolation, and if there was any breach because of not wearing the PPEs, then there was a potential risk for transmission to others, such as other residents, staff and her visitors. On 04/11/2017 at 9:46 AM, chart review found the (MONTH) (YEAR) Physician's Order Statement said the resident is on contact isolation from 8/15/16 for a [DIAGNOSES REDACTED]. On 04/12/2017 at 9:42 AM, the DON provided their policy and procedure, Isolation Precautions, No. 125-400-040. It stated, V. [NAME] Contact Precautions: These precautions are to be used to reduce the risk of transmission of resistant microorganisms by direct or indirect contact with a patient and/or patient's environment .CDC recommends continuing Contact Precautions routinely for ALL patients colonized or infected with MDROs. Gowns and gloves should be worn at a minimum. Masks are worn if splashes or projectile secretions are possible .HCWs (Health Care Workers) should always explain the necessity of PPEs and expanded precautions to the patient, patient's family and visitors. The facility failed to ensure staff followed the contact isolation precautions increasing the risk and potential for transmission of disease.",2020-09-01
31,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,490,F,0,1,1M3411,"Based on record review, interviews and review of the facility's policies and procedures, the facility failed to ensure it is administered in a manner that enables it to use its resources effectively and efficiently in order for the residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Finding includes: There is non-compliance with this regulation based on the deficient findings/outcomes in the areas of Resident Assessment, Quality of Care with substandard quality of care and harm for R #77, Quality of Life, Nursing Services and Pharmacy services. This is evidenced and cross-referenced at F157, F221, F279, F280, F281, F323, F334, F353, F371, F425, F431, F441 and F520. Inclusive are the survey observations, interviews, record reviews, and reviews of the facility's policies and procedures. Per interview with the NHA on the morning of 4/21/17, he acknowledged the preliminary survey findings and stated that aside from the transition period the long term care unit is going through, he attributes the lack of an effective QAPI (quality assurance and performance improvement) program to have been a factor that may have prevented the facility to have identified these care related issues found by the State Agency. The NHA also stated they have taken steps to remedy how quality improvement measures and policy making will be addressed by their governing body in the future.",2020-09-01
32,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,520,F,0,1,1M3411,"Based on observations, record review, interviews and review of facility policies, the facility failed to maintain an effective quality assessment and assurance (QA&A) committee which included analyses of identified performance improvement activities, including specific standards for quality of care and related outcomes for their residents. Finding includes: On 04/13/2017 at 10:22 AM, an interview with the NHA, DON and Staff #122 was done. They were asked about their quality assurance/performance improvement (QAPI) plan and what quality care areas were being reviewed. The DON stated each department attends their QAPI meetings to discuss department specific PI projects. The DON said they also review the Casper Report and what their triggers were. The NHA stated they also reviewed their audits on documentation, such as the prior survey's bathing citation as an example. The NHA said the nurse managers were actively involved in the audits as well. The DON and NHA concurred however, that most of their PI work has been focused on the transition process with their facility to transfer management to a new entity effective 7/1/17. Despite knowing the needs of the long term care unit and the need to maintain the quality of care, they both acknowledged their focus has been directed on the lack of staffing related to the transition. The NHA said their QAPI meetings entailed more of a review of the Casper Report in aggregate and were general discussions about their dashboard. They acknowledged the State Agency's preliminary quality concerns found during the survey, but yet were unable to demonstrate they had identified similar concerns, or any new concerns using their own PI methodology to demonstrate an effective PI program. Thus, based on the State Agency's clinical outcomes and quality concerns, the facility failed to demonstrate areas of quality performance improvement measures, including the identification of, or monitoring the effect of any implemented changes and with improvements to their action plans. The facility's primary focus has been on the transition process, however, the outcomes found in the areas such as Resident Assessment and Quality of Care was not identified in their on-going quality improvement process. Cross-reference to findings at F157, F221, F279, F280, F281, F323, F334, F353, F371, F425, F431, F441 and F490.",2020-09-01
33,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2019-05-31,657,D,0,1,IFL211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review (RR) and observation, the facility failed to revise/update changes in the care plan for three of 18 residents (R16, R6, and R279) in a timely manner. Care planning drives the type of care a resident receives. Because of this deficient practice, interventions and monitoring to promote effective continuity of care to safeguard against adverse events may not have occurred. This has the potential to affect all other residents in the facility. Findings include: 1)Interview on 05/29/19 at 09:09 AM with resident (R)6 who states sometimes my bowel movement is like a golf ball and sometimes I drop one or two and sometimes I go six or seven times a day and it is like golf balls . They are not giving me anything for the bowel movement. Record Review (RR) on 05/30/19 at 09:19 AM reveals doctors orders for 1) [MEDICATION NAME] evacuation 10 mg suppository. 2) Milk of Magnesia (Mom) in evening if not adequate bowel movement for to days. 3) Enema use one rectally whenever necessary if no/inadequate bowel movement for two days. RR and concurrent interview with Nurse manager, staff(S)2 on 05/31/19 at 10:02 AM shows no care plan was developed for constipation. This was confirmed with S2. 2) RR of R16 revealed she was taking an anticoagulant/blood thinner (Xarelta) for a [DIAGNOSES REDACTED]. She was transferred to an acute care hospital on [DATE] for possible [MEDICAL CONDITION]. The blood thinner was discontinued at that time. R16 was readmitted to the facility on [DATE]. She was restarted on the blood thinner after her condition stabilized on 02/28/19. Review of R16's care plan failed to reveal any goal, interventions, or monitoring for complications related to the blood thinner. On 05/30/19 at 09:23 AM, during an interview with Unit Manager (UM1), queried if R16's care plan included monitoring for complications of a blood thinner. UM1 said, the care plan wasn't updated. UM1 agreed monitoring R16 for complications related to the blood thinner should be in the care plan. On 05/30/19 at 01:51 PM UM1 provided a copy of an updated care plan for R16 that included Risk for Hemodynamic Instability R/T . use of Xarelto. 3) RR revealed R279 had a stroke with left [MEDICAL CONDITION] (loss of some motor function) and needed assistance with activities of daily living. R279's progress notes revealed the following: 05/16/19 at 02:30 PM entry by PT aide, patient found asleep in w/c (wheel chair) with left arm caught in w/c . 05/23/19 at 06:55 AM entry by PT aide, Lap/arm tray put on left arm rest to increase patient safety due to arm (left) getting caught in wheel. Nursing educated on importance of using tray and to only remove for meals RR revealed no progress notes of skin assessment after the two incidents that R16 caught his arm in the wheelchair, and R279's care plan did not include the intervention of the lap/arm tray implemented by PT aide. 05/29/19 an entry was made to R279's care plan, Left arm tray remove at meals. 05/30/19 09:04 AM during an interview with UM1, reviewed R279's progress notes and care plan. UM1stated, theres not an incident report because there was no injury. UM1 also stated, I was not aware of the first incident. On 05/30/19 at 09:45 AM, observed R279 while receiving physical therapy. It was observed that R279 had limited use of his left arm. An interview was conducted at that time with the PT aide (PT) that witnessed R279's arm caught in the w/c. She stated, He (R279) often leans to the left and left arm drops to the side. The lap tray was put on to help prevent this from occurring. When asked what the liklihood was that R279 could dislodge his arm without help, she replied, He probably couldn't. On 05/30/19 at 10:06 AM during an interview with the Occupational Therapy Manager (OT), she stated, I didn't know about it (the incidents R279 caught his arm in w/c) until yesterday. PT is a [MEDICATION NAME] and just started. Nursing is being trained to keep the lap tray on the w/c except at meal time. When asked what should have occurred, OT stated, It should have been reported to me the same day, and we would have monitored him. If not a one-time incident, it should be put in the care plan, and staff educated.",2020-09-01
34,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2019-05-31,686,G,0,1,IFL211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to intervene in a timely manner when the resident refused to remove compression gloves to left hand for five days. As a result of this deficient practice, R54 out of two sampled residents (R54 and R23) developed a Stage 4 pressure ulcer to the left fifth digit. Findings include: Observation on 05/30/19 at 12:03 PM of R54's dressing change with Staff(S)1. S1 stated, R54 acquired the wound in the hospital and his finger was amputated. R 54 wears compression gloves for [MEDICAL CONDITION] arthritis associated with joint pain in his hands. R54 had compression gloves on and would refuse to take them off or let the nurses monitor his hand and it was too late. Record Review on 05/30/19 at 01:01 PM shows in the past, R54 requested that his 4th finger on left hand be removed due to contracture, pain and a buttonneire deformity. Treatment record of doctors orders written on 01/14/18 to monitor both hands for impaired skin integrity twice a day. (Gloves off 04/13/19). Treatment record comments shows on 4/08/19 the resident declining to remove gloves up until 04/13/19. On 04/13/19, documentation stating wound skin impaired noted to left 5th digit. Doctor notified. From that point on, gloves were off. Progress notes dated 04/13/19 states R54 was complaining of pain to touch to left 5th digit of left hand. Resident did not want to remove gloves at first. Resident removed it later and left 5th digit by flexor/crease with wound open 1.3 centimeter length. Whitish, pink with scant bleeding. Cleansed with normal saline and covered. Called doctor at 10 AM and informed of open wound to left 5th digit. Keep clean and open to air. Further RR reveals doctor visit on 04/13/19 at 1400. Doctors exam confirmed R54's left fifth finger with open wound at proximal interphalngeal (PIP) joint, tendon visible, wound moist, swelling and [DIAGNOSES REDACTED]. Appears to have infection and swelling and [DIAGNOSES REDACTED]. Interview on 05/30/19 at 04:03 PM with S2 who stated There was no documentation from 04/06/19 to 04/13/19 until the wound was discovered at Stage 4. No report or attempt to call the MD about the refusals. I think it should have been reported. He is a man who decide what he wants and does not want. The nurses should have reported. Interview on 05/30/19 at 04:14 PM with S3 who stated The gloves was an ongoing problem and when you would try to remove them, he would get upset. I did not let the doctor know that he was refusing to take the gloves off. He would become agitated with us. I feel that we could have discovered the wound earlier but the amputation was unavoidable. Interview on 05/30/19 at 04:30 PM with medical doctor who stated he has never been very cooperative. He wanted the 5th finger off and he wouldn't cooperate with treatment. It's possible that the pressure ulcer developed within the five days that he refused to take the gloves off. The facility failed to intervene in a timely manner by reporting refusal of treatment for [REDACTED].",2020-09-01
35,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2019-05-31,842,D,0,1,IFL211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have accurate information in the medical record of one of 18 sampled residents. The medical record for R61 had conflicting information on the Advanced Healthcare Directive (AD) and the Provider Orders for Life-Sustaining Treatment (POLST). An AD is a legal document used to provide guidance about what types of treatments you may want in case of a future unknown emergency. A POLST form is a medical order for the specific treatments you want during a medical emergency. A POLST form does not replace an advance directive, but they work together. Findings Include: A review of R61's Advanced Care Planning documents revealed the POLST and AD had conflicting information. The POLST (Section C, artificially administered nutrition) signed by Surrogate dated 01/31/13 includes an order for [REDACTED]. During an interview with Social Worker (SW1) on 05/29/19 at 01:44 PM, inquired what the process was to obtain advance directives on admission. She stated, most of our residents come from acute care and they do them there and send with the resident. If they do come from the community, the SW will ask on admission if they have one, and give them information in the admission packet. When asked who was responsible for viewing the content of the advanced care planning documents to ensure they matched, and she said, I'm not sure.",2020-09-01
36,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2018-06-22,584,D,0,1,GCA011,"Based on observation and interview, the facility failed to ensure the bedroom landing mats placed at the bedside was sanitary, safe and in good condition for 1 of 24 residents (R33). In addition, the facility failed to ensure the bathroom floor's black skid strips were in good condition for 1 of 24 residents (R56) and a dining room table was maintained in good, safe condition. Findings Include: 1) During the observation of Resident 33's (R33) bedside landing mat on 06/20/18 at 08:43 AM, it was found that both of the resident's beige colored landing mats had long cracks and tears throughout. As a result, some of the woven mesh underneath the beige cover could be seen. 2) During a bathroom observation 06/20/18 at 08:31 AM, it was found that R75's bathroom floor had large black skid strips that were peeled off and missing on four of the strips. 3) On 06/21/18 at 09:34 AM, during a concurrent room observation with Staff 5 (S5), she confirmed the beige floor mats for R33 were in disrepair, worn and torn. S5 said the mats needed to be replaced. S5 also concurred it did not present to be a safe and clean home environment, as there was a potential risk for falls due to the tears on the surface of the mats, and that the mats were potentially unsanitary due to the exposure of the woven material visible through the tears. 4) On 06/20/18 at 09:07 AM, R56 was observed holding onto the edge of a round table in the activity/dining room on 4 North. Portions of the table's white laminate type of siding were missing/torn off, leaving an uneven surface that could potentially affect (poke or scratch) one's skin. R56 gripped onto the side where the missing laminate was and used her hands to push and pull her wheelchair back and forth. No staff was present to observe her. On 06/21/18 at 09:52 AM, a concurrent observation of the activity/dining room on 4 North was done with S5. S5 verified there were portions of white siding missing on the table's edge. S5 said she did not want anything to cause injury to the residents and maintenance would be notified.",2020-09-01
37,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2018-06-22,689,D,1,1,GCA011,"> Based on observation, record review and interview, the facility failed to ensure the residents' environment remains as free of accident hazards as is possible, and each resident receives adequate supervision to prevent accidents for 2 of 38 residents (R56 and R31) reviewed. Findings Include: 1) On 06/19/18 at 11:18 AM, R56 was observed sitting at a table with oversized red Lego-type and wooden building blocks on it. The building blocks were being used by another resident, R71, who is blind. R56 had already grabbed one of the large red blocks and was trying to insert it into her mouth but it was too big. After licking it, she put it down on the table. She then grabbed a blue rectangular wooden block and tried to insert that large block into her mouth as well. S15 was in the hallway and was asked to observe R56. S15 intervened and said R56 was not supposed to be handling these building blocks. The blocks were pushed toward R71 without being sanitized and R71 resumed using them. S15 said it was not okay that R56 was found putting the big wooden block into her mouth or the other red blocks. S15 said they were only staffed with one aide and although their activity room got very crowded, it was how they're running us more now. S94 then moved R56 to her usual table in the adjoining room. S94 said the aide who had been sitting next to R56 left, and she was tending to residents on the other side. Observation found there are walls which separated the three adjoining rooms. As a result, staff attending to residents in the first TV room where most of the residents congregated, could not fully view the residents in the middle room by the round table against the wall. And, if staff were in the first room, they would not be able to see the residents in the third low stimulation room, unless the resident sat on the couch in the low stim room. Otherwise, their view was blocked by the side walls. Thus, when R56 was found with the building blocks in her mouth, although S94 was in the first room, she could not see R56 and had been busy attending to the residents in the first room. There was no staff supervising or watching R56. S94 stated, We only have one staff in here usually and it's really hard with just one staff. 2) R31's random observations and record review was done, including a review of a facility reported incident (FRI). It was revealed from interviews of S5, S1 and S2 on 6/21/18 that on the morning of 3/15/18, a night charge nurse (S23) who was assigned to R31's care on the 4th floor had taken a late dinner break. S5 stated there was a unit protocol already in placed for the night shift staff whereby breaks after 0500 (5:00 AM) were not allowed. S5 verified S23 did not follow the unit protocol and as the charge nurse that night, was to have followed it. Interviews with S1 and S2 revealed S23 was a newer nurse, had fallen behind on her paperwork and thus took a late dinner break on the morning of the incident. As a result, there was one less staff available on the unit. The two certified nurse aides had been attending to other residents when R31 fell at 5:20 AM, with the resident calling out for help after her fall. R31 was a fall risk and S5 said R31 calls out for help because she cannot use her call light. S5 said also at the time, it was when most of the residents were going to be getting up. The breaks cannot occur during the turns, so at 0430 and 0500 everyone starts going and at 0500, the residents start to get a little more restless. So should be no breaks at 0500. The staff should be on the unit. Thus a potential contributing factor was that S23 failed to follow the unit's protocol, leaving the unit short staffed when she should not have done so.",2020-09-01
38,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2018-06-22,725,D,0,1,GCA011,"Based on observation, record review and interview, the facility failed to ensure it has sufficient nursing staff to provide nursing and related services to assure resident safety and for each resident to attain or maintain the highest practicable physical, mental and psychosocial well-being for 11 of 24 residents (R56, R71, R31, R46, R75, R6, R39, R16, R30, R40 and R44) on one of the 4th floor nursing units. Findings Include: Cross-reference to findings at F689. On 06/19/18 at 10:55 AM, R56 was found in the hallway yelling out loud that she wanted to go to the activity room. Even after two minutes of yelling, no staff attended to her. At 10:57 AM, surveyor approached S15 who was standing by a medication cart at the end of the hallway. S15 stated S90 had just brought R56 into the hallway after toileting her. However, the resident remained yelling while trying to push her wheelchair forward, but could not move. S90 then attended to the resident and wheeled her into the activity room. The nursing unit's census included 24 residents. On 06/19/18 at 11:28 AM, there were ten residents in the activity room. There was one certified nurse aide (S94) who was attending to R75 at the time. One resident, R6, was loudly mumbling words over and over and tried to reach out and grab other people while sitting at her table. R71 was observed touching the wall, touching the building blocks in front of her and/or sat trying to move her wheelchair around. S94 was not able to either calm or attend to these residents one to one, as they were spread out in two of the adjoining rooms. Then after the incident with R56 whereby she was found trying to insert the large building blocks into her mouth, S94 stated, We only have one staff in here usually and it's really hard with just one staff. On 06/19/18 at 12:30 PM, during the lunch observation, it was found that R31 was able to feed herself. By 12:39 PM however, the spinach and beans were pushed toward the edge of her plate and ready to come off. The same observation was made earlier for R46 at 12:23 PM. R46 was using her left pointer finger to push her food onto her spoon so the food would not come off the edge of her plate. S15 observed this and concurred that these residents could benefit from a lipped or divided plate. No staff had observed R31 and R46's food coming off the edge of the plate as they were focused on delivering the meal trays to the residents and trying to feed those residents who needed closer monitoring and assistance. On 06/20/18 at 08:55 AM, observed R56 rocking back and forth in her wheelchair as if she wanted to move, but could not. R56 yelled out occasionally, and then quieted down. S97 said R56 rocks for comfort and liked to be by the window in the low stim room. However, during random observations of R56, she was often left alone with no meaningful activity. The low stim room however, was found to be a room where certain residents were left unsupervised because staff said it was to provide for a low stimulation environment. Yet, the observed outcome was that these residents (R56 and R39) were often left unattended with their needs not being assessed. At 09:07 AM, S97 stated in their activity room they had a lot of residents with dementia.with behavioral. S97 expressed that it was really hard to monitor them. S97 said they separated the residents out, such that the TV room had six residents, the middle room had two residents and the other adjoining low stim room had two residents, including R56. S97 said due to her own health status, she would have to call for back-up help, which would then leave the floor staff short of one more aide. On 06/21/18 at 09:38 AM, S5 said they have one person to monitor the three adjoining activity rooms. S5 acknowledged their activity room floor plan did not allow for visibility from one side to the other because of the walls. S5 said some of their residents who were known to be socially disruptive, made it difficult for only one staff to attend to all of these residents congregated in those rooms. S5 said because their unit had these socially disruptive residents, they were not brought up to attend the 5th floor group activities which residents of the other floors enjoyed. On 06/21/18 at 03:18 PM, an interview with S94 was done. S94 said often only about three of their residents attended the 5th floor large group activities. S94 said as soon as they (the three 4th floor residents) make noise they were brought down to the 4th floor right away due to their behaviors. S94 said as a result, one staff on their unit is always locked down to monitoring. S94 said although they may have four aides scheduled, only three aides could provide direct care since one person was assigned to the activity room to do unit activities with the residents. S94 said the unit activities were pretty much the same thing every day such as watching a DVD movie for those who can, and going to the low stim room for others. Random observations found it was the same routine for the residents as S94 described, but without enough staff to oversee the care for the majority of the residents placed in the rooms. On 06/21/18 at 03:42 PM, R39 was observed in the low stim activity room sitting alone in a wheelchair. R39 kept saying, Ah, ah, ah, ah, ah, both moaning and mumbling some illegible words. S51 was in the first large TV room assisting R16, and was unable to see R39. At 03:44 PM, S51 came into the low stim room from the hallway with R16 at her side. She saw R39 and said, what's wrong papa? but walked past R39, through the rooms and out into the hallway. R39's needs were not assessed as S51 did not attend to him with R16 at her side, nor did S51 ask for help. S51 walked into the low stim room again with R16, walked past R39 and had R16 sit at a table in the first room. At 03:48 PM, S51 was observed attending to R31 and to R71. R16 then tried to stand up and surveyor had to let S51 know what R16 was attempting to do. S51 quickly turned around as she was talking to R71, and said, Oh, wait! and then asked R16 if she wanted to walk again. At 03:51 PM, another aide came into the room; then a licensed staff at 03:52 PM. The staff however, were all situated in the first room where R31, R6 and R16 were. The licensed staff then walked into the low stim room where R39 was, but turned around and walked back to the first room. At 03:54 PM, S51 came to R39's side to ask if he was okay. Yet, S51 and other staff failed to attend to R39's needs when he had been moaning and saying things. During an interview with S5 thereafter, S5 was queried whether there was sufficient staff to care for each resident in meeting their highest practicable well being on this unit. S5 said no, because of the type of engagement their residents required which was for more one to one interaction. S5 said their unit had residents with more behaviors, were more dependent and the cognitively lower functioning residents. On 06/22/18 at 07:29 AM, S94 said it was to a point where they were burning out. S94 said their residents were often bypassed and not brought to attend the 5th floor activities. S94 acknowledged that safety too was a concern with just one staff monitoring 10 or more dependent residents with mood and behavioral issues. S94 said their staffing was decreased from five aides to four. S94 stated, We're trying to provide activities, so actually our day shift has three aides for 24 residents since the assigned activity monitor (one of the four aides) cannot toilet the residents. S105 who was feeding R30 at this time, was observed trying to engage R30 during the meal, but had to also watch R16 because she would stand unassisted and unexpectedly. R40 was then seen pouring her orange juice (OJ) into her oatmeal. R71 sat in the middle room eating hurriedly out of her bowls, but S105 could not see her from where she was sitting with R30 because of the side wall. S105 said, it's difficult when you have (R16), (R40), (R44), (and another newly admitted resident) trying to stand all at once--it makes it hard. Observation of the breakfast found S105 trying to keep an eye out for the other residents around her while she was trying to assist and feed R30. But, S105 was not able to prevent R40 from pouring her OJ into the oatmeal, nor could S105 see R56 and R39. These two residents were sitting in their wheelchairs in the low stim activity room unattended and out of S105's view. On 06/22/18 at 07:45 AM, S5 stated their residents were those with advanced dementia with behaviors. S5 said approximately 15 of the 24 residents could be socially disruptive and/or physically/verbally aggressive during care. S5 said this made it hard for their unit staff and for new hires or floaters to work on this unit. S5 acknowledged because their residents were more dependent with ADLs (activities of daily living) and because of their behaviors, they were not included in the large group activities upstairs. S5 said given the needs of these residents, staffing for this unit is not available. S5 concurred the way S105 had to feed R30 while on edge trying to keep an eye out for R16 and the rest of the residents was what their staff endured. S5 also acknowledged that although their fall rates have decreased, she concurred with the surveyor's observations that many of their residents were left unattended, without adequate supervision/engagement due to lack of staff coverage. S5 said it has been difficult to ensure their 14 residents who required assistance with meals and approximately 17 residents who required extensive to total assistance in their ADLs received their highest quality of life as a result.",2020-09-01
39,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2018-06-22,812,D,0,1,GCA011,"Based on observation, interview and policy review, the facility failed to distribute food to residents in a sanitary manner. The deficient practice placed residents at risk for illness, infection and the potential for foodborne illness. Findings Include: During the lunch observation on 06/19/18 at 12:41 PM, Staff 36 (S36) was passing trays to the residents. S36 was observed to wipe his brow and touch his cheek on two occasions, and did not sanitize his hands before passing a tray to the next resident. S36 was observed to empty a tray into the refuse can and then passed another tray to a resident without sanitizing his hands. During an interview with S36 on 06/19/18 at 02:45 PM, he stated he didn't sanitize his hands after throwing food into the garbage or when he proceeded to get another resident's tray. S36 said, I guess I had the white coat syndrome. Review of the Hand Hygiene policy 125-500-020 stated, To reduce to as low as possible, the number of viable microorganisms on the hands in order to prevent transmission of healthcare associated pathogens from one patient to another, and to reduce the incidence of healthcare associated infections. 4. Before eating, after eating, . S36 did not follow sanitary hand hygiene practices.",2020-09-01
40,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2018-06-22,849,D,0,1,GCA011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility and the hospice did not collaborate in the development of a coordinated plan of care for 1 of 3 residents (R179) receiving hospice services. Findings Include: On 06/20/18 at 08:17 AM, R179 was heard yelling from her room. Staff 6 (S6) stated R179 was a hospice resident. S6 said when staff attends to her yelling, she tells them that she didn't know she was yelling. Surveyor went to R179's bedside and asked her if she was in pain. R179 replied, Yes, all over. A staff came into R179's room to get towels from the closet and stated she would attend to R179 after finishing up with another resident. S6 came to assess R179's pain and informed S22. After adjusting R179's position and pillows, S22 asked resident what type of pain meds she preferred, either [MEDICATION NAME] or Tylenol. R179 stated, Do I have a choice? When queried later, S22 stated that R179 used to be able to say what type of pain she had (e.g., pain level of 9-10), but from yesterday, she was unable to. S22 said, [MEDICATION NAME] is prn every 4 hrs and last dosage given last night at 20:15 (8:15 PM). S22 stated she just gave R179 [MEDICATION NAME] because, Resident was crying so probably severe pain. After receiving the pain meds, R179 was provided breakfast and observed that resident ate without pain and a CNA assisted her. On 06/20/18 at 08:38 AM, interviewed S6. He stated that R179 will be discharged from hospice because the resident was admitted as hospice but as full code and that it did not make sense to him. S6 talked to the hospice provider and was told the hospice provider got into trouble for not accepting residents who were full code and R179 was placed into hospice care at the hospital she was transferred from. The [DIAGNOSES REDACTED]. The hospice benefit period was 06/08/2018 - 09/05/2018. The hospice physician's signature on 06/08/18 also included information of the resident's code status (attempt resuscitation); diet as tolerated; activity as tolerated; and oxygen 2-5L via NC/Mask for dyspnea/comfort PRN. On 06/20/18 at 09:26 AM, interviewed S20. She stated the hospice nurse came twice a week and the hospice CNA three times a week. There was no set schedule for the hospice nurse but she came in to address R179's change in mental status. R179 became delusional, confused with increased yelling, so S20 suggested it was over medication with benzodiazepine which the hospice nurse agreed with on 06/17/18. The benzodiazepine was discontinued on that date and the telephone order read back (TORB) was done with the hospice physician. On 06/21/18 at 10:33 AM, review of the facility's baseline care plans (CP) for R179 was done. The activities assessment, under Emotional Mood/Behavioral Status, per (friend/therapist), noted R179 had history of delusions while hospitalized . There was no family on the island and R179's former therapist assisted the resident with her current situation. The baseline CP included intervention/approaches for, Staff to administer medications (meds) as ordered and observe for effectiveness and side effects. The medications ordered for R179 included meds for depression, diabetes, [MEDICAL CONDITION], and low [MEDICAL CONDITION] function. The meds ordered as needed (PRN), included [MEDICATION NAME] for pain, Tylenol suppository for pain/fever, [MEDICATION NAME] for pain/fever, and [MEDICATION NAME] for pain/shortness of breath. The hospice CP with start date 06/08/18 and last updated on 06/18/2018 for problem of physical comfort alteration secondary to [DIAGNOSES REDACTED]. /stress level. Notify MD if necessary. On 06/22/18 at 08:28 AM, surveyor interviewed the hospice nurse. She stated the hospice director developed the CPs for R179 and the hospice nurse will add to it if something came up. The meds were the previously established hospice meds which the hospice MD would adjust as needed. The CPs were faxed over at admission and the hospice nurse does a 24 hour follow-up to ensure CPs are appropriate. There were no changes to R179's CP at the 24 hr follow-up. Queried the hospice nurse about the pain meds and when facility staff should use [MEDICATION NAME] sulfate (MS) versus [MEDICATION NAME]. She stated that PRN MS was a standard pain med for hospice and should be specified in the order. Review of the admission physician orders [REDACTED]. On 06/22/18 at 09:23 AM, S22 said she was on vacation when R179 was admitted . Queried S22 what pain meds she would give R179 for pain, and S22 stated she would ask resident her preference. When S22 returned from vacation, she didn't have time to look at R179's CP and just asked resident her preference and she wanted [MEDICATION NAME]. On 06/22/18 at 09:26 AM, interviewed S20 and she stated that after R179 was admitted on [DATE], the hospice physician came once on 06/11/18. S20 stated the hospice admission process was confusing because the facility never admitted a hospice resident before. S20 said usually the resident was already in the facility and switched to hospice status. S20 wasn't sure if she should call the family/representative for changes in R179's condition or call the hospice nurse, stating she didn't want to duplicate calls to the family/representative. On 06/22/18 at 09:41 AM, interviewed the hospice CN[NAME] She said she gave R179 a bath on Mondays, Wednesdays, and Fridays at 10:00 AM. Queried the CNA if there was a CP developed by hospice for her to follow. There was no CP found for this. The long term care staff was unaware of the hospice staff's schedules, whether R179 was an appropriate hospice admission, whether the type of pain meds given to R179 achieved pain relief as her different pain meds had similar parameters to follow, and, the facility staff was not familiar with the roles of the hospice staff nor followed a coordinated CP delineating each care and service the hospice was to provide for R179.",2020-09-01
41,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2018-06-22,880,D,0,1,GCA011,"Based on observation and interview, the facility failed to ensure it maintained a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 24 residents (R56, R71) in the sample. Findings Include: On 06/19/18 at 11:18 AM, R56 was observed sitting at a table with oversized red Lego-type and wooden building blocks on it. The building blocks were being used by another resident, R71, who is blind. R56 had already grabbed one of the large red blocks and was trying to insert it into her mouth but it was too big. After licking it, she put it down on the table. She then grabbed a blue rectangular wooden block and tried to insert that large block into her mouth as well. S15 was in the hallway and was asked to observe R56. S15 intervened and said R56 was not supposed to be handling these building blocks. The blocks were pushed toward R71 without being sanitized and R71 resumed using them. On 06/21/18 at 09:38 AM, S5 said they have one person to monitor the three adjoining activity rooms. S5 was informed of the observation whereby the blocks were not sanitized before it was given to R71, but had no comment. S94 said a lot had been going on that day when R56 tried to insert the blocks into her mouth. S94 said they usually wiped each block with the purple top disinfecting wipes and dried them for a couple minutes before putting them away. However, on 06/19/18 the blocks were not sanitized before they were returned to R71.",2020-09-01
42,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2019-07-12,550,D,0,1,QXJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff members, the facility failed to ensure a resident is provided care with respect and dignity to promote and enhance her quality of life during skin assessments resulting in the resident feeling embarrassed. Findings include: Resident (R)78 was admitted to the facility on [DATE] from an acute facility. R78 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. On 07/09/19 at 10:50 AM an interview was conducted with R78. R78 reported that she is uncomfortable with the skin assessment, it made her feel like a criminal. The resident clarified, she asked to undress and lay in bed for the skin assessment. R78 further reported another staff member was also present. Queried whether the staff member draped her body during the assessment, R78 replied, no. R78 also shared that she doesn't understand why another staff member has to be present and was not asked whether it was okay to have another staff member present during the assessment. R78 also stated that she doesn't understand why the skin assessment has to be done weekly. On 07/12/19 at 08:15 AM an interview was conducted with Licensed Nurse (LN)2. Inquired how are skin assessments performed. LN2 reported residents usually come from the acute hospital and are dressed in a hospital gown. LN2 reported residents are not asked to undress and are informed the nurse will check their bottom and for women, look under their breast. LN2 further explained the resident's hospital gown is removed only to expose areas that are being assessed. The LN confirmed there are two nurses present during the skin check to assist with turning and one person to write and one person to measure. A record review was done on 07/10/19 at 01:19 PM. A review of the admission Minimum Data Set (MDS) with assessment reference date of 06/21/19 found R78 yielded a score of 15 (cognitively intact) when the Brief Interview for Mental Status was administered. R78 was also noted to require limited assistance with one person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture).",2020-09-01
43,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2019-07-12,689,D,0,1,QXJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and record review, the facility failed to utilize a bedside blue mat, as indicated on the care plan for Resident (R) 2. With this deficient practice, the facility put R2 at risk for increased accident hazards. Findings Include: Resident 2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the latest minimum data set ((MDS) dated [DATE] revealed that R2 had a brief interview of mental status (BIMS) score of 3 indicating the resident had severe cognitive impairment. The resident was assessed to require extensive assistance, dependent with all activities of daily living (ADL's). A review of the MDS Coordinator's note showed that R2 was at risk for falls, due to depression and taking [MEDICAL CONDITION] medication. On 07/09/19 at 01:36 PM, R2 was observed in his room, sleeping on his bed. At the same time, a blue bedside mat observed not in use and leaning up against two chairs. On 07/10/19 at 07:20 AM, R2 was observed in his room, sleeping on his bed. At the same time, the blue bedside mat was again not in use and leaning up against two chairs. On 07/10/19 at 10:30 AM, R2 was observed in his room, lying in his bed. This time; however, the blue bedside mat was now in use, placed on the floor next to R2's bed. On 07/10/19 at 01:25 PM, Licensed Nurse (LN) 3, was interviewed about the bedside mat usage. LN3 stated that whenever R2 is lying or sleeping in bed, the blue bedside mat should be used and placed on the floor next to the bed and the care plan should say that as well. On 07/10/19 at 01:25 PM A review of R2's care plan stated the following: Problem: resident is at risk for falls due to confusion and resident is very forgetful, requires assist with ADL's. Interventions: bedside blue mat initiated on 04/23/18.",2020-09-01
44,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2019-07-12,842,E,0,1,QXJ511,"Based on record review, staff interview, and review of a list of approved abbreviations provided by the facility, the facility failed to use approved abbreviations and/or acronyms when charting in the progress notes, for four of the nine residents reviewed. With this deficient practice, there was a risk of misinterpreting the un-approved abbreviations and thus causing adverse outcomes for any, or all the residents. Findings Include: 1. During review of the clinical notes for Resident (R) 11, the following abbreviations/ acronyms were used, in various places, in the clinical notes: OOP, SO. According to the Accepted Abbreviations - Medical Terminology list (provided by the facility), these abbreviations/acronyms were not approved to be used for charting. 2. During review of the clinical notes for Resident (R) 27, the following abbreviations/ acronyms were used, in various places, in the clinical notes: OOP, ATB. According to the Accepted Abbreviations - Medical Terminology list (provided by the facility), these abbreviations/acronyms were not approved to be used for charting. 3. During review of the clinical notes for Resident (R) 61, the following abbreviations/ acronyms were used, in various places, in the clinical notes: OTA, ABT, CDI. According to the Accepted Abbreviations - Medical Terminology list (provided by the facility), these abbreviations/acronyms were not approved to be used for charting. 4. During review of the clinical notes for Resident (R) 12, the following abbreviations/ acronyms were used, in various places, in the clinical notes: P[NAME], ASE, ABT. According to the Accepted Abbreviations - Medical Terminology list (provided by the facility), these abbreviations/acronyms were not approved to be used for charting. On 07/11/19 at 02:24 PM, an inquiry regarding facility approved abbreviations with the Chief Nursing Officer (CNO) was made. CNO provided the list of facility approved abbreviations titled Garden Isle Healthcare, Accepted Abbreviations - Medical Terminology which is currently in use and being followed by the facility.",2020-09-01
45,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2019-07-12,880,D,0,1,QXJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy and protocol (P&P) review, the facility failed to ensure that staff used infection prevention and control program (IPCP) standard precautions in wound dressing change for 1 of 2 residents observed for dressing change. The deficient practice put resident (R)25 at risk for an infection. Findings Include: On 07/11/19 at 10:00 AM observed licensed nurse (LN) 1 prepare for dressing change to R25's [DEVICE]. LN1 gathered the dressing change supplies from the treatment cart and dropped the normal saline (NS) ampoule onto the floor, which was picked up and placed into the plastic basket with the other clean dressing supplies. In R25's room observed LN1, who placed the plastic basket of supplies onto R25's overbed table with paper towels underneath, and then helped to reposition R25 with clean gloves on. LN1 changed gloves without sanitizing hands, and then removed the soiled dressing from the PEG site. LN1 was also observed to use the NS ampoule that was dropped on the floor in the dressing change. After leaving R25's room informed LN1 of observations as written above. LN1 stated that she should have discarded the dropped NS [MEDICATION NAME], and changed her gloves after removing the soiled dressing but forgot. On 07/12/19 at 08:07 AM interviewed the DON on the facility's IPCP and she stated that staff are inserviced right there and then, when seen with improper hand hygiene and/or glove changes. The last hand hygiene inservice was held on 04/23/19. The facility's policy and protocol for dry, clean dressing was revied and it was noted that it was last updated on 09/14/17, and states, Steps in the Procedure; . 4. Have biohazard or plastic bag readily available . 6. Wash and dry your hands thoroughly; 7. Put on clean gloves and remove and discard dressing; 8. Wash and dry your hands thoroughly; 9. Open dry, clean dressing(s). 12. Wash and dry your hand thoroughly; 13. Put on clean gloves.",2020-09-01
46,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2018-07-13,578,E,0,1,2CGJ11,"Based on electronic medical record (EMR) reviews, interviews and policy review, the facility failed to ensure that for a resident who does not have an advance directive (AD), the resident (R) was informed of his or her right to develop one, provided assistance in doing so or was periodically reassessed in his/her decision making capacity to do such, for 5 of 33 residents (R6, R79, R54, R60 and R73) in the survey sample. Findings Include: 1) An EMR review conducted for R79 on 07/11/18 at 8:21 AM revealed this resident did not have an AD, but only a POLST. On 07/12/18 at 3:47 PM, during an interview with the Social Services staff, they confirmed R79 did not have an AD, but only a POLST. 2) An EMR review conducted for R6 on 07/11/18 at 9:46 AM revealed he did not have an advance directive (AD), nor were there clinical notes showing the resident was informed of his right to develop one or provided assistance in doing so. 3) On 07/11/18 01:03 PM the EMR review for R54 found that the resident had a Designation of Code status acute care form signed by his spouse on 8/20/12; the form designated do not resuscitate, (DNR). On 07/12/18 at 02:00 PM interviewed the resident care manager (RCM) on the Kona unit and she validated that R54 did not have an advanced directive on file. The RCM stated that 54's spouse was coming to the facility and the SW would be discussing AD with her. 4) The EMR review for R73 noted on the physicians orders (PO), DNR. On 07/12/18 at 01:58 PM interviewed the Kona unit RCM who provided a designation of code form that was signed in 12/2012. The RCM stated that the form was a POLST, and not an advanced directive form. 5) The EMR review for R60 found that a POLST was signed on 11/03/15. On 07/12/18 at 2:02 PM validated with the Kona unit resident case manager (RCM) that R60 did not have an advanced directive on file. A review of the facility's policy and procedure (P&P), Advanced Directive (effective date 9/1/2017) stated, . 5. Social Services will check with resident/guest or resident/guest representative to confirm treatment choices at the time of the initial care conference, during quarterly and annual care conferences, or at the time of significant change of condition. The resident/guest has the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive. 6. Changes or revocations of a directive, which can be written or oral, must be noted in the resident/guest's medical record. All of the above residents (R79, R6, R54, R60, and R73) did not have documentation in their clinical record about the treatment choices in the formulation of, or refusal of an AD during quarterly and annual care conferences, or at the time of significant change of condition.",2020-09-01
47,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2018-07-13,584,D,0,1,2CGJ11,"Based on resident and staff interview the facility failed to ensure that the personal property for 1 of 33 residents (R60) on the survey sample was not lost or stolen. Findings include: On 07/10/18 at 12:32 PM during interview of R60, she reported that she had a pink and white sleeveless dress that was sent for wash to the facility laundry and never returned. The resident stated that the dress has been missing for couple weeks now. On 07/12/18 at 02:06 PM interviewed LN19 about the facility procedure when a resident reports about a missing personal item. LN19 stated that if laundry was not returned, then staff would ask the laundry department and help the resident to locate the item. If staff were unable to find the missing item, a facility form was used to report to the social worker that the resident is missing personal item(s). The social services department would help the resident resolve the missing item. The resident reported to LN1 about the missing dress, and LN1 stated that a missing item form was not completed because the dress was returned the day after the resident reported it missing. According to LN1, R60 also told her that it was found. Both LN19 and LN1 stated that they would clarify with R60 about the missing dress. On 07/13/18 at 11:30 AM queried R60 if her missing dress was found and she reiterated that the pink and white dress did not return from the laundry and told staff again that it wasn't in her closet. Interviewed LN19, and she validated that staff went through clothes with R60 and the pink and white sleeveless dress was not found. The staff completed a missing item form which was sent to social services for follow-up.",2020-09-01
48,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2018-07-13,641,D,0,1,2CGJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical record (EMR) review and staff interview the facility failed to accurately assess and code in the minimum data set (MDS) for 1 of 33 residents (R4) on the survey sample. Findings Include: On 07/10/18 at 01:44 PM during EMR review for R4 it was noted that the resident required one person support for bed mobility on the MDS dated [DATE], and the MDS dated [DATE] noted R4 required two plus persons physical assist for bed mobility. On 07/12/18 at 11:05 AM interviewed the MDS coordinator and inquired about the change that R4 had, inquired if this was a decline in bed mobility or if this was a coding error. MDS coordinator stated that she would follow up with floor staff and let me know. 07/12/18 03:21 PM MDS coordinator stated that this was a coding error on her part and that she would submit a modification for the 04/30/18 MDS.",2020-09-01
49,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,241,D,0,1,U50511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of their individuality. Dignity also means interactions with residents such that facility staff carry out activities that assist the resident to maintain and enhance their self-esteem and self-worth. This facility failed to ensure staff responded in a timely manner to a resident's request for assistance for 2 of 31 residents (Resident #183 and Resident #171) in the Stage 2 sample. Findings include: 1. Resident #183 was admitted to the facility as a short stay resident and was receiving skilled rehabilitation services. During an interview with Resident #183 on 10/26/16 at 8:07 AM, they stated, To be perfectly honest, I think they are short staffed. I get up to use the bathroom, but I'm not allowed to get up by myself because of my fracture and they don't want me to fall. And I don't want to have accidents either, but sometimes, I wait, and I wait, and I wait, and I've had a couple of accidents--yes, shi-shi (urine) or bowels, either one. They said because they couldn't wait for staff to attend, they get out of bed, when I'm really desperate. Resident #183 said because of the long wait times, they have had four accidents. When asked how staff responded when they had these accidents, they said, Not especially anything and I tell them, oops sorry. A lot of times, it's right at the toilet and I can't get there fast enough and I know it's coming. When you gotta go, you gotta go, and they're not here for me. They're busy elsewhere, which is understandable, a lot of other people are here. They're very nice here, don't get me wrong. But, whether it's the early morning, late at night, sometimes there's not enough of them and that's the only reason why I think they're short handed. During an interview with the MDS-C on 10/27/2016 at 1:28 PM, they said Resident #183 scored a 15 on their BIMS, and is alert and oriented x 3 based on the MDS ARD of 10/11/16. They stated this resident is totally continent. On 10/28/2016 at 7:52 AM, a re-interview with Resident #183 was done. They reiterated there is a problem with the shortage of staff and, the primary reason is because they're having to attend to others. They said it was their honest observation being admitted at this facility and it was undignified for them having these accidents of soiling themselves. 2. Resident #171's family member was interviewed on 10/25/16 at 1:21 PM. Resident #171 was admitted on [DATE] for skilled rehabilitation services after an acute hospital stay. During the interview, the family member stated the resident was not treated with respect and dignity and stated it was because of how a nurse's aide did not want to assist the resident to be toileted. The family member said it recently happened when the resident had to wait until after the lunch was over. The family member stated as a result, the family member had to assist the resident to be toileted and they had soiled themselves. On 10/28/16 at 8:58 AM, during another interview with Resident #171's family member, the family member reiterated the nurse's aide who did not want to toilet the resident also walked down the hall the opposite way, just like ignoring us. The family member said, I was going to put them on, but the therapist came and took the Resident #171 and had to help me, because (the aide) said the residents are eating. But already Resident #171 wanted to make, so it came out, all on the bed because their diaper was leaking and the wheelchair was all with the shi-shi (urine), and the therapist took Resident #171 to the bathroom to clean them up and put on the diaper. (The aide) was in the next room, and said can you take them because they want to get out of bed to go to the bathroom, but we're still having lunch, so have to wait. Resident #171 came all wet because they couldn't wait. The family member said afterward, another nurse's aide came to help change the soiled bedding. The family member said it was upsetting, they felt ignored, and because Resident #171 all wet, the bed and the chair all soaked like that, Resident #171 got angry, so I got angry. On 10/28/2016 at 9:24 AM, interview with the speech therapist (ST #1) was done. ST #1 verified the family's member's account when Resident #171 had recently transferred themselves to the chair and was soiled. ST #1's said the reasoning was because the aide for Resident #171 had been attending to another resident who fell , which coincided with Resident #171's request to be toileted. ST #1 said they reported it to the day charge nurse, LN #3, and verified the aide was attending to the other resident while they stepped in to help Resident #171. On 10/28/2016 at 9:38 AM, LN #3 confirmed that ST #1 had told them that Resident #171 was all wet and (the aide) was also going to do Resident #171, change them also, but therapy was the one who had to change them because they went there to do the therapy early. LN #3 said they did not go to speak with Resident #171 nor to the family member after the incident happened. LN #3 was asked whether they thought about providing an explanation to the resident and/or family member, but LN #3 stated, No, I was only talking to the therapy. On 10/28/2016 at 9:52 AM, RCM #2 said if the charge nurse was aware of what happened, the charge nurse, is supposed to investigate with the family, ask the family, and the charge nurse is supposed to inform me or the DON. RCM #2 acknowledged LN #3 should have done that, and understood why the family member felt there was no respect or dignity afforded to Resident #171, after having soiled themselves when the family member asked for staff assistance.",2020-09-01
50,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,272,D,0,1,U50511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical review (EMR) and staff interviews, the facility failed to ensure that 1 of 31 residents (Resident #90) on the Stage 2 resident sample list, received a comprehensive assessment as part of an ongoing process to identify mood and behavioral symptoms and psychosocial well-being, Also, documentation of assessment information in support of clinical decision making was not found. Findings include: On 10/26/2016 at 07:59 AM, reviewed Resident #90's physician orders [REDACTED]. The resident was prescribed antidepressants and anti-anxiety medications and was sampled for unnecessary medications for Stage 2 of the survey. On 10/26/2016 at 4:00 PM, further EMR review on Resident #90 noted on the facility's PharMerica Resident Change in Condition MRR Request Form, a request to change Resident #90's antidepressant medication due to the resident exhibiting inappropriate sexual behaviors. The form documented: Status change: Increased sexual behaviors, touching self inappropriately in public. Resident kissed another resident. Diagnosis: [REDACTED].>Current medications: [REDACTED] Possible contributing medications: [REDACTED] Name medication regimen is not thought to directly contribute to inappropriate sexual behaviors. however, __ may benefit from a change in therapy (see below). Pharmacy recommendation: Changing Name [MEDICATION NAME] ER 50 mg once daily to [MEDICATION NAME] may provide continued therapeutic benefit for treatment of [REDACTED]. Please consider decreasing [MEDICATION NAME] ER to 50 mg by mouth once every other day x 3 doses. Then start [MEDICATION NAME] 10 mg by mouth once daily x 7 days then increase to [MEDICATION NAME] 20 mg by mouth once daily thereafter. Pharmacist Signature: Name Date: (MONTH) 13, (YEAR). On 10/27/2016 at 8:20 AM, interviewed LN#3 and asked them to access the EMR to find any documentation regarding Resident #90's inappropriate sexual behavior, as the surveyor could not find any. The LN #3 accessed the resident's Behavior Monitoring Log on the EMR which documented, Behavior #1 masturbating in Makai lobby, and on 10/02/2016 the behavior log was marked with 1, and N/A in the Interventions column. The LN #3 went to the EMR Notes tab and could not find any corresponding progress notes on 10/01/2016. Under the Care Plans tab there was a care plan (CP) ___will not show any inappropriate behavior around other residents within the next quarterly review. The interventions included: __ reports he is not aware of his behavior during staff approach. He reports he is fixing his Foley catheter; assist in covering self; assist to private area like his room; direct care staff to remove female residents when __is in the TV unit area; discuss with __in a straightforward matter of fact manner that his behavior is inappropriate. On 10/27/2016 at 8:50 AM interviewed RCM #3 to access the EMR. Asked RCM #3 to verify behavior log documentation on 10/02/16, and RCM #3 was not able to find any progress notes in the EMR to corroborate with the behavior monitoring log. The RCM #3 stated that the nurse on that date during evening shift would know what happened. Queried RCM #3 if the staff that observed Resident #90 kissing another resident made an incident report, and RCM #3 stated that there were no progress notes on the incident on 10/02/2016 but that social worker (SW) services may have the documentation. On 10/27/2016 at 9:56 AM interviewed social workers (SW), and both SWs stated that they investigated the incident of Resident #90 kissing a female resident after being informed by LN #4. According to both SWs, Resident #90 was interviewed and counseled about inappropriate behavior of kissing female resident in the TV lobby. Resident #90 claimed to have given a female resident a chaste kiss of Aloha on the cheek after receiving condolences on the recent passing of his wife. Resident #90 apologized to the SWs for kissing the female resident and stated that he is Hawaiian style and wanted to thank her with a kiss on the cheek. The SWs both stated that Resident #90 understood after being told by them that kissing of other resident is inappropriate in the facility. The SW's stated that they also spoke with the female resident and she didn't think that Resident #90 had any sexual overtures and didn't feel offended or unsafe in the facility. When asked for documentation of SW interviewing and counseling of residents on the incident and inappropriate sexual behaviors, both SW's had none to provide. Both SW's stated that they developed a care plan (CP), to address Resident #90's inappropriate behaviors. On 10/27/2016 at 10:22 AM interviewed LN #4 who had witnessed the incident of Resident #90 kissing a female resident in the TV lobby. According to LN #4, she saw Resident #90 bend down and kiss the female resident more towards her lips than the cheek area and repeatedly. LN #4 was at the nursing station within view of the TV lobby on the third floor where the female resident was sitting. Resident #90 was ambulating around the unit with the FWW and stopped to talk to the female resident. It was then that LN #4 observed Resident #90 bend down to kiss the female resident more than once. The LN #4 called out to Resident #90 to stop and another LN #5 ran over to separate them. From LN #4's observations the female resident was holding on to Resident #90 hand and didn't want to separate. Also, LN #4 had observed Resident #90 masturbating in the TV lobby, and resident would be looking around to see if anyone around. LN #4 stated that when they observed Resident #90 masturbating, they was sitting at the nursing station and stood up to ask Resident #90 if everything was ok and resident replied, I'm Ok and stopped what he was doing. LN #4 stated that they wern't the only one that observed Resident #90 masturbating in the TV lobby because other nursing staff have also reported same observations. LN #4 stated that they reported observations to RCM #3 who reported the incident to the SWs. On 10/27/2016 at 10:36 AM, interviewed the DON regarding Resident #90's inappropriate sexual behaviors with no documentation of dates, incidents, interviews, and/or IDT meetings to address the behaviors. According to the DON, Resident #90 walked into their office and DON had a spontaneous conversation with Resident #90 but cannot remember the date. Resident #90 was concerned because the DON observed the resident the evening before that conversation, sitting in the TV area with hands on his groin area. The DON stated that they had discussed with Resident #90 that others could perceive this differently and think it was inappropriate. The resident stated that they tend to sit like that and agreed it could be observed doing something inappropriate. The DON stated that they did not talk to Resident #90 about masturbating in the TV lobby. The DON verified that there was no documentation on Resident #90's inappropriate sexual behaviors as discussed by the SWs, nursing staff and themselves. On 10/27/2016 at 10:50 AM, interviewed RCM #3 and he stated that their role is that of a nursing supervisor. The RCM #3 stated that after nurses reported inappropriate sexual behaviors displayed by Resident #90, the incidents were reported to the team (DON & SWs). The issues were discussed but RCM #3 stated that they would have to go through Resident #90's EMR to find any documentation. On 10/28/16 reviewed the EMR for Resident #90 and noted that RCM #3 and SW made late entries on 10/27/2016 in progress notes to document the above incidents: Social service wrote: On 9-8-16 writer spoke with Resident #90 in SS office, RCM informed SS that Resident #90 was observed touching his private area out in Mauka 3 lobby area. Writer followed up with Resident #90 and he confirmed he is not touching self and is fixing his Foley tube. Resident #90 verbalize to writer that he keeps his hands close to his private area all his life as he is most comfortable, Writer informed Resident#90 .He is not a risk to others. He doesn't go into other resident's rooms, no displays of aggressive behaviors or sexual behaviors towards others. Nursing Late Entry: Writer asked Resident #90 about any issues with the catheter, if has any itch on the area or any discomfort; because per nurses he is seen putting his hand near his genitals; resident verbalized that he does not have any discomfort in area; writer discussed this incident with the IDT; as for further intervention for past sexual behaviors, writer made a medication review consult thru pharmacist; added a behavior log for further monitoring of past sexual behaviors; Resident #90 is not a threat to any resident in the facility and has not displayed any sexually aggression to anyone; or noted to be sexually inappropriate to anyone, The EMR review also included these CPs: CP: ___had been noted with hands close to his genitals. ___confirmed he is not touching self inappropriately and is fixing his Foley tube. ___verbalize to SS that he keeps his hands close to his private area all his life as he is most comfortable. Goals: ____will not be observed having close hand contact to genitals with in the next quarter Int: ___reports he is not aware of his behaviors during staff approach. He reports he is fixing his Foley catheter, assist __in covering self, assist to private area like his room Direct care staff to remove female residents when ___is in the TV unit area Discuss with ___in a straightforward matter of fact manner that his behavior is unacceptable ___Reports he has a habit of placing his hands in his upper thigh area close to his private part ___has regular visits with neurology doctor. MD response made d/t behaviors and MD stated d/t SE of his [MEDICAL CONDITION] medication Remind ___of need to respect other resident's rights OBSERVE ___at times-keep other female resident distance from him CP: __is on [MEDICATION NAME] for REM disorder/[MEDICAL CONDITION] __has [MEDICATION NAME] DX: Situational depression. [MEDICATION NAME] d/c'd on 09/16/16 and started on [MEDICATION NAME] on 9/25/16 for situational depression.",2020-09-01
51,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,278,D,0,1,U50511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on EMR review and staff interview the facility failed to ensure that the assessment for urinary continence was accurately reflected for 1 of 31 residents (Resident #99) sampled on the Stage 2 Sample Resident List. Findings include: On 10/27/2016 at 3:08 PM the EMR review for Resident #99 found that the resident's minimum data set (MDS) 3.0 on admission date of [DATE], coded urinary continence as frequently incontinent (code 2). By the 90 day quarterly review assessment on 09/06/2016, Resident #99 was coded for always incontinent (code 3) for urinary continence. On 10/28/2016 at 8:23 AM conducted an EMR review on Resident #99 for decline in urinary continence. The progress notes dated 06/03/16 documented that Resident #99 was alert, pleasantly confused, able to follow simple instructions, denied pain and discomfort, incontinent of bladder. The evening shift on 06/03/2016 also documented that Resident #99 was incontinent of bladder. On 10/28/2016 at 9:19 AM interviewed the MDS-Co-ordinator and they accessed the EMR documentation on 06/03/2016 where the RN wrote that the resident is incontinent. The MDS-Co-ordinator looked at the CNA flowsheet and found that Resident #99 was continent only first couple of shifts but incontinent thereafter. Discussed discrepancy of nurses progress notes and CNA flowsheet documentation. The MDS-Co-ordinator stated that the CNA's will be receiving training in coding and probably coding error for urinary continence, as coded frequently (2), and should have been always incontinent (3) from admission.",2020-09-01
52,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,323,D,0,1,U50511,"Based on a review of a self-reported incident report (IR) submitted to the State Agency (SA) and investigated through record review, staff interviews and policy and procedure review during the recertification survey, the facility failed to ensure that the resident's environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. Finding include: On 3/7/16, an IR was filed with the SA regarding Resident # 68 who sustained an unwitnessed fall in the shower room on 3/4/16. The IR documented that Resident #68 was found laying on floor with their head up against (BR) bathroom wall. Resident #68 complained of left ribcage pain and bilateral hip pain. On 3/5/16, radiology department notified facility of left rib fracture. On 10/27/16 at 7:26 AM, Resident #68's Electronic Health Record review (EHR) and concurrent review with the Minimum Data Set Coordinator (MDS-C) dated 4/6/16 was done. In Section C. Cognitive level noted the resident scored a 4 on the Brief Interview for Mental Status (BIMS). According to the Centers for Medicare Services' Resident Assessment instruction (RAI) Version 3.0 manual, the BIMS is a brief screener that aids in detecting cognitive impairment 13-15: cognitively intact: 8-12: moderately impaired; 0-7 severe impairment. 10/27/16 at 7:31 AM, EHR review reveals a careplan with fall prevention interventions stating: 1) Provide one assist with stand pivot transfers from bed to wheelchair. 2) Check on Resident #68 frequently while resting in bed or while up in wheelchair. 3) Ensure laser alarm in place, on and functioning at all times when Resident #68 is in bed and care is not being given. 4) Ensure bedside mattress in place. 5) Assess for dizziness and allow to rest approximately 2-3 minutes prior to transfers from sitting to standing position. 6) Assess for side-effects of Mirtazapine use (twitching, abnormal thinking, restlessness, nausea, dizziness) and notify MD PRN. 7) Keep floor clean, dry and free of clutter. 8) Keep floor clean, dry and free of clutter. 9) Provide low bed. 10) Ensure clip alarm is attached to Resident #68's clothing and that it is located on the inside of their bed towards the wall when they are in the bed. 11) Ensure pad alarms are in place, on, and functioning at all times when care is not being given. Interview on 10/27/16 at 9:32 AM, MDS-C confirms that intervention #11 (Ensure pad alarms are in place, on, and functioning at all times when care is not being given) was added on 3/7/16 to the careplan after Resident # 68 fell on on 3/4/16. LN #1 acknowledged that intervention #11 was added to the careplan after the fall (Ensure pad alarms are in place, on, and functioning at all times when care is not being given). Interview on 10/27/16 at 10:00 AM with Resident #68. Resident #68 is able to recall their spouse and verbalize their needs. Resident # 68 stated that they would like to visit her spouse. Observation on 10/27/16 at 12:10 PM at bedside. Resident #68 was assisted out of bed and transferred to wheelchair to visit spouse. After transport to the Kona unit, this surveyor and CNA #1 went to check on assistive device - pad alarm. CNA #1 acknowledged that the pad alarm was in place; however, the alarm button was not turned on. CNA #1 turned on the alarm button which beeped and a green light was noted. On 10/27/16 at 3:11 PM, interview with Resident Care Manager #2 (RCM). RCM #2 stated that Resident #68 fell in the bathroom. RCM #2 could not remember if there was a certified nurses aide with Resident #68. 10/27/16 at 3:20 PM, Interview with LN#1 stated that We found Resident #68 on the floor with their head against the wall by themselves. Resident #68 is able to roll by themselves. We are not sure how Resident #68 got there. Immediately after the fall, Resident #68 complained of left rib pain and we called the MD. Resident #68 was x-rayed the next day. Resident #68 underwent restorative treatment as ordered also. Resident #68 would refuse pain meds. Resident #68 is now back to their baseline level. When asked how did Resident #68 get to the bathroom on their own? LN #1 stated that Resident #68 is able to propel themselves and staff will push Resident #68 as well. When asked if this as avoidable, LN #1 stated that yes, we could have been checking on Resident #68 more frequently and make sure they call for assistance. The facility could not provide a monitor sheet that showed how they frequently monitor and check the residents. LN #1 stated that Resident #68 has only had one fall in the last six months.",2020-09-01
53,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,371,D,0,1,U50511,"Based on observation and staff interview, the facility did not store, prepare, distribute and serve food under sanitary conditions. Finding include: On 10/25/16 at 8:00 AM, an initial tour with the kitchen manager (KM) revealed an expired quart of yogurt in the entrance refrigerator. The date opened was labeled 10/18/16. KM stated that once food item opened, it is labeled with the date opened and will have an expired date within three days. The yogurt had been expired for four days. On 10/28/16 at 10:00 AM, inspection of the Kona 2 snack and nourishment room revealed an expired 1/2 gallon orange juice container. Staff acknowledged the expiration date and threw away the carton immediately. In summary, the facility failed to store food under sanitary conditions.",2020-09-01
54,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,441,D,0,1,U50511,"Based on observation and staff interview, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Findings include: Observation of a medication pass for Resident #130 was done on 10/27/2016 at 6:45 AM with licensed nurse #4 (LN #4). LN #4 said they were going to test the resident's blood sugar and took out a glucometer from their clothing pocket, saying we share it and placed the glucometer directly onto the resident's blanket. After the testing was done, LN #4 sanitized their hands, grabbed the glucometer and returned it to the cart. The glucometer had not been sanitized yet, but was placed atop the clean medication cart. LN #4 sanitized their hands again, then pulled a Sani cloth wipe and proceeded to wipe the glucometer and placed it back onto the same spot atop the medication cart. Per interview with LN #4, they acknowledged there was a breach in infection control as they had kept the glucometer in their pocket, laid it on the resident's bed and returned it to the clean medication cart without having sanitized it before placing it down. LN #4 said they were kinda new to all this but understood the cross-contamination observed. On 10/27/2016 at 10:32 AM, during an interview with the Resident Care Manager (RCM #1), they verified it was not their practice for licensed staff to leave the glucometer in their clothing pocket. RCM #1 validated it is an infection control issue as to how LN #4 performed it, and they should have used a separate small plastic container to hold the glucometer/supplies for blood sugar checks. RCM #1 also acknowledged the potential for transmission of disease with the way the glucometer was placed on the resident's bed to the clean cart without being wiped down first.",2020-09-01
55,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,514,D,0,1,U50511,"Based on staff interviews and EMR reviews the facility failed to ensure that the clinical record for 1 of 31 residents (Resident #90) on the survey Stage 2 sample resident list, had enough record documentation for staff to conduct care programs and to manage the resident's progress in maintaining or improving behavioral and psychosocial status. Findings include: On 10/27/2016 at 8:20 AM, interviewed LN #3 and asked then to access the EMR to find any documentation regarding Resident #90's inappropriate sexual behavior, as the surveyor could not find any. The LN #3 accessed the resident's Behavior Monitoring Log on the EMR which documented, Behavior #1 masturbating in Makai lobby, and on 10/02/2016 the behavior log was marked with 1, and N/A in the Interventions column. The LN #3 went to the EMR Notes tab and could not find any corresponding progress notes on 10/01/2016. On 10/27/2016 at 8:50 AM interviewed RCM#3 to access the EMR. Asked RCM#3 to verify behavior log documentation on 10/02/16, and RCM #3 was not able to find any progress notes in the EMR to corroborate with the behavior monitoring log. The RCM #3 stated that the nurse on that date during evening shift would know what happened. Queried RCM #3 if the staff that observed Resident #90 kissing another resident made an incident report, and RCM #3 stated that there were no progress notes on the incident on 10/02/2016 but that social worker (SW) services may have the documentation. On 10/27/2016 at 9:56 AM interviewed social workers (SW), and both SWs stated that they investigated the incident of Resident #90 kissing a female resident after being informed by LN #4. According to both SWs, Resident #90 was interviewed and counseled about inappropriate behavior of kissing female resident in the TV lobby. When asked for documentation of SW interviewing and counseling of residents on the incident and inappropriate sexual behaviors, both SWs had none to provide. Both SWs stated that they developed a care plan (CP), to address Resident #90's inappropriate behaviors. On 10/27/2016 at 10:22 AM interviewed LN #4 who had witnessed the incident of Resident #90 kissing a female Res in the TV lobby. According to LN #4, they saw Resident #90 bend down and kiss the female resident more towards her lips than the cheek area and repeatedly. Also, LN #4 had observed Resident #90 masturbating in the TV lobby, and resident would be looking around to see if anyone around. LN #4 stated that she wasn't the only one that observed Resident #90 masturbating in the TV lobby because other nursing staff have also reported same observations. LN #4 stated that she reported observations to RCM #3 who reported the incident to the SWs. On 10/27/2016 at 10:36 AM, interviewed the DON regarding Resident #90's inappropriate sexual behaviors with no documentation of dates, incidents, interviews, and/or IDT meetings to address the behaviors. The DON verified that there were no documentation on Resident #90's inappropriate sexual behaviors as discussed by the SWs, nursing staff and themselves. On 10/27/2016 at 10:50 AM, interviewed RCM #3 and he stated that his role is that of a nursing supervisor. The RCM #3 stated that after nurses reported inappropriate sexual behaviors displayed by Resident #90, the incidents were reported to the team (DON & SWs). The issues were discussed but RCM #3 stated that he would have to go through Resident #90's EMR to find any documentation. On 10/28/16 reviewed the EMR for Resident #90 and noted that RCM #3 and social services made separate late entries on 10/27/2016 in progress notes to document above incidents of the residents inappropriate sexual behaviors.",2020-09-01
56,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,156,E,0,1,8L5Q11,"Based on observation and interviews with resident and staff member, the facility failed to ensure names, addresses and telephone numbers of all pertinent State and advocacy group is posted in a form and manner accessible to residents and resident representatives. Findings include: The resident council interview was done on the afternoon of 10/25/17. The resident representative identified a staff member as the Ombudsman and was not aware the State Agency could be contacted for complaints. Inquired where the posting is located, the representative pointed to the side of nursing station, stating there is a bulletin board located there with the information. Observation found there is no bulletin board for the residents outside of the nurses' station. Further observation found two bulletin boards, one located on the wall outside of the Weinberg Family room and a second bulletin board on a wall outside of the social services office. The information for the telephone number and address of the State Agency was printed on an 8-1/2 by 11 inch paper and tacked on the second row of the information posting. The print and placement were noted to make it difficult for a resident seated in a wheelchair to review. On 10/25/17 at 4:00 P.M. concurrent observation and interview was conducted with Staff Member #324. Staff Member #324 confirmed there are two bulletin boards in the entire facility. The staff member confirmed the information posted on both boards would be too high for residents in wheelchairs to view the information. The staff member also acknowledged the print was small which would be difficult for residents with visual impairment and/or seated in the wheelchair to read.",2020-09-01
57,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,241,D,0,1,8L5Q11,"Based on interviews the faility failed to ensure residents were treated in a respectful and dignified manner for one out of 26 Stage 2 residents. Findings: During an interview with Resident # 98's husband on (MONTH) 23, (YEAR) he stated that staff #-- quite often would speak to his wife and himself in a disrespectful manner. He went onto say this has occured on many occassions and that he and his wife find the manner in which they are spoken to by staff #-- offensive. He also stated he would ask staff #-- to do things for his wife in a particular manner and that staff #-- would not do so. He used an example of asking staff #-- to fold the blanket down on his wife's bed in a particluar way so that it was easy for her to pull it up when she needed it. Staff # --proceeded to fold the blanket into a small square and place at the end of her bed that would make it difficult for her to reach when she needed it. During another interview with Resident #98's husband on (MONTH) 25, (YEAR), he continued to express his concerns about staff #-- manner in which he speaks to both himself and his wife and the blanket incident.",2020-09-01
58,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,242,D,0,1,8L5Q11,"Based on interviews with residents and staff members, the facility failed to ensure a resident has a right to make choices about aspects of his or her life that are significant to the resident for 3 (Residents #53, #248 and #180) of 15 residents interviewed. Findings include: 1) On 10/23/17 at 1:15 P.M. an interview was conducted with Resident #248. The resident was asked whether she is able to choose how many times a week a bath or shower is provided. The resident responded she receives showers twice a week, Mondays and Thursdays. Resident #248 clarified her preference would be for three times a week. A record review was completed on 10/26/17 at 8:15 [NAME]M. A review of the admission Minimum Data Set (MDS) with assessment reference date (ARD) of 2/16/17 notes in Section F0400. Interview for Daily Preferences, Resident #248 reported it is very important to choose between a tub bath, shower, bed bath or sponge bath. The resident's care plan for Activities of Daily Living Assistance notes the resident prefers a shower. A subsequent quarterly MDS with an ARD of 8/17/17 documents, Resident #248 yielded a score of 13 (cognitively intact) when the Brief Interview for Mental Status was administered. On 10/25/17 at 10:00 [NAME]M. an interview was done with Staff Member #114. Inquired how the facility determines the frequency of showers a resident receives. The staff member reported during the first family meeting the facility offers showers twice a week and bathing frequency is discussed. The families are asked how often the resident received showers at home or the resident will be asked if they want more showers. The staff member also reported families and residents are periodically asked about the frequency of showers, usually during the quarterly assessments. On 10/26/17 at 8:20 [NAME]M. Staff Member #113 was asked to provide documentation of the discussion related to frequency of showers during the admission and subsequent quarterly review. Subsequently an interview was done with the Assistant Director of Nursing (ADON) at 8:34 [NAME]M. The ADON reported residents or their representatives are asked their preferences (evening or afternoon) and frequency for bath/shower. The residents or their representatives are asked at the time of admission and periodically during their quarterly reviews. A request was made to the ADON to provide documentation of the facility's discussion with the resident or the representative related to baths/showers. On 10/26/17 at 9:35 [NAME]M., Staff Member #113 reported a review of Resident #248's electronic record found there is no documentation at admission or subsequently related to asking the resident's preference for the frequency of baths/showers. 2) An interview with Resident #53's spouse on the afternoon of 10/23/17 at 1:30 P.M. revealed she and/or her husband were not given the choice of how many showers he received weekly. Resident #53's spouse stated, I would like him to bathe every day. She reported she did not have a choice but rather was informed of the facility's shower schedule. On the morning 10/26/17 at 9:30 [NAME]M., a review of Resident #53's weekly shower schedule found he received showers on 10/19/17, 10/21/17, 10/23/17, 10/25/17, and 10/26/17. Resident #53 did not refuse any showers offered. An interview of Staff #55 on the morning of 10/26/17 at 9:30 [NAME]M. revealed residents/families are able to discuss their shower preferences during the initial family meeting which occurred shortly after a resident's admission. After the initial family meeting, Staff #55 stated shower preferences were discussed at Resident Care Conferences on a quarterly basis. An interview of the Assistant Director of Nursing (ADON) on the morning of 10/26/17 at 8:35 [NAME]M. revealed residents' shower frequency was based on their preferences. A review of Resident #53's latest Resident Care Conferences dated 10/3/17 and the one prior on 7/19/17 did not discuss his shower preferences. The facility failed to give Resident #53 and/or his family members the opportunity to choose his shower frequency. 3) During an interview on 10/23/17 at 12:56 PM, Resident #180 stated that she would like to take a bath three times a week, instead of two times per week as scheduled. On 10/25/17 the activities of daily living (ADL) verification worksheet was reviewed. In the past month the resident had showers on 9/28/17; 10/02/17; 10/05/17;10/09/17; 10/12/17; 10/16/17; 10/19/17; 10/23/17 and 10/26/17, concurring with the staff interview and review of the care plan which states Her shower at this time are Mondays and Thursdays in the morning. The resident's Care conference notes for the same period were reviewed and revealed that the resident's preferred shower schedule is not documented. During an interview on 10/25/17 at 1:40 PM staff #85 stated that the frequency for showers/ bath's is not written in the bath policy. The resident and/or representative is interviewed upon admission, the bath preference is discussed and care planned. The resident and/or representative are informed the resident can choose how many times per week they prefer a shower and/or bath. If a resident wants a bath more often during the week they need to ask the CNA or Licensed Nurse. The request will be given to the Senior CNA who will find out what the resident's preferences are and put it on the shower schedule. At the most recent Interdisciplinary Team Meeting the resident did not request a change in shower frequency from two to three times per week. Review of the bath (shower) policy on 10/26/17 concurred with staff #85 that type and frequency of shower and amount of assistance required should be listed under the resident's plan of care for self-care deficits. The facility failed to give Resident #180 the oportunity to choose the frequency of weekly showers.",2020-09-01
59,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,329,D,0,1,8L5Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview and facility policy review, the facility failed to ensure that the medication regimen for one of five residents, Residents #234, was closely monitored for mood and behaviors. Findings include: Resident #234 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #234 had a physician's orders [REDACTED]. The facility did not provide routine mood and behavior monitoring for Resident #234, making it unclear why he was receiving an antipsychotic medication. A review of Resident #234's medical record on the afternoon of 10/25/17 revealed no documentation of behaviors in the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/8/17 (Admission). A review of the nurse's notes did not find notes titled Behavior or any documentation that indicated he was experiencing mood/behavior issues. Additionally, the facility was not routinely monitoring Resident #234's behaviors. On the afternoon of 10/25/17, a review of a form titled, Behavior Monitoring, dated 10/19/17 revealed Resident #234: Did not display moods during the monitoring period; No behavior symptoms displayed during the monitoring period; Resident was currently taking [MEDICAL CONDITION] medications to address mood/behavior symptoms; Current medications are effective in alleviating mood and/or behavior symptoms; No [MEDICAL CONDITION] side effects observed during the monitoring period; There's a current plan of care with intervention to address the resident's mood and/or behavior symptoms; The interventions in place are effective for the resident's mood and/or behavior symptoms. The form further noted the monitoring frequency was to continue weekly monitoring. The rationale for monitoring frequency was left blank. An interview of Staff #46 on the afternoon of 10/25/17 at 3:53 P.M. found Resident #234 had been transferred to his current unit from another unit in the facility on 10/17/17. Staff #46 reported the resident was doing okay during the evening shifts until 10/24/17. She reported Resident #234 experienced hallucinations on the evening of 10/24/17 when he was distressed and reported seeing his foot detached from his body. Staff #46 further noted the resident was attempting to lift the table to pick up his detached leg from under the table. She informed Resident #234 she didn't see anything and turned his wheelchair around. The resident then attempted to hit the Certified Nurses Aide (CNA) who was standing behind his wheelchair. The resident then attempted to stand and climb over his foot rest. Staff #46 stated that it became unsafe as Resident #234 almost tripped over his foot rest. Staff #46 reported Resident #234's behaviors to the physician and an order was placed for [MEDICATION NAME] 0.25mg every 8 hours as needed for restlessness, hallucinations, and difficulty to redirect. Staff #46 was asked where she documented Resident #234's behaviors. She replied she did not document the behaviors on the evening of 10/24/17 and stated, but I can do a late entry. When asked what the facility's policy was for monitoring residents' behaviors, Staff #46 stated, I don't know the policy. A review of Resident #234's care plan found one for the use of antipsychotic medication related to [MEDICAL CONDITION]. Interventions included, Evaluate indications for usage of antipsychotic medications including specific behaviors and effect of behaviors on resident and/or others. Identify target behaviors and document in clinical record. An interview of Staff #113 on the afternoon of 10/25/17 at 3:55 P.M. found her understanding of behavior monitoring was initial monitoring occurred when a resident was new to the facility, had newly identified mood/behaviors, or changes in [MEDICAL CONDITION] medications. This initial monitoring was done every shift for one week. After the first week, the nurses monitored residents weekly for a total of 8 weeks. After the eighth week, the staff would discontinue behavior monitoring. When asked about Resident #234's behaviors on the evening of 10/24/17, Staff #113 reported they hadn't followed the facility's policy of monitoring behavior every shift after a change in Resident #234's [MEDICAL CONDITION] medications. Additionally, Staff #113 reported that Staff #46 should have entered a nurse's note for Resident #234's behavior on the evening of 10/24/17. An interview of the Assistant Director of Nursing (ADON) on the morning of 10/26/17 at 8:20 [NAME]M. revealed the facility started (10/19/17) routine behavior monitoring for any resident on [MEDICAL CONDITION] medications. The ADON reported the facility was changing their policy to include mood and behavior monitoring every shift for as long as the resident was receiving [MEDICAL CONDITION] medications. The ADON further noted that since this is a recent change in their policy, not all nurses are aware. The ADON reported that Resident #234 should be monitored for behaviors every shift for as long as he is on [MEDICAL CONDITION] medications. A review of the facility's policy titled, Mood and Behavior Management Policy and Assessment Procedure with revision date of 2/16 noted, B. Routine Behavior Monitoring: 1. Initiation of new [MEDICAL CONDITION] medications or changes (whether increasing or decreasing) in current dosage of [MEDICAL CONDITION] medications is made. The facility failed to closely monitor and document Resident #234's behaviors, making it unclear for the rationale of using an antipsychotic medication.",2020-09-01
60,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,371,E,0,1,8L5Q11,"Based on observations and staff interviews the facility failed to ensure proper food handling practices to prevent the outbreak of foodborne illness. Findings include: On 10/23/2017 at 10:15 AM during the initial kitchen tour with Staff#163, observed that the bread storage rack had brown plastic trays to place the bread loaves on and the brown racks were discolored with blackish residue. According to Staff#163 the bread company provided the bread rack and can probably provide a new rack. The walk-in refrigerator #4 contained 4 packages of sliced Swiss cheese with expiration date of 10/07/17 and cole slaw and creamy Italian dressing with no expiration dates. Staff#163 removed the items at that time. The facility did not follow food handling practices to prevent the outbreak of foodborne illness.",2020-09-01
61,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,431,D,0,1,8L5Q11,"Based on observations, staff interview and facility policy review, the facility failed to properly label and store medications. Findings include: During a review of medication storage on two of the six units in the facility on the morning of 10/25/17 at 10:43 [NAME]M. found multiple bottles of medications which were incorrectly labeled and/or stored: 1) Artificial Tears Solution which noted it was opened on 8/10/17. Staff #80 reported the facility's policy was to discard eye drops 60 days after it was opened (10/10/17). Additionally, the medication was discontinued on 9/1/17 but the bottle was still being stored in the medication cart. 2) Artificial Tears Solution which was opened on 10/6/17. The pharmacy label covered the bottle's expiration date and the label did not contain an expiration date. 3) Artificial Tears Solution with a label which noted the prescription was filled on 7/24/17. Staff #80 reported the bottle had been opened but the opened date was not written on the bottle. Staff #80 was unsure of when the bottle should be discarded. 4) Artificial Tears Solution which was opened on 9/12/17. The pharmacy label was blank as though the words were rubbed off - no name, medication name or prescription fill date could be visualized on the label. The manufacturer label noted the expiration date of 2/2020. 5) Artificial Tears Solution which was opened on 10/25/17 but the expiration date of the medication was covered by the pharmacy label. 6) Dorsolamine HCl Ophthalmic Solution with a pharmacy label which was blank as though the words were rubbed off. Additionally, the eye drops were opened on 8/16/17 indicating an expiration of 10/16/17, 60 days since opened. 7) Artificial Tears Solution which was opened on 9/17/17. The pharmacy label covered the bottle's expiration date. 8) Haloperidol 1mg tab which was individually wrapped and did not contain a label. The expiration date was 5/2017. 9) Tuberculin PPD Solution which was opened on 9/18/17 was found in the medication refrigerator. Staff #80 noted that PPD Solution should be discarded 30 days after opening (10/18/17). 10) Alcohol Wipes - 5 boxes containing 200 wipes in each did not have expiration dates on the boxes or the individual packets. Staff #80 stated the expiration may have been on the larger box they were shipped in. However that larger box had already been discarded. Staff #80 stated she wasn't sure if the alcohol wipes were effective since there wasn't an expiration date. On the morning of 10/26/17 at 8:20 [NAME]M., a review of the facility's policy titled, Medications and Medication Labels with revision date of 5/16 noted: 1. Each prescription medication will be labeled to include: h. Expiration or end-of-use date, if not dispensed in original manufacturer packaging; 4. The provider pharmacy permanently affixes label to the outside of prescription containers. Medication labels are not inserted into vials, bags or other containers. For medications designed for multiple administration (for example, inhalers or eye drops), a label is affixed to product to assure proper resident identification; and 5. Non-prescription medications not labeled by the pharmacy are kept in the manufacturer's original container. Nursing care center personnel may write the resident's name on the container or label as long as the required information is not covered, if applicable by state regulations. The facility failed to properly label and store medications.",2020-09-01
62,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,469,E,0,1,8L5Q11,"Based on observation, interview with resident and staff members and review of the facility's invoices and e-mails, the facility failed to ensure the maintenance of an effective pest control program. Findings include: On 10/23/17 at 1:27 P.M. while standing in the hallway outside of Room 148, a staff member was observed to stomp his foot on the ground, kick something on the ground toward the bathroom and began talking to the Resident #287. The staff member then walked over and picked something off the floor with a paper towel. The staff member was heard informing the resident that he killed a cockroach. Subsequently an interview was done with Resident #287. The resident replied negatively regarding cockroaches; however, reported there are a lot of lizards on the ceiling above her and has concerns that they may fall on her while she is lying in bed. Throughout the survey (10/23/17 through 10/26/17) ants were observed to be crawling on the conference room table. On 10/26/17 at 11:55 [NAME]M. an interview and walk through the facility was done with Staff Member #365. The staff member reported the facility has a contract for pest control. The contractor will come in quarterly for maintenance; however, Staff Member #365 does not keep track/log of when the contractor provides quarterly maintenance. Staff Member #365 also reported the facility will call their contractor if there are concerns. The staff member stated he was not aware of lizards in the facility. The staff member was agreeable to review and provide invoices and e-mails that document that quarterly maintenance (pest control) services were provided by the contractor. On 10/26/17 at approximately 12:30 P.M. Staff Member #365 provided invoices documenting the following: quarterly pest control and rodent control on 9/12/17; rodent control trapping on West Wing Nursing Station on 1/4/17; rodent control trapping, day health on 1/4/17; and quarterly pest control and quarterly rodent control on 12/8/16. A review of the e-mails provided found services were provided on the following dates: 9/26/17 (Pikake Unit, Room 103 ants in room on the floors and walls); and 10/6/17 (Ilima Unit, large black ants on clerk and nurse desk area as well as on wall and floor). An e-mail dated 9/7/17 from the contractor notes the need to schedule the following pest control services: quarterly pest control in/out on 9/12/17 and kitchen monthly pest control on 9/12/17. There is no documentation of quarterly pest control services by the contractor from 12/8/16 through 9/12/17. The facility failed to ensure an effective pest control program was maintained as evidenced by no documentation of quarterly and annual pest control services from the facility's contractor.",2020-09-01
63,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,561,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with resident, the facility did not promote a resident's right to make choices regarding personal hygiene (shaving) for 1 (Resident 162) of 2 residents sampled. Findings include: On 11/20/19 at 11:30 AM an interview was conducted with Resident (R)162. During the interview, R162 was observed to be unshaven. The resident had short hair stubbles on cheeks, chin and over the lip. R162 was asked if facial hair is his preference. The resident responded, no, clarifying staff members shave him twice a week when he receives a shower. R162 further explained that he would prefer to shave himself as there are times when staff members cut him by the lip, chin and under his chin while shaving him. R162 also reported he receives a shower twice a week (Tuesday and Friday) but wouldn't mind showering more often. A record review found a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/28/19 documenting R162 is independent for cognitive skills for daily decision making regarding tasks of daily life. R162 is also noted to require extensive assist with one person physical assist for personal hygiene (how resident maintains personal hygiene, including shaving). R162 also requires one person physical assist for part of bathing. A review of the annual/comprehensive MDS with an ARD of 05/13/19 notes for the resident's preferences for customary routines and activities, R162 rated choosing between a tub bath, shower and sponge bath as very important. The care plan for activities of daily living notes R162 will participate with combing his hair, shaving and cleaning dentures daily. The intervention includes providing sufficient time for the resident to complete bathing, dressing and performing personal hygiene, as well as, providing adequate rest periods between activities (especially after receiving [MEDICAL TREATMENT] treatment).",2020-09-01
64,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,568,E,0,1,6SOG11,"Based on interviews with resident and staff members, the facility failed to establish a process/system to ensure residents with personal funds are actually provided with their financial statements. At the time of survey, there was 102 residents with a personal fund account. Findings include: On 11/20/19 at 11:30 AM an interview was conducted with Resident (R)162. R162 affirmed he has a personal funds account with the facility. Further queried whether he receives a quarterly statement from the facility. R162 responded he does not receive statements from the facility notifying him of how much money he has in his account. The resident speculated he may have about a hundred dollar in his account but not sure. On 11/26/19 at 09:20 AM an interview was conducted with the Financial Controller (FC) and Business Office Clerk (B[NAME]). The B[NAME] confirmed R162 has a personal funds account. Inquired how often does the facility provide statements to the residents? The B[NAME] replied the residents are provided with monthly statements. Further queried what is the process for providing the statements to the residents. The B[NAME] responded, the business office will print the statements, the statements are provided to social services to disperse, then social services will deliver the statements to the units and the unit clerks will provide the statements to the residents. And for those residents that have a representative, the statements are mailed to the representative. The business office does not have documentation/log that the resident actually received their statements. The business office provided a listing of all residents with personal funds. There are 102 residents with accounts. A review of R162's statement for 09/01/19 through 09/30/19 documents he has more than a hundred dollars in his account. The statement lists the facility address for this resident and does not indicate the statements are mailed to a representative. On 11/26/19 at 09:33 AM an interview was conducted with Social Services (SS) staff member. Inquired what is the role of social services for providing financial statements to residents. The SS initially replied we don't do anything. Upon further query, SS replied the business office prints out the statements then the ward clerks on the unit delivers the statements. And for those that have a representative, the statements are mailed.",2020-09-01
65,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,640,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to successfully transmit data within 14 days of discharge for Resident (R)1. Findings include: On [DATE] at 02:18 PM a record review was done for R1. R1 was admitted to the facility on [DATE] from an acute hospital. R1 expired on [DATE] and there was no Minimum Data Set (MDS) assessment submitted over 120 days. There is documentation in the electronic health record a MDS was done on [DATE]; however, there was no evidence the discharge assessment was transmitted. On [DATE] at 02:32 PM, an interview and concurrent record review was done with the Resident Assessment Assistant (RAA). The RAA confirmed the assessment was done; however, was not successfully transmitted.",2020-09-01
66,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,641,D,0,1,6SOG11,"Based on record review and interview with staff members, the facility failed to accurately reflect a resident's status for skin conditions. Findings include: Cross Reference to F684. A review of the facility matrix provided by the facility found Resident (R)93 was identified with a facility acquired pressure ulcer. A review of the comprehensive Minimum Data Set (MDS) with an assessment reference date of 11/07/19 found in Section M. Skin Conditions, R93 was coded with a stage 3 pressure ulcer. The documentation from the facility's private supply vendor assessed R93 was a stage 3 pressure ulcer. Further record review and interview with staff members found R93 has a wound to the left inner buttock, which is not a stage 3 pressure ulcer.",2020-09-01
67,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,658,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with facility staff, the facility failed to meet professional standards of quality. Observation of two medication carts found each cart with one pill splitter with residual pill powder from unknown medications. As a result of this deficiency, residents were placed at risk of experiencing a potential adverse outcome, due to resident's allergies [REDACTED]. Findings include: On 11/22/18 at 09:20 AM, observed medication pass on one of four units. Each medication cart contained a medication pill splitter. Observed medication powder residue on the inside compartment (the area pill is secured, blade for splitting the medication, and the internal compartments) for both medication pill splitters stored on the medication carts. Licensed Practical Nurse (LPN)13 and Registered Nurse (RN)17 both confirmed the pill splitter was used to split various medications for multiple residents. RN17 and LPN13 confirmed the residual pill powder on the pill splitter poses a potential risk to residents and should have been cleaned. LPN13 and RN17 could not confirm the standard professional method used to properly clean the pill splitter to avoid a potentially harmful situation for a resident. An interview on 11/23/19 with the Director of Nursing (DON) confirmed the pill splitter should be cleaned with soap and water after each use.",2020-09-01
68,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,684,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with staff members, the facility failed to ensure a resident, Resident (R)93 with a wound was accurately assessed and based on the assessment, determine appropriate treatment and interventions for healing and prevention of further skin breakdown to maintain his highest practicable physical well being. The wound reportedly was erroneously assessed as a stage 3 pressure ulcer. The facility also failed to coordinate and provide continuity of care for R93 as evidenced by observation of not applying the heel lift boot at all times; using a half sheet to pull resident up to reposition (creating shear and friction); not following recommendation of the Advanced Practice Registered Nurse to place resident on right side while in bed, not having an OTC ([MEDICATION NAME]) available for treatment, and lack of interventions to decrease moisture while in the facility and during [MEDICAL TREATMENT] treatment. Findings include: Cross Reference to F641. Resident (R)93 was admitted to the facility on [DATE]. R93's [DIAGNOSES REDACTED]. R93 has history of skin breakdown to his right buttock, excoriation to the scrotum and also to his right outer ankle. R93 was identified on the facility matrix with a facility acquired pressure injury. A review of R93's comprehensive Minimum Data Set with an assessment reference date of 11/07/19 found in Section M. Skin Conditions, R93 was coded with a Stage 3 pressure ulcer, this pressure ulcer was not present upon admission/entry or reentry. On 11/25/19 at 01:33 PM the facility provided a copy of the Care Area Assessment (CAA) which was signed by Resident Assessment Coordinator (RAC)1 on 11/17/19. A review of the CAA notes R93 with a stage 3 pressure ulcer to the left buttock that initially started as shearing, but worsened. R93 noted to be incontinent of bowel and bladder, utilizing briefs to manage incontinence. R93 also requires extensive assistance with one to two person staff assist for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). R93 received [MEDICAL TREATMENT] three times a week, requiring him to sit for a prolonged period during treatment. R93 was also noted to have open wounds to the scrotum and right buttocks, which have healed. A review of the R93's care plan found interventions related to risk for skin breakdown and moisture associated skin damage due to bowel and bladder incontinence. The interventions included: use of pressure reducing cushion to wheelchair and alternating pressure mattress; reduce potential for shearing, friction, rub injury, or bruising during transfers, elevation and repositioning by using a turn sheet; activity staff will assist with repositioning and encourage good fluid intake; keep right lower extremity rotated outward with direct pressure off of right lateral malleolus while in bed, use the heel lift boot at all times; and offer assistance with toileting before a big event or outing. The clinical note dated 11/08/19 notes an interdisciplinary team meeting was done to address weight loss due to decreased oral intake. There is documentation of open wound to left buttock, scrotum and right shin. R93's [MEDICATION NAME] level was noted to be within normal limits. The team decided to provide Boost pudding at med pass once a day to promote wound healing. On 11/20/19 at 11:30 AM and 02:15 PM, R93 was observed lying in bed asleep. R93 was positioned on his back with a pillow placed under his right knee. On 11/22/19 at 11:37 AM, R93 was observed asleep, placed on his back with a blue bolster pillow under his upper right extremity. On 11/26/19 at 09:12 AM, R93 was observed lying in bed with his right leg bent at knee (v-shape) with a pillow placed under the knee and ankle. R93 had an elastic bandage on his right foot which extended above the ankle. Interview with Certified Nurse Aide (CNA)5 found the resident has a foam boot which is placed on for two hours and removed every two hours. CNA5 also reported R93 is repositioned every two hours. On 11/20/19 at 09:25 AM an interview was done with the Neighborhood Supervisor (NS)1. NS1 reported R93 has a stage 2 pressure ulcer to the left buttock and a stage 1 pressure ulcer to the right buttock, further reporting it started as excoriation. NS1 also reported R93 had a scrotal wound which has healed. NS1 explained the resident goes to [MEDICAL TREATMENT] and despite attempts to coordinate with them to offload, it has been difficult. A review of the wound assessment worksheets found an assessment dated , 06/17/19 of a stage 2 wound to the left inner buttocks measuring 0.8 cm (length) x 1 cm (width) x There was no documentation of wound assessments from 06/17/19 until 07/14/19. The assessment of 07/14/19 notes the wound deteriorating. There was no documentation of wound assessment from 07/14/19 until 09/17/19. The size of the wound increased to 3 cm (length) x 1.5 cm (width) x 0.1 depth. The resident's wound was noted to be a previous wound that is now open despite barrier cream administration. The wound was noted with scant serosanguinous exudate. On 10/01/19 the wound was documented to have improved, the treatment included cleansing with normal saline and apply [MEDICATION NAME] to affected areas. The wound deteriorated on 10/22/19, slough was noted. On 10/22/19 the wound noted to deteriorate, increased in size measuring 3.7 cm (length) x 5.2 cm (width) x Further review found a report dated 11/12/19, entitled (Facility Name) - Wound Care *Skin Integrity* Evaluation which documents the presence of a stage 3 pressure ulcer to the left buttock. The size was 16.00 cm (length) x 2.60 (width) x The last assessment dated [DATE] notes the wound measured 1.5 cm (length) x .75 cm (width) x A review of the APRN note of 09/23/19 notes the wound to the medial left buttocks worsening and R93 complaining of pain while sitting during [MEDICAL TREATMENT] treatment. Also noted the [MEDICATION NAME] was not available and house stock zinc oxide was being used. The APRN notes open wound is not over bony prominence, there is partial thickness to the wound, probably due to shearing. The plan was to use baza cream three times a day and as needed after peri-care until [MEDICATION NAME] is available. Further recommendations include: keep pressure off site by positioning on right side when in bed, may use bordered foam dressing for comfort during [MEDICAL TREATMENT] and continue to monitor. On 11/25/19 at 12:43 PM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON reported the facility does not have a wound nurse. The ADON explained the assessment of 11/12/19 which documents a stage 3 pressure ulcer was done by the private supply vendor. The ADON reported the vendor is a certified wound nurse and makes recommendations for treatment. Inquired whether it is within the vendor's scope to assess wounds and did the vendor actually assess R93's wound. The ADON was agreeable to follow up. On 11/25/19 at 12:54 PM the ADON provided a copy of the service agreement by the vendor. At this time the ADON shared that she did not notice the resident was assessed with [REDACTED]. On 11/25/19 at 11:36 AM an interview was conducted with the APRN. The APRN reported R93 went out on pass with his family and returned with excoriation to the left inner buttock which is not a pressure ulcer as it is not on a bony prominence. The APRN explained the wound is on the inside of the buttock, the fatty part where the butt cheeks touch. Further queried whether a root cause analysis was done to determine the type of wound the resident has and what were contributory causes for the breakdown. The APRN responded it could be moisture associated skin damage. A subsequent interview was done with the ADON regarding the lapse of documentation of the wound. The ADON reported the lapse may have been attributed to the healing of the wound. And when the assessments started again, the wound may have presented itself again. On 11/25/19 at 03:30 PM, the NS1 now reports R93's wound started with moisture and the house barrier cream was used. The NS recalled the wound was noticed after the resident returned from a family visit. The NS confirmed the resident's family will provide peri-care during his visit. The NS stated she has been trying to work with the [MEDICAL TREATMENT] facility to assist in repositioning and providing incontinence care. The NS reported although R93 receives [MEDICAL TREATMENT], he continues to urinate. At this time, the NS1 was asked to clarify how are staff repositioning the resident to reduce shearing and friction. The NS explained a half sheet in the middle of the bed is being used and the sheet is pulled up to reposition. The NS further clarified the half sheet is different from using the bed sheet, decreasing friction and sheer.",2020-09-01
69,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,689,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to identify potential accident hazards for the following: on two units the housekeeping and supply closets were not secured and supplies on delivery cart were not secured. As a result of this deficient practice, the facility put the safety and well-being of the residents at risk for accident hazards. Findings include: 1) During an observation of the Gardenia Neighborhood Nursing Unit on 11/21/19 at 08:42 AM, a housekeeping closet door was not secured. The closet contained various cleaning solutions including OxyFect H Peroxide disinfectant cleaner and Clorox germicidal bleach. Resident (R)182 was seen propelling self with his/her wheelchair near the unsecured closet and there was no staff in the immediate vicinity. R182 was admitted to the facility on [DATE]. A review of R182's Minimum Data Set (MDS), comprehensive assessment, with an assessment reference date (ARD) of 11/03/19 showed the Brief Interview for Mental Status (BIMS) score was 9 (nine) which indicates that R182 has moderately impaired cognition. During staff interview with the Housekeeper (HSKPR)1 on 11/21/2019 at 10:40 AM, HSKPR1 stated that the housekeeping closet door should be secured at all times. HSKPR1 also revealed that the door has to be pushed a little harder in order for it to close completely. 2) During an observation of the North Neighborhood Nursing Unit on 11/21/19 at 11:00 AM, a central supply closet was not secured. The closet contained various supplies including Sani-cloth germicidal disposable wipes, [MEDICATION NAME] shampoo gel, Purell hand sanitizer foam, and Attend briefs. Resident (R)32 was seen propelling self with his/her wheelchair near the unsecured closet and there was no staff in the immediate vicinity. R32 was admitted to the facility on [DATE], a review of the MDS, quarterly assessment, with an ARD of 03/09/17 showed the BIMS score was 3 (three) which indicates that R32 has severely impaired cognition. During staff interview with Certified Nurse Assistant (CNA)1 on 11/21/19 at 11:10 AM, CNA1 acknowledged that the central supply closet door should have been secured. 3) On 11/25/19 at 12:20 PM, observed a flatbed cart, filled with boxes of supplies, unattended in the hallway of 1 of 4 units. Observed Resident (R)171, self-propel his/her wheelchair up to the unattended cart and used his/her wheelchair to stand. Once standing, R171 reached into an uncovered plastic bin, which contained various items including a box of (100 count) lancets. R171 proceeded to feel around in the uncovered plastic bin and attempted remove items. Staff observed R171 reaching into the uncovered bin, however, did not attempt to relocate or secure the supplies on the cart. R171 was left unattended at the supply cart. R171 was observed to leave the area and return to his/her room. A review of R171's medical record, care plan, and progress notes documents a history of hoarding items and aggression towards other residents in the facility. A review of the Minimum Data Set, comprehensive assessment, with the Assessment Reference Date of 10/03/19, R171 scored an 11 (eleven) on the Brief Interview for Mental Status, indicating R171 has moderately impaired cognition.",2020-09-01
70,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,690,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews with facility staff, and record review, the facility failed to provide appropriate catheter care and monitoring of the catheter tubing for sediment build up/clotting for Resident (R)159. As a result of this deficiency, R159 is placed at an increased risk for further complications and infection related to the use of a foley catheter. Findings include: R159 was admitted on [DATE] with the [DIAGNOSES REDACTED]. On 11/19/19 at 11:20 AM, initially observed small clots and sediment in the resident's catheter tubing. Observed the catheter tubing on six (6) subsequent days (11/19/19 at 01:03 PM; 11/20/19 at 10:10 AM; 11/20/19 at 12:51 PM; 11/21/19 at 09:28 AM; 11/21/19 at 12:45 PM; and 11/22/19 at 09:45 AM). Each day there was an increase in number of visible small clots and in the size of the build-up of sediment in the tubing. On 11/22/19 at 10:10 AM, observed the catheter tubing with registered nurse (RN)17. RN17 confirmed the catheter tubing and bag should be changed due to the number of small clots, sediment visible in the catheter tubing, and the possible obstruction of urine flow. On 10/23/19, R159 was diagnosed with [REDACTED]. Subsequently, on 10/24/19 R159 was diagnosed with [REDACTED]. R159 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of R159's Minimum Data Set (MDS), Assessment Reference Date (ARD) of 10/27/19, documents R159 is totally dependent on staff for all care including bed mobility, transferring (bed/wheelchair), personal hygiene, dressing, eating, and toilet use. On 11/22/19 at 09:11 AM, observed certified nurse aides (CNA)21 and CNA3 provide catheter care to R159 due to fecal incontinence. CNA21 wiped R159's perineal area (soiled with feces) with a disposable wipe then used the same disposable wipe to clean the right labia majoria. The disposable wipe was visibly soiled with feces. The facility's policy and procedure, Catheter Care, instructs staff to not contaminate area with feces and to clean the area from front to back. CNA21 used another single disposable wipe and cleaned the catheter tubing, starting approximately 3 inches away from the meatus (insertion site), with a back and forth motion which would reintroduce contaminants. R159's care plan documents to clean around the catheter with soap and water, not a disposable wipe. The facility's policy and procedure for catheter care, documents staff is to cleanse the area at the catheter insertion site, starting at the meatus and working away from the body.",2020-09-01
71,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,692,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with resident and staff members, the facility failed to ensure 1 of 3 residents was monitored for weight loss. The system for reporting significant weight loss for a resident receiving daily weights was not established; therefore, the resident was not assessed by a Registered Dietitian (RD). Also, the facility failed to develop a care plan to address weight loss related to the resident's [MEDICAL CONDITION] and use of diuretics. Findings include: Resident (R)209 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 11/19/19 at 2:30 PM an interview was done with R209. R209 reported loosing weight, approximately 4 to 5 pounds. Further inquired whether she was on a special diet, she replied no. Observation also found R209's lower extremities were mottled with red spots and appeared to be swollen. R209 reported she fell at home and the red spots were the result of [MEDICAL CONDITION] crawling on the carpet. On 11/20/19 at 09:15 AM R209 was observed sitting outside of her room and had eaten all her breakfast. R209 stated breakfast is the best meal. Record review found the following weights for R209: 166 (11/01/19); 163 lbs. (11/06/19); 159 lbs. (11/13/19); 153 (11/14/19); 148 (11/19/19); 145 (11/21/19) and 143 (11/25/19). On 11/01/2019, the resident weighed 166 lbs. and on 11/25/2019, the resident weighed 143 pounds which is a 14% weight loss in less than a month. A review of the physician's orders [REDACTED]. twice daily for generalized [MEDICAL CONDITION]. The admission Minimum Data Set with an assessment reference date of 11/06/19 notes R209 did not have a weight loss and indicates R209 received diuretics during the assessment period. A review of the Comprehensive Nutritional Assessment, signed 11/11/19 notes the following diet recommendations: 3 gram sodium; regular texture; and fluid restriction. R209 also noted to have fair to good intake at meals with 2+ [MEDICAL CONDITION]. The assessor also notes R209 had slight weight loss since admission suspected due to fluid. A subsequent Mini Nutritional assessment dated [DATE] notes R209's food preferences and a plan to weigh the resident daily prior to breakfast. R209's care plan was reviewed on 11/22/19 at 11:11 AM. The goals include: maintaining stable weights (+/- 5% admission weight, ideal body weight 112.5 lbs.) and labs; being free of signs and symptoms of constipation and dehydration; and maintaining the best quality of life by being well nourished. On 11/26/19 at 08:39 AM a copy of the care plan was provided by the facility. A review of the document found the goal of maintaining stable weights was discontinued (no date documented of when this goal was discontinued). In addition the goal of loosing weight due to [MEDICAL CONDITION] and [MEDICATION NAME] treatment was added to the care plan. There is no documentation of the date this goal was added to the resident's care plan. On 11/25/19 at 10:05 AM an interview was done with the Neighborhood Supervisor (NS)1. Inquired whether the Registered Dietitian (RD) was notified of R209's weight loss. NS1 reported weights are sent to the RD weekly (Saturdays) and based on the calculated percentage of loss or gain, this would trigger the need to do a comprehensive review and consult the RD. NS1 reported R209 receives [MEDICATION NAME]; therefore, weight loss was expected. On 11/26/19 at 07:20 AM an interview and concurrent record review was done with the Dietitian Coordinator (DC). The DC reported R209's record regarding the weight loss was reviewed. Inquired when was she informed of the resident's weight loss, DC replied yesterday (11/25/19). The DC reported R209 had a planned weight loss, inquired whether this was included in the resident's care plan, the DC reported she would check on this. Concurrent record review found no care plan related to a planned weight loss. The DC further explained R209 was [MEDICAL CONDITION] and on [MEDICATION NAME] so the weight loss was expected. Further queried how to determine whether the loss is attributed to fluid loss or a true weight loss. The DC reported even if a weight loss is expected the nursing staff needs to report the loss to the dietitian. The DC clarified R209 is on daily weights and there may have been a glitch in the new system as this resident was not included in the weight reports. The system supports reports for residents on weekly and monthly weights but not daily weights. Therefore, R209's weight loss was not triggered. The DC explained the process entails nursing to upload weights in the electronic medical record (EMR) and the report is received by the dietitians on Saturday. Staff members are required to report a 2% weight loss in a week to the dietitian, physician and as applicable the resident's representative. Also, a reportable is a 5% weight loss in a month. The DC provided an update for R209 which was dated 11/25/19. The note documents R209's weight as 143.4# on 11/25/19, 147.6# on 11/18/19, and 161.8# on 11/11/19 which reveals a 2.8% decrease in one week (between 11/18/19 to 11/25/19) and 9% decrease (11/11/19 and 11/18/19). A review of the meal intake found the resident's food intake at meals ranges from 50-100% and R209 meets the daily fluid intake. Also noted R209 received [MEDICATION NAME] intravenously, continues on oral diuretic ([MEDICATION NAME]) and has +1 [MEDICAL CONDITION] to bilateral lower extremities. The DC notes it is suspected the weight loss is mainly due to fluid as the resident has had fair to good intake since admission. There is an expectation of continued weight loss. The plan is for nursing to notify the dietitian of weekly significant weight changes. On 11/26/19 at 08:39 AM the facility provided a copy of R209's care plan. The facility copy now included the goal for wanting to lose weight due to [MEDICAL CONDITION] and [MEDICATION NAME] treatment and weight loss is expected and beneficial. The interventions include the following: monitor resident for greater than 2% weight changes weekly; send weekly reports to dietitian for further evaluation of weight changes greater than 2%; and report the significant changes to the physician, dietitian and resident representative.",2020-09-01
72,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,755,D,0,1,6SOG11,"Based on staff interview and a review of facility records, the facility failed to document the narcotic count log on 1 of 4 units. As a result of this deficiency, there is a risk of potential diversion of controlled medications. Findings include: On 11/22/19 at 09:30 AM, a review of the narcotic log on one of four units found the narcotic log was not completed. On 11/19/19, the off-going (night shift) and the oncoming (day shift) failed to complete the narcotic log. The staff did not document the number of actual narcotic medication counted between the shifts; however, as evidenced by their initials, they attested to the count (which was blank). A review of the individual narcotic count sheets for every resident notes a total of 5 of 11 medications were administered. Licensed Practical Nurse (LPN)25 confirmed, the facility utilizes the narcotic log as part of a three-check system to count and account for narcotic medications. The count on the narcotic log is used at the change of each shift. One licensed nurse from the off-going and the licensed nurse coming on duty reconcile the narcotic log against the actual narcotic medication (tablets, solutions, patches) stored in the narcotic drawer and the resident's individual narcotic sheet. LPN25 confirmed the narcotic log should not be left blank.",2020-09-01
73,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,756,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure the attending physician responded to the pharmacist's recommendation regarding the use of an antipsychotic medication ([MEDICATION NAME]) for Resident (R)137. As a result of this deficiency, R137 could potentially experience adverse outcomes and may not be receiving the lowest possible dose with the most benefit. Findings include: A record review found a progress note, 04/27/19 at 09:39 AM by Pharm1 documenting a Drug Regimen Review (DRR) was completed. Pharm1 documented, R137 has been receiving an antipsychotic [MEDICATION NAME] 0.25 mg QAM (every morning) and 0.5 mg QPM (every night) since 10/21/18. Pharm1 requested the attending physician complete an evaluation of the current dose and to consider a gradual taper of the dose to ensure (R137) is receiving the lowest possible effective/optimal dose. There was no documentation of the pharmacist's report to the physician regarding use of [MEDICATION NAME] or a response from the physician. A subsequent review by the pharmacist on 05/30/19 at 09:31 PM, notes the attending physician failed to respond to a previous request for an evaluation/gradual taper of dose for [MEDICATION NAME]. At this time, Pharm1 planned to resend last months note (dated 04/27/19). On 11/22/19 at 08:51 AM, the Assistant Director of Nurses (ADON) was unable to find the 04/27/19 documentation of the correspondence from the pharmacist to the attending physician. The ADON provided documentation which was dated 05/31/19 in which the attending physician responded to the pharmacist. The date of the response is illegible (possibly (MONTH) 2019).",2020-09-01
74,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,758,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff members, the facility failed to address the gradual dose reduction and use of an antipsychotic to treat a specific condition for 1 of 5 (Resident 189) residents reviewed for unnecessary medication. The facility inconsistently monitored the resident's targeted behaviors for use of [MEDICATION NAME], the targeted behaviors to address the use of [MEDICATION NAME] was changed over a period of time which does not provide accurate monitoring of the targeted behaviors related to the drug usage. Also, the start date of the medication was inconsistent, therefore, there was no documentation by the pharmacist of a recommendation for gradual dose reduction and the pharmacist did not address the increase of the [MEDICATION NAME]. Findings include: Resident (R)189 was admitted to the facility following an acute hospitalization on [DATE]. R189's [DIAGNOSES REDACTED]. R189 also has an indwelling foley catheter. On 11/19/19 during the initial tour, R189 was observed laying in bed asleep. Subsequent observation at 02:14 PM found the resident lying in bed with a pillow between his legs. On 11/20/19 at 09:10 AM, R189 was observed to be asleep in bed with the television on. At 11:30 AM, R189 appeared awake and attempted to screen the resident for appropriateness of interview. R189 attempted to sit up, setting off his clip alarm, a staff member entered the room and he asked whether lunch was coming. Inquired if he was hungry, he replied no. The screening was discontinued. Later stopped in to visit the resident at 02:15 PM, he was lying in bed asleep. A record review done on 11/22/19 at 07:35 AM noted physician orders [REDACTED]. (start date of 07/22/19) at hour of sleep for [MEDICAL CONDITION] with behavioral disturbance; and [MEDICATION NAME] 50 mg. (start date of 06/30/19) twice a day for [MEDICAL CONDITION] with behavioral disturbance. A review of the [MEDICAL CONDITION] medication review found the recorded date a medication was initiated is inconsistent. The review for 08/23/18 has an initiation date of 07/31/18 for [MEDICATION NAME] (50 mg. twice a day). A subsequent review, dated 06/24/19 for [MEDICATION NAME], the same dosage documents an initiation date of 05/25/18. There is also documentation of [MEDICATION NAME] 100 mg at bedtime in the review for 08/23/18 and 01/29/19. On 06/29/19 the [MEDICATION NAME] dosage was changed to 50 mg at bedtime. Subsequently, the dosage was increased to 150 mg at night on 06/30/19 as documented in the 10/28/19 assessment. There is no documentation of a gradual dose reduction. Also, the pharmacist is not documented as a participant in all the [MEDICAL CONDITION] medication review meetings. Further review of the [MEDICAL CONDITION] medication review found the monitoring of targeted behaviors related to the use of the medications varied. The targeted behaviors identified for the use of [MEDICATION NAME], 50 mg twice a day include: restlessness, anxiety, and calling for wife (08/23/18); yelling, aggressive talking, wandering and disorientation (01/29/19); exit seeking, yelling and verbalizing accusations (06/24/19); and agitation, yelling, exit seeking and throwing personal belongings (10/28/19). The use of [MEDICATION NAME] at bedtime identified the following targeted behaviors: 50 mg - falling asleep and staying asleep (06/24/19); 100 mg - yelling aggressive talking, wandering and disorientation (08/13/18); and 150 mg. agitation, yelling, exit seeking, and throwing personal belongings (10/28/19). The review also documents the number of occurrences of the targeted behavior which determines whether an increase of medication or a gradual dose reduction is indicated. On 11/25/19 at 09:20 AM an interview was conducted with Neighborhood Supervisor (NS)1. Inquired how does the facility monitor residents' targeted behavior. It was explained the nursing staff documents a progress note when a resident exhibits a behavior. NS1 further reported the ADON will count the target behaviors for the [MEDICAL CONDITION] medication review meetings to document the number of occurrences since the last review. NS1 clarified the ADON has to go through the resident's record to calculate the occurrences. A review of R189's care plan found interventions under Mood and Behavior for the interdisciplinary team to recommend gradual dose reduction based on the following: target behaviors are no longer present; target behaviors no longer affect the health and safety of the resident and/or others; target behaviors are successfully redirected with use of non-pharmacological interventions; and whether the side effects/risks outweigh the benefits of treatment. A review of the pharmacist drug regimen review found notification on 04/20/19 regarding consideration of dose reduction for [MEDICATION NAME] (15 mg qd since 06/25/18). The subsequent note of 05/19/19 documents [MEDICATION NAME] at 22.5 mg. The review does not address the increase of [MEDICATION NAME] from 100 mg to 150 mg at bedtime. The review on 07/16/19 notes possibly re-evaluate co-administration of [MEDICATION NAME] and [MEDICATION NAME] due to recent suicidal tendency. Also noted on the 08/07/19 review, consideration of tapering of [MEDICATION NAME] to discontinue started due to geri-psych evaluation (polypharmacy). Further noted resident found on floor on 07/18/19 at 07:00 AM. The review does not address the increase of [MEDICATION NAME] from 100 mg to 150 mg on 07/22/19 at bedtime. The pharmacist does not address consideration of dose reduction for use of [MEDICATION NAME] 50 mg. twice a day with a start date of 05/25/18 or 07/31/18. On 10/22/19, the APRN documents a GDR for [MEDICATION NAME] is contraindicated. The review of the psychiatric consultant report dated 07/10/19 notes the following findings: no depressed, no recent suicidal ideation, sleeping well, no side effects with [MEDICATION NAME] to [MEDICATION NAME] change and still with possible constipation and low back pain. The recommendation was to consider stopping [MEDICATION NAME] and monitoring for [MEDICAL CONDITION]. Subsequent visit, dated 08/14/19 notes R189 denied suicidal thoughts and stated he puts the cord around his neck to know which remote is which and to easily reach it. The recommendation was to continue to monitor for [MEDICAL CONDITION] and continue to work on polypharmacy.",2020-09-01
75,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,761,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to: label the blister back for a blood pressure medication with the correct dose for one Resident (R)47 which would place the resident at high risk for injury due to receiving the wrong medication and/or the wrong dose of medication; appropriately discard an antibiotic ointment medication from the treatment cart (the label was non-readable); and failed to label medications with discharge date s. Findings include: 1) During a medication administration observation with LN52 noted a blister pack for R47, the medication was [MEDICATION NAME] (a medication to decrease blood pressure) give 25 milligram (mg) tab 37.5 mg (1.5 tabs) by mouth (PO) twice per day (BID) Diagnosis: [REDACTED]. A hand written note in black ink was noted on the top left corner of the blister pack that stated direction changed, refer to chart. When asked what the correct dosage for R47 was LN52 stated, the new dose was just changed and the new order states to give 25 mg (1 pill) BID. We were giving 25 mg, 1-1/2 tabs, daily which totals 37 mg. LN52 verified that the dosage was changed and now R47 receives only one 25 mg tab, and the label on the blister pack does not reflect the new dose. Medical record reviewed. The Medical Doctor (MD) order dated 11/02/19 states [MEDICATION NAME] 25 mg tabs. Give 1 tab PO BID. During an interview with LN52 on 11/22/19 at 11:00 AM, discussed the labeled blister pack. LN52 stated that in a situation where the order is changed and the medication is the same but the dosage is changed, normally the new dose is written on the top left corner of the blister pack and highlighted in yellow. The nurses normally don't cross out the old dosage information and will continue to use the medication in the blister pack until it runs out. LN52 further explained, since each blister has 1-1/2 tabs, and the order is now 1 tab, they will use the whole tab, then the half tabs (2) until they are all gone or there is only one half tab left. During an interview with the Charge Nurse (CN) on 11/22/19 at 11:21 AM who stated that when we have an order for [REDACTED]. The CN concurred that the blister pack for the [MEDICATION NAME] should be immediately discarded and a new blister pack is obtained from the pharmacy with the correct dose. 2) During a random inspection of the medication/ treatment cart on 11/22/19 at 11:02 AM in the Pikake neighborhood a small tube of Mupirocin (an antibiotic) ointment was found in a drawer. The label appeared old with the print completely worn off making it non-readable. When Licensed Nurse (LN)52 was asked if he knew which resident it belonged to or when the expiration date for the ointment was, LN52 responded that its very hard to tell which resident, I can't see the name . I think we should throw it away. 3) On 11/22/19 at 08:58 AM an inspection of the medication cart on the Ilima Unit was done with the assistance of Licensed Nurse (LN)2. The observation found a vial of [MEDICATION NAME] labeled with an opened date of 10/26/19 with no discard date. Inquired when is insulin discarded, LN2 responded after 28 days and confirmed the discard date should have been written on the label. Observation of other opened vials of insulin found it was labeled with a discard date. Further queried what is the discard date for this vial. LN2 asked another nurse how long before insulin is discarded, the nurse responded 28 days but for [MEDICATION NAME] it is 42 days. LN2 calculated the dates and stated this vial is to be discarded tomorrow (11/23/19). Further inspection found an opened bottle of lantoprost (eye drops for [MEDICAL CONDITION]) labeled with an open date of 11/17/19. LN2 was asked when is this medication discarded. LN2 replied, she thinks it is 30 days and confirmed there was no discard date documented on the label. During the exit conference on 11/27/19, the facility staff reported labeling medications with the discharge date is not required. At this time, a request was made for the pharmacy policy regarding labeling of medications. The facility was agreeable to provide the pharmacy policy and procedure via facsimile. On 12/03/19, the facility sent a policy and procedure entitled Medication Storage, Storage of Medication. The procedure notes the following: 12. Insulin vials should be stored in the refrigerator until opened. Date insulin vials when first opened, may store opened vial in refrigerator or at room temperature. Do not freeze insulin. If insulin frozen, do not use (Refer to Section 9.12, Expiration Dating). Correspondence through e-mails with the Administrator from 12/03/19 to 12/04/19 found the facility was unable to provide Section 9.12, Expiration Dating or a policy and procedure related to labeling medications with expiration date.",2020-09-01
76,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,584,E,0,1,6SFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to have an adequate process in place to ensure mosquito nets installed in several of the resident's rooms in the East and West neighborhoods were adequately maintained, and equipment removed when not in use. As a result of this deficiency, there were several rooms on the east and west neighborhoods that did not have a clean, homelike environment. Findings Include: 1. On 11/27/2018 at 10:47 AM observed several resident rooms in the West Neighborhood had mosquito nets installed. The nets were tied in a knot to keep them from hanging on the floor and pulled to the side of the room. Several other rooms (Rm), Rm 5, Rm 7A, Rm 8B, Rm10A, Rm 10B, Rm 11A, and Rm 14A had a rope/string hanging above the center of the resident's bed. The hanging ropes made the rooms look unappealing and not homelike. Several of the mosquito nets were in poor condition and needed to be replaced or cleaned. Rm 12A was discolored and gray, Rm 13B had multiple holes and Rm 8B had dead insects in the net. During an interview with Registered Nurse (RN)126 on 11/29/2018 at 3:30PM, looked at the mosquito net in Rm 12A and stated that it needed to be taken down or washed. We used the nets when residents were getting bit a lot, but we are not currently using many. That was quite a while ago. If a family requests one, we will put one up. We fill out a work order and maintenance put it up. RN126 stated, I'm not sure who cleans them, housekeeping or maintenance. During an interview on 11/30/2018 at 10:00 AM with the Maintenance and Equipment Coordinator who explained Maintenance does PM (preventive maintenance) on the mosquito nets every six months and we change them out. We don't wash them, we throw them away and put a new one up. It's nursing's responsibility to do a work order to replace it. 2. During a resident interview on 11/28/18 at 08:33 AM observed a small rope hanging over the middle of R183's bed (four to six feet). R183 stated its creepy isn't it? but I think it is for a mosquito net. The doors are left open wide all of the time and sometimes we have mosquitos here. During an observation of a few of the rooms on the East neighborhood on 11/28/18 at 09:09 AM observed mosquito nets attached to the middle of the ceiling and hanging to the side of the bed tied in a knot in several of the rooms on the East neighborhood. During an interview with the Nursing Supervisor on the East neighborhood on 11/19/18 at 03:00 PM, who stated the mosquito nets are put up for residents when they or their families request. Maintenance puts the nets up and takes them down. She wasn't aware of the ropes/ strings that hang down over the bed and asked to be shown where they are. Accompanied her to room [ROOM NUMBER] B where the string was found hanging down from the ceiling over the residents bed. She responded by saying that must be kept in place in case the resident requests a mosquito net. Every month maintenance staff put put up, take down or clean the nets. Infection control mosquito nets policy section 4 reviewed To ensure that resident remain protected from mosquitos and any infections caused from mosquito bites. 1. Residents can request mosquito nets to be placed over the bed at any time . Maintenance conducts bi-annual checks under their preventative main. If mosquito nets are found inept, they are discarded . Replaced bi-annually and as needed via work order. During an interview with the Assistant Administrator on 11/29/18 at 03:40 PM who stated the nets are taken down and thrown away when they become dirty or worn.",2020-09-01
77,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,656,D,0,1,6SFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement respiratory care into Resident (R)54 comprehensive person-centered care plan. The deficient practice resulted in the lack of measurable objectives and timeframe's to appropriately evaluate treatment plan for R45's oxygen (O2) therapy. Findings include: During an observation on 11/28/18 at 01:57 PM R54 was in bed on her right side with oxygen (O2) via nasal cannula. The O2 concentrator was set at two liters (L). R54 Respirations were noted to be steady and slightly labored. The minimum data set (MDS) assessment summary dated 11/02/18 was reviewed. R54 was ordered 02 for comfort, and denied any shortness of breath (SOB). R54 is anticipated to decline due to her non modifiable conditions and power of attorney (POA) has agreed to no hospitalization s at this time. Comprehensive care plan reviewed, no respiratory goals or interventions were noted on R54 care plan. During an interview with Registered Nurse (RN)173 on 11/29/18 at 05:01 PM who stated that R54 is declining, we discussed with the family about hospice and they declined. The MD was the Locum and made a note about offering hospice care. The family decided not to have R54 hospitalized . The family is supportive and comes here often. Physician (MD) orders reviewed with Nursing supervisor revealing no orders for O2. Per RN173 on 10/17/18 R54 was declining and thought to be actively dying. The oxygen was placed at that time for comfort. We did not pursue an order for [REDACTED].>",2020-09-01
78,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,657,D,0,1,6SFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review (RR), the facility failed to meet professional standards of care that would dictate the care plan be revised/updated to reflect changes in condition and approaches for meeting the needs of two Resident's (R), R44, and R127. Care planning drives the type of care a resident receives. Because of this deficient practice, interventions to promote continuity of care and communication amongst nursing staff to safeguard against adverse events were not identified and documented in a timely manner. Findings Include: RR of R127's medical records revealed that R127 had a reoccurring [MEDICAL CONDITION] of the left thigh. R127's care plan identified the problem at risk for skin breakdown i.e. ulcers, rashes, skin tears, with the goal of extrinsic risk factors for skin breakdown will be reduced or eliminated. 11/15/2018 Physician (MD)1 addendum note for R127, includes: recurrent left upper thigh [MEDICAL CONDITION]/rash of left medial and lateral thigh. The warmth of the room and keeping pt. covered contributes to this .ask if pt (sic) can be kept a little cooler. RR of R127 revealed no evidence of documentation that the care plan had been revised to identify interventions to address the contributing factors to the [MEDICAL CONDITION] (warmth of the room, and keeping the resident covered) identified by MD1. During an interview with RN126 on 11/28/2018 at 02:25 PM who stated, I hadn't seen that entry. Inquired if MD1 had communicated the concern to anyone, and RN126 replied, No, but it should have been in the care plan. RR of R44 revealed a new [DIAGNOSES REDACTED]. There was no evidence of documentation that the care plan for R44 was updated to include appropriate interventions and monitoring to minimize complications related to the Pneumonitis (i.e. shortness of breath, fever, drop in oxygen level). During an interview and RR on 11/29/18 with RN126 who agreed the care plan had not been updated to include the new [DIAGNOSES REDACTED]. It was an oversight. If care planning is not complete or is inadequate, the consequences may negatively impact the resident's quality of life, as well as the quality of care and services received.",2020-09-01
79,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,689,D,0,1,6SFF11,"Based on observations and interview the facility failed to identify a resident's risk for an accident, including the need for supervision and assistive devices for one of 68 residents ((R)117) in the survey sample. The deficient practice did not provide adequate supervision and professional standards of practice placing R117 at an increased risk for injury. Findings Include: On 11/27/18 at 12:11 AM observed a certified nursing assistant (CNA) 194, pushing R117 in her wheelchair backwards down the hallway. The resident was talking in her native language and appeared agitated at the CN[NAME] Queried CNA194 why R117 was being pushed backwards in the wheelchair. The CNA 194 stated that R117's wheelchair footrests were broken and going forward may cause her feet to be run over. On 11/30/18 at 10:00 AM interviewed the unit's charge nurse (CN) 279 and inquired about R117's broken foot rests. The CN279 stated that residents in wheelchairs should not be pushed backwards, and only if going through a door. The CN279 stated that she will re-educate staff.",2020-09-01
80,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,761,E,0,1,6SFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure six medication labels were properly labeled with discard dates, and one medication remained in inventory beyond the expiration date. The deficient practice had the potential to affect the efficacy of the expired drug, and the timely identification and removal of medications when they are expired. Findings Include: 1. An inspection of the medication room on the West Neighborhood was completed on [DATE] at 09:34 AM. Pharmerica, is contracted to supply all pharmaceuticals except for over the counter medications, which are purchased by the facility. The procedure for both Pharmerica and the facility is to hand write the discard date on the label of the medication container or package. Registered Nurse (RN) 126 was present during the inspection and asked to review the labels for expiration and discard dates. The following did not have discard dates written on the label: One bottle Antacid, one bottle of Polyethylene [MEDICATION NAME] Powder, one package of Nicotine gum, one bottle of [MEDICATION NAME] and one bottle Sentry Multivitamin. 2. The WEST Neighborhood Medication cart number two was inspected on [DATE] at 10:00 AM which revealed the labels of one bottle of [MEDICATION NAME] and one bottle of [MEDICATION NAME] 1 milligram (mg) did not have discard dates. 3. During an observation of the North Neighborhood Medication Cart on [DATE] at 08:56 AM, an expired packet of [MEDICATION NAME] was found in the storage drawer. The label read discard after ,[DATE]. During an interview with Licensed Nurse (LN) 2 on [DATE] at 08:57 AM who acknowledged that the [MEDICATION NAME] packet was expired and should have been removed. The facility policy on disposal of medications was reviewed stating It is the policy and practice of Hale Makua Health Services that all medications that have been discontinued, expired, or require wasting will be identified and removed from the medication supply in a timely manner and disposed of in accordance with federal and state laws. 4. During a random inspection of the medication refrigerator on East Nursing station medication room on [DATE] at 09:27 AM with the Nursing Supervisor, an open multi-dose vial of positive protein derivative, (PPD) solution was found with no label dating when it was opened. 5. During a tour of the East unit on [DATE] at 01:35 PM, room [ROOM NUMBER]A a small intravenous (IV) bag was found hanging next to R321's bed did not have a date/time hand written on the IV bag or tubing to indicate when it was placed or needed to be discarded. During an interview with the Nursing Supervisor on [DATE] at 02:00 PM who stated we usually hang up the IV antibiotic and throw it away the next day. Medical record reviewed revealing R321 has a [DIAGNOSES REDACTED].",2020-09-01
81,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,812,E,0,1,6SFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure safe food handling processes. The kitchen staff did not ensure proper storage by tracking when to discard perishable food. The deficient practice placed residents at risk for illness. Findings Include: During the initial kitchen tour on [DATE] at 10:27 AM with the director of nutrition services (DNS), found in the kitchen small pantry, an opened case of parmesan cheese packets with expiration date of ,[DATE]. In the produce refrigerator observed a bunch of brown colored celery, and in refrigerator #6 there was a bottle of blackberry puree with an expired date.",2020-09-01
82,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,842,D,0,1,6SFF11,"Based on interview, record and policy review, the facility failed to document the signature date on an Advance Health-Care Directive (AHCD) form for Resident (R) 162. As a result of this deficient practice, the AHCD form would be invalid, and R162 may not have received the care as indicated on the prepared AHCD form. Findings Include: During record review for R162, it was noted that the AHCD form did not contain a date that was required on the form. The AHCD form read Signatures; Sign and date the form here. The section where the date was required contained a signature instead. During an interview on 11/29/18 at 03:04 PM with the Director of Health Information Management (HIM Director), HIM Director acknowledged that the AHCD form was missing the required date. During review of the Facility policy on Advance Directives which stated The Director of Admissions will review any advance directive to be sure it is valid under current law.",2020-09-01
83,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,880,E,0,1,6SFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record and policy review, the facility failed to post a warning sign of contact precautions at the entrance of two resident rooms, Resident (R) 192 and R8's room. The deficient practice put the staff and visitors at risk of contracting R192's known illness of [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) and R8's active infestation of lice. The facility also failed to ensure direct contact staff demonstrated proper use of gloves with hand hygiene and proper technique for wound care/dressing change. The deficient practice increased R204's risk of illness/ complications of infection. Findings Include: During a record review for R192, revealed the resident had a [DIAGNOSES REDACTED].>During an observation of R192's room, on 11/27/18 at 12:24 PM, several carts were noted to be parked outside the room. One of the carts was yellow, and the other cart was blue and gray. The carts were not marked with a warning sign that would indicate that R192 was on contact precautions. Anyone could have entered the room not knowing that contact precautions were needed. During an interview with Charge Nurse (CN) 41 on 11/27/18 at 12:28 PM, CN41 acknowledged that a warning Sign should have been posted at the entrance of R192's room. Facility policy titled Hale Makua Infection Control Manual for LTC, Contact Precautions was reviewed, it stated At the time a resident is place on Contact Precautions, the Unit Clerk will notify all pertinent departments. Before entering the room of a resident on Contact Precautions, staff and visitors should consult with a licensed nurse for instructions on specific precautions to be taken and Personal Protective Equipment to be used. 2. During an observation on 11/27/2018 at 12:30 PM observed a conspicuous sign outside R8's room that said isolation. The sign did not have any other information (i.e. type of isolation or instructions to report to the nursing station prior to entry) on it. Two residents, R8 and R44 were observed in the room sitting in wheel chairs approximately 5 feet apart. Neither R8 or R44 had any personal protective equipment (PPE) on to prevent transmission of a condition requiring isolation by direct or indirect contact. During an interview on 11/27/2018 at 01:15 PM Licensed Practical Nurse (LPN)130 stated, R8 has head lice, and is on contact precautions. On 11/28/2018 at 10:00 AM, observed the isolation sign on R8's room was gone. During an interview with LPN130 at 10:15 AM who stated that we took it down because someone thought it was a dignity issue. During further interview with LPN130, she pointed out a very small magnet sign located on the door frame. It was difficult to see. On 11/30/2018 Maintenance worker (MW) 115 went to R8's room to check the temperature and was advised R8 was in isolation. Prior to entering the room, MW115 approached surveyor and stated, I didn't see an isolation sign. After the small signage was pointed out to MW115 he put on the appropriate PPE and entered the room. During an interview with RN126 on 11/28/2018 at 2:00PM about the presence of R44 observed in the isolation room [ROOM NUMBER] on 11/27/2018. RN126 stated, That is her regular room. She has been sleeping in another room while R8 is on isolation. R44 didn't want to go to another room and is able to wheel herself around in her wheelchair. She keeps going back into her old room. The facility did not have a process in place to ensure R44 did not enter the isolation room putting her at risk. 3. On 11/29/2018 at 11:16 AM, observed LPN107 preparing for and providing wound care/dressing change on R204's left heel. LPN197 did not clear and clean a space for supplies and did not prepare the supplies in advance. LPN107 did not perform proper hand hygiene and wash hands prior to beginning removing the old dressing. After LPN107 put non-sterile gloves on, she removed the old dressing and disposed of it. With the same gloves LPN107 opened two different drawers on the dressing cart and removed clean supplies from each of the drawers. Some of these supplies were placed on R204's bed. The remainder of the dressing change was completed after washing hands and putting on new gloves. Professional standards of care state when changing a dressing, standard of care is to use aseptic technique to avoid introducing infections into the wound. Position the resident, wash your hands, clear and clean available space for dressing supplies (usually a bedside table), prepare the supplies for the dressing, and wash hands. To remove dressing, after washing hands, put on non-sterile gloves, and remove the old dressing. A wound assessment and visual check should be done. The gloves should be removed, hands washed, and new gloves put on to clean the wound, and again to put on the new dressing.",2020-09-01
84,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2017-06-02,280,D,0,1,HXLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and medical record review (MRR) the facility failed to utilize interdisciplinary expertise to improve range of motion (ROM) for 1 of 24 residents (R#129) on the Stage 2 survey sample resident list. Findings include: On 06/01/2017 at 12:13 PM observed R#129 with splint on the right (R) hand. On 06/01/2017 at 12:37 PM, the MRR on R#129 found that a ROM assessment was last done on 4/28/17. The interdisciplinary conference notes included the rehab report for U/E Range of Motion: No changes noted with _R#129's U/E ROM this screen .Resident received U/E ROM 2 x/week on unit since her return from acute hospital. Use of R handroll for contracture management and utensil with build-up handle for facilitating in feeding. The care plan (CP)#2, I am at risk for further decline in ROM d/t impaired mobility secondary to medical problems; with Goals: I will have no further decline in ROM; and interventions included: 6. encourage me to use utensil with build-up handle for feeding; 7. Use right handroll 2-3 hrs every am and pm shift for contracture management. Check for redness or skin breakdown. Discontinued use of handroll immediately if redness or skin breakdown, & notify CN or OT department; 8. maintenance OT/PT programs 2 x/week UE/LE exercises. Behind the CP#2 were instruction sheets for R handroll use with instructions to place handroll on right hand for 2-3 hours every a.m. and p.m. shift. On 06/01/2017 at 2:32 PM observed R#129 sleeping in bed and the handroll was not placed in R#129's hand, but around the wrist. The resident's family member was at the bedside visiting and stated that R#129 cannot stretch fingers & whenever they try to stretch the fingers R#129 complains, sore. The family member also tried to use a pressure ball in the hand but R#129 refused. Queried Staff#59 if the resident's handroll was properly placed and Staff#59 stated that R#129 moved the handroll and sometimes will throw it. On 06/02/2017 at 11:42 AM observed R#129's food tray with Staff#24 and Staff#88 in the dining/activity rm. There was a regular spoon on the resident's tray and not a built-up spoon as was ordered by the rehab therapist. According to Staff#24, the resident used the built-up spoon only when dining in-room because they didn't want to misplace the built-up spoon. Staff#88 further stated that R#129 didn't like to use the built-up spoon and would sometimes throw it. Staff#88 went to get the built-up spoon from R#129's rm and stated that she would try to make the resident use it. Discussed with Staff#24 that the use of the built-up spoon should be re-evaluated as resident observed to be using small disposable plastic cups to drink pureed food. The facility did not explore care alternatives through a thorough care planning process in which the resident was able to select from alternative treatments after staff observed that R#129 would throw the built-up spoon and the handroll. 2) On 06/01/2017 at 1:59 PM reviewed Resident (Res) #50 medical record. Care plan was reviewed and noted that there is a plan in place for risk for Diabetes Mellitus and [MEDICAL TREATMENT] (HD)-related complications. It was noted that the last review date was 04/17/2017 and next review to be done in July. The care plan stated that the resident will continue to maintain post HD weights within target weight goal of 105.6 lbs +/- 5 lbs. Reviewed note from the [MEDICAL TREATMENT] facility from 05/15/2017 which had the new DW (Dry Weight) 47 kg (103.4 lbs) per staff from Liberty [MEDICAL TREATMENT] Hawaii, LLC and this information was not on Res #50 care plan. On 06/01/2017 at 2:46 PM interviewed staff #24 and staff #124 to find out why the new dry weight 47 kg was not placed on Res #50 care plan and staff #24 stated that it would be updated in (MONTH) at the next care plan revision. It was explained to staff #24 and #124 the importance of this information that needs to be shared with all the staff who are taking care of this resident to avoid any injury that could result in harm to the resident. The facility failed to update 2 of 27 residents Care Plans from the Stage Two survey sample which may result in injury to the resident.",2020-09-01
85,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2017-06-02,313,D,0,1,HXLB11,"Based on record review, resident and staff interview the facility failed to ensure that 1 resident of the 27 Sample Stage 2 residents received proper treatment and assistive devices to maintain their vision. Findings include: On 06/01/2017 at 12:09 PM Resident (Res) #123 was observed eating his lunch without use of glasses. At 12:27 PM interviewed Res #123 and resident stated that they do not use glasses and feels their eyesight is good. On 06/02/2017 at 10:56 AM review of resident's record showed there were no eyeglasses on the property sheet, no care plan for the use of eyeglasses and no mention of the need for eyeglasses in the physical completed by the physician. Interview of staff #4 at that time stated that resident can read without glasses and that resident did not come in with glasses. On 06/02/2017 at 11:30 AM record review of last quarterly MDS, which was completed on 04/21/2017 has the following checked off under vision: Impaired-sees large print, but not regular print in Newspaper/books. Interview of staff #28 shared that the resident's family makes their appointments at the VA and that maybe the daughter could bring in glasses for the resident. At that time Res #123 did not have an eye appointment scheduled. On 06/02/2017 at 11:40 AM interview with staff #65 stated that resident was tested for his vision before it was documented in the MDS and the resident was only able to read the large print on the newspaper and not the small print, the coding was done correctly for Res #123. The facility failed to ensure that the resident receive proper treatment and assistive devices to maintain their vision.",2020-09-01
86,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2017-06-02,325,D,0,1,HXLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and medical record reviews (MRR), the facility failed to ensure that the physician participated in the nutritional assessment, and that a more in-depth nutritional assessment was done to identify nutrition related risks for 1 of 24 residents (R#129) on the survey Stage 2 sample resident list. Findings include: On 06/01/2017 at 12:03 PM observed R#129 eating lunch in the activity/dining room (rm) on the facility's second floor unit. The resident was able to self-feed the pureed meal served on a divided plate. The resident drank all of the fluids served in 6 ounce plastic cups and also the 1/2 cup of applesauce. After finishing all of the liquids of milk, apple juice, water and pureed applesauce, R#129 started to eat spoonfuls of pureed beef mac casserole and chicken rice soup. The resident was sampled for nutrition due to having a body mass index (BMI) of 18.2 and with no physician ordered supplement. On 06/01/2017 at 1:01 PM the MRR on R#129, found that the 2/7/17 speech/swallowing therapy evaluation for swallowing recommendations were for pureed solids and honey consistency liquids with feeding by nursing to observe for actual swallow. The residents weight (wt) on 5/24/17 was 87 lbs; 5/10/17 was 89 lbs in the units weight book. On 06/01/2017 at 1:05 PM interviewed Staff#24 as noted that the last nutritional assessment was done on 2/1/17 after an acute hospitalization for [DIAGNOSES REDACTED] ulcer perforation when R#129 was on GT feeding. Staff#24 stated that R#129 pulled out his/her gastrostomy tube (GT) on 2/14/17, and was put on intravenous (IV) fluids and pureed diet. The R#129 also pulled out the IV. On 2/15/17 the MD recommended not to replace GT/JT because the resident would continue to pull out tubes and would replace if he/she had poor intake. Since 2/15/17 R#129 received a pureed diet and doing well. Staff#24 stated that registered dietitian (RD) was included on interdisciplinary (IDT) meetings and provided documentation for the 2/14/17 IDT meeting on R#129, which the RD noted significant wt loss and resident on TF. Queried Staff#24 if RD did nutritional evaluation after R#129 switched to pureed diet and CN provided that 5/2/17 IDT meeting notes documented, see RD notes 5/2/17, but Staff#24 unable to locate RD notes. Staff#24 called RD and RD had documentation in her office. Continued to do MRR and R#129's care plan (CP) #12 dated 5/9/17, I am underweight related to significant weight loss AEB BMI Queried Staff#24 if supplement should be in treatment record. Staff#24 looked at R#129's treatment record and there was no supplement included. Staff#24 went to the unit's refrigerator and Boost Plus 120 ml was on the nourishment tray for R#129. According to Staff#24, the IDT develops each resident's CP and the resident's supplement should have been on the treatment record. On 06/01/2017 at 2:10 PM interviewed Staff#24 who was find out why the RD didn't reassess R#129 for supplement recommendation after the GT was discontinued on 2/15/17 but she could not provide an explanation. Queried Staff#24, on why supplement was started on 5/17 but sig wt loss was noted at the 2/17 IDT meeting, and she could not provide an answer. The resident's nursing assessment on 3/20/17, documented a wt of 85.2 lbs; and on 3/29/17, wt 85.4 lbs. On 06/01/2017 at 2:16 PM interviewed the RD and she related that on 2/17/17 the resident's niece and family were convincing R#129 to eat because the resident was refusing to eat and on that date started the supplement on a trial basis to see if the resident would drink the supplement. The IDT progress notes dated 2/17/17 Nutrition Follow-up, documented, Boost Plus 240 ml PO TID between meals. On the 5/2/17 IDT conference notes documentation; decreased Boost Plus 120 ml TID btw meals d/t improved intakes. Staff#24 and the RD looked through R#129's medical record and could not find an MD order for the supplement. On 06/02/2017 at 11:01 AM, the MRR on R#129, found a physicians telephone order dated 06/01/17 written with, (late entry for 5/2/17); 1) D/C Boost Plus 240 ml P.O. TID between meals 2) Decrease to Boost Plus 120 ml P.O. TID between meals. T.O. Dr. R. Gries, signed by Staff#24. On 06/02/2017 at 11:42 AM observed R#129's food tray with Staff#24 and Staff#88 in the dining/activity rm. There was a regular spoon on the resident's tray and not a built-up spoon as was ordered by the occupational therapist. According to Staff#24, the resident used the built-up spoon only when dining in-room because they didn't want to misplace the built-up spoon. Staff#88 further stated that R#129 didn't like to use the built-up spoon and would sometimes throw it. Staff#88 went to get the built-up spoon from R#129's rm and stated that she would try to make the resident use it. Discussed with Staff#24 that the use of the built-up spoon should be re-evaluated as resident observed to be using small disposable plastic cups to drink pureed food. The facility failed to provide nutritional care and services consistent with a comprehensive assessesment as the MD did not write the order for nutritional supplements, the built-up spoon was not re-evaluated for use when staff knew that the resident did not want to use it.",2020-09-01
87,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2017-06-02,333,D,0,1,HXLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that 1 resident of the 27 Stage Two sample of residents was free from significant medication error. Finding includes: On 05/31/2017 at 3:00 PM while reviewing Resident (Res) #95 chart and Medication Administration Record (MAR) a medication error was discovered. Res #95 has a doctor's order written on 04/11/2017 for the following medication [MEDICATION NAME] 70-30 vial, inject 18 U SQ q AM and 6 U SQ q PM, If resident eats 25% or less give [MEDICATION NAME] 70-30 9 U SQ Q AM and 3 U SQ q PM. Hold if BS On 06/02/2017 at 10:42 AM met with staff #28 to discuss medication error that occurred on 05/26/2017. Staff #28 reported that staff #20 discussed medication error with them on 05/31/2017 and they filled out the event report and notified the resident's physician and the physician in turn clarified the order. The facility failed to ensure this resident was free from a significant medication error which could have resulted in an injury to the resident.",2020-09-01
88,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2017-06-02,428,D,0,1,HXLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interviews the facility failed to review medications in collaboration with the MD for 1 of 24 residents (R#84) on the Stage 2 survey sample residents list. Findings include: On 06/01/2017 at 8:38 AM the MRR on R#84 found on the (MONTH) (YEAR) physician order [REDACTED]. for the [DIAGNOSES REDACTED]. The facility's pharmacist review dated 5/15/17 noted, 5/3 decrease (drawn arrow pointing down); 5/3 INR 3.1 re-titrate; MD Warfarin update. The lab results for PT/INR done on 5/03/17, had results of , PT 31.8 secs/ INR 3.1. The physician telephone order on 5/3/17 noted, Coumadin 1 mg PO on MWFSS and 2 mg PO on TTH. Check Protime in 1 month. The MD progress notes on 5/18/17 for the recertification visit noted on the, Plan: On coumadin cont medication. Adjust dose as indicated. Q 2 week INR checks .; Medications ordered: Warfarin 2 mg oral tab; Sig - route: Take 1 tablet by mouth once daily on T, TH, Sa, Su and take 1/2 tab on the other days for thinning the blood . Interviewed Staff#24 to clarify discrepancy of Jun 17 PO and MD visit on 5/18/17 with different orders for Warfarin. Staff#24 had to check with the MD as could not find documentation that new order was clarified with MD. MD report was faxed to facility on 5/22/17 12:36:54 AM. The IDT progress notes on 5/28/17 noted that the MD was notified & staff received telephone order for [NAME]itussin DM Q 6 hr for cough as R#84 was coughing/wheezy earlier that day. The residents CP#13, I am at risk for possible SE r/t use of Warfarin, included interventions: 1. Provide medication as ordered. (Warfarin Na). Observe for side effects like bleeding, behavioral changes, skin rashes, etc, document and notify MD as indicated. Lab works as indicated. Notify MD for changes. 3. Check my skin every shift and monitor for early signs of skin breakdown like redness blisters, rashes, bruises or an signs of bleeding, document and notify MD as indicated 5. refer to Pharmacy/MD for drug review and follow recommendations. The facility failed to ensure that R#84 was administered the correct dosage of Coumadin as prescribed.",2020-09-01
89,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,578,D,0,1,55H911,"Based on record review and interview the facility failed to complete an advanced health care directive (AHCD) for one of four residents investigated (resident (R)29 ). Findings include: Electronic Medical Record (EMR) for R29 reviewed. No AHCD or documentation that the resident or family representative refused to have an AHCD was found in record. The Maluhia resident's rights and responsibilities and advance directive and decision-making support documentation reviewed for R29. The Family member (FM)1 Advance Directives form checked that R29 does not have an advanced directive and that FM1 would like to have more information about advanced directives. Plan for follow up stated check with social worker. Signed and dated by the Power of attorney and dated 7/01/14. No follow up from the Social Worker (SW) was documented in the EMR. During an interview with the SW23 on 07/11/19 at 12:30 PM stated during the admission process, we will discuss the AHCD with the resident and/ or representative. If they have an AHCD done, we will review it and file it, but if they don't have one they will be given the forms to complete. We will have our notary do it. At the annual Inter-disciplinary team meeting (IDT) we can review it and /or follow up. When R29 was admitted to Maluhia, we completed the intake forms and did not follow up to ensure family was given information on the AHCD. Now moving forward we are addressing the AHCD at the time of admission and annually at the IDT meeting to ensure it was done.",2020-09-01
90,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,584,D,0,1,55H911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide clean bed rails in good condition for one of two residents (R)256 investigated. The deficient practice compromised the infection prevention control for R256 and lacks a homelike environment . Findings include: During an observation of the bed rails for R256 on 07/09/19 at 12:55 PM noted they appeared to have soiled tape wrapped around the rails that contained yellow/ brown residue on the tape. During an interview with the Licensed practical nurse (LPN)21 on 07/12/19 at 09:20 AM , upon review of the taped rails and asked what the tape was for LPN21 responded I am not sure but I will follow up and get back to you. During an observation on 07/12/19 at 09:42 AM the Director of Nursing (DON) and Head Nurse (HN)22 went into room [ROOM NUMBER] with LPN 21. The HN22 responded that the rails are taped because the foam on the rails was peeling off, I will ask maintenance to change it.",2020-09-01
91,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,695,D,0,1,55H911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that a resident who needs respiratory care, including [MEDICAL CONDITION] care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of one residents (Resident (R) 20) selected for review. This deficient practice had the potential to affect the other residents identified by the facility to require [MEDICAL CONDITION] care. Findings Include: On 07/09/19 at 03:33 PM, a random observation of Resident (R) 20 was done. R20 has a [MEDICAL CONDITION] and a care plan for being at risk for respiratory difficulty related to his [MEDICAL CONDITION] (trach) site. R20's care plan states he also requires frequent suctioning 4-6x (times) per day, including suctioning to [MEDICAL CONDITION] as needed for excessive oral secretions, and to assess his respiratory status (i.e., increased respiratory rate). During this observation, R20 exhibited an increased respiratory rate, intermittent gurgling like sounds and had whitish secretions coming out from [MEDICAL CONDITION] onto a napkin placed around [MEDICAL CONDITION]. At that time, the certified nurse aide (CNA) 1 who had taken R20's vital signs was in the hallway along with registered nurse (RN) 3. CNA1 stated she reported R20's status to the on-coming evening shift nurse, RN1, about five minutes prior. CNA1 said she told RN1 that R20 needed to be suctioned and had an increased respiratory rate around like 30 (breaths per minute). RN3 then stated the nursing endorsement can wait at the change of shift and went to find RN1. On 07/09/19 at 03:37 PM, RN1 came to attend to R20 at bedside. She prepped using sterile technique, but had some difficulty donning the gloves since she opened the sterile glove set on the resident's bed, along with [MEDICAL CONDITION]. There was an overbed table to use, but she did not use it. At 03:42 PM, she began the tracheal suctioning of the resident and suctioned R20 three times. Afterward, RN1 removed a napkin that had been placed around [MEDICAL CONDITION]. Upon removal, the front part of R20's clothing was wet from the secretions. RN1 said she was going to ask the CNA to change him. She also said, I'm gonna change this one too, (the [MEDICAL CONDITION] under the ties) and stepped out to get some saline. Upon her return, she cut a small hole in the middle of a new napkin and placed it over [MEDICAL CONDITION]. It was observed RN1 did this to replace the soiled one. On 07/09/19 at 03:49 PM, RN1 said that CNA1 told her that R20 needed to be suctioned but did not mention any urgency. RN1 stated she had been, counting and getting report from the day shift nurse. She affirmed however, she heard from the endorsement report that R20 needed to be suctioned more frequently than usual. At 04:03 PM, RN1 said she was going to suction R20 again. In the same manner as the first set up, she placed her sterile glove [MEDICAL CONDITION] again on R20's bed. At 04:06 PM, RN1 began the second round of tracheal suctioning, which she did twice. After this, she confirmed it was not until RN3 informed her about R20 that she dropped everything to do this. RN1 said, If she (CNA1) would tell me he really needed then I would have come. It wasn't mentioned that he was gurgly. On 07/09/19 at 04:14 PM, per a re-interview of CNA1, she re-verified she mentioned to RN1 that R20 needed to be suctioned and his breathing rate was higher when RN1 was getting report. On 07/09/19 at 04:37 PM, during an interview with the unit's head nurse, RN2, she said RN1 was a per diem nurse. Then during a concurrent observation at R20's bedside with RN2, she saw [MEDICAL CONDITION] and said, should always be visible and open and removed the napkin which RN1 had placed over it through the cut out opening to replace the soiled one. On 07/09/19, at approximately 5:10 PM, during an interview with RN3, she said, We have some young nurses, but the nurse has to go to the resident and assess and you can ask someone else to cover what you're doing. I'll be talking to them. On 07/11/19 at 09:09 AM during an concurent record review and interview with RN2, it was found that RN1 had no documentation related to her care provided to R20 on the evening shift of 07/09/19. There was no nursing assessment, no interventions/care provided, nor a follow-up note on R20's respiratory status. R20 had been suctioned five times, had increased secretions and an increased respiratory rate. Further, RN2 verified the only entry was a 07/09/19 15:30 (3:30 PM) entry showing R20's respiratory rate was documented at 30 breaths/minute with a warning High of 28.0 exceeded. When RN2 was asked about the expectations/standard of care for documentation by licensed staff, RN2 said she spoke to her staff about communication and the need to respond. She also said that nursing staff were no longer to place napkins over [MEDICAL CONDITION]. RN2 said R20 recently finished a course of antibiotics for seven days for pneumonia, and acknowledged there was a lack of documentation by RN1 regarding R20's condition and status. On 07/11/19 01:10 PM, during a concurrent review with RN2 regarding the job description (JD) for RN1 as a per diem nurse, it stated under major duties and responsibilities, [NAME] Nursing Care: . 3. Assesses resident's condition (physical and psychological); prioritizes needs; . 5. Reports and records pertinent observations and reactions to care rendered. B. Patient care activities, 2. b. Assess and reflects condition of resident accurately. d. Documents assessments. On 07/12/19 at 10:24 AM, RN2 said if there was anything out of baseline, the licensed staff, need to do a progress note. Even if they did do the suctioning, (only that documentation) looks like just a routine event versus something else going on at that time. She said for RN1 as a per diem nurse, she worked on the unit about once or twice a month, but affirmed there should have been some documentation by RN1 about her assessments and provision of care provided to R20 on 07/09/19. This failure to document was an indication of the lack of competency using standard nursing practices, for a resident who requires and is dependent on staff to provide airway management and on-going care.",2020-09-01
92,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,726,F,0,1,55H911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the licensed nurses contained documentation that the core competencies were filed in each employees education record. The deficient practice compromised competent nursing care is being provided to all of the residents residing in the facility. Findings include: 1) During an investigation into the competency of one licensed nurse (LN) on 07/11/19 at 03:41 PM it was discovered that the employee competencies for the entire nursing staff were missing from their employee training records. During an interview with the Director of Nursing (DON) on 07/11/19 03:43 PM stated that the employee skills and competency checklists for one licensed nurse were not found. Upon further investigation by the Employee Education coordinator it was discovered that none of the nursing staff had the skills and competency checklists filed in their employee records. The DON added that any training completed by the employee is documented and filed in their personal records. We keep everyone's records in the files until the employee leaves work at the facility. Our legal person drafted an affidavit for the employee in question and was notarized and signed stating that she completed the competency checklist. I told the level asked the level six Registered Nurses have all Licensed Nurses complete the core competency training as soon as possible. Each licensed nurse who could not provide a copy of the core competency check list will complete a notarized affidavit stating the requirements were completed at the time of hire. In the interim, we have already started to re-certify our licensed staff in the competency's and it will take a while. 2) Cross-reference to findings at F695. On 07/12/19 at 10:24 AM, RN2 said if there was anything out of baseline, the licensed staff, need to do a progress note. Even if they did do the suctioning, (only that documentation) looks like just a routine event versus something else going on at that time. She said for RN1 as a per diem nurse, she worked on the unit about once or twice a month, but affirmed there should have been some documentation by RN1 about her assessments and provision of care provided to R20 on 07/09/19. RN2 also failed to document her observation and action of removing the napkin that had been placed over [MEDICAL CONDITION] site during a concurrent observation on 07/09/19 at 04:37 PM. This failure to document nursing assessments and actions was an indication of the lack of competency to follow standard nursing practices, and especially for a resident who requires and is dependent on staff to provide airway management and on-going care.",2020-09-01
93,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,804,E,0,1,55H911,"Based on observation, interview and record review the facility failed to monitor safe temperatures on the steam table during meal preparation. The deficient practice placed residents at risk for food borne illness. Findings include: During an observation of the tray line on 07/11/19 between 11:30 AM to 11:50 AM during the lunch preparation it was noted that dietary staff were serving up the menu items onto trays for individual resident meals for the long term care (LTC) facility, the Adult Day Health Center (ADHC) and Meals on Wheels. The trays were then loaded into carts. Dietary staff did not check the internal temperatures of the beef tomato, peas or rice being served for the lunch time meal. The temperature logs for the steam table were not found. During an interview with the Dietary manager (DM) at 11:50 AM regarding the location of the temperature logs replied the log is kept on the bulletin board and pointed to a large bulletin board on a wall near the walk in freezer. Review of the temperature logs for the steam table revealed a blank temperature log. When asked when do the dietary staff check the temperatures the DM replied the temperatures are checked before and after the tray line and written down later. Observed the DM walk over to the tray area and retrieve a digital thermometer out of the drawer, clean with an alcohol wipe and proceed to the tray line while stating we keep the food really hot then checked the temperature of the beef tomato 190 degrees Fahrenheit (F), and the peas 200 degrees F. Facility Food Temperature Safety guide reviewed. Ground Meats are to be kept at 155 degrees F. The (YEAR) food and drug administration (FDA) food code reviewed. A summary chart for minimum cooking food temperatures and holding times required. Chapter 3 Meats (145 degrees) and 3 minutes holding time required for safe temperatures.",2020-09-01
94,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,842,D,0,1,55H911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review (RR) the facility failed to maintain accurate medical records for one resident (R)85 of 47 sampled residents. Medical records were not updated to reflect the most current diagnoses. There was a discrepancy of active [DIAGNOSES REDACTED]. This deficient practice has the potential to affect all residents. Findings include: 1. R85 was admitted to facility 12/24/09 after acute care hospitalization . Transfer [DIAGNOSES REDACTED]. urinary tract infection, and status [REDACTED]. Hospital course included, [MEDICAL CONDITION]. This patient was treated on her outpatient medication, [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION]). 2. A Pre-admission Screening /Resident Review Psychiatric Evaluation Part II Serious Mental Illness (SMI) Criteria (PASRR11) was completed on 06/23/16. The PASARR II revealed the facility marked Yes, to The patient is [AGE] years or older and has a possible [DIAGNOSES REDACTED]., but the PASARR II did not list [MEDICAL CONDITION] as a diagnosis.The [DIAGNOSES REDACTED]. 3. Minimum data set assessment ((MDS) dated [DATE] active [DIAGNOSES REDACTED]. 4. RR revealed one of the current active [DIAGNOSES REDACTED]. 5. During an interview 07/11/19 at 10:00 AM with the MDS Coordinator (RN 12), she confirmed that [MEDICAL CONDITION] was currently listed as an active [DIAGNOSES REDACTED]. 6. RR of psychiatric consults dated 05/23/19, 01/12/17, 06/23/16, and 09/18/14 revealed no documentation of [MEDICAL CONDITION], hallucinations or paranoia. 7. On 07/11/19 08:28 AM during an interview with the Director of Nursing (DON), the discrepancy of the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. She stated when R85 first came to the facility, R85's records indicated [MEDICAL CONDITION] and she was on medication. All residents were rescreened in (YEAR) to identify those who needed the additional PASARR 11 pre-admission screening. R85 was identified as needing the screening, which was completed on 06/23/16. DON did not think R85 had [MEDICAL CONDITION]. On 07/12/19 DON reported that the psychiatrist had examined R85 that morning and made the recommendation to discontinue the [DIAGNOSES REDACTED]. 8. Psychiatry consult for R85 dated 07/11/19 included the following: Psychiatric [DIAGNOSES REDACTED]. There is no evidence of [MEDICAL CONDITION]- no delusions, hallucinations . No evidence of [MEDICAL CONDITION] - suggest removal from any problem list to avoid confusion. After receiving the psychiatrist's recommendation, the attending physician was contacted, and gave a verbal order that read, DC (discontinue) Dx (diagnosis) of [MEDICAL CONDITION] per psychiatrists recommendation. [MEDICAL CONDITION] was removed as an active [DIAGNOSES REDACTED].",2020-09-01
95,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,880,E,0,1,55H911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR) and interviews, the facility failed to clearly identify and communicate the appropriate personal protective equipment (PPE) and precautions to be taken while performing their daily routine (i.e. housekeeping) or while providing care for residents that were on droplet precautions (actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions). One resident (R)33 of the five sampled did not receive enough education to understand why he was placed on droplet precautions or why he continued to be on them. Two other residents (R11 and R66) were also affected by the lack of knowledge/training related to the use of PPEs. The facility did not have a clearly defined policy or process in place to direct staff how to determine when the precautions were no longer needed, nor how to consistently implement transmission based precautions. Findings include: 1. The facility had residents on droplet precautions located on two different units (second and third floors). 2. On 07/09/19 at 09:00 AM, observed a laminated orange sign posted next to the doors of Room (Rm) 215, 216, 217 and 218. The sign read: Droplet Precautions . Respiratory protection: Mask required when working within 3 feet of patient (or when entering room). Check your hospital policy. At that time observed Rm 215, 217, and 218 were shared rooms with other residents. Rm 216 had separate entrances between them. There were droplet precaution signs posted over the bed of 215-3, 216-1, 217-3 and 218-2. 3. On 07/09/19 at 11:30 AM, during an interview with R33, he stated, I don't know why I have that sign (droplet precaution) up there. Asked if staff had informed him why he needed it (the precaution sign above his bed), and he replied, they just say because I have a cough. I've had a cough since I came in here. I'm afraid my family won't bring my grandkids in. 4. On 07/09/19 at 12:00 PM, during brief interview with RN13 about the droplet precaution signs, heard R33 calling from his room. RN13 responded and entered the room without putting on any PPE. RN13 was within three feet of R33 and had a conversation about the precaution sign. RN13 was not able to answer R33's questions to his satisfaction and requested RN11 to speak with him. RN11 informed R33 it's because of your cough. Remember, we discussed this. R33 was still frustrated. At that time, RN11 did not provide any additional information to R33 why he had droplet precautions or when the sign could come down. 5. Review of policy number ORIC0017 titled Outbreak control: Respiratory & [MEDICATION NAME] infectious conditions dated 01/23/19, directs staff for droplet precautions, to put on the PPE upon entering the patient's room. The policy did not include any direction for staff to determine duration of precautions. 6. 07/10/19 10:11 AM during an interview with the Infection Preventionist (IP), asked what the facility policy was for droplet precautions, and what staff are expected to do when resident is in a shared room. IP replied, I know, it isn't clear. I've done research on this, and the literature supports that three feet (distance from resident) is enough, and would apply in shared rooms. I've looked for different signs that would simplify this for the staff but can't find any. We have an annual competency and demonstration of donning and doffing (putting the PPE on and off), but we may need to add something about transmission to link to the type of isolation. We do need to make it clear how multiple occupancy rooms are addressed, and the signs need to be changed. 7. 07/10/19 12:02 PM Collaboratively reviewed R33's medical records with IP. IP discussed R33's course of treatment with RN11. R33's antibiotics were discontinued on 06/07/19. R33's temperature was 99 degrees on 07/04/19 and 96.9 degrees on 07/10/19. RN11 confirmed R33 had been afebrile (no fever) for some time but still had some cough. IP interviewed R33 and listened to his lungs. R33 expressed concern to the IP over the posted sign and why he was on precautions. IP explained he had a fever earlier and increased cough so needed to be put on droplet precautions. R33 understood the explanation. IP determined R33 no longer needed the precautions and removed the sign. 8. On 07/11/19 at 09:00 AM, observed staff putting PPE (gloves and mask) on prior to entering rooms with droplet precaution signs. Asked CNA15 if she had been informed the practice had been changed, and she replied, we were told to put it on before we enter now. 9. On 07/11/19 at 04:00 PM, during interview with RN11, asked when the communication had gone out to staff regarding the change in required PPE (put on entry versus three foot distance) . She said at shift endorsement on the evening shift. Asked if she had received that communication from IP, and she replied No. Stated there had been a discussion and questions the previous day, so to be cautious, she had instructed the staff to put the PPE on prior to entering the room rather than using the three-foot guideline. 10. On 07/12/19 at 07:52 AM interviewed RN16 about staff orientation and training for transmission-based precautions and what staff was taught to do for droplet precautions. Also asked if there were any special instructions for shared rooms. RN16 stated they are taught to use mask and gloves for droplet precautions. We use isolation signs on the front of the door. Asked how staff know which resident in a shared room has the precautions, and RN16 said, I'm not sure with the beds. Visitors check in with nursing. 11. On 07/12/19 at 03:00 PM, observed RN14 in the process of putting on a gown to enter Rm 217 (shared room with one resident on droplet precautions). The IP asked RN14 why she was putting on the gown and explained to her she did not need it with droplet precautions. 12. On 07/09/19, during the initial tour of the 3rd floor makai nursing unit, it was observed that Resident (R) 11 was on droplet precautions due to fever, cough and a finding of pneumonia per the registered nurse (RN) 4 caring for R11. The signage at the door of R11's room stated Droplet Precautions. This was a semi-private room (two resident beds) and R11 was in the bed by the window. At 09:11 AM, a housekeeper (H) 1 entered R11's room pushing a large dry mop. H1 entered the front part of the room without wearing any personal protective equipment (PPEs). RN4 was observed entering after H1 and asked him to come out and gave him a yellow mask to wear. Interview of H1 thereafter revealed he was supposed to wear gloves and a mask, but said he forgot to do so. 13. On 07/10/19 at 06:58 AM, an interview with RN 2 was done. She stated for droplet precautions, Because we have multiple residents with similar symptoms, so droplet precautions, we have to wear mask, gloves and gown. If we're just going in there to talk to them, or they're not coughing and we're about 3 feet away, no need to gown. 14. On 07/10/19 at 07:39 AM, on the 2nd floor mauka nursing unit, observed RN5 enter R66's room to turn off his bed alarm. There was signage for Droplet Precautions posted at R66's door. RN5 did not wear any PPEs when she entered the room. When RN5 exited the room and was asked whether she was to wear any PPEs, she said, Oh I just went in to turn off the alarm, but yeah, yeah, that is for the entire room and said she should have worn PPEs prior to entering the room. In addition to the orange Droplet Precaution sign, there was also a green placard for visitors. The fifth bullet on the green sign stated, Use of gloves, and mask when visiting. 15. On 07/10/19 at 09:35 AM, during a brief interview with RN 3, she said, Yes, before they (staff) enters room they should be wearing PPEs. Even if the resident in bed 2, because the air circulates and the other resident (in bed 1 by the door) may need help that staff should be wearing PPEs before they entered the residents' rooms identified with droplet precautions. 16. On 07/11/19 at 08:16 AM, H2 was briefly interviewed. H2 said he wears all PPEs before entering the room with droplet precautions in place, and proceeded to do so. 17. On 07/11/19 at 09:22 AM, during a medication administration observation for R66, RN6 donned full PPEs. She said, We have to (wear) full PPEs outside before entering the room. This was a change from yesterday, which was just a mask and gloves for some staff and none for others based on random observations. 18. On 07/12/19 at 12:45 PM, during an observation of the 3 makai unit, RN7 said for droplet precautions, just the mask to put on. CNA2 was seen with only a mask on in room [ROOM NUMBER], which had signage for droplet precautions posted when she brought out the first meal tray with no gloves on. A visiting chaplain also went into the room to visit the resident in bed 1, and he only wore gloves. CNA2 said, it's only the mask for the PPEs because R11 was the one identified for droplet precautions and not her roommate. There was a failure to systematically ensure transmission based precautions were properly implemented by staff and monitored by the infection control preventionist and designated head nursing staff of the affected units.",2020-09-01
96,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2018-08-28,686,D,0,1,QVE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and review of facility policy, the facility failed to place a pillow between resident's feet to prevent pressure on her feet. This practice would put Resident (R) 73 at risk for developing a pressure ulcer (PU) on her feet. This deficient practice had the potential to affect the 4 residents identified by the facility to have pressure ulcers. Findings Include: On 08/22/18 at 10:06 AM during record review (RR) of R73's electronic medical record (EMR) noted R73 had documentation of recurrent open area on her right big toe dated 06/18/18. Reviewed R73's skin assessment dated [DATE] at 1304 found there was a PU that was unstageable that was acquired in facility. On 08/27/18 at 11:14 AM at R73's bedside, with licensed practical nurse (LPN)1, requested to see R73's right foot. LPN1 pulled back R73's blanket and sheet noted R73's right big toe was healed. LPN1 stated I will put a pillow when it was discovered that R73's feet were resting near each other, side by side, touching each other. Further RR found PU documentation on 08/14/18 stated PU was new but at bottom of documentation it stated under notes Wound RN assessed and seen-resolved. Record review (RR) found R73 coded for a stage 2 PU on her last annual Minimum Data Set ((MDS) dated [DATE]. It was noted on R73's care plan (CP) that she is at risk for skin breakdown due to vegetative state, incontinence and diabetes. R73's CP was in place for PU wound and foot care but no intervention listed to place a pillow between feet to prevent the development of a PU. On 08/27/18 at 11:55 AM interviewed Head Nurse (HN) 2 who stated staff should be placing a pillow between residents feet to prevent putting pressure on the foot/feet. Review of facility Skin Care and Pressure Injury Prevention policy stated D. Protection from Friction, Shear and Pressure 6. Use positioning wedges or pillows. 7. Suspend heels while in bed. Neither of these were done for R73 upon observation 08/27/18 at 11:14 AM, putting this resident at risk to develop another PU on her feet.",2020-09-01
97,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2018-08-28,689,D,0,1,QVE911,"Based on observations and staff interview, the facility failed to secure a storage room located on the third floor. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards. Findings Include: 1. During an observation of the storage room (located on the third floor) on 08/21/18 at 10:13 AM, it was noted that the door (which contained a key pad lock mechanism) to enter the room was not locked and anyone could have entered freely. There was also no staff in the immediate vicinity to prevent anyone from entering the room. The room had three large trash containers, one floor buffing machine, a fan blower, two orange road cones, a wooden cabinet to store biohazards, and other miscellaneous items such as trash bags, and a floor sweeper. Access to this room may have put the safety of the residents and the public at risk for accident hazards. On 08/21/18 at 10:20 AM, after the above observation, the Administrator was questioned about the door. The Administrator stated that the door to that storage room should have been locked and secured. Then, upon further investigation of the door lock, it appeared that someone stuffed a napkin so that the door latch would not lock. The Administrator acknowledged the risk for accident hazards if the residents or the public had access to that room.",2020-09-01
98,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2018-08-28,700,D,0,1,QVE911,"Based on observation, record review, staff interview and facility policy review the facility failed to assess two residents (Resident (R) 34, R53) selected from the 40 resident sample for risk of entrapment from bed rails prior to installation and failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails. This deficient practice has the potential to affect all residents at the facility who have bed rails and newly admitted residents. Findings Include: 1) On 08/21/18 at 08:30 AM observed R34's bed had bilateral upper quarter bed rails on the bed. On 08/27/18 at 03:20 PM record review (RR) of R34 hard copy medical chart and electronic medical record (EMR) did not find an assessment for risk of entrapment from bed rails and no informed consent to use bed rails. Inquired with head nurse (HN)2 on 2 Makai unit who confirmed that R34 did not have a risk assessment for bed rail use and no informed signed consent form to use bed rails. HN2 explained the facility had started a new process in (MONTH) (YEAR) that includes doing an assessment and also the bed rail consent form with each resident's next MDS assessment. 2) On 08/21/18 at 02:42 PM observed R53 had bilateral upper bilateral quarter side rails on her bed. On 08/27/18 at 04:14 PM RR found R53 is total dependence on staff for activities of daily living (ADLs) such as feeding, brushing teeth and bathing. R53 had upper bilateral quarter side rails (these were removed during survey) and is immobile in bed even though her care plan (CP) states that bed rails are used for bed mobility. Inquired with evening shift RN1 who confirmed that R53 could not use bed rails on her own. RN1 stated R53 can hold rolled wash cloths in her hands and can hold onto the bed rail if her hand is placed there by staff. RR of resident's hard medical chart found that R53 had a side rail evaluation dated 04/24/18 and it stated no side rail in use. RR noted R53 did not have a signed informed consent for bed rail use. Inquired with HN2 who confirmed that R53 and R34 do not have signed informed consents to use bed rails. Review of facility's Bed Safety policy, provided by HN2, stated Policy Interpretation and Implementation 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails.",2020-09-01
99,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2018-08-28,880,D,0,1,QVE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to maintain infection control precautions for two residents out of 40 residents selected for review. Resident (R)8's open suction tubing with opposite end attached to suction canister was left on the bed side table. R73 had an open 0.9% Sodium Chloride (Normal Saline) container with an open date of 07/19 left at bedside with suction equipment was found on 08/28/18. The deficient practice had the potential to affect all residents who require suctioning at the facility. Findings Include: 1) On 08/21/18 at 08:30 AM observed R8's suction tube, leading from the suction canister, left on R8's bedside table and open end laying on top of the bedside table. On 08/21/18 at 09:45 AM inquired of HN2 if suction tube should be left open and on R8's bedside table and she concurred that suction tubing should not be left open on the bedside table. Later in the day, after lunch, HN2 stated that she changed out all of the suction attachments for all the residents on 2 Makai. 2) On 08/21/18 at 09:00 AM observed R73's bedside table with suction machine, tubing and normal saline. Noted that normal saline was open and dated 07/19. On 08/21/18 at 09:45 AM inquired of HN2 how long facility keeps open normal saline and she stated 24 hours. On 08/28/18 at 10:10 AM interviewed licensed practical nurse (LPN)2 who confirmed that she opened the 0.9% Sodium Chloride (Normal Saline) on 07/19 and stated that she used it one time for R73's [DEVICE] dressing change to cleanse the site, dated the bottle 07/19 and accidentally left it at bedside. LPN2 stated that it was her fault that she forgot to throw it out. LPN2 confirmed that they only use and keep the normal saline for 24 hours once it is opened.",2020-09-01
100,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2018-08-28,908,E,0,1,QVE911,"Based on observation, staff interview, and review of facility policy, the facility failed to perform routine maintenance, based on manufacturer's recommendation, and failed to keep preventative maintenance records for two out of fourteen oxygen concentrators reviewed. This deficient practice put the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: 1. During an observation and interview, on 08/21/18 at 2:30 PM, with staff RN3. RN3 stated the cleaning of all Oxygen Concentrator Filters were done on a weekly basis by the Certified Nursing Aides (CNA). However, during an interview with CNA1 on 08/21/18 at 2:31 PM, CNA1 was unable to cite when and how the cleaning of the Oxygen Concentrator Filter was performed. During an interview with the Central Supply Manager (CSM) on 08/21/18 at 3:03 PM, CSM stated that the floor CNAs were the ones to do the cleaning of the Oxygen Concentrator Filters. However, CSM acknowledged that the facility did not keep a record of the cleaning and there was no way to verify that the Oxygen Concentrator Filters were being cleaned as recommended by the manufacturer. During a review of facility policy pertaining to the cleaning and disinfection of equipment, it stated that the cleaning and filter changing of the Oxygen Concentrator's will be done based on manufacturer's recommendations. The facility failed to perform that. During an interview with Director of Nursing on 08/28/18 at 09:00 AM, it was acknowledged that the manufacturer's recommendations for their oxygen concentrators were not being followed.",2020-09-01
101,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2018-08-28,919,D,0,1,QVE911,"Based on observation, record, staff interview and family interview, the facility failed to adequately equip Resident (R)154's ability to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. Findings include: Observation on 08/21/18 09:00 PM call light noted to be resting on bed board hanging behind the patient's bed. Resident was sleeping. 08/21/18 02:04 PM Interview with R154's daughter and wife. During interview, tube feeding pump kept beeping and daughter pressed the tube feeding pump several times to silence the alarm. Daughter noticed that call bell was not within reach. Family called for the Registered Nurse (RN)2 to attend to the tube feeding pump. RN2 went to the panel on the all and turned off the call light and then tended to the machine. Call bell still left on bed board behind the bed. 08/21/18 at 03:46 PM Interview with RN2 who acknowledged the call bell was not reachable to the resident and he was not sure who placed it there.",2020-09-01
102,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2019-05-03,580,D,0,1,VD7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff, Resident (R)101's physician was not immediately informed of a significant weight loss. The deficient practice had the potential to prevent physician from commencing a new form of treatment for [REDACTED]. Findings include: On 05/01/19 at 08:55 AM a review of R101's record reflected that resident had a significant weight loss on 12/02/19, a 9.87% weight loss in a month from the previous month. Review of R101's record did not reflect any facility staff documented communication of the significant change to R101's physician. On 05/02/19 at 10:24 AM an interview with Staff(S)43, a registered dietician, validated that resident had a significant weight loss on 12/02/19, and that this significant change was not immediately communicated to R101's physician. S43 said that she was on leave for four weeks when R101's significant weight loss occurred. S43 said that while she was on leave, Staff(S)20, a registered dietician was providing coverage for her while she was on leave, and also did not communicate the significant weight loss to R101's physician.",2020-09-01
103,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2019-05-03,584,D,0,1,VD7611,"Based on observation and interview with Staff (S)128, the facility failed to provide a resident, Resident 34 with a homelike environment. The curtains were taped shut to the wall with several small pieces of clear plastic tape. Findings include: During an interview with Resident (R)34 on 05/03/19 at 11:53 AM the curtains were closed, taped to the wall with small clear plastic tape strips. R34 stated that although there is a preference to look out the window, the curtains are closed to reduce the glare in the room, the glare from the sun worsens his/her vision. During an interview and concurrent observation with S128, S128 stated the tape doesn't look very good in R34's room. Further stating, the curtains are taped to make the room less bright. S128 recognizes R34 has a problem with vision and the glare makes it more difficult for him/her to see. S128 was agreeable to think of another way to make the room less bright and the curtains better.",2020-09-01
104,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2019-05-03,641,D,0,1,VD7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately document the discharge of one Resident (R)106 on the Resident Assessment Instrument (RAI). Findings include: During record review of R106, the progress notes indicated that the resident was discharged home on[DATE]. There was also a doctor's order which indicated the same; resident discharged to home. However, upon review of the RAI discharge assessment (02/26/19), it indicated that the resident was hospitalized . During inquiry with the MDS Coordinator (Coord) 59 on 05/03/19 at 10:28 AM, Coord 59 acknowledged that there was wrong information in the discharge assessment. Coord 59 also could not explain why the information was inputted wrong. Coord 59 then proceeded to correct the information to reflect R106 being discharged home.",2020-09-01
105,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2019-05-03,656,D,0,1,VD7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, one resident (Resident 34) did not have a care plan for a visual impairment. Resident (R)34 is diagnosed with [REDACTED]. Findings include: During an interview with R34 on 05/01/19 at 10:14 AM, R34 asked can you please stand at the end of my bed so I can see you? I can't see. Its a [MEDICAL CONDITION] thing, I guess because I'm 88 it just happens. The staff do the best they can. I have a difficult time with the menu, but really can't be helped. Noted curtains were closed shut with pieces of clear plastic tape and taped back to the wall. R34 stated I really like the windows and would like to look out but my curtains are shut because the glare from the sun makes it harder to see. Electronic medical record (EMR) reviewed for R34. MDS dated [DATE] reviewed. Section B vision is coded moderately impaired. MDS dated [DATE] reviewed. Section B vision is coded moderately impaired. CAA: triggers include visual function for care plan. Care plan reviewed. No interventions, goals or objectives found for visual impairment. Consultation report by ophthalmologist was reviewed. R34 was evaluated on 04/08/19 and diagnosed with [REDACTED]. R34 is legally blind (able to see faces and reading is difficult). However, peripheral vision is normal. During an interview with Staff (S)34 on 05/02/19 at 10:00 AM, S34 stated a provider who works here donated an I-pad. S34 stated he will adjusting the color, brightness and fonts larger so she may be able to can read. During an interview with S128 on 05/03/19 at 11:00 AM, S128 stated that there were no care planned goals and interventions to accomodate R34's visual impairment.",2020-09-01
106,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2019-05-03,657,D,0,1,VD7611,"Based on record review and interview with staff, the facility failed to revise 1 of 23 care plans that were reviewed. Resident (R)101's care plan was not revised for three months after a significant weight loss. The deficient practice had the potential to prevent a timely person-centered, comprehensive care plan from being revised according to resident's needs. Findings include: On 05/01/19 at 08:55 AM a review of R101's record reflected the resident had a significant weight loss on 12/02/19, a 9.87% weight loss in a month from the previous month. Review of R101's record did not reflect R101's care plan was revised. The care plan was revised on 04/24/19, nearly four months after the significant weight loss event. On 05/02/19 at 10:24 AM an interview with Staff (S)43, a registered dietician, validated that resident had a significant weight loss on 12/02/19, and that R101's care plan was revised on 04/24/19 for this significant weight loss. S43 reportedly was on leave for four weeks when R101's significant weight loss occurred. S43 said that while on leave, S20, a registered dietician was providing coverage and also did not revise care plan when the significant weight loss occurred.",2020-09-01
107,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2019-05-03,697,D,0,1,VD7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews with resident and staff members, and review of the facility's policy and procedures, the facility failed to manage residents' pain in accordance with the physician's orders [REDACTED]. Findings include: On 04/30/19 at 09:10 AM, Resident (R) 96 was interviewed. R96 reportedly has back pain to the lower back which makes it difficult to walk. R96 was asked whether the facility provides medication to manage the pain, the resident reported the medication is effective. R96 was sitting on the bed and during the interview, R96 was observed to grimace with movement. R96 reportedly receives antibiotics intravenously due to a blood infection. A record review was done on the afternoon of 05/01/19. R96 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The admission Minimum Data Set (MDS) with an assessment reference date of 04/16/19 documents R96 yielded a score of 15 (cognitively intact). A review of Section [NAME] Pain Management notes R96 has a scheduled pain medication regimen and receives pain medication prn (as needed). R96 also reported to have almost constant pain over the last five days which does not interfere with sleep at night; however, limits day-to-day activities. R96 describes the pain as moderate. The care plan identifies R96 has moderate to severe pain related to osteo[DIAGNOSES REDACTED], lumbar [MEDICATION NAME] abscess, and bilateral psoas abscess. The goal included: the pain will be adequately controlled and I will be able to participate with my daily care comfortably. The interventions included: administer my routine [MEDICATION NAME] as ordered and offer me tylenol for mild pain or [MEDICATION NAME] IR as needed every 4 hours if you notice that I am getting restless or I have severe pain; assess me for pain every shift, prior to being out of bed, and when you pass my room and notice that I am awake; assist me with my transfers and give me adequate time to move at my own pace; do gentle passive ROM to extremities during care, observe for pain complaints and update my physician; and offer to pre-medicate for pain prior to therapy so I can better participate. A review of the physician orders [REDACTED]. capsule by mouth, three times a day for [MEDICAL CONDITION]; [MEDICATION NAME] tablet, 325 mg., 2 tablets by mouth every 4 hours as needed for pain; [MEDICATION NAME] HCI tablet 5 mg., give 2 tablets every 4 hours as needed for moderate pain; and [MEDICATION NAME] HCI tablet 5 mg., give 3 tablets by mouth every 4 hours as needed for severe pain. Further review found a physician's orders [REDACTED]. Subsequently the physician ordered continuance of PT (5x/week) and OT (5x/week) services effective 04/30/19 until 05/07/19. On 05/02/19 at 07:32 AM a review of R96's admission Pain assessment dated [DATE] notes the resident is almost constantly in pain. R96 is provided with [MEDICATION NAME], 5 mg. tablet, two tablets every 4 hours for moderate pain and 3 tabs every 4 hours for severe pain. Non-pharmacological intervention identified was talking to the resident. A review of the Medication Administration Record [REDACTED]. R96 was provided with [MEDICATION NAME] tablet on the following days: 04/09/19 at 03:37 PM with a pain level of 10; 04/16/19 at 01:30 PM with a pain level of 3; 04/17/19 at 11:58 PM with a pain level of 7 (ineffective); and 04/19/19 at 0901 AM with a pain level of 8. R96 was provided with 2 tablets of 5 mg. [MEDICATION NAME] for moderate pain for pain levels ranging from 4 to 8. The dosage was ineffective on 04/12/19 (pain level of 4); 04/14/19 (pain level of 7); 04/15/19 (pain level of 7); and 04/17/19 (pain level of 6). The resident was provided with 3 tablets of 5 mg. [MEDICATION NAME] for severe pain on 04/09/19 (pain level of 8) and 04/10/19 (pain level of 6). Also, there is documentation for 04/24/19 that pain medication was not administered according to the physician's orders [REDACTED]. At 07:55 PM two tablets were administered for a pain level of 5 and at 09:09 PM (one hour and fourteen minutes later) another dosage (2 tablets) was provided for a pain level of 5. On 05/02/19 at 08:54 AM an interview was conducted with Registered Nurse (RN) 56. Queried what is the numeric pain level for mild, moderate and severe pain. RN56 responded mild is 1 to 4, moderate is 5 to 7, and severe 8 to 10. The staff member requested (Head Nurse) HN82 to assist. HN82 reported R96 is able to identify the dosage required for the level of pain, the resident is able to tell the nurse what is needed. Concurrent review of the MAR indicated [REDACTED]. HN82 responded the resident was not transferred to the facility with the [MEDICATION NAME] so was provided with the [MEDICATION NAME] until the orders and medication were available. HN82 reported skilled PT and OT was placed on hold due to the resident's report of pain. Further queried whether the prn pain medication is being administered according to the numeric pain levels for mild, moderate and severe pain. HN82 reported R96 is cognizant therefore, will know what medication will alleviate the pain and will tell the nurse what is needed. HN82 later stated a physician will not give an open order to administer pain medication per resident's request. On the morning of 05/03/19, the facility provided a copy of the policy and procedures entitled Pain Assessment and Care Management. In Section IV. Procedure, pain is identified and screened for residents without cognitive impairment with a pain rating scale of: 1-3 suggesting mild pain; 4-6 suggesting moderate pain; and 7-10 suggesting severe pain.",2020-09-01
108,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2019-05-03,755,D,0,1,VD7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with staff, the facility failed to acquire two medications to meet the needs of Resident (R)256 because the medications were found to be expired. The deficient practice potentially could have resulted in R256 not receiving sufficient medications to treat R256's mood disorder and blood cholesterol. Findings include: On 05/02/19 at 01:48 PM A supply of [MEDICATION NAME] 15 mg, an antidepressant medication was found in the locked 5th floor, Team 1 medication cart, which expired on 02/06/15 for R256. A supply of [MEDICATION NAME] 20 mg, a medication used to control blood cholesterol was found in the locked 5th floor, Team 1 medication cart, which expired on 10/17/14 for R256. On 05/02/19 at 01:48 PM Staff Nurse 31 validated that the both medications were expired. It was confirmed that R256, who was admitted on [DATE], did not receive any of the expired medications.",2020-09-01
109,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2019-05-03,758,D,0,1,VD7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure a gradual dose reduction for the use of an antipsychotic was attempted, unless clinically contraindicated for 1 of 5 residents (Resident 54) reviewed for unnecessary medication. Findings include: Resident (R) 54 was admitted to the facility on [DATE], [DIAGNOSES REDACTED]. On 04/30/19 at 10:25 AM a record review found a physician order [REDACTED].e. I'm scared, I'm going to fall). Further record review was done on the morning of 05/02/19. A review of the annual Psychoactive Medication Tracking Form - V2 dated 03/19/19 documents the use of [MEDICATION NAME] 0.25 mg three times daily with a start date of 03/22/18. The anticipated gradual dose reduction (GDR) date was six months with an anticipated quarterly review date of 05/21/19. On 05/12/19 at 09:42 AM an interview was done with Head Nurse (HN)82. Inquired whether a GDR was done or considered for R54. HN82 reported the pharmacist completed a medication regimen review in (MONTH) 2019 and requested consideration of a GDR for R54. HN82 provided documentation dated 03/12/19 from the pharmacist to the physician requesting to evaluate R54's current dose of [MEDICATION NAME] (0.25 mg. three times daily) and consideration of a gradual dose taper to ensure the resident is using the lowest possible effective/optimal dose. HN82 explained the physician did not respond; therefore, the pharmacist followed up on 04/06/19. HN82 provided documentation entitled Medication Regimen Review Recommendations by Outcome Response which indicates response is still pending. HN82 reported the facility has contacted the physician; however, the physician has not come to the unit to review this recommendation.",2020-09-01
110,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2019-05-03,812,F,0,1,VD7611,"Based on observations, staff interview, and policy review the facility failed to clean and sanitize three drains/pipes located on the kitchen floor. As a result of this deficient practice, the facility put the residents at risk for potential foodborne outbreaks. Findings include: During observation of the kitchen on 04/30/19 at 07:45 AM, three drains/pipes were noted to be covered with dirt/rust/and various food particles. Simultaneously during the above observation, the Kitchen Manager (Mgr)138 was queried about the dirty drains/pipes. Mgr138 acknowledged that the drains/pipes were dirty and that the issue was previously discussed by their team. Mgr138 stated that there was a cleaning schedule for the kitchen, but that did not include cleaning the drains/pipes. During observation of the kitchen on 05/02/19 at 11:00 AM, the three drains/pipes, previously mentioned, were noted to be unchanged; covered with dirt/rust/and various food particles. A review of facility's policy on Resident Rights stated the following: Environment, the facility must provide housekeeping and maintenance services necessary to maintain a sanitary . interior.",2020-09-01
111,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2019-05-03,883,E,0,1,VD7611,"Based on record review, staff interview, and review of policy, the facility failed to offer pneumococcal immunizations for two out of five Residents, (R)11 and R28, selected for review. The schedule for the pneumococcal immunizations follows the recommendation of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). As a result of this deficient practice, the facility put R11 and R28 at risk for acquiring, transmitting, or experiencing complications from pneumococcal disease. Findings include: During a review of the immunization/vaccination record for R11, it was documented that the last pneumococcal vaccination was given on 09/12/09. There was no other documentation indicating that the vaccination was offered any time thereafter. During a review of the immunization/vaccination record for R28, it was documented that the last pneumococcal vaccination was given on 10/31/13. There was no other documentation indicating that the vaccination was offered any time thereafter. During an interview with Charge Nurse (CN)134 on 05/02/19 at 02:32 PM, CN134 acknowledged the previous findings, where R11 and R28 was not offered the pneumococcal vaccination after the last date that they received it. During staff inquiry with Unit Clerk (UC)179 on 05/02/19 at 02:35 PM, UC179 revealed that the pneumococcal vaccinations were previously monitored using a vaccination record worksheet. However, that worksheet was no longer being used since the health record was moved to the electronic health record. Accordingly, UC179 acknowledged that the pneumococcal vaccinations were not being monitored. A review of facility's policy on Immunizations stated the following: Purpose; delineate the immunization requirements for all patients admitted to (facility's identified region) for the purpose of avoiding vaccine preventable diseases. Policy; Oahu region facilities utilize the current recommendations of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). The policy also contained the CDC guidelines titled Pneumococcal Vaccine Timing for Adults. The guidelines state to make sure your patients are up to date with pneumococcal vaccinations.",2020-09-01
112,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2019-05-03,921,E,0,1,VD7611,"Based on observations, staff interview, and review of policy, the facility failed to secure a storage room where an electrical panel box was located. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards. Findings include: During an observation of the [NAME] 2 Nursing Unit (Y2 Unit) on 04/30/19 at 10:22 AM, a storage room which contained an electrical panel box was not secured. No staff members were in the immediate vicinity to prevent any residents and/or visitors from accessing the storage room/electrical panel box. Also, four residents (Resident (R) 2, 15, 27, 90) were noted to be rolling themselves around, in their wheelchairs, close to where the storage room/electrical panel box was located. During a second observation of the Y2 Unit, done with the Maintenance Staff (Maint Staff) 25 on 04/30/19 at 01:45 PM, Maint Staff 25 acknowledged that the storage room/electrical panel box is supposed to be secured; the door should have been locked. Maint Staff 25 then locked the storage room door and assured that the storage room/electrical panel would be secured. A review of facility's procedure titled Resident Rights and Responsibilities stated the following: Environment: The facility must provide a safe . environment. Again, the storage room which contained an electrical panel box was not secured/not locked.",2020-09-01
113,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2018-08-02,578,D,0,1,GPL111,"Based on medical record (MR) review and staff interview the facility failed to provide follow up information regarding Durable Power of Attorney (DPOA) and advance directives as requested by resident (R) 32 untill seven months later. Findings include: On 07/26/18 during MR review for R32 found R32 had reviewed the Advance Directive and Decision- Making Support Documentation form, dated 12/07/16, and requested for more information on DPOA for Health Care decisions. This was documented in MR as referred to Social Services. On 07/31/18 at 10:40 AM interviewed Social Worker (SW) 9 and inquired when Social Services followed up with R32 concerning DPOA for Health Care decisions. SW9 stated she followed up with R32 on 07/29/17 regarding R32's DPOA for Health Care decisions. SW9 confirmed this was a slip up on her part, and stated she should have followed up earlier regarding this matter. On 07/31/18 at 11:22 AM SW9 stated that she could not find any documentation that was made by her regarding a conversation she had with R32's daughter discussing R32's advance health-care directive. Requested and was given facility's policies and procedures regarding advanced healthcare directives. Review of the facility's Advance Directive policies and procedures (P&P) with effective date of 01/01/09, found section IV. Procedure [NAME] 3. If the individual would like more information or to execute an advance directive, a referral will be made to Social Services for assistance. The social service staff will document their intervention on the Advance Directive and Decision Making Support Documentation Sheet.",2020-09-01
114,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2018-08-02,623,E,0,1,GPL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on residents' MR review and staff interview, the facility failed to notify a representative at the State Office of the Long-Term Care (LTC) Ombudsman for four residents (R) 53, R75, R86, and R96 who were transferred or discharged from the facility to an acute hospital. Findings include: 1) On 07/26/18 at 02:28 PM during MR review for R75 found R75 was discharged or transferred from the facility to an acute hospital and readmitted back to the facility on several occasions. R75 was discharged on [DATE], readmitted on [DATE] and transferred on 03/15/18 and readmitted on [DATE]. On 08/01/18 at 09:04 AM interviewed SW9 who confirmed that a representative at the State Office of the LTC Ombudsman had not been notified of R75's discharge or transfer from the facility to an acute hospital. SW9 concurred that the Ombudsman was supposed to be notified and Social Services Department missed some of these notifications. Requested from SW9 who then provided facility P&P on transfers/discharges. 2) On 07/27/18 at 10:53 AM during MR review found R96 was discharged from facility on 03/18/18 to an acute hospital and readmitted back to facility on 03/23/18. On 08/01/18 at 09:02 AM interviewed SW9 who stated she could not find documentation the LTC Ombudsman was notified of R96's discharge from the facility. Inquired if a representative at the State Office of the LTC Ombudsman should have been notified, SW9 confirmed that the Ombudsman was not notified and should have been. 3) During MR review on 07/30/18 at 2:35 PM, Health Unit Clerk (HUC) 8 provided facility transfer document dated 05/09/18 showing R53 was transferred to an acute hospital on [DATE]. During interview on 08/01/18 at 1:20 PM with SW9, SW9 stated they did not send notification to the State Office of the LTC Ombudsman when R53 was transferred to an acute hospital on [DATE]. 4) On 08/01/18 at 10:28 AM MR review for R86 noted in progress notes R86 was transferred from facility to an acute hospital on [DATE]. On 08/01/18 at 09:04 AM interviewed SW9 who confirmed that a representative at the State Office of the LTC Ombudsman had not been notified of R86's transfer from the facility to an acute hospital. SW9 confirmed the State LTC Ombudsman was supposed to be notified and Social Services Department missed some of these notifications. Inquired of SW9 if facility had P&P for transfers/discharges which she provided. Reviewed of facility's P&P with effective date of (MONTH) 07, (YEAR) and under section IV. Procedure: C. The Discharge/Transfer Notice to the Long Term Care Ombudsman . Then send the Transfer/Discharge Notice and facility's Transfer/Discharge Notice to the Long Term Care Ombudsman either by e-mail: . , fax: . , or phone: .",2020-09-01
115,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2018-08-02,641,D,0,1,GPL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and MR review, the facility failed to accurately assess and record three Residents' (R) 32, R69, and R73 Minimum Data Set (MDS) out of 33 residents selected for review. The facility failed to accurately assess and record R69's medical condition and status and R32 and R73 for bed rail/grab bar use at the time of the assessment. Each portion of the MDS assessment must accurately reflect the resident's status as of the assessment date. Findings include: 1) On 07/31/18 at 8:34 AM MR review of R69's MDS with ARD of 09/07/17 showed discrepancy noted in section: H Bladder and Bowel under [NAME] Indwelling catheter, and B. External (condom) catheter, both areas were marked off. During interview with MDS Licensed Nurse (LN) 5 on 07/31/18 at 8:40 AM regarding R69's admission MDS with ARD of 09/07/17 under section H Bladder and Bowel, both Indwelling catheter and External (condom) catheter were marked off, MDS LN5 stated it was coded incorrectly. 2) On 08/01/18 at 02:30 PM MR review found R32 had signed an Informed Consent and Release form for Side Rails. R32's latest Minimum Data Set (MDS) quarterly assessment dated [DATE] was coded with bed rails not used. On 08/01/18 at 02:48 PM interviewed LN8. Inquired why R32 was coded in MDS quarterly assessment as not using bed rails when R32 has bed rails on her bed. LN8 stated it was an error, confirmed that R32 should have been coded for bed rail use in the last MDS quarterly assessment dated [DATE]. 3) On 08/02/18 at 09:33 AM R73 was observed with bilateral upper grab bars on his bed. MR review for R73 found R73 had signed for a risk assessment and a consent for bed rail use. R73's quarterly MDS dated [DATE] was not coded for side rails/grab bars use. MR review found R73 has a care plan in place for grab bar use in bed for mobility/turning. On 08/02/18 at 09:45 AM interviewed MDS LN6 who concurred R73 does have bilateral upper grab bars on his bed and concurred that R73 should have been coded for bed rail use in the quarterly MDS dated [DATE].",2020-09-01
116,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2018-08-02,655,D,0,1,GPL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and MR review, the facility failed to complete and implement the baseline care plan within 48 hours of resident's admission for two Residents (R) 44 and R310 out of 33 residents selected for review. This had the potential to affect the necessary medical information to properly care for R44 and R310, immediately upon their admission, which would address resident specific health and safety concerns to prevent decline or injury, such as Falls or elopements. Findings include: On 07/30/18 at 10:09 AM MR review found R44 was admitted to the facility on [DATE]. R44's baseline care plan (CP) was signed by nurse and R44. Noted was the baseline CP for R44 was created and implemented nine days after R44's admission to the facility. Interviewed LN7 who confirmed baseline CP's are to be created and implemented within 48 hours of residents' admission to the facility. Review of facility's Nursing Services Memorandum Subject: Interim CP CHANGE to Baseline CP states under Procedure: 2. The unit's LN who is admitting the resident will initiate the Baseline CP . within 48 hours. 2) On 08/02/18 at 11:29 AM MR review of R310's showed Interdisciplinary Admission Care Plan was created but no signstures and or dates were noted on this document. During interview with LN1 on 08/02/18 at 12:35 PM, LN1 confirmed there are no signatures and/or dates noted to the Interdisciplinary Admission Care Plan for R310. LN1 stated the Interdisciplinary Admission Care Plan was done for R310's admission and should have been signed and dated by staff who created this care plan.",2020-09-01
117,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2018-08-02,656,D,0,1,GPL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on MR review and staff interview the facility failed to develop a CP for R56's dental care. The facility failed to create and implement a CP to notify the dietitian of a six pound (lbs) weight gain for R32 who is receiving [MEDICAL TREATMENT]. Findings include: 1) On 07/26/18 at 01:05 PM During interview with R56 who reported she has a cavity and has not seen a dentist. On 07/27/18 at 04:06 PM MR review found R56 was seen on 06/03/18 by the dentist at the facility. The CP was not updated and expanded to include Oral/dental health problems r/t teeth carious until 07/30/18 which is more than a month after R56 saw a dentist. 2) On 08/01/18 at 11:54 AM MR review found R32 has a [DIAGNOSES REDACTED]. Review of R32's MDS dated [DATE] has R32 coded for [MEDICAL TREATMENT] services. MR review found R32 has a CP in place for [MEDICAL TREATMENT] which includes interventions such as diet (Renal, Heart Healthy), and notify Registered Dietitian (RD) of five pounds gain or loss within a month. On 08/01/18 at 12:44 PM MR review of R32's weights found R32's weight on 10/28/17 was 112.8 lbs and on 11/28/17 was 118.8 lbs. This was a six pound weight gain in a month. On 08/01/18 at 01:00 PM telephone interview with RD who stated she was not notified of R32's six pound weight gain during that period of time. Inquired who would notify RD of the six pound weight gain and RD stated it would be nursing staff. On 08/01/18 at 01:05 PM interviewed LN1 who confirmed nursing is responsible for notifying RD of weight change. Interviewed LN7 who confirmed there was no documentation in R32's progress notes that nurses documented they notified RD regarding R32's weight gain.",2020-09-01
118,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2018-08-02,677,D,0,1,GPL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, MR review, and staff interview the facility failed to provide proper oral care for R33 resulting in R33 having a pronounced foul odor from his mouth which potentially affected other residents especially residents who are in the same room as R33. Findings include: On 07/24/18, before lunch, while walking around [NAME] four unit, passed R33's room and smelled foul odor coming from the room. R33 was noted to be in the room with three other residents. On 07/25/18 at 01:58 PM Observed R33 in bed and noted there was a very strong foul odor coming from him, was unable to determine where the foul odor was coming from. On 07/25/18 at 02:20 PM interviewed LN7 in R33's room at bedside. Inquired what the smell was and where it was coming from. LN7 checked R33 and noticed the foul odor was coming from R33's mouth. On 07/25/18 at 02:30 PM interviewed LN1, inquired if she was aware of foul odor that was coming from R33's mouth. LN1 stated she noticed it a couple of months ago and started a nursing intervention. The nurses assigned to R33 would monitor R33's oral care every shift as stated on R33's treatment administration record (TAR) which was started on 05/21/18. The nursing intervention was done in (MONTH) (YEAR) and documented on R33's TAR but not carried over onto R33's (MONTH) (YEAR) TAR. On 07/26/18 at 09:11 AM MR review found R33 has a [DIAGNOSES REDACTED]. Review of R33's Minimum Data Set (MDS) quarterly assessment dated [DATE] coded R33 is totally dependent on staff to perform personal hygiene such as oral care. On 08/01/18 at 04:08 PM met with LN7 and inquired if R33 was seen by his physician for foul odor from his mouth. LN7 stated R33 was seen by the dentist on 06/03/18 and produced the consultation sheet from this appointment. The dentist charted R33's . Oral hygiene (OH) poor, mod amount of plaque build up . Inquired of LN7 if staff should do more to help R33 to prevent the foul odor in R33's mouth and she concurred.",2020-09-01
119,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2018-08-02,686,D,0,1,GPL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on MR reviews, staff and resident interviews, and observations the facility failed to assure that 1 of 2 residents (R) 77 with pressure ulcers (PU) on the survey sample of 33 residents, received care consistent with professional standards of practice to promote healing of existing PU/injuries (including prevention of infection to the extent possible). Findings include: On 07/25/18 at 11:15 AM Interviewed R77 and inquired about his Stage 3 sacral PU. R77 stated the sacral PU is off and on, and that some nursing staff turn him properly and others lay him flat. Also, the wedges used to position him are sometimes shoved in a little too far. On 07/27/18 at 3:00 PM interviewed R77 for permission to see PU dressing change the next time it is done. R77 stated he went to the wound clinic today (07/27/18) and dressing change was done. R77 gave permission to observe the next dressing change scheduled for Monday (07/30/18). Inquired when R77 would be repositioned again based on his scheduled repositioning every (Q) two hours. R77 stated he was just repositioned to the right side and that position changes were at odd hours (1, 3, 5 . ). Observed that R77 laid on his back with head of bed up and inquired if he repositioned himself. R77 stated he is not comfortable when positioned on his side so staff just adjust wedges around him. On 07/30/18 at 10:26 AM Observed R77's dressing change on his Stage 3 sacral PU done by licensed nurse (LN) 11 with assistance provided by LN2 and LN1. After the dressing change was completed R77 directed the nurses on how wedges should be placed. On 07/30/18 11:01 AM interviewed nurses and inquired how R77 acquired sacral PU. LN1 stated that R77 had old PU injuries that kept opening up. Inquired what is being done differently now to prevent PU's and LN2 stated that R77 now goes to a wound clinic. Both nurses also stated that R77 has tendency to lay on his back after being positioned on side, as prefers to be on his back. LN2 provided the recent wound clinic report dated 07/27/18; and it noted: Today's wound orders: Keep pressure off wound at all times, if need to sit on wound reposition every 10 min; wound dressings 1; Cleanse wound gently with : wound cleanser; protect skin around the wound with : barrier wipes comment - or moisture barrier paste; Primary dressing: silver alginate; Change dressing: Every 3 days as needed. Pointed out the discrepancies of the wound clinic orders with the wound care just observed. Noted during the wound dressing change that normal saline (NS) was used to cleanse the wound and no moisture barrier paste was used. According to LN1, the PU treatment record dated 06/27/18 noted cleanse with NS. LN11 stated that barrier paste was not used because it would prevent the foam dressing from adhering to the skin. LN2 stated that the wound clinic order was just received today (07/30/18) and R77's physician did not review. Queried how long staff wait to verify new orders and nurses weren't sure. On 07/30/18 at 1:33 PM interviewed the Director of Nursing (DON) and she stated that R77 would get very upset with staff if repositioned Q 10 minutes per wound clinic orders. Inquired how facility staff reconciled PU treatment from the wound clinic with R77's physician orders; and, how staff know which orders to follow. The DON asked LN1 to find documentation and interview continued with LN1. According to LN1, the staff would follow R77's physician orders [REDACTED]. LN1 provided MR documentation that on 05/24/18 the wound nurse consultant recommended NS to cleanse R77's sacral PU and on the 05/30/18 wound clinic report it was written, continue same wound care regimen . On the 06/27/18 wound clinic report it was noted that antibiotics were ordered for the Stage 3 PU; and progress notes on the same date noted that antibiotics were received from the facility's pharmacy and administered to R77. Reviewed R77's MR with LN1 and there were discrepancies on dressing change treatments on the weekly skin condition form and progress notes documentation. For example, on the 05/24/18 weekly skin condition form it noted, Cleanse sacral pressure injury with NS, spray with sting free barrier to surrounding skin, apply 2x2 [MEDICATION NAME] AG extra primary dressing, cover with [MEDICATION NAME] foam adhesive 8x7 as secondary dressing, then spray sting free barrier to edges of foam. Change q other day. The progress notes on: 06/14/18 and 06/16/18 for skin/wound notes by LN13 documented that R77's Stage 3 PU was cleansed with NS, silver alginate aplied, and [MEDICATION NAME] foam dressing applied per MD order; and, 06/20/18 for skin/wound notes, LN13 documented that, R77's Stage 3 PU was cleansed with NS, skin barrier spray applied, [MEDICATION NAME] Ag applied, and [MEDICATION NAME] foam adhesive dressing applied. On 06/27/2018 the weekly skin condition form documented that the wound clinic with new orders of treatment, Cleanse sacral skin pressure injury with NSS, apply silver alginate q other day and as needed (PRN) til healed. Augentin for infection. On 07/11/18 the weekly skin condition form noted, Went to QMC wound clinic with same order but Triad/Zinc on maceration of the wound area. On 07/30/18 at 4:41 PM interviewed R77 and observed that he laid on his back with the HOB up. R77 reiterated that some CNAs reposition him better than others, and that when he laid flat there is no pressure on his sacrum. Inquired who told resident that no pressure on the sacral area when laid flat. According to R77, he has been doing that from before, prior to going to the wound clinic. The wound clinic staff also told him that he doesn't have to be completely off sacrum to take off pressure. R77 stated that it is hard to lie on his side so is repositioned only with wedges. R77 also stated that he has no pain because unable to feel in that area, (R77 is quadriplegic due to [DIAGNOSES REDACTED]). On 07/31/18 at 8:34 AM the DON, LN1, LN2 and the administrator requested to be interviewed and provided more background information on R77's Stage 3 PU. According to the DON and nursing staff, R77 was very non-compliant with off-loading pressure on his sacrum and doesn't like to be repositioned to the side. Performance Improvement Project (PIP) was started in 10/2018; staff used stop and watch form and skin assessents done weekly Q Thursday. R77 was referred to the wound clinic in (MONTH) (YEAR) when wound worsened and needed to be debrided. The wound clinic staged the sacral PU at Stage 3 and provided education to R77 on off-loading sacrum to relieve pressure. The weekly skin condition form documented on: 02/06/18 that R77's sacral wound measured 11.5 cm x 1 cm x 3.1 cm; 07/27/18 measured 1.8 cm x 0.3 cm x 0.4 cm. Requested documentation that facility staff reinforced education on importance of off-loading sacrum to R77; and, documentation that staff were trained by therapist on how to place wedges/pillows to alleviate pressure to R77's sacrum. The facility could not provide documentation that R77 received education from facility staff the importance of off-loading sacrum area; and, that staff were trained on the proper placement of wedges when repositioning R77 to off-load sacrum.",2020-09-01
120,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2018-08-02,842,D,0,1,GPL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on MR review and staff interview the facility failed to complete the Interfacility Communication for [MEDICAL TREATMENT] Residents form for resident (R) 32 prior to R32 having [MEDICAL TREATMENT] service on 07/28/18. The facility failed to communicate in writing to the [MEDICAL TREATMENT] center regarding R32's vascular access site, R32's condition or complaints and signature and title of the staff filling out the communication form. The facility also failed to closely monitor R73 post fall by not completely documenting R73's neuro checks and vital signs on the Nursing Observation flowsheet for 72 hours post fall. Findings include: On 08/01/18 at 01:05 PM while reviewing R32's MR with LN7 it was noted the Interfacility Communication for [MEDICAL TREATMENT] Residents form dated 07/28/18, the box for checked patency prior to transfer was left blank, Condition/Complaints was left blank, and Name of Nurse/Title (print) was also left blank. Inquired with LN7 if this was supposed to be filled out and she concurred that staff was supposed to have filled out the information before R32 went to his [MEDICAL TREATMENT] appointment. Requested and was given the facility's P&P on Guidelines for Nursing Care of [MEDICAL TREATMENT] Resident/Patient. Review of facility's policies and procedure, Guidelines for Nursing Care of [MEDICAL TREATMENT] Resident/Patient, found under III. Procedure E. 1 c. Complete Inter-Facility Communication sheet prior to transport and fax to the [MEDICAL TREATMENT] center. 2) On 08/02/18 at 09:53 AM during MR review noted R73 had fallen on 05/04/18. R73 was to have been monitored closely for any changes in clinical condition for 72 hours as stated on facility Nursing Observation flowsheet. R73's Nursing Observation flowsheet dated 5/4/18 was not completely filled out. The neuro check, range of motion (ROM), pain level/site, staff initials and titles were left blank for 1520, 1535, 1605, 1635, 1735, 1835 and 2235. Documentation on 5/7/18 at 0535 showed the temperature, pulse, respirations, blood pressure, O2 saturation, neuro checks, ROM, pain level/site and staff initials and titles were left blank. Inquired if this Nursing Observation flowsheet was supposed to be completely filled out, she stated yes. Requested facility P&P regarding Neuro Checks after falls and LN7 provided the Post Falls Monitoring P&P. Review of facility's Post Fall Monitoring P&P found Procedure 4. a. Continue monitoring resident's condition for the next 3 days and document status in the medical record . b. Vital signs, including pain score, (neuro checks if there is any possibility that resident may have struck head) as follows: Every 15 min. for first hour; if stable then every 30 min. x 2; if stable then every hour x 2; if stable then every 4 hours x 5; if stable then every 8 hours x 2 days.",2020-09-01
121,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2018-08-02,880,F,0,1,GPL111,Based on observation and staff interview the facility failed to prevent cross-contamination of residents' freshly washed clothing from air blowing from a soiled processing area. Findings include: On 07/31/18 at 09:28 AM interviewed staff (S) 15 in the laundry room. Inquired what the multiple plastic strips hanging on a rod at the top of the door frame separating the room with the washers and the room with the dryers. S15 stated he requested from S16 for a wooden sliding door to be installed on a rail instead of the plastic strips. The plastic strips did not prevent air blowing from the soiled processing area into the freshly washed clothing area. S15 concurred with the assessment.,2020-09-01
122,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,164,D,0,1,LNUE11,"Based on observation and staff interviews, the facility failed to provide visual privacy of a resident's body during the provision of care for 1 of 32 residents (Resident #118) in the Stage 2 sample. Finding includes: On 08/14/2017 at 9:43 AM, surveyor observed Resident #118 (Res #118) turned to her left side through the open door of her room and through both the anteroom's window and her bedroom window. The resident was totally naked while personal care was being done for her by two certified nurse's aides (CNAs) at her bedside. Staff #39 came to observe and said, Oh, privacy. Staff #39 said Res #118 has been in this room (the unit's isolation room) for about two weeks upon being transferred from the fifth floor. The Director of Nursing (DON) and the unit's nurse manager, Staff #59, also came to the room and saw the resident lying naked on her bed and exposed to full public view. At 9:50 AM, Staff #40 confirmed the resident has been in this room for about two weeks but had asked for curtains to be put up. Staff #40 said, the regular (staff) in here asked housekeeping, but to date she said nothing was provided. The DON stated they needed to do something right away to Staff #59. The DON affirmed Res #118 was not afforded privacy of her body during personal care and was exposed to public view.",2020-09-01
123,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,225,G,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of the facility's policy and procedure, the facility failed to ensure that all alleged violations involving potential abuse and neglect, including injuries of unknown origin are thoroughly investigated with evidence of it for 1 of 32 residents (Res #116) in the Stage 2 sample. Finding includes: 1) Res #116 was found to have sustained multiple fractures from an unwitnessed fall on 11/14/16 at 7:30 PM. As a result of this fall, she sustained six right rib fractures, a comminuted [MEDICAL CONDITION] midclavicle, and a right radius fracture. The facility submitted their completed event report form (ERF) to the State Agency (SA) on 11/15/16. On 8/15/17, a family interview was done as this resident remains in the facility and was in the Stage 1 sample. The family member stated in response to the staffing and notification of change questions that this facility did not have enough staff. He/she stated Res #116's fall was because the staff was not there to answer (resident's) call light and she ended up being hospitalized with a wrist, collarbone and rib fractures. The family member stated Res #116 told the family she called to get up to go to the bathroom, but no one responded. The family member said for the bed alarm, We could be there and pretty much standing her up, but no one would come. So why have a bed alarm when no one comes? So this one night she called, no one came so she tried to get out of bed on her own to go to bathroom and she fell . So that night we got a call that (resident) fell and they said they're going to monitor her. No, she suffered through the night with all these broken bones and after all of that, (another family member) goes over the next day and she's in all this pain and they downplayed it but said that she may have fractured something but it's up to you folks if you want to call 911 and take her to the hospital because we're not. The family member stated the resident was taken to a nearby hospital where she was admitted and then later returned back to this facility. The family member said only upon readmission to the facility was she moved closer to the nurse's station. The family member said, Here's a [AGE] year old woman that was saying she wants to die because of it--and I thought that was just really unnecessary that she had to go through all that. She also recalled being told the night of the fall from a staff who called that she did not need to come to the facility because they would be addressing resident's pain with Tylenol. The family member expressed because of what had transpired, and the way things were communicated to them, another family member has been vigilant about visiting the resident almost daily and believed this has helped to keep staff more aware of the resident's needs. On 08/15/2017, review of the ERF submitted by Staff #59 was done. Staff #59 was asked whether her completed investigation included documented interviews of staff who worked the night and morning of 11/14 and 11/15/16. On 08/16/2017 at 10:44 AM, per the DON, she said with Staff #59 standing next to her, There is no written investigation of the staff involved. Unfortunately she did not do a follow-up. Staff #59 was asked how then did she conclude on the ERF that no abuse/neglect was found given for a [AGE] year old resident with an unwitnessed fall and multiple fractures requiring hospitalization . Staff #59 said, It was whatever staff gave me information verbally. Yes, that's how I completed the report. She confirmed she had no documentation of witness statements. Review of the facility's policy and procedure, Prevention of Resident Abuse, Neglect, ., Policy No. LPAT0003, eff. 1/01/09, it stated, I. Purpose B. To report and conduct a thorough investigation of all incidents and provide appropriate corrective actions and preventive measures .III. [NAME] NEGLECT means failure to provide goods and services necessary to avoid physical harm, mental aguish or mental illness .IV. Procedure B. Step 3. Assessment & Complaint Documentation 1. Staff shall complete an Event Report form to document the initial complaint and/or witnessed information, including a list of personnel on duty or pertinent witnesses .3. The Charge nurse will perform a physical assessment of the resident and document findings in the resident's medical record. 4. The DON or designee will gather further information and begin a confidential folder. 5. All documentation including preliminary reports to the State agencies will be routed to the Administrator. C. Investigation .3. a. Review the resident's medical record .b. Review the background information .c. Review records of work schedules and staff and resident assignments .e. Conduct and document all necessary interviews with staff, witnesses, resident .g. Submit a written report to the Administrator detailing findings and recommendations . The SA's on-site investigation of the resident's fall included the following: a) On 08/15/2017 at 2:39 PM, an interview with Res #116 was done in Japanese by the surveyor. The resident is an alert [AGE] year old resident who was able to reply back in Japanese. She said she used to be able to walk before but once she became bedridden, she has been unable to walk. She did not recall the fall in (MONTH) (YEAR). She denied being in any pain at this time. She said one family member visits her every day and said she's uncertain what each day brings when she awakens. b) On 08/16/2017 at 1:58 PM, a telephone interview of Staff #141 was done. She completed the SBAR fall event report as she was the licensed nurse on the 11/14/16 evening shift when Res #116 fell at 7:30 PM. She stated while she passed medications that night she heard a loud noise and when she went to check on the resident with a CNA, they found Res #116 on the floor lying on her side. Staff #141 recalled the resident talking and she said she likes to use the bedside commode at that time and the commode to one side, but tipped over. She was on the ground by bedside. So we needed to assess her, get her up, back to bed, check vital signs, neuros, and I called the doctor and he told me to continue check neuros and I called family to let them know about the incident. I asked if she's in pain, and she said she was in pain, but sometimes she says no, but she was able to help us, able to move her extremities. Surveyor asked Staff #141 what did you do, range of motion? She replied, I checked her leg if able to bend it, extend it. What about the right side? Staff #141 replied, She's able to move her hand. Throughout the night? Staff #141 replied, Uh-huh. And I even check on her and able to grab my hand, squeeze my hand. She cannot really tell me 1-10, can speak simple English too. Staff #141 said, she's not frowning, no moaning, no crying, so I assuming she's comfortable because she didn't show any signs of pain. I am not sure if I gave--I can't remember too much because I'm a floater. Did you send her out? Staff #141 replied, I think not. Did anyone else interview you about this? Staff #141 replied, I think my head nurse actually asked me about the incident. I don't know what happened to (resident). I just heard from there that this patient was sent out. So I don't know exactly what happened, if it happened on my shift. No, nobody followed up with me. When I give the report, (Staff #59) asked me what happened and I told her what happened. Did this patient use her call light? Staff #141 replied, That time I couldn't remember for sure if she used the call light. Did you hear an alarm or anything? Staff #141 replied, I cannot remember if there's alarm. What was staffing that night? Staff #141 replied, Uh, I cannot recall, but just to tell you the truth, most of the time we are short of CNAs, but the CNA really assigned to this patient was on break. So the other CNA (Staff #99) was the reliever because 1 person will go break and the other CNA is the reliever. Four CNAs split two and two each side, but only one licensed. I'm the only RN for 38 residents. This is on [NAME] 5 at the time. Staff #141 recalled speaking with a family member to let them know their policy and procedure was to call as well as the doctor. Staff #141 was asked for a [AGE] year old resident with a fall, did she consider sending the resident to the ED? She replied, We can consider that too, but she didn't have any signs of fracture and I didn't really realize she need to go to the emergency at that time and I continued to check her neuros and pain at that time. My shift ended at 11:30 (PM) and then every time I go home, I reported to incoming shift about her fall and continue to monitor. Staff #141 was asked what the purpose of the bed alarm was for this resident. Staff #141 replied, For us to know if patient gets up, to go and check the patient for their safety. So everytime, I was passing medicine and close to that room, one door away so I heard the loud noise, so if the call light is on, I will drop everything and answer the call light, because if she does press call light, i could have been there and help her right away. Have there been falls because short staff? Staff #141 replied, Yeah i think it's a factor too, because we cannot help it, we have to help the resident from falling. I need to drop what I'm doing to help the patient who is falling. One person falls down, it will hold me up so I'm trying my best to help the aides--especially the restless patients. We understand staffing get enough, but we have sick calls, so that's how ended up being short. Note: Record review found Staff #141 did not do neurological checks, failed to initiate and document the resident's pain level, etc. Cross-reference to findings at F309 and F323. c) On 08/16/2017 at 2:25 PM an interview of Staff #59 was done. She said for her investigation and ERF report to the SA, she did not do any interviews of the staff who worked the night and morning shifts of 11/14/17. She stated she did not have any documentation other than the ERF and the root cause analysis (RCA) form regarding Res #116's fall. The RCA was reviewed and Staff #59 was asked to explain it. She stated, I try to determine what caused the fall. So the cause is toileting, maybe she wasn't checked or toileted before this happened and maybe she tried to stand up and this happened. When I did interview with them this is what I found out that she was found with urine and BM in her diaper. So, the recommendation is prompted toileting, which means CNAs have to check her every 2 hours and check if she's incontinent or to use the bathroom. Staff #59 said she completed this on the next day, 11/15/16. Staff #59 was asked what other things would have been considered in doing the RCA, and she replied, Consider environment, lighting. What about your staffing at that time? Staff #59 replied, Less supervision when there's less staff. Surveyor asked if she was aware that one CNA had been on break when Res #116 fell . Staff #59 said, Yes. I missed that. She also confirmed Res #116 was able to ambulate prior to the fall, but after the fall, she is unable. d) On 08/16/2017 at 2:48 PM, an interview with Staff #99 was done. She recalled on the evening shift of 11/14/16, she came to the aid of Res #116 who had fallen. She recalled coming off her break. She said they did not hear the resident's call light when she went to aid the resident. She said Staff #141 assessed the resident, and after that the two of us asked other staff and she came to help us and we picked her up and we took her to the bathroom. Staff #99 was asked to clarify this and said, So two of us carried her (resident) into the wheelchair and took her to bathroom toilet. Staff #99 said the resident was not soiled at all when they found her on the floor. She said the resident actually sat on the toilet, not the bedside commode. Then afterward they put the resident back to bed. Staff #99 said she did not think the resident was in any pain, Because she was able to handle it, seems it was fine. And then after that the charge nurse took over. Staff #99 stated she was not interviewed by anyone after this incident nor wrote an account of what happened. Staff #99 said she spoke to the charge nurse only but not to Staff #59. Staff #99 also recalled their staffing that evening prior to resident's fall. She said, We are four that day and we are good for that. But it falls under during the break, but I was there close by to respond. Staff #99 was asked if the resident was ambulatory before the fall and she replied, The resident was able to stand up and assist before the fall. Note: The SA found the ERF submitted to the SA stated the resident had been found on the floor incontinent of urine and bowel. Staff #99 also stated she did not speak to staff #59 after this incident. e) On 08/17/2017 at 7:00 AM, interview of Staff #106 was done. He said he was familiar with Res #116 and verified his nursing entry of 11/15/16. Staff #106 stated he worked the night shift and recalled at first the resident had no pain. But at 1:45 AM she complained of pain. Pain to her right side. He did not fully recall the details of the fall, but stated, I want to test if the Tylenol gonna work and felt it was effective. He verified it was his sole entry on the Pain Monitoring Flow Sheet. Staff #106 said Res #116 told him verbally what her pain was. I let her describe from 1-10. Can you rate your pain from 1-10, 10 being the most painful and 0 being no pain. And she said 9. She's a times 2-3 (alert) and there are some occasions that she's confused. Staff was asked if he would have used the PAINAD scale for her. He replied, No, I wouldn't use that one for her because she's really conversant at that time and can tell me. He said that scale was used for those with dementia those who cannot really verbalize. He stated the nurses are supposed to use the Pain Monitoring Flow Sheet. Staff #106 was asked if Res #116 was able to use her call light, and he replied, Yeah, she's the one who use her call light. Even if she wants to be changed already, she calls. Sometimes she requests water. She can really verbalize her needs. Prior to the incident, she could walk. He repeated, She does use her call light. Even with turning she helps. Note: Record review found Staff #106 also did not follow the nursing observation neurological checks as there was no documentation found by either Staff #141 and #106. In addition, the ERF completed by Staff #59 mentioned unable to rate pain using the PAINAD. Staff #59 was asked why she wrote, Unable to to rate pain using the PAINAD on the completed ERF, as she stated she would not have considered using it for this resident. Staff #59 said she did not remember why she put it in there. She acknowledged the PAINAD scale is used for those residents who are with severe to advanced dementia. This resident scored a BIMS of 12 and was able to self-report her pain. f) On 08/17/2017 at 10:14 AM, a re-interview of Staff #59 was done. She stated she recalled on the day Res #116 was transported out to the hospital, she spoke to family members. She said, I explained to them she's in a lot of pain so that's why transferring out. She could not recall if the family members had questions about the fall injuries after the mobile x-ray was done. Staff #59 could not recall if she even saw the results. Like I said we were busy transferring patients down to this unit. But every time we have tests like this, I do want to see it and make sure we call the doctor .Yes now I remember. I wanted to call the doctor, for the abnormal results. I talked to the family and the doctor and the doctor wanted to order some type of narcotic pain medication. No, the family just wanted her to go to the hospital already. Staff #59 was asked why was there such a lag time before the ambulance was called, especially since Staff #59 stated she was in a lot of pain. She replied, I cannot recall anymore, yes, she was only getting the Tylenol. She was asked why there was no on-going clinical documentation about the resident's condition. Staff #59 stated, Only whatever my charge nurse wrote is it. Staff #59 stated, Yes, it is a significant fall with fractures. She was asked if her investigation included ruling out the potential for abuse and neglect. She replied, Oh yes, if unusual situations like this. I did talk to the CNAs that were working that evening, but because I didn't go deeper. I should have. You really need to find out how did it happen and what the situation was, what was the resident doing at the time and even prior to the event report. However, she affirmed she had no documentation except for the RCA she prepared. She was asked again, if she even considered neglect given the extent of the resident's injuries and the staffing for the evening. She replied, Oh yes, yes. I think so. Well resident is alert and she can ambulate and if she was checked before that, then maybe it could have prevented the fall. But then again the staffing, we only had 3 CNAs that time. But the thing I know is one CNA was helping the RN already. Staff #59 was asked whether the night shift supervisor was involved in this at all, and she replied, No mention of it. Because even when I talked to the RN, she should have sent her out already because she was in pain. Staff #59 said when she looked at the record, she felt the resident should have gone out and not waited until the next morning. I could have expected the evening shift, the time it happened, I told her that, my charge nurse, you should have just sent her out already. I'm not sure she remembers, but I told her that, yes. Staff #59 verified after reviewing the resident's record, the 11/14/16 evening charge nurse who found the resident on the floor failed to initiate and document on: 1) the Nursing Observation Flowsheet, 2) the Pain Monitoring Flow sheet, 3) the Medication Administration Record [REDACTED]. Staff #59 also said she would not have considered using the PAINAD scale for this resident because, she's alert and this one only for those that are confused. I told her why did you not send her out. g) On 08/21/2017 at 8:17 AM, during another interview with the DON and Staff #59, the DON agreed the RCA was not done as it lacked an in-depth review to see what the antecedent factors preceding the resident's fall may have been, which staff were present and whether was there enough staff available at the time this resident wanted to be toileted, as well as what their witnessed and documented accounts were. The DON reiterated, This was not done. Staff #59 also confirmed that Staff #141 was supposed to have documented a follow-up note. She stated she expected a physical assessment to have been done by Staff #141, but said there was nothing documented about it. On 08/21/2017 at 8:47 AM, the DON and Staff #59 re-verified the neurocheck flowsheet was not done by Staff #141 and also failed to initiate a pain monitoring flowsheet and complete her documentation on the MAR for the Tylenol she gave to the resident at 8:50 PM on 11/14/16. h) On 08/17/2017 at 06:40 AM, Staff #129 said the nurse who sent the resident to the hospital on [DATE] was unavailable for interview as she was out on extended leave. Thus, for this resident who sustained numerous physical injuries, declined in her functional ability to walk, coupled to a lack of a thorough investigation to rule out neglect, the facility failed to ensure this resident was provided the necessary care and services. This is further evidenced by the lack of clinical documentation by the licensed staff regarding the fall, no neurocheck flowsheet, no on-going pain monitoring and an incomplete RC[NAME] By the time resident was discharged to the hospital, the documentation only included Staff #106's entry, the x-ray result of 11/15/16 at noon, one vital sign entry on 11/15/16 at 2:20 PM and the discharge/transfer note of 11/15/16 at 3:15 PM.",2020-09-01
124,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,226,D,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, interviews and review of the facility's policies and procedures, the facility staff failed to report a resident-to-resident incident that involved one resident taking another resident's cap (Res #71 and Res #12), who are part of the 32 residents in the Stage 2 sample. Finding includes: On 08/14/2017 at 12:18 PM during the lunch observation in [NAME] 4 unit's solarium, Res #71 was observed to deliberately snatch the baseball cap off of Res #12's head while they were sitting at their table. The CNAs were passing the trays and no staff were in the room at the time. The meal cart had come up at approximately 12:09 PM. Once Res #71 put the cap on his head, another resident yelled out if he felt better having done that to Res #12. Then Staff #40 came into the solarium and saw Res #71 wearing Res #12's cap and asked him to give it back several times. Once he complied, Staff #40 took it and placed it back onto Res #12's head. (Res #12 is unable to fend for himself as he requires assistance in eating and has a medical history of [REDACTED].) Staff #40 then stated, That's why I give you another table and brought in an overbed table and moved Res #71 away from Res #12. However, Res #71 then reached out to grab Staff #40 and/or made hand gestures of come, come to her. During this observation, it was found the residents in the solarium were left unsupervised when the meal trays were being delivered from the cart in the hallway. Res #71 was noted to be very mobile while in his wheelchair and his action of removing Res #12's cap was very swift. On 08/16/2017 at 8:00 AM, Res #12 was observed in the solarium having finished his breakfast. There were six residents in there, but there was no staff to oversee the residents. At 8:02 AM, surveyor asked Res #12 how it made him feel when Res #71 took off his cap. He stated, piss off, and closed his eyes. On 08/16/2017 at 6:50 AM, the DON stated based on what occurred between the two residents, they initiated an event report to the State Agency. The DON confirmed Staff #39 failed to do an ERF for resident to resident abuse and that Res #71 also tried to grab Staff #40. On 08/16/2017 at 08:10 AM, the unit's nurse manager, Staff #59 said the incident on 8/14/17 had been reported by Staff #40 to Staff #39. Staff #59 said Staff #39 should have written it down, whatever the observation was that was reported to him. Staff #59 said her expectation was Staff #39, should have reported it, documented it and done something about it and instructed staff that the two (residents) should have been separated and more intensive. She verified Staff #40 did report it. Staff #59 confirmed and known by staff that Res #71 targeted Res #12's cap. Staff #59 confirmed there was no progress note documentation by the charge nurse that day. Review of the facility's policy and procedure, Prevention of Resident Abuse, Neglect as Policy No. LPAT003, effective 1/1/09, the purpose states, [NAME] To ensure the prevention, protection, and safety of all residents, .receiving care and services from the facility from incidents of abuse, .and/or misappropriation of property B. To report and conduct a thorough investigation of all incidents and provide appropriate corrective actions and preventive measures .II. Policy .B. All employees are required to report alleged complaints and/or violations involving abuse, neglect, .and misappropriation of property immediately to the Administrator of the facility .Step 3: Assessment & Complaint Documentation 1. Staff shall complete an Event Report form to document the initial complaint and/or witnessed information, including a list of personnel on duty or pertinent witnesses. The facility's licensed staff failed to implement an initial reporting of a resident-to-resident incident and failed to ensure further procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property was done as verified by the DON.",2020-09-01
125,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,241,D,0,1,LNUE11,"Based on observation and interview with a staff member, the facility failed to treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. Findings include: On 8/14/17 at 12:10 P.M. observation of the dining room on [NAME] 2 found four residents seated at a table facing the television. The television was on and set to a station with a movie. The movie depicted cannibalism, during the observation the program showed two people eating raw meat with blood splattered on their mouths. Subsequently, the program showed a man biting and consuming a woman's flesh. The closed caption was on and there was profanity in the dialogue. Interview with Staff Member #85 reported Resident #27 likes to watch that particular station. Observation found Resident #27 was seated at another table with his back facing the television. A visitor reported that her mother enjoys that particular station as well; however, her mother was in bed. Staff Member #85 began to watch the program and reported she was not aware of what show was on and commented that the program was gruesome. The staff members asked the residents if it was okay to change the station, there was no opposition and the staff members attempted to find the music station.",2020-09-01
126,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,242,E,0,1,LNUE11,"Based on resident and staff interviews and medical records review (MRR), the facility failed to ensure that 3 of 15 residents (R#15, R#95, anonymous) interviewed on the Stage 1 census sample report were given a choice on how many baths they received in a week. Findings include: 1) On 08/14/2017 at 10:54 AM during Stage 1 of the survey, resident interview question on whether the resident had a choice for the number of baths/showers per week, R#15 responded that only 2 showers/week were allowed at the facility, but she would prefer to shower at least 3 times/week. Inquired whether the resident made her preference known to staff; and R#15 did request, but was told an additional shower could be provided based on staff availability. The resident stated that the staff are always busy and never enough staff. On 08/16/2017 at 10:26 AM the MRR on R#15 found documentation on the (MONTH) (YEAR) Activiites for Daily Living (ADL) log that the resident received a shower/shampoo (SS) 4 times so far this month. On 08/21/2017 at 9:32 AM, reviewed R#15's EMR and the annual minimum data set (MDS) 3.0 dated 06/15/17 noted that the resident scored 15/15 on the brief interview for mental status (BIMS); and, under daily preferences for choice between a tub bath, shower, or sponge bath, was coded very important. The resident was coded total dependence for bathing and needed one person for physical assist. 2) On 08/15/2017 at 08:28 AM during Stage 1 of the survey, resident interview question on whether the resident had a choice for the number of baths/showers per week, R#95 responded only 2 times/week could have SS. When asked if that was okay with her, R#95 stated that she would prefer 4 times/week but was told no can. On 08/16/2017 at 10:40 AM, interviewed Staff# 71 and he stated that the facility's standard is for SS 2 times/week and that residents can ask for more. Informed him that residents interviewed are told not enough staff or no can, when they request additional showers. Discussed that facility standard should be based on resident's right to have a choice. The Staff#71 stated that CNAs should have told the charge nurse and SS would have been scheduled when residents requested. Staff#117 was also in the discussion and stated that she goes through MDS questions and doesn't ask in detail how many SS resident wants only rates how important activity is. The Staff#117 stated that she would want to shower daily. On 08/21/2017 at 9:03 AM the MRR on R#95 found that it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. The resident care record for ADLs for (MONTH) (YEAR) noted that R#95 had SS 7 times that month and 8 times in (MONTH) (YEAR). The MDS 3.0 noted that R#95 was total dependent for bathing and needed one person physical assist. 3) On 8/15/17 at 8:13 [NAME]M. a confidential resident interview was conducted. The resident reported that they do not choose how many times a week they will receive a bath or shower. The resident reported that currently she/he receives showers three times a week and clarified a request for a daily shower. Inquired whether residents can request more showers, the resident reported that in the past she/he has made a request for a shower and is told that there is not enough nurses to give the shower. A brief record review done on the afternoon of 8/15/17 found the resident is cognitively alert as evidenced by a score of 15 on the Brief Interview for Mental Status. Further review found an annual assessment indicating the resident reported it is very important to choose between a tub bath, shower bed bath or sponge bath. On 8/16/17 at 11:00 [NAME]M. an interview was conducted with Staff Member #110. Inquired how the facility determines how many baths/showers will be provided. The staff member reported they will ask the resident or the family member how the resident normally showers and when they like to shower on admission. The staff member also reported if a resident requests a shower they will work it in for the resident.",2020-09-01
127,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,257,E,0,1,LNUE11,"Based on observation, resident and staff interviews, the facility failed to ensure it maintained comfortable and safe temperatures levels for 3 of 32 residents (Residents #118, #15, and #102) in the Stage 2 sample. Findings include: 1. During the observation of Res #118's lack of privacy issue on 8/14/17 at 9:43 AM, it was found the resident's room was also hot and had little to no ventilation. The DON stated they kept the anteroom door and bedroom doors open to allow the corridor air (air conditioned (AC) air) into her room, but acknowledged the anteroom door was not to have been propped open for that reason. The DON asked the staff to close the anteroom door after the morning observation. Then on 08/15/2017 at 2:44 PM, a maintenance person (Staff #2) toured with surveyor to check Res #118's room temperature. Staff #2 stated he used to have a laser gun, but broken so I using dietary's thermometer (digital) to take it. The resident stated it was hot when Staff #2 asked about her room temperature. Staff #2 stood between the right side of the resident as she lay in her bed and the room's window. He held the thermometer at the height of where she lay in bed. In that vicinity, the thermometer showed her room temperature where the resident lay to be 89.9 degrees Fahrenheit (F). Staff #2 said even with the two fans on, no more ventilation, yeah, it's hot in here. He also moved to the end of the room and obtained a temperature reading of 89.4 degrees F. He said there was not much difference. Staff #2 was asked for those room without AC how maintenance monitored for safe and comfortable temperature levels for their residents, especially during the summer months. He stated, I have no idea, we just maintenance guys and we'll do whatever it takes. We make sure we get fans in the rooms, that's it. But the ventilation-the fans only going kick up hot air. He said if the nursing staff or others entering the residents' rooms did not mention anything to maintenance about it being warm or hot, they would not know about it. He said they do not have a temperature monitoring log, we never had one, as they never took room temperatures before. 2. Res #15's room temperature was taken next with Staff #2 on 08/15/2017 at 2:54 PM. It was explained to the resident what Staff #2 was doing and then she said, Hot in here! Hot! The resident lay in bed with her nasal cannula on with oxygen flowing with a thin bed sheet on. Staff #2 used the same thermometer and recorded a temperature of 91.0 degrees F at the height of her bed and by the window where she lay. He also went to check the temperature by bed A in Res #15's room and obtained a reading of 89.2 degrees F. He said it was almost 2 degrees different. 3. Res #102's room temperature was taken with Staff #2 on 08/15/2017 at 2:59 PM. Upon entering, Staff #2 said, Oh, he get AC. Yet, Res #102 said at night, for his room he stated, It's super cold. I'm freezing, it's super cold. They used to have temperature recorders placed but I don't know what happened. Staff #2's thermometer recording registered the midday room temperature by his bed to be 83 degrees F. Staff #2 asked the resident why did he not say anything it being so cold and proceeded to adjust the resident's AC unit to economy. The facility failed to ensure all residents were afforded comfortable and safe room temperature levels.",2020-09-01
128,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,272,D,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews (MRR) and staff interviews, the facility failed to assess, identify and address physical functioning and structural problems for 2 of 41 residents (R#15 & R#106), on the Stage 2 resident sample list. Findings include: 1) On 08/16/2017 at 9:03 AM during medication administration for R#106, observed that the residents toes on the right (R) foot had blackened nail beds from the great toe to the 4th toe. The toe nails were long and the great toenail looked slightly lifted with small reddish blisters on the sides of the toes. On 08/16/2017 at 10:23 AM Interviewed Staff#71 and he stated that R#106's skin assessment would be in the electronic medical record (EMR) and that R#71 had a condition that caused blisters. On 08/16/2017 at 10:40 AM, Staff# 156 printed weekly skin assessments done on R#106 and all were for an open area on the left buttock with dates of: 8/13/2017, 7/30/2017, 7/23/2017, and 7/17/2017. Staff were unable to find any assessments of the resident's toes on the R foot. Both Staff#71 and Staff#156 went to assess R#106's toes on the R foot and asked the resident if toes were sore. Staff#71 mentioned that R#106 probably had podiatry consult as resident had above the knee amputation (AKA) on the left (L) leg and was diagnosed with [REDACTED]. Staff#71 looked in R#106's medical record and could not find a podiatry consult. Staff#71 then called the podiatrist to ask if there was any record of resident being seen by podiatrist, and the podiatrist did not have any record on R#106. 2) On 08/17/2017 at 1:46 PM interviewed R#15 at her bedside. Queried R#15 if staff performed range of motion (ROM) on any of her limbs, and resident stated that no one does ROM, nor does anyone look at her toes. Visualized resident's toes and bilateral toes appeared to point downwards. On 08/17/2017 at 2:10 PM, the MRR on R#15 did not find any documentation on her toes being contracted. Queried Staff#162 about R#15's toe contractures and whether an assessment was done. Staff# 162 could not recall whether R#15 had toe contractures so went to assess the resident's toes. Accompanied Staff#162 to the resident's bedside and when she looked at resident's toes stated, Oh yes, your toes are contracted. Staff#162 stated that the CNAs usually do ROM and would have kept charge nurses informed. R#15 stated that no one does ROM and Staff#162 reassured the resident that she will let Rehab maintenance know to do ROM. At the nursing station requested to see any documentation that staff were aware of R#15's toe contractures. Staff#162 was unable to find anything in the resident's medical records, and stated that maybe in old RNA folder but no longer have RNA program and CNAs now do task. Staff#162 called Rehab staff and found out that R#15 was never on RNA program list and that Rehab would have to evaluate the resident. On 08/21/2017 at 9:41 AM reviewed R#15's EMR and the annual MDS 3.0 completed on 06/15/17 documented that the resident had impairment on both sides of upper extremities and lower extremities (hip, knee, ankle, foot) for functional limitation in ROM. The facility did not conduct comprehensive assessments to address all care needed by the residents to ensure proper foot care for R#106 with diabetes and [MEDICAL CONDITION]; and, R#15 ROM for bilateral toe contractures.",2020-09-01
129,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,278,D,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with facility staff, the facility failed to ensure that each resident received an accurate assessment of the resident's status and needs for 1 of 16 residents (R#87). Findings include: On 8/15/17 at 10:00 [NAME]M. a record review was done for Resident #87. The comprehensive (admission) Resident Assessment Instrument (RAI) with an assessment reference date (ARD) of 4/13/17 indicated Resident #87 has an active [DIAGNOSES REDACTED]. 0400 Functional Limitation in Range of Motion, the resident was coded to have no impairment. The subsequent quarterly assessment with an ARD of 7/5/17 found the resident was coded to have no upper extremity impairment and an impairment on one side of the lower extremities. On 8/15/17 at 10:20 [NAME]M. an interview and concurrent record review was done with Staff Member #110. The staff member reported Resident #87 has functional limitation in range of motion to both upper and lower extremities involving both sides of the body, with one side being more involved. The staff member confirmed the RAI information for both the comprehensive and quarterly assessment was inaccurate. On 8/15/17 at 1:30 P.M. a review and interview was done with Staff Member #110. The staff member opened the resident's electronic record and a review found that there was no assessor documented for the admission assessment. Staff Member #110 reported a correction to the assessment is being completed. The facility did not accurately assess Resident #87 for functional range of motion.",2020-09-01
130,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,279,D,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and staff interviews, the facility failed to develop and implement a comprehensive, person-centered care plan that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 32 residents (Res #128) in the Stage 2 sample. Finding includes: Cross-reference to findings at F314. Res #128 was admitted to the facility on [DATE] for skilled nursing services with [DIAGNOSES REDACTED]. The record review found a handwritten entry by Staff #59 dated 4/27/17 for Stage 3 open area to coccyx. This was added to an existing at risk for skin breakdown care plan dated 5/5/17. However, the approaches to this care plan included range of motion exercises and device applications to prevent further contractures to the fingers, hand and elbow. It also included an intervention for nursing to place disposable washcloths to scrotal area & cover with blue brief (to minimize irritation from urine touching skin). Res #128 is a female. There were no approaches to comprehensively address the resident's problem of a Stage 3 open pressure ulcer within this care plan as there were no measurable goals/timeframe, appropriate treatment interventions and/or approaches to heal the wound. On 08/21/2017 at 1:30 PM, during a concurrent record review with the DON, she verified the existing care plan was not related to the Stage 3 coccyx wound. The DON said, This doesn't even pertain to the resident. The DON also stated the wound also had to be measured because, it will tell us if it's healed. It's not healed with no measurements. The facility failed to develop an accurate comprehensive care plan for a resident identified to be at risk for skin breakdown and was admitted with a Stage 3 pressure ulcer to the coccyx.",2020-09-01
131,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,280,E,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure the residents' existing comprehensive care plans were evaluated and revised as the resident's status changed for 4 of 32 residents (Residents #12, #71, 38, #114) in the Stage 2 sample. Findings include: 1) Cross-reference to findings at F226. During a concurrent record review and interview with Staff #59 on 08/16/2017 at 2:40 PM, it was found Res #12's care plan #9 for problem related to history of conflict with resident was not updated to include Res #71. This was confirmed by Staff #59 who stated she did not update it. She said the existing care plan stating, All staff to ensure res is not seated next to/near res ( /BL) at any time referred to a resident who had been discharged . Staff #59 said the current plan of care thus had not been updated to include Res #71's targeting obsession to take Res #12's baseball cap, which was not his property. Staff #59 said, I haven't done it yet. Although not written here, the staff know should not be sitting together but acknowledged it was to have been put into a care plan. 2) For Res #71, his attending physician's note of 3/1/17 identified the resident with, New hyper sexual behaviors and comments noted by staff. The physician's note did not elaborate what the new hyper sexual behaviors/comments were and to trial [MEDICATION NAME]. A care plan for Socially inappropriate behavior developed on 3/2/17 included the [MEDICATION NAME] use, and All staff to closely observe resident for inappropriate behavior like: touching/grabbing staff's buttocks/take appropriate steps such as redir provide an alternate activity. The 5/5/17 Interdisciplinary Conference Notes stated, Resident has been observed w/worsening of inappropriate behavior like grabbing/touching staff buttocks and refusing to take his medications . Yet, based on the observation of the res-to-res incident on 8/14/17 by surveyors, and other random observations of Res #71 on the unit, during an interview with the DON on 8/15/17, the DON stated the care plan was incorrect. The DON said it should have been for sexually inappropriate and not socially inappropriate behaviors for Res #71. The approach for a referral to a geropsych consult with managing the resident's behavior also had no date as to when this addition to the care plan was made. 3) Cross-reference to F309. On 08/15/2017 at 2:39 PM, Res #38 was observed in bed with her lower legs uncovered. It was found her right lower shin area had a dressing applied to it and her left shin area had a large bruised area to it. The resident is non-interviewable. On 08/17/2017 at 12:53 PM, record review found Res #38 was readmitted to the facility on [DATE] after a hospital stay post-fall. Her initial skilled nursing admission record however, found when she was admitted on [DATE], there was documentation of BLE (bilateral lower extremities) with small faded bruises. Both staff were further queried if a readmission baseline skin assessment was not done, how would staff determine whether Res #38's skin condition was improving or worsening, and what changes were actually being monitored for. Staff #72 said as nurses they see the resident every day so they can tell if it's an old discoloration versus a new bruise. When surveyor further queried if monitoring is being done, when did her bilateral lower extremity skin condition change from being small faded bruises to a larger discoloration. Surveyor finally asked Staff #59, Where's your baseline measurement for this discoloration? There is none? Staff #59 nodded affirmatively that there was none. As such, the resident's existing care plan #5 for at risk for skin breakdown was never reviewed nor revised with changes to the resident's bilateral lower extremities. The DON also verified this on 8/21/17. 4 ) Cross Reference to F315. Resident #87 exhibited a decline in urinary continence from admission to the 90 day evaluation. On admission, the resident was coded as being occasionally incontinent (less than seven episodes of incontinence) and at 90 days was coded to as frequently incontinent (seven or more episodes of urinary incontinence, but at least one episode of continent voiding). An interview with Staff Member #110 confirmed the interdisciplinary team did not assess for causal factors contributing to the decline in bladder continence. Based on an assessment of the causal factors contributing to the decline, the facility did not revise Resident #87's care plan to implement interventions to maintain or improve the resident's bladder functioning. 5) Cross reference to F323 On 08/16/2017 at 3:30 PM met Staff#116 and showed her R#114's care plan (CP) which had written interventions Seat belt alarm when in W/C, Bed alarm when in bed and Bilateral fall mats. Staff#116 stated that the interventions were written by her and recognized the hand writing as her own. The staff member could not remember when she wrote it in R#114's CP as there was no start date for these interventions on the CP. Staff#116 also stated that the facility used a CP template and the intervention, Staff to follow procedures as specified in Leahi policy for Physical restraints #110-3-14, with a start date of 09-12-16, was not removed although R#114 was never put into restraints.",2020-09-01
132,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,282,D,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and medical record reviews (MRR), the facility failed to ensure that comprehensive care plans were developed and implemented for 2 of 41 residents (R#15 & R#106) on the Stage 2 resident sample list. Findings include: 1) Cross to F272, F318 On 08/14/2017 at 12:26 PM, while interviewing R#15 noticed that her bilateral toes looked contracted. On 08/17/2017 at 1:46 PM interviewed R#15 who was lying in bed covered with a sheet. Queried resident if staff performed ROM exercises on any of her limbs. The resident stated that no one does ROM and also stated that toes have been contracted for awhile now and that staff never look at her toes. The R#15 allowed surveyor to visualize her toes and bilateral toes appeared contracted downwards. On 08/17/2017 at 2:10 PM, R#15's MRR found no documentation of bilateral toes contractures. Queried Staff#162 and she went to look at R#15's toes. While looking at the resident's toes, Staff#162 stated, Oh yes, your toes are contracted. Queried when nursing assessments would have noticed contracted toes and Staff#162 stated, CNAs usually do ROM and should have kept charge nurses informed. The resident stated that no one does ROM on her, and Staff#162 reassured R#15 that Rehab maintenance will do ROM. At the nursing station asked Staff#162 for documentation on assessments of R#15's toe contractures. Staff#162 was unable to find any documentation regarding toe contractures in R#15's MR and stated facility no longer have restorative nursing assistant (RNA), and that CNAs now do ROM task. Staff#162 called Rehab department to check if R#15 used to be on the RNA maintenance program, but Rehab Staff#80 told her that R#15 was never on Rehab maintenance program list. Staff#162 then stated that someone from Rehab would come to evaluate R#15 for maintenance program. The MRR on R#15 found that the resident was alert and oriented as documented on the annual interdisciplinary (IDT) conference notes dated dated 6/22/17. The Wound Care Measurement and Assessment form dated 8/14/16 and completed by Staff #156, of the resident's left (L) great toe open lesion, included a color picture of the wound on the contracted big toe. The Wound Care Measurement and Assessment form dated 7/28/16 and completed by Staff#162, of skin tears on the resident's R 1st & 2nd toes, included a picture of the wounds and toes contracted. 2) Cross to F272, F 328 On 08/16/2017 at 9:03 AM during medication administration for R#106, observed that the residents toes on the R foot had blackened nail beds from the great toe to the 4th toe. The toe nails were long and the great toe nail looked slightly lifted with small reddish blisters on the sides of the toes. On 08/16/2017 at 10:23 AM Interviewed Staff#71 and he stated that R#106's skin assessment could be in the electronic medical record (EMR) and that he could print. Staff#71 further stated that R#71 had a condition that caused blisters. On 08/16/2017 at 10:40 AM, Staff# 156 printed weekly skin assessments on R#106's open area on the left buttock for dates of: 8/13/2017, 7/30/2017, 7/23/2017, and 7/17/2017, and was unable to find any assessments of the resident's toes. Both Staff#71 and Staff#156 went to assess R#106's right (R) foot and asked the resident if toes were sore. Staff#71 mentioned that R#106 probably had podiatry consult as resident had above the knee amputation (AKA) on the L leg and was diagnosed with [REDACTED]. Staff#71 looked in R#106's medical record and could not find a podiatry consult. The Staff#71 then called the podiatrist to ask if there was any record of resident being seen by podiatrist, and the podiatrist did not have any record on R#106. Staff#71 then stated that resident had [MEDICAL CONDITION] and nothing to prevent necrosis of toes but can be protected and monitored. Staff#156 looked at Medication Administration Record [REDACTED]. Staff#156 replied that no open area on toes and reiterated that resident had [MEDICAL CONDITION] so didn't see how [MEDICATION NAME] cream would prevent necrosis. Queried if MD prescribed [MEDICATION NAME] cream for the toes and she wasn't sure. Queried Staff#71 on facility protocol for diabetic foot care for residents with above knee amputation (AKA) on one side. Staff#71 stated that not a facility protocol but nursing protocol should be to monitor and protect. Staff#71 stated that staff wiould be making referral for podiatry and/or vascular surgeon consult. On 08/16/2017 at 2:58 PM interviewed Staff#71 on status of R#106's toes and he stated that the Podiatrist would come that evening to assess R#106's toes and to provide clarification on [MEDICATION NAME] cream order. Staff#71 stated that he was anticipating that podiatrist will probably recommend referral to vascular surgeon.",2020-09-01
133,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,309,G,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews (MRR) and staff interviews the facility failed to ensure that 3 of 32 residents (R#38, R#116, R#46), obtained optimal improvement and/or did not deteriorate within the limits of their recognized pathology and the normal aging process, and, each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in the Stage 2 sample. Findings include: 1. On 08/15/2017 at 2:39 PM, Res #38 was observed in bed with her lower legs uncovered. It was found her right lower shin area had a dressing applied to it and her left shin area had a large bruise-like area to it. The resident is non-interviewable. On 08/17/2017 at 12:53 PM, record review found Res #38 was readmitted to the facility on [DATE] after a hospital stay post-fall. Her initial skilled nursing admission record however, found she was originally admitted on [DATE]. In the 2013 clinical record, there was documentation showing resident's BLE (bilateral lower extremities) with small faded bruises was assessed, but without baseline measurements. During an interview with Staff #59 and Staff #72 on 08/17/2017 at 1:21 PM, Staff #72 said the resident does not have bruises, but that it was her usual skin discoloration. She stated, has been that way ever since she was here--years. She was on aspirin before but not anymore ever since she developed a hematoma. Always had the discoloration, but it's her skin that's discolored, but no swelling or anything .She was with us, went to another floor, and then came back to us. Her shins have been like that for awhile. Both staff were queried with the resident's readmission, if a baseline measurement of the bruising or discoloration which their nurses have been documenting since (YEAR) in the progress notes was ever done. They reviewed the 2013 skin assessment note that showed the same leg areas with only small faded bruises. Staff #59's reply was, When she came back, we knew she already had that, but it should be somewhere in the older record. Staff #72 said, Myself, I never measured it, but has always been her whole shin area, right down here. Both staff were further queried if a readmission baseline skin assessment was not done, how could nurses, therapists, etc. determine whether Res #38's skin condition was improving or worsening, and/or what changes were actually being monitored for. Staff #72 said as nurses they see the resident every day so they can tell if it's an old discoloration versus a new bruise. When surveyor again asked if this monitoring is being done, when did the resident's bilateral lower extremity skin condition change from being small faded bruises to a larger discoloration. Finally Staff #59 was asked, Where's your baseline measurement for this discoloration? There is none? Staff #59 nodded affirmatively that there was none. On 08/17/2017 at 1:21 PM, per Staff #59, she said resident's skin discoloration has been that way ever since she was here--years. She was on aspirin before but not anymore ever since she developed a hematoma. Always had discoloration, but it's her skin that's discolored, but no swelling or anything. She was with us, went to another floor, and then came back to us. Her shins have been like that for awhile. On 08/17/2017 at 1:39 at PM, the DON said Res #38's weekly skin assessment shows bilateral old bruises, but no baseline documentation for it. On 08/17/2017 at 3:00 PM, during the infection control task meeting, Staff #115 and another licensed staff stated for wounds, skin conditions, etc., for Res #38 bilateral lower extremities, the nursing staff should have baseline measurements. They concurred it was basic nursing practice to do so. On 08/21/2017 at 7:59 AM, the DON told Staff #59 she wanted Res #38's legs to be covered with leg protectors and whether there were issues with positioning of the resident. Staff #59 said the attending physician did not know about the lower leg extremity and although nursing has been monitoring it all this time, Staff #59 said the attending physician has never documented on it. The DON asked, what's causing all this? If (attending physician) could only write and do a consult. So all this time . The DON expressed, I want them to further look at the area, the condition of the affected area. So protection of skin to prevent from breakdown. Go beyond the assessment, yeah. Then of course we want to know the cause of this. On 08/21/2017 at 9:00 AM, surveyor asked the DON to clarify the 8/17/17 measurements obtained by her nursing staff. It had stated, Left leg shin area with discolored measured: Length 29 cm and width 9 cm. Photo taken per . The DON said this skin assessment was not acceptable. The DON and two other licensed staff went to re-do the skin assessment to obtain what would be the initial baseline measurements. The DON provided this revised 8/21/17 skin assessment which stated, Resident with brownish discoloration to Lt leg shin measuring 24.0 cm x 9.0 cm with small dark bluish discoloration (dime-sized) approx 1.0 cm x 0.75 cm within the brownish discolored area on upper lateral lt. shin and another reddish discoloration approx. 3.0 cm x 1.0 cm within the brownish discolored area on lower lt. shin. No swelling or [DIAGNOSES REDACTED]; resident denies pain or discomfort. The DON acknowledged the size of it was pretty large. It was pointed out the 2/28/17 photographs of resident's left lower extremity showed what appeared to be macerated skin with open areas. Yet, there were no measurements and the photographs were pictured on a totally blank wound care measurement and assessment form. In addition, surveyor pointed out the original 7/25/2013 documentation noting the resident was admitted with bilateral lower extremities small faded bruises was not what was assessed to be her current status as evidenced by the wound measurements obtained on 8/21/17. Thus the facility failed to ensure Res #38's skin condition had noticeable optimal improvement as there was no concise assessment starting with basic measurements of its size to know what, if any, were related to recognized pathology and the normal aging process versus an injury or unknown origin. 2) Res #116 sustained multiple fractures after she fell on [DATE]. On 08/21/2017 at 8:47 AM, the DON and Staff #59 verified the neurocheck flowsheet was not done by Staff #101 and she also failed to initiate a pain monitoring flowsheet and complete her documentation on the MAR for the Tylenol she gave to the resident at 8:50 PM on 11/14/16. Cross-reference to findings at F225, F323 for Res #116. 3. On 08/15/2017 2:17:02 PM, the MRR on R#46 found that the resident was admitted to the facility on [DATE] for respite care with approved form 1147 (authorization request) for 29 days ( 04/17/17 to 05/15/2017). The level of care (L[NAME]) evaluation form(DHS 1147) notes that R#46 primary [DIAGNOSES REDACTED]. The resident was assessed and determined to have complete absence of speech, unable to communicate wants/needs; disoriented (partially or intermittently)required supervision; tube fed; did not assist in transfer or is bedfast; unable to walk; incontinent; cannot bathe without asst; requires total help in dressing, undressing , and grooming. The required skilled procedures for R#46 were: non-ventilator dependent tracheotomy care/suctioning 6 times/day; tracheotomy care; and, therapeutic diet of [MEDICATION NAME] 1.2 kcal, 1 can 5 x/day. The skilled procedures for decubitus ulcers (Stage III and above) and decubitus ulcers (less than Stage III); wound care was marked N ( not applicable /Never). The adult residential care home (ARCH) from where R#46 was transferred from, also faxed over the resident's individualized service plan (ISP), that included, Impaired skin integrity risk, follow skin breakdown prevention protocol ( position, change, keep clean & dry), proper nutrition. On 08/16/2017 at 7:09 AM continued MRR on R#46 and on the long term care facility transfer form dated 04/17/17, documentation included: no pressure ulcers; medications reviewed and renewed on 02/21/17; .[MEDICATION NAME] ointment apply to buttock area with each diaper change PRN for skin breakdown. The facility's interdisciplinary admission care plan (CP) dated 4/17/17, for CP#4 Potential for Skin Breakdown/Skin Breakdown, included interventions of: Encourage resident to turn every 2 hours or assist resident to to turn every 2 hours; Assess resident's skin every week and document findings; Report skin breakdown to Skin Care Nurse for consult . The facility's interdisciplinary progress notes dated: 4/23/17, #4 At risk for skin breakdown, documented that R#46 had a small cut on left side of lip. 4/27/17, #4 at risk for skin break down (buttocks), the progress notes documented that the resident had 3 open areas on his/her buttock measuring 2 x 1 cm and 1 x 1.5 cm to L buttock; and, 2 x 2.5 cm. [MEDICATION NAME] was applied to the area and resident was turned side to side as much as possible. 05/03/17 the wound care nurse documented that buttock/coccyx breakdown noted 04/27/17; contacted me 05/03/17. The facility's CP dated 4/27/17, problem #4 (SKIN) At risk for pressure ulcers due to limited bed mobility (including inability to reposition self and body parts) and exposure to excessive moisture from fecal incontinence; with measurable goals, Intact skin on buttocks and perineum without evidence of redness, irritation, or maceration; goal date 05/29/17. On 08/16/2017 at 8:18 AM interviewed Staff#70 and queried why staff waited 6 days before informing the wound care nurse. The DON stated that the wound care nurse was monitoring R#46's pressure ulcers and that by the resident's discharge date the wounds were healed. On 08/16/2017 at 10:36 AM a telephone interview of R#46's home caregiver (CG) was done. The CG stated that the resident was placed at the facility for respite care and at the time of discharge back to her care home, facility staff apologized that the resident had skin breakdown at the facility. The CG stated that the resident has been in her care home for 7 years and never had pressure ulcer or skin breakdown. The CG related that resident is incontinent of bowel/bladder and is changed right away when brief is wet to prevent skin breakdown. CG also stated that DOH comes to inspect her care home and in care home records this resident never had pressure ulcer under her care. On 08/17/2017 at 9:13 AM interviewed Staff#98 to discuss R#46's skin breakdown while in the facility. According to Staff#98, the resident's pressure ulcers (PU) were not staged because buttock area has no bone so not considered PU. Staff#98 further stated that R#46 was admitted to facility with [MEDICATION NAME] ointment and discoloration on resident's buttocks shows that resident had skin breakdown before. Staff#98 diagnosed skin breakdown as incontinence associated [MEDICAL CONDITION] and not PU. The nursing staff were instructed on how to treat incontinence associated [MEDICAL CONDITION] (IAD) and may be reason why staff reported skin breakdown to her on 05/03/17 and not on 04/27/17 when discovered. Staff#98 last saw R#46 on 5/08/17 and determined then, that within several days skin breakdown would be healed. The wound care measurement and assessment forms dated: 4/27/17 included a picture of reddened areas on the residents buttocks, with no exudates and normal wound edges; 5/3/17 included a picture of the L buttock and coccyx, with wound type described as single thickness wound, no exudates, normal wound bed, surrounding skin color, and wound edges. The measurements written at the bottom were, #1 L butt - 3.0 x 2.0; #2 coccyx 1.0 x 1.0; 5/8/17 included a picture of the L butt, single thickness 3.5 x 2.0 cm, no exudates, wound bed [MEDICATION NAME] tissue, normal surrounding skin color and wound edges. Written at the bottom of the sheet, coccyx healed. On 08/21/2017 at 2:49 PM the MRR on R#46 found on the Leahi Hospital SBAR REPORT dated 5/3/17; To: R. Gries; From: Y3 Leahi Hospital; Situation/Assessment (SBAR); Resident's buttocks with skin breakdown (excoriation) TX done per Leahi protocol; [MEDICATION NAME] ointment TID & PRN; Background: DX: [MEDICAL CONDITION]; Assessment/Recommendations: Pls assess & any recommendations. The (MONTH) 17 Physician order [REDACTED]. The admission orders [REDACTED]. The Daily system Assessment Performed (sheets) documented on these dates and times day(D), evening (E), and night (N): 4/17-24/17 skin intact, warm and dry 4/25/17 (D) L buttock denuded [MEDICATION NAME] apply; (E) L corn of lip scab 4/26/17 Buttocks excoriated on (D,E, N) 4/27/17 D) buttocks excoriated, calasime applies; E) [MEDICATION NAME] applied to buttock 4/29/17 Buttocks still excoriated/open areas 4/30/17 D) Buttocks still excoriated, continue to apply [MEDICATION NAME]; E) buttocks still excoriated [MEDICATION NAME] applied 5/1/17 D) buttock excoriated 5/2/17 D) buttock still moist, cont reposition Q 2 hr & apply [MEDICATION NAME]; N) Buttocks remain open The facility did not provide the necessary skin care and services consistently to maintain R#46's skin integrity to prevent IAD.",2020-09-01
134,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,314,D,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and staff interviews, the facility failed to ensure that based on a comprehensive assessment, a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing of the existing wound for 1 of 32 residents (Res #128) in the Stage 2 sample. Finding includes: Cross-reference to F279. Res #128 was admitted to the facility on [DATE] for skilled nursing services with [DIAGNOSES REDACTED]. The record review found a handwritten entry by Staff #59 dated 4/27/17 for Stage 3 open area to coccyx. The resident's clinical record also noted the coccyx/sacral wound measured 3 x 2 x 0 cm and 2 x 1.5 x 0 cm. There was no depth nor tunneling and undermining noted to the wound. However, there were two separate measurements for it although there was only one sacral decubitus. The wound care certified nurse, Staff #98's initial wound care entry dated 4/28/17 stated, Due to incontinence suggesting topical application .see photo 04/27/17. Suggest zinc oxide ([MEDICATION NAME]) to area with each brief change and prn . There was no documentation that Staff #98 consistently documented and reviewed the wound care measurements. In fact, the next 5/4/17 weekly skin assessment stated, Coccyx intact & pink. No rashes noted. Then the 5/11/17 wound care note by Staff #98 stated, Out for PT/OT zinc oxide already applied. Due for photos prior to dc of coccyx and elbow. The last 5/11/17 weekly skin assessment entry by another licensed staff noted, Coccyx light pink superficial open dry kept area clean & dry [MEDICATION NAME] cream applied. A 5/12/17 nursing note on resident's day of discharge found a similar entry to the 5/11/17 entry stating, .coccyx superficial open dry kept (illegible) clean & dry [MEDICATION NAME] cream. There also were no treatment orders for the [MEDICATION NAME] and/or [MEDICATION NAME] found in the (MONTH) and (MONTH) physician order [REDACTED]. The DON also saw the picture of the resident's elbow and stated it was not the coccyx as written on the measuring guide. On 08/21/2017 at 1:30 PM, during the concurrent record review with the DON, she said the wound also had to be measured because, it will tell us if it's healed. It's not healed with no measurements.",2020-09-01
135,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,315,D,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members the facility failed to ensure 1 of 2 residents (Resident #87) selected for urinary incontinence receives appropriate treatment and services to restore continence to the extent possible. Findings include: Cross Reference to F280. Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on the afternoon of 8/15/17 between 2:30 and 2:45 P.M. Resident #87 was on the unit in the wheelchair. The resident was later observed in room [ROOM NUMBER] watching television in an empty room alone. The staff member reported Resident #87 spends time in this room while the other residents are eating as she/he receives tube feeding. On 8/17/17 at 10:30 [NAME]M. Resident #87 was observed being wheeled by Staff Member #157 back to the unit. The resident's oxygen saturation was checked, the resident communicated that Staff Member #157 was nervous. At this time the resident requested to use the bathroom. A record review was done on 8/15/17 at 2:19 P.M. A review of the resident's Minimum Data Set (MDS) found an admission assessment with an assessment reference date (ARD) of 4/13/17 notes the resident yielded a score of 11 (moderately impaired) on the Brief Interview for Mental Status. In Section [NAME] Functional Status, Resident #87 requires extensive assistance with one personal physical assist for toilet use. The resident was also noted to be not steady, only able to stabilize with staff assistance for moving on and off the toilet. The resident was noted to be occasionally incontinent of bladder. In comparison, the quarterly MDS with an ARD of 7/5/17 notes the resident yielded a score of 13 (cognitively intact). The resident was assessed to be totally dependent on staff with one personal physical assist for toilet use. Resident #87 was coded to be frequently incontinent of bladder. A review of the admission Urinary Incontinence assessment dated [DATE] noted the resident is aware of urinary urge and requires physical assistance for toileting due to impaired mobility. During the resident interview done on 8/14/17 at 12:50 P.M., Resident #87 reported waiting 20 minutes after the call light is activated for assistance. The resident clarified the call light is pressed to request assistance for toilet use. On 8/16/17 at 10:20 [NAME]M. an interview and concurrent record review was conducted with Staff Member #110. The staff member confirmed the decline in bladder incontinence from occasionally to frequently incontinent and also confirmed the accuracy of the MDS findings. Inquired whether a root cause analysis was done to determine the cause of the decline in bladder incontinence. The staff member reported Resident #87 was alert and oriented on admission and was totally incontinent. The staff member further reported Resident #87 uses a urinal and can ask to use the toilet, holds up two fingers for bowel movement. The resident is not time toileted. The staff member confirmed there is no documentation by the interdisciplinary team regarding why Resident #87 had a decline in urinary continence and confirmed there is no care plan update to reflect a causal analysis was done. The facility failed to assess Resident #87 for causal factors contributing to the decline in bladder continence and based on this assessment revise the resident's care plan to provide services to restore continence level.",2020-09-01
136,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,318,D,0,1,LNUE11,"Based on observations, medical record reviews (MRR) and interviews, the facility failed to ensure that 1 of 41 residents (R#15), received appropriate treatment and services to prevent further decrease in range of motion (ROM). Findings include: On 08/14/2017 at 12:26 PM, while interviewing R#15 noticed that her bilateral toes looked contracted. On 08/17/2017 at 1:46 PM interviewed R#15 who was lying in bed covered with a sheet. Queried resident if staff performed ROM exercises on any of her limbs. The resident stated that no one does ROM and also stated that toes have been contracted for awhile now and that staff never look at her toes. The R#15 allowed surveyor to visualize her toes and bilateral toes appeared contracted downwards. On 08/17/2017 at 2:10 PM, R#15's MRR found no documentation of bilateral toes contractures. Queried Staff#162 and she went to look at R#15's toes. While looking at the resident's toes, Staff#162 stated, Oh yes, your toes are contracted. Queried when nursing assessments would have noticed contracted toes and Staff#162 stated, CNAs usually do ROM and should have kept charge nurses informed. The resident stated that no one does ROM on her, and Staff#162 reassured R#15 that Rehab maintenance will do ROM. At the nursing station and asked Staff#162 for documentation on assessments of R#15's toe contractures. The Staff#162 was unable to find any documentation regarding toe contractures in R#15's MR's. Staff# 162 stated facility no longer have restorative nursing assistant (RNA), and that CNAs now do ROM task. Staff#162 called Rehab department to check if R#15 used to be on the RNA maintenance program, but Rehab Staff#80 told her that R#15 was never on Rehab maintenance program list. Staff#162 then stated that someone from Rehab would come to evaluate R#15 for maintenance program. The MRR on R#15 found that the resident was alert and oriented as documented on the annual interdisciplinary (IDT) conference notes dated dated 6/22/17. The Wound Care Measurement and Assessment form dated 8/14/16 and completed by Staff #156, of the resident's left (L) great toe open lesion, included a color picture of the wound on the contracted big toe. The Wound Care Measurement and Assessment form dated 7/28/16 and completed by Staff#162, of skin tears on the resident's R 1st & 2nd toes, included a picture of the wounds and toes contracted. On 08/17/2017 at 3:29 PM interviewed Staff#71 and he was shown pictures as described above. Staff#71 stated that the L great toe looked arthritic. Queried whether staff will not do ROM for contracted toes if arthritic, and Staff#71 replied that Rehab makes recommendations for ROM. Informed Staff#71 that Rehab didn't know about R#15's toe contractures as Staff#162 checked with them. Staff#71 reiterated that Rehab recommends ROM and responsible for evaluating contractures. Queried Staff#71 whether there were P&P's or process that staff followed to let Rehab know what residents needed to be evaluated for contractures; and/or whether nursing staff should have reported after doing skin assessments on contracted toes. Staff#71 stated that the facility doesn't have P&P's and should be standard nursing practice. Went to discuss R#15's MRR with Staff#70, and she stated that the facility does have a process to let Rehab know about contractures for evaluation. On 08/21/2017 at 9:41 AM reviewed R#15's EMR and the annual MDS 3.0 completed on 06/15/17 documented that the resident had impairment on both sides of upper extremities and lower extremities (hip, knee, ankle, foot) for functional limitation in ROM. The resident was admitted with limited range of motion and did not receive appropriate treatment and services to prevent further decrease in range of motion.",2020-09-01
137,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,323,G,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, interviews and review of the facility's policy and procedure, the facility failed to ensure the resident environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance to prevent accidents for 3 of 32 residents (Res #116, #38 and #114). Findings include: 1) Res #116 was admitted to the facility on [DATE]. Res #116 was found to have sustained multiple fractures from an unwitnessed fall on 11/14/16 at 7:30 PM. As a result of this fall, she sustained six right rib fractures, a comminuted fracture of the right midclavicle, and a right radius fracture. The facility submitted their completed event report to the State Agency (SA) on 11/15/16. Cross-reference to findings at F225. Res #116's clinical record found her Minimum Data Set (MDS) admission assessment showed her BIMS score at 12. The resident also signed her own Advanced Health Care Directive and other admission forms including the 10/27/16 Conditions of Admission for Leahi Hospital. After admission, a 11/4/16 SBAR report by Staff #59 to the resident's attending physician noted this resident used to attend their adult day health center and was ambulatory with a walker with supervision. The recommendation at that time was to add maintenance physical therapy as nursing noted a decline in her ADL function and believed she could benefit from maintenance therapy. The 11/4/16 IDT conference notes also stated, Can ambulate with walker with supervision. Has brace on right hand due to previous fracture. Her fall assessment on admission found prior to admission she had a right wrist hairline fracture, with a Fall risk score of 8, triggering an initiation of the fall protocol level 2 Falling Star program. She initially came in for long term care placement with no skilled therapies at the time. However, per interview with Staff #59, the maintenance therapy did not occur for this resident before the resident fell on the evening of 11/14/16. The resident's fall was investigated by the SA during this survey. It revealed that a thorough investigation had not been conducted for this resident who sustained multiple fracture injuries on 11/14/16. The staff interviews revealed discrepancies in the details of the resident's fall and differed from what was submitted on the facility's final ERF to the S[NAME] There also was no documentation of the investigation which was verified by both the DON and Staff #59 during their interviews. In addition, the licensed staff who attended to Res #116 after the fall, failed to initiate post-fall monitoring checks, which included vital signs, pain scoring, neurological or neuro checks and blood pressure checks as there was no Nursing Observation Flowsheet found. Thus, Staff #141 who found the resident post-fall, failed to ensure Res #116 received the necessary clinical care, treatment and services to ensure she was being monitored for changes in her condition which should have started with checking the resident every 15 minutes for the first hour, and if stable, progress to 30 minutes x 2, and if stable then, every hour x 2 and so forth. The lack of this documentation was verified by the DON and Staff #59. Staff #141 also failed to document her physical assessment of the resident and her assessment of the resident's pain levels throughout her shift. She also failed to document the actual fall and status of the resident in her progress note. In addition the fall risk assessment to be done post-fall was not dated. Yet, Staff #141 scored the resident with a fall risk of 7, which was an improvement in her fall risk score from her admission score of 8. On admission the resident was known to be able to ambulate with an assistive device with supervision reflected in her 10/31/16 assessment. However, the second undated entry by Staff #141 showed a zero for assistive device use to ambulate and/or transfer. The RCA done post-fall by Staff #59 also failed to identify nor address any of this. By Staff #59's admission that she did not conduct a thorough investigation nor conduct a thorough RCA, it further demonstrates failure by the facility to ensure Res #116 was provided with adequate supervision and monitoring when she was known to be a Falling Star fall risk since her admission. In addition, post-fall, there was no review of antecedent factors, such as whether the resident had access to her front wheel walker at bedside, whether there was a bedside commode and whether her call light or bed alarm were adequately functioning. This is where no query was done by Staff #59 as part of her RC[NAME] In fact, the DON stated, this is not a RCA when she reviewed it. 2. Res #38 sustained a fall in the facility on 2/24/17 resulting in a right hip fracture. On 08/21/2017 at 9:20 AM, the DON said her review of the record found the resident was sent to ED. The resident was admitted to the hospital for a right proximal intertrochanteric femur fracture with right proximal cephalomedullary nail fixation done secondary to the fall. The resident was readmitted to the facility on [DATE], but yet again sustained another fall on 3/27/17. This second fall was an unattended fall from her wheelchair while she tried to wheel herself back to her bed. Then on 4/1/17 the resident was transferred to the hospital again for swelling to her right thigh with pain. Her CT results showed she had a minor avulsion fracture, non-operative and was most likely due to her 3/27/17 fall. A doppler with ultrasound also showed deep vein thrombosis (DVT) with a psuedoaneurysm at the femoral artery and the resident was sent out to the hospital again on 4/12/17. She was again readmitted to the facility on [DATE]. During an interview with Staff #59 with the DON present, she stated at first this resident was ambulatory, and after the first fall, although she received limited skilled rehabilitation therapy, she had a second fall. After the second fall, she developed leg swelling (hematoma), a DVT and was sent to the hospital again. Yet, the RCA done on 3/29/17 stated the recommended actions/solutions with measurable outcomes/indicators to be: close supervision, frequent visual. The DON and Staff #5 were asked if a thorough investigation and RCA was done for this resident's two significant falls, and the DON replied, we are now putting the interviews into the root cause analysis. That's why it's only root cause. Staff #59 stated the process had changed but was unaware of the date it happened. The DON stated, It's not completed. No sufficient documentation on the RCA with the second fall . The DON said even the RCA for the first fall, same thing, it should be a team approach but it was not done. On 08/21/2017 at 10:40 AM, the DON stated, We didn't do enough with the first fall, then the second fall .then a decline in her adl function. Oh my god. The facility failed to ensure the residents received adequate supervision, care and assistive devices to have prevented an accident and is evidenced by a lack of clinical documentation and a failure to conduct a thorough investigation to further ensure there was no neglect for Res #116 and Res #38's who both suffered significant fall related injuries. On 08/15/2017 at 9:54 PM the facility faxed an incident report to the State agency for R#114's fall on 12/31/2016 that resulted in an injury. The resident sustained [REDACTED]. This was the 4th fall occurence for R#114 since admittance to the facility in (MONTH) (YEAR). The facility completed a fall assessment after each fall. Fall assessments done on the dates of 12/31/17, 03/05/17 and 07/01/17, did not include the resident's restlesness which would have increased the fall risk assessment scores by a point and corresponding fall risk assessment scores should have been 10, 11, and12. On 08/16/2017 at 3:30 PM met Staff#116 and showed her R#114's care plan (CP) which had written interventions Seat belt alarm when in W/C, Bed alarm when in bed and Bilateral fall mats. Staff#116 stated that the interventions were written by her and recognized the hand writing as her own. The staff member could not remember when she wrote it in R#114's CP as there was no start date for these interventions on the CP. Staff#116 also stated that the facility used a CP template and the intervention, Staff to follow procedures as specified in Leahi policy for Physical restraints #110-3-14, with a start date of 09-12-16, was not removed although R#114 was never put into restraints. Validated with Staff#116, interdiciplinary progress notes that specified that R#114 should be monitored for a minimum of 72 hours per facility policy after a fall. There should have been 9 consecutive nursing progress notes by shift each time the resident fell but this was done only once out of the 6 times that the resident fell . Queried Staff#116 about the missing nursing progress notes and she stated, I don't know why. When queried if there is any oversight to nurses documentation and Staff#116 didn't provide oversight for nurses documentation in the medical records.",2020-09-01
138,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,328,D,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews (MRR) and staff interviews, the facility failed to provide preventive foot care for 1 of 41 residents (R#106) on the Stage 2 resident sample list. Findings include: On 08/16/2017 at 9:03 AM during medication administration for R#106, observed that the residents toes on the R foot had blackened nail beds from the great toe to the 4th toe. The toe nails were long and the great toe nail looked slightly lifted with small reddish blisters on the sides of the toes. On 08/16/2017 at 10:23 AM Interviewed Staff#71 and he stated that R#106's skin assessment could be in the electronic medical record (EMR) and that he could print. Staff#71 further stated that R#71 had a condition that caused blisters. On 08/16/2017 at 10:40 AM, Staff# 156 printed weekly skin assessments on R#106's open area on the left buttock for dates of: 8/13/2017, 7/30/2017, 7/23/2017, and 7/17/2017, and was unable to find any assessments of the resident's toes. Both Staff#71 and Staff#156 went to assess R#106's right (R) foot and asked the resident if toes were sore. Staff#71 mentioned that R#106 probably had podiatry consult as resident had above the knee amputation (AKA) on the L leg and was diagnosed with [REDACTED]. Staff#71 looked in R#106's medical record and could not find a podiatry consult. The Staff#71 then called the podiatrist to ask if there was any record of resident being seen by podiatrist, and the podiatrist did not have any record on R#106. Staff#71 then stated that resident had [MEDICAL CONDITION] and nothing to prevent necrosis of toes but can be protected and monitored. Staff#156 looked at Medication Administration Record [REDACTED]. Staff#156 replied that no open area on toes and reiterated that resident had [MEDICAL CONDITION] so didn't see how [MEDICATION NAME] cream would prevent necrosis. Queried if MD prescribed [MEDICATION NAME] cream for the toes and she wasn't sure. Queried Staff#71 on facility protocol for diabetic foot care for residents with above knee amputation (AKA) on one side. Staff#71 stated that not a facility protocol but nursing protocol should be to monitor and protect. Staff#71 stated that staff wiould be making referral for podiatry and/or vascular surgeon consult. On 08/16/2017 at 2:58 PM interviewed Staff#71 on status of R#106's toes and he stated that the Podiatrist would come that evening to assess R#106's toes and to provide clarification on [MEDICATION NAME] cream order. Staff#71 stated that he was anticipating that podiatrist will probably recommend referral to vascular surgeon. The facility did not provide preventive care to avoid foot problems for R#106 who had diabetes and [MEDICAL CONDITION].",2020-09-01
139,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,329,E,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews (MRR) and stafff interviews the facility failed to ensure that 4 of 5 residents (R#15, R#71, R#94, R#62) sampled for unnecessary medications were monitored for [MEDICAL CONDITION] use and behavior response. Findings include: 1) On 08/16/2017 at 10:26 AM, a MRR was done on R#15 as the resident was sampled for unnecessary medications. The residents physician orders [REDACTED]. The Behavior/Intervention Monthly flow Record for (MONTH) (YEAR), for [DIAGNOSES REDACTED]. The behaviors monitored were: [MEDICAL CONDITION], sad affect/[MEDICAL CONDITION]. The dates for monitoring behaviors started from 6/22/17. The (MONTH) and Aug (YEAR) behavior/intervention monthly flow records started from the 1st of the month and was marked and initialed daily. Queried Staff#79 on the (MONTH) (YEAR) behavior/intervention monthly flow record starting on 6/22/17 instead of the 1st of the month. Staff#79 asked Staff#71 who explained that the behavior monitoring restarted in (MONTH) (YEAR) when the new DON came on board as the previous DON did not require behavior monitoring for [MEDICAL CONDITION]. 2) Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review done on the afternoon of 8/17/17 found the (MONTH) physician order [REDACTED]. tablet (for [MEDICATION NAME]) one tab PO on Monday, Wednesday and Friday for a [DIAGNOSES REDACTED]. tablet one tab PO at bedtime (2000) with [DIAGNOSES REDACTED]. tablet, 1/4 tab (12.5 mg.) PO every 6 hours prn (as needed) for non-redirectable acute anxiety or [MEDICAL CONDITION]. A review of the Medication Administration Record (MAR) notes prn of [MEDICATION NAME] was administered on the following dates: (MONTH) - 6/2/17, 6/8/17, 6/12/17, 6/14/17. 6/15/17, 6/16/17, 6/17/17 and 6/25/17; and (MONTH) - 7/3/17, 7/5/17,7/17/17 and twice on 7/26/17. Further review found missing documentation related to the efficacy of the prn administered on 6/14 and 6/17/17. A review of the Behavior/Intervention Monthly Flow Record (BIMFR) for (MONTH) and (MONTH) was done. The BIMFR records behaviors of anxiety/restlessness and [MEDICAL CONDITION] for the prn use of [MEDICATION NAME]. The review found a prn of [MEDICATION NAME] was administered on 6/12/17 and 6/14/17 after 3 episodes of anxiety/restlessness. There is no documentation in the progress notes regarding the resident's behavior on these two dates. On 6/16/17 a prn of [MEDICATION NAME] was administered at 0403. There is no supporting documentation in the BIMFR (anxiety/restlessness or [MEDICAL CONDITION]) and progress note to substantiate the need of the prn on 6/16/17. A review of the MAR and BIMFR for the month of (MONTH) was done. The review found prn of [MEDICATION NAME] was administered on 7/5/17 at 2100 and 7/17/17 at 1700 with documentation of one episode of anxiety/restlessness and no documentation in progress note to document Resident #94's behavior to require a prn of [MEDICATION NAME]. Further review found documentation in the BIMFR of prn being provided on 7/25/17 and 7/31/17; however, this is not recorded in the MAR. The progress note of 7/25/17 does not indicate prn was provided; however, the resident was documented to be hallucinating and refusing meals and care. There is no documentation related to prn given or progress note related to behavior for 7/31/17. The care plan for Resident #94 was provided by the facility on 8/17/17 at 2:25 P.M. The care plan review noted a problem the resident is at risk for fall related injury. Interventions related to the use of [MEDICATION NAME] included: IDT (interdisciplinary team) to evaluate use of antidepressant ([MEDICATION NAME] prn anxiety) quarterly and prn; nursing to offer [MEDICATION NAME] prn anxiety; and when resident is restless in bed nursing to check if resident needs to void or already wet, transfer to wheelchair and place resident in an area where he can be observed. The facility developed a care plan for use of sedative/hypnotic therapy related to [MEDICAL CONDITION]. There is no intervention related to the use of [MEDICATION NAME] to address the resident's [MEDICAL CONDITION] (the resident is also on routine [MEDICATION NAME]). On 8/21/17 at 10:00 [NAME]M. an interview and concurrent record review was done with Staff Member #110. The staff member reported the [MEDICATION NAME] is given between 8:00 and 9:00 P.M. to improve Resident #94's sleep. The staff member confirmed the findings of the record review. Inquired how does staff know when to provide a prn of [MEDICATION NAME] as the documentation notes staff members giving a prn after three episodes of behavior and other staff members provided a prn after one episode as well as when to give prn for [MEDICAL CONDITION] as the resident receives routine [MEDICATION NAME] (ordered for 8:00 P.M.). Staff Member #110 confirmed the care plan is not specific to address when a prn of [MEDICATION NAME] related to anxiety/restlessness and [MEDICAL CONDITION] is to be administered. The facility failed to ensure the parameters for the use of prn [MEDICATION NAME] was provided to ensure consistency of the administration (restlessness and/or [MEDICAL CONDITION]). Also, the facility failed to consistently document behavior identified which required a prn of [MEDICATION NAME] as well as document the efficacy of the medication. 3) On 08/17/2017 at 10:13 AM, record review was conducted for Res #62. The resident was admitted on [DATE] with the following Diagnoses: [REDACTED]. The clinical record showed the resident had been taking her antipsychotic medication, [MEDICATION NAME] 25 mg po three times daily at 0800, 1200 and 1700 in (MONTH) (YEAR), with only 3 doses not given because the resident had been asleep at those times (7/3/17 at 1700, 7/17/17 at 0800 and 1700). The [MEDICATION NAME] was ordered 12/7/15. The resident had a care plan for delusional behavior with the [DIAGNOSES REDACTED]. The measurable goals were that resident would respond to redirection by staff when exhibiting targeted behaviors with the long term goal dated for 6/21/16. The care plan's interventions included nursing to administer scheduled Quetiapine medication as ordered by the physician for dementia with behavioral symptoms/visual hallucinations, to place resident in sight of staff for close monitoring when exhibiting target behaviors, nursing to document resident's behavior on the BIMFR, monitor effectiveness and side effects of psychoactive medications per guidelines, nursing to refer for a psych consult prn .with all staff to approach resident in a calm, gentle manner, try to identify the immediate cause of frustration/anxiety/fear, focus on resident's feelings, etc. On 08/17/2017 at 11:07 AM, a review of the monthly pharmacist medication regimen review (MRR) found the pharmacist reviewed the resident's medications and noted on 9/7/16 the resident's family and staff were reporting the resident continued to have hallucinations. On 08/17/2017 at 11:15 AM, Staff #116 was interviewed about the resident's Behavior/Intervention monthly flow record, which documented resident was taking [MEDICATION NAME] 12.5 mg po HS (bedtime) and [MEDICATION NAME] 7.5 mg daily. Yet, it was found the resident was currently taking only [MEDICATION NAME] 25 mg po TID and was not taking [MEDICATION NAME]. Staff #116 said the behavior monitoring flow records had not been updated and confirmed it was an oversight. Staff #116 stated the night shift nurses printed the records and said the forms were on a template and it did not get rolled over. 4) Res # 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was found to be on [MEDICATION NAME] 40 milligram (mg) 1 tablet orally daily for a [DIAGNOSES REDACTED]. Review of the resident's Behavior/Intervention Monthly Flow Records for (MONTH) (YEAR) and (MONTH) (YEAR) however, found the flow records had the [DIAGNOSES REDACTED]. The targeted behaviors were listed as, Come sit on my lap and touching other peoples butt. On 08/16/2017 at 8:10 AM, Staff #59 stated the [DIAGNOSES REDACTED]. She acknowledged depression would included targeted behaviors such as sad affect, crying, etc., but not for the current targeted behaviors listed. Staff #59 also confirmed there was no behavior monitoring for the observed behavior of Res #71 taking Res #12's hat, which she said was a known behavior he has. On 8/16/2017 at 9:53 AM, the DON reviewed the resident's behavior monitoring flow record and acknowledged the target behaviors and the [DIAGNOSES REDACTED]. The DON stated they will also need to monitor the resident's sexually inappropriate behaviors, such as grabbing, inappropriate language, reaching out to others, and his obsession of taking the hat of another resident. The DON stated she will also be talking with the psychiatrist as Staff #59 stated the psychiatrist did not review the behavior monitoring records. In addition, Staff #59 said the flow records are incomplete as the side effects of the drugs are not listed but should be. Review of the facility's policy and procedure, Psychoactive Drug Use, Policy No. LNUR0013, eff. 2/17/10, it states at IV. Procedure .D. 4. There must be documented daily/shift monitoring of episodes of symptoms or behaviors, interventions rendered, outcomes results from interventions, and possible side effects from the psychoactive medication on Behavior/ Intervention Monthly Flow Record (BIMFR) .",2020-09-01
140,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,353,H,0,1,LNUE11,"Based on observations, interviews and medical record reviews, the facility failed to ensure that there were sufficient qualified nursing staff available to meet each resident's needs for nursing care in a manner and in an environment which promotes each resident's highest practicable physical, mental and psychosocial well-being for enhancing their quality of life. Findings include: 1. There is non-compliance with this regulation based on the cumulative deficient findings/outcomes in the various regulatory groupings which include Resident Assessment, Resident Behavior and Facility Practice, Quality of Care, Quality of Life, Nursing Services, etc. The cumulative findings are cross-referenced at their cited regulatory tags at F164, F225, F226, F241, F242, F257, F272, F278, F279, F280, F282, F309, F314, F315, F318, F323, F328, F329 and F514. 2. Additional findings include: On 08/14/2017 at 12:09 PM, an initial dining observation on the [NAME] 4 unit was done. Staff #40 said several of the residents sitting in the solarium needs assistance with eating. At 12:25 PM, Res #12 had his food tray placed in front of him, but it was not until 12:39 PM that Staff #137 starting taking the food off his tray onto a placement. Then she sat next to Res #12 to feed him. In addition, when Staff #59 was asked about the number of residents who required closer supervision, cueing and/or feeding assistance on this unit, she stated she had the most. The list she provided included 14 total residents for feeding assistance. Staff #59 acknowledged there should be staff in the solarium to supervise the residents, when there was none. Staff #59 then queried the surveyor and asked, How do the other facilities do it? It was found the residents in the solarium were left unattended with many of them requiring feeding assistance by staff who were not available to help. For Res #118's in-room dining, it was found that by 1:05:57 PM, her meal tray had been left in her room from the time the meal cart had arrived onto the unit. The resident still had not been fed. The three CNAs available during lunch were busy assisting the other residents to eat in the solarium. At 1:09:08 PM, CNA #137 said, I'm going to feed her now and went into Res #118's room. Thus, it took one hour before this resident was assisted to eat. It was also later found during an environmental rounds tour that this resident's room temperature was hot and close to 90 degrees Fahrenheit. Cross reference to findings at F257. Her meal tray had been sitting in the hot, unventilated room for one hour. 3. Then on 08/15/2017 at 8:28 AM, there were five residents in the solarium but with no staff present. One of the residents began dumping out her thickened juice onto the table with a spoon. Staff #59 observed this when the surveyor asked her to do a concurrent observation. Staff #59 reiterated they have a lot of residents who require feeding assistance. She said although they had their maximum number of CNAs (five), she acknowledged for one other resident (Res #93), her meal was hardly touched. Staff #59 said this resident needs a lot of encouragement as she will not just sit down and eat. Again, there was no staff in the solarium to assist this resident to eat, while the other resident was dumping out her thickened liquid onto the table. There was not enough staff to consistently assist these residents as part of their overall dining experience. 4. On 8/15/2017 during a Stage 1 family interview, the family member for Res #116 stated in response to the staffing and notification of change questions, that this facility did not have enough staff. He/she stated Res #116's fall was because the staff was not there to answer (resident's) call light and she ended up being hospitalized with a wrist, collarbone and rib fractures. The family member stated Res #116 told the family she called to get up to go to the bathroom, but no one responded. The family member said for the bed alarm, We could be there and pretty much standing her up, but no one would come. So why have a bed alarm when no one comes? So this one night she called, no one came so she tried to get out of bed on her own to go to bathroom and she fell . So that night we got a call that (resident) fell and they said they're going to monitor her. No, she suffered through the night with all these broken bones and after all of that, (another family member) goes over the next day and she's in all this pain and they downplayed it but said that she may have fractured something but it's up to you folks if you want to call 911 and take her to the hospital because we're not. The family member also expressed that because of what had transpired, and the way things were communicated to them, another family member has been vigilant about visiting the resident almost daily and believed this has helped to keep staff more aware of the resident's needs. 5. On 08/16/2017 at 1:58 PM, a telephone interview of Staff #141 was done concerning the care she provided for Res #116 on the evening of 11/16/17. During her interview, she stated in response to what the staffing was that evening, Uh, I cannot recall, but just to tell you the truth, most of the time we are short of CNAs, but the CNA really assigned to this patient was on break. So the other CNA (Staff #99) was the reliever because 1 person will go break and the other CNA is the reliever. Four CNAs split two and two each side, but only one licensed. I'm the only RN for 38 residents. This is on [NAME] 5 at the time. And despite the fact she stated in her interview that she continued to check the resident's neurological status and her pain, these were quality of care areas which were found not have been done due to the lack of clinical documentation. Additionally, Staff #141 acknowledged that being short of staff, Yeah I think it's a factor too, because we cannot help it, we have to help the resident from falling. I need to drop what I'm doing to help the patient who is falling. One person falls down, it will hold me up so I'm trying my best to help the aides--especially the restless patients. We understand staffing get enough, but we have sick calls, so that's how ended up being short. 6. For the fall incidents related to Res #116, #38 and #114, the facility failed to ensure they reviewed the staffing patterns and failed to complete thorough root cause analyses of their falls, albeit the residents sustaining serious physical injuries.",2020-09-01
141,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,371,D,0,1,LNUE11,"Based on observation and interview with staff members, the facility failed to ensure food was stored in accordance with professional standards for food service safety. Findings include: 1) On the morning of 8/14/17 a brief initial tour was done with Staff Member #20. Concurrent observation with Staff Member #45 of the pantry refrigerator found a plastic tub of miso paste that was not labeled. The staff member reported the miso paste was opened on Saturday and will be discarded based on the manufacturer's date. Also observed two small plastic tubs of beef based that was not labeled with an open date and there was one glass bottle of chili sauce that was not labeled with an open date. The pantry refrigerator also contained a partially consumed commercial bottle of water and a flask. Staff Member #20 reported these are personal items belonging to the staff. Concurrent observation was done with Staff Member #20 of the back up refrigerator behind the tray line. Observation found the following: one large plastic container of French dressing with a label indicating to use by 7/7/17; one small squeeze bottle of french dressing that was labeled to use by 8/7/17; and one small squeeze bottle of salad dressing with a label affixed to the side but was not filled out with an open and discard date. Interview and concurrent observations were done with Staff Member #61 on 8/14/17 at 8:45 [NAME]M. The staff member reported food is labeled with the date opened and supposed to be labeled with the date to discard, which would be 7 (seven) days after it is opened. The Manager also confirmed personal items are to be stored in the employee break room, not in the kitchen refrigerators. 2) On 8/15/17 at 11:00 [NAME]M. observed Staff Member #161 wearing gloves and spooning mayonnaise onto bowls of beets. The staff member walked to the trash can and lifted the lid to dispose of trash. The staff member did not change his gloves and continued to spoon the mayonnaise on the beets. The staff member failed to change the gloves after touching the trash can lid to preparing food.",2020-09-01
142,LEAHI HOSPITAL,125010,3675 KILAUEA AVENUE,HONOLULU,HI,96816,2017-08-21,514,D,0,1,LNUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the accuracy of the clinical records for 1 of 32 residents (Res #116) in the Stage 2 sample. Finding includes: Cross-reference to F225, F323. Res #116 suffered an unwitnessed fall with multiple rib fractures, a mid-clavicle fracture and fracture of her right wrist on 11/14/16. She was admitted to a hospital but later returned to the facility on [DATE]. However, the attending physician's 11/28/16 history and physical (readmission) note documented the resident had a past medical history of [REDACTED]. Nor were any additional new diagnoses, including [MEDICAL CONDITION] found in the records. The hospital's CT results noted the resident's cervical spine, lumbar spine, [MEDICATION NAME] spine and x-ray of her knee showed no acute osseous abnormalities. The x-rays of her clavicle and hand showed the fractures she sustained and the knee showed mild tricompartmental [MEDICAL CONDITION] and chrondrocalcinosis, but not [MEDICAL CONDITION].",2020-09-01
143,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2020-01-09,880,D,1,0,VRE811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, the facility failed to ensure nursing staff practiced aseptic technique to prevent the transmission of microorganisms during [MEDICAL CONDITION] care for one of three residents (Resident (R) 5) selected for review. This deficient practice had the potential to spread microorganisms to other residents and other individuals. Findings include: 1) On 01/08/20 at 12:30 PM, R5's [MEDICAL CONDITION] care was observed. The resident's assigned certified nurse's aide (CNA1) said she checked the contents of R5's [MEDICAL CONDITION] bag in the morning, but said since it was full, she needed to change it. R5 was found to have a [MEDICAL CONDITION] due to a [DIAGNOSES REDACTED]. CNA1 then gathered the new ostomy bag, bandage scissors, normal saline (NS) bullets and two plastic bags. She placed these items directly onto R5's bedding and proceeded to cut the ostomy borders, to adjust the size with the bandage scissors. CNA1 then removed the [MEDICAL CONDITION] bag, wiped the surrounding feces and used the NS bullets to clean the stoma site. These soiled items went into one of the plastic bags placed on the resident's bed. CNA1 was gloved appropriately. However, observation found there was no barrier provided between the clean supplies placed on R5's bedding as well as the plastic bag containing the soiled items. At 12:35 PM, the registered nurse (RN) 1 came to R5's bedside and proceeded to apply the [MEDICATION NAME] and new ostomy bag to the stoma site. Once completed, RN1 took the soiled bag to the soiled utility room and placed it into a blue bin. At 12:40 PM, CNA1 placed the bandage scissors into the other plastic bag and placed it onto RN1's medication cart. RN1 at the time, was engaged with walking another resident in the hallway. At 1:00 PM, the plastic bag with the bandage scissors in it was pushed between the drink container and the sani wipe container on the nursing medication cart. This plastic bag which had been on R5's bed and placed onto the nurse's medication cart, was not discarded and the bandage scissors within it had not been sanitized. At 04:45 PM, during an interview with the UM, she said the CNAs are trained by staff development to change the ostomy bags. Per the staff development nurse (SDN), she said, In terms of the ostomy change, they have to have all clean products, gloves, what they're going to take off, put on, so many pairs of gloves, how they do it, and they have to talk me through it when I'm watching and intervention, corrections along the way. When the SDN was asked about the set-up of the ostomy supplies, she said, Has to be on clean table, has to be on even surface, most times on overbed table and wiped down with bleach and the contact time. The SDN said this was their expected standard from nursing. The SDN said, No, that's not clean, when queried if it was okay to place the supplies directly on a resident's bed. She stated, You need to put the barrier down, you know the drape, you need a solid surface, your trash can needs to be there, your gloves get dirty, change your gloves. Further interview of RN1 was done at 5:00 PM. She said she was a float nurse this shift. RN1 confirmed CNA1 should have had a barrier between the supplies, the bags and the bed. She acknowledged she should have said something as she came to see R5 to complete her treatment, but did not. 2) On 01/08/20 at 2:10 PM, observation found the nursing unit manager (UM) move R5's overbed table out of her room and placed it in front of R6. It was observed however, that the UM failed to sanitize R5's overbed table before moving it to R6 to use while he sat in his wheelchair in the hallway. The UM acknowledged she did not sanitize the overbed table before placing it in front of R6.",2020-09-01
144,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2019-05-14,600,D,0,1,DZSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with Ombudsman, residents and staff members, and a review of the facility's policy and procedures, the facility failed to ensure 1 of 2 sampled residents (Resident 255) was free from physical abuse by not removing Resident (R)255 from his roommate who was presenting with escalating behavioral symptoms (hallucinations, kicking walls, punching himself, and urinating in the hallway). Findings include: Cross Reference F609. On 05/09/19 at 02:30 PM, the volunteer Ombudsman reported an incident involving Resident (R)255 and R143. The Ombudsman reported R255 and R143 were roommates when R143 attacked R255. R255 sustained a laceration on the right wrist. Subsequently, R255 was moved to another room. The Ombudsman reported that he spoke with the Administrator and was told R143 was trying to protect his roommate. On 05/09/19 at 02:42 PM an interview was conducted with R255 by two surveyors. R255 reported there was a strange incident which occurred approximately three weeks ago between midnight and 04:00 AM, when a noise was heard. R255 reportedly was awakened by R143 who had grabbed both of R255's arms. R255 thought R143 would break his wrist; however, R255 was able to twist his wrist to be free of R255's grasp. R255 reported a skin tear was sustained from twisting his arm to release R143's grasp. R143 further reported R255 thought a hit man from the mafia was going to stab him and was attempting to stop the hit man. R255 reportedly did not scream or call for help and following the incident R255 sat back down on the bed. Inquired whether he felt afraid, R255 replied he was a veteran and did not feel threatened and concluded R143 was hallucinating and may have seen a silhouette which made R143 believe someone was trying to attack and kill R255. R143 recalled R255 having strange conversations with himself. R255 continues to see R143 and will exchange greetings with him. A follow up interview was conducted with R255 on 05/13/19 at 08:48 AM. R255 reported that he feels safe and feels sorry for R143. R255 was aware of R143's hallucinations; however denied being aware of R143 banging the wall or hitting himself. R255 further reported he was shocked when it happened as previously they would have conversations with one another. R255 again stated that he did not feel threatened by R143 before the incident. On 05/09/19 at 03:09 PM an interview was conducted with R143 by two surveyors. R143 was sitting at the nurses' station on the unit. R143 stated the he would be sitting at the station until he goes to the bathroom. R143 was asked whether he hears any voices, R143 replied no. R143 admitted to seeing people standing around but did not feel that he would be attacked by these people. R143 was unable to recall the incident with former roommate. R143 denied hitting anyone. R143 recalled that there was a room change; however, thought it was because of a sore leg. And again, R143 denied hitting anyone. On 05/09/19 at 03:35 PM a record review was done for R255. R255 was admitted to the facility on [DATE], [DIAGNOSES REDACTED]. A review of R255's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 04/30/19 notes, R143 yielded a score of 15 (cognitively intact) when interviewed for the Brief Interview for Mental Status. R255 was not coded for mood or behavioral issues. A review of the physician's orders [REDACTED]. A review of the progress notes found documentation on 04/09/19 at 02:15 PM, a Certified Nurse Aide (CNA) reported to nurse that upon answering R255's call light, the resident was found to have a skin tear to the forearm, as a result of R143's roommate trying to protect him by holding his arm. R143 was observed to be sitting on the bed. R255 reported to the nurse that the skin tear was sustained when he had to pull his arm back with a twisting motion as the roommate held onto his arm. Subsequent entry on 04/09/19 at 03:01 PM notes both residents were calm. The progress note also documents R255 was transferred to another room on 04/09/19. Observations during the survey of R143 was done by the surveyor assigned to the resident's unit. R143 was selected for investigation related to concerns regarding pressure ulcer and falls. The surveyor was also aware to observe R143's behavior. There were no concerns regarding R143's behavior presented to the survey team. On 05/09/19 at 03:19 PM a record review was done for R143. R143 was admitted to facility on 01/20/17 with the following Diagnoses: [REDACTED]. A review of R143's quarterly MDS with an ARD of 04/03/19 found R143 yielded a score of 10 (cognition is moderately impaired) when the Brief Interview for Mental Status was administered. R143 requires extensive assistance with one person physical assist for walking between locations in his room. In Section E. Behaviors, R143 was coded to have hallucinations and not coded with behavioral symptoms. R143's care plan includes interventions to address behaviors, combativeness, hit another resident with his hand and when having periods of hallucination, he has tendency to be physically aggressive. The interventions include 1:1 supervision when agitated and combative as needed (exhibiting increased restlessness, persistent rocking motion); administer medications as ordered; ensure resident is seated away from residents when agitated; monitor/record/report to MD risk of harming others; and approach resident calmly and gently when yelling and combative. A review of the progress notes from 04/01/19 through 04/09/19 found documentation of R143 having visual and auditory hallucinations, falling and displaying aggressive behaviors. R143 was being monitored for behavior and hallucinations. R143 had two falls on 04/02/19. On 04/01/19 the progress notes document R143 was hallucinating, stating family members were trying to kill him, pointing a gun at him and taking money. On 04/04/19, R143 got mad at staff and began yelling and swearing. R143 was also documented to see centipedes on the ground and having children poking at his legs. On 04/06/19, R143 was noted to punch himself in the face, kick at walls and elevator, and shouting. There is documentation on 04/07/19 of R143 kicking a wheelchair and walls and urinating in the doorway of another resident's room. On 04/08/19, R143 was noted to have increased visual hallucinations and agitation, banging the forward wheel walker on the wall and pulling at the privacy curtain. On 04/08/19, the facility received an order to send R143 to the emergency department (ED). Upon arrival, the ambulance responders were unable to convince R143 to get on the stretcher, an attempt was made to administer [MEDICATION NAME] and medication; however, the resident refused, pushing the responders' hands away. The police were called to assist and eventually the resident was taken to the ED at 11:15 AM. R143 returned from the ED at 06:36 PM. The resident was agreeable to take medications; however, still had visual hallucinations. On 04/09/19 the progress note documents R143 continues with episodes of yelling and visual hallucinations. The note of 04/09/19 at 03:15 PM notes R143 with visual hallucination, R255 was using the cordless phone when R143 got up and held R255's arms to protect him against being injured from what he thought was a screw driver. A review of R143's behavior monitoring documents R143 with visual hallucinations, angry/agitated, screaming/yelling, punching self and refusing treatment. The resident was also noted as a danger to others on 04/06/19, 04/07/19, 04/08/19, and 04/09/19. The Medication Administration Record [REDACTED]. On the morning of 05/10/19 a request was made to review the facility's incident report between R255 and R143. On 05/10/19 at 08:26 AM the Director Of Nursing (DON) was interviewed and provided a copy of the investigative notes. The DON reported on 04/09/19 the Unit Manger (UM) called to report R255 has a skin tear which reportedly was a result of R143 holding onto his hands tightly. DON recalled R143 was being monitored for delusions and hallucinations. The DON reported following interviews/investigation, it was determined that R143 was confused and R134's intent was to protect R255; therefore, the incident was not reported as an allegation of abuse. The DON reported following the incident, R143 has not had a roommate; however, notes R143 has mellowed and is doing well. R143 has been attending activities and participating in sing along activity. The DON also reported R143's medications have been adjusted with the introduction of a new medication pimavanserin (atypical antipsychotic). At this time there are no plans to move another roommate into R143's room. A review of the DON's investigation for an injury of known cause documents a skin tear to R143's right arm. The DON interviewed staff members that were working on 04/09/19. The DON concluded the investigation on 04/16/19 and based on interviews with staff members surmised it was the intent of R143 to protect R255. On 05/13/19 at 08:18 AM an interview was conducted with Unit Manager (UM)10. The UM reported being out sick at the time of the incident; however, reported R143's behavior is being monitored and the behavior had improved in (MONTH) and March. The UM reported to prevent another incident from occurring, the residents would be separated right away and R143 will be kept away from other residents. Also, the UM reported closer monitoring would be necessary and a referral for psychiatric consult may be indicated. The UM did not think abuse occurred as R143 was not in his right mind. On 05/13/10 at 08:32 AM an interview was conducted with Registered Nurse (RN)13. RN13 was working on 04/09/19. RN13 recalled the CNA informed them of skin tear. When RN13 asked R255 what happened, R255 reported R143 was protecting him. RN13 reported prior to the incident the roommates would converse with one another. RN13 stated that if R143 received another roommate and begins to exhibit behavior, a request will be made to move the roommate to another room. A review of the facility's policy and procedures entitled Freedom from Abuse, Neglect and Exploitation documents in the subsection, Prevention, Staff will identify, assess, develop care plan interventions and monitor residents with needs and behaviors which might lead to conflict or neglect, such as: a. Verbally aggressive behavior; b. Physically aggressive behavior .",2020-09-01
145,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2019-05-14,609,D,0,1,DZSO11,"Based on record review and interview with staff members, the facility failed to report an allegation of abuse to the State Survey Agency immediately and failed to report the results of the investigation within five working days. Although the facility investigated the incident, the facility did not identify the incident as an allegation of abuse. Findings include: Cross Reference to F600. On 05/09/19 the volunteer Ombudsman reported an incident of Resident (R)143 attacking R255. On the morning of 05/10/19 a request was made to review the facility's investigative report. On 05/10/19 at 08:26 AM the Director of Nursing (DON) provided a copy of the investigative notes. The DON stated the Unit Manager (UM) reported R255 sustained a skin tear as a result of R143 holding onto R255's hand tightly. The DON confirmed this incident was not reported to the State Survey Agency as an allegation of abuse. A review of the DON's investigation found the incident was classified an an injury of known cause. The staff members were interviewed regarding the incident. The Acting UM, Licensed Practical Nurse (LPN)15 reported R255 just completed lunch and was making a phone call with the cordless phone. Later the Registered Nurse (RN) also reported the Certified Nurse Aide (CNA) informed her of a skin tear to R255. The LPN15 went to assess R255 and found both residents were calm. R255 reported R143 held his arm/hand to protect him from someone that was trying to stab him in the throat with a screw driver. LPN15 asked R143 what happened, R143 reported, he was trying to protect R255. Later staff members found that R143 hid the phone under his pillow. R143 reportedly informed the LPN15 that he was trying to keep it safe. The LPN15 documents the facility made arrangements to move R255. RN13 is noted to report R255 sustained a skin tear to the right forearm as a result of R255 holding/grabbing his hands to protect him from being stabbed. At this time, R143 denied pain and the skin protocol was initiated. CNA14 was also interviewed. The CNA reported finding the skin tear on R255's right forearm during rounds. The CNA further reports R255 stated that R143 held/grabbed his hand to protect him as there are a lot of people that want to hit R255. The CNA notes prior to the incident R255 did not complain about R143. The DON documents completion of the investigation was done on 04/16/19 and found R143's action was an effort to protect R255. The DON visited R143, R143 did not express any concerns or further injuries from the incident and was agreeable with the new room change.",2020-09-01
146,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2019-05-14,679,D,0,1,DZSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff member, the facility failed to provide 1 of 3 residents (Resident 176) reviewed for activities with an ongoing activity program to meet the resident's need. Findings include: On 05/08/19 at 10:47 AM, Resident (R) 176 was observed to be asleep in bed. On 05/08/19 at 11:50 AM, observed R176 laying in bed. The resident was screened for a resident interview. R176 appeared confused, the resident started talking about having concern as she had to keep giving up her babies as the babies were born deformed and had to given away. Observation on 05/09/19 at 07:52 AM found R176 had eaten breakfast and was laying in bed. Subsequent observation on 05/10/19 at 09:50 AM and 12:03 PM found R176 lying in bed, placed on the left side facing the wall. R176 has a television; however, R176 was not observed to watch television and there was no music. There was no observation of newspapers or magazines. The observations found R176 laying in bed either sleeping/eyes closed. R176 was readmitted to the facility on [DATE]. R176 [DIAGNOSES REDACTED]. On 05/10/19 at 10:13 AM a record review was done for R176. A review of the annual Minimum Data Set with an assessment reference date of 04/15/19 found R176 yielded a score of 9 (cognition moderately impaired) when the Brief Interview for Mental Status was administered. R176 was interviewed for daily and activity preferences. R176 was noted to rate the following as very important: choosing clothes to wear; taking care of personal belongings; choosing between a tub bath and shower; being provided with snacks; having family or close friend involved in their care; and having a place to lock things. The resident rated using the phone in private and choosing a bedtime as not very important. The interview for activity preferences found R176 rated the following as very important: having books, newspapers, and magazines to read; listening to music; keeping up with the news; doing favorite activities; and going outside to get fresh air. R176 rated being around animals and doing thing with groups of people as not very important. A review of R176's ACT Activities/Recreation Quarterly/Annual Review dated 04/15/19 notes the resident prefers to participate in independent activities with resting/relaxing as favorite activities. R176 is provided with 1:1 visits consisting of light exercises, listening to music and socializing with staff. A review of the previous assessment dated [DATE] notes R176 enjoys watching movies on personal phone and using personal electronics to watch movies. A review of R176's care plan found R176 refuses to attend group activities due to medical concerns. The preference is to remain in the room and do leisure activities. The goal is for R176 to maintain current activity level of 1:1 visits and leisure activity. The interventions included: provide 1:1 visits consisting of talking/reminiscing (hiking, horseback riding, traveling, books and current events, reality orientation); bed side exercises and pet visits; praise R176 when engaging in independent activities such as listening to music, socializing with peers and resting/relaxing; and respect R176's preference to stay in room and on floor. A review of R176's activities for the past 30 days found documentation that R176 was provided with talking/reminiscing on 6 (six) days, 04/16/19, 04/17/19, 04/19/19, 04/25/19, 04/30/19 and 5/06/19. R176 was provided with music on 04/15/19 and 05/03/19. On 05/13/19, R176 was provided with other therapy. On the morning of 05/14/19 an interview was conducted with Recreation Assistant (RA)3. RA3 reported R176 is provided with 10 to 15 minutes of 1:1 activity. Recently, pet visits were added to R176 activities; however, the dog hasn't been coming due to illness. RA3 reported R176 would watch movies on his/her personal phone; however, the resident's phone needs to be updated. RA3 spoke with the family about the possibility of updating the phone with no result from the family. RA3 also reported R176's television is broken and has no radio. R176's family has not been approached regarding a new television or getting a radio. RA3 confirmed R176 enjoys listening to Hawaiian music. RA3 was asked whether the facility has the ability to provide R176 with a radio. RA3 responded the facility has radios to loan to residents.",2020-09-01
147,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2019-05-14,684,D,0,1,DZSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with staff members and resident, and a review of the facility's bowel regimen program, the facility failed to implement a resident's (Resident 98) bowel regimen in accordance with the physician's orders [REDACTED].>Findings include: Resident (R)98 was initially admitted to the facility on [DATE] and readmitted on [DATE] following an acute hospitalization . R98 was hospitalized for [REDACTED]. R98's [DIAGNOSES REDACTED]. On 05/08/19 at 10:30 AM an interview was done with R98. R98 was asked whether there are any problems with bowel movements or constipation. R98 reported having difficulty with bowel movement. Further inquired whether the facility provides medication. R98 responded the medication helps to move his/her bowels. On 05/10/19 at 01:36 PM a record review was done. A review of the quarterly Minimum Data Set with an assessment reference date of 03/13/19 found R98 is cognitively intact, yielded a score of 15 when the Brief Interview for Mental Status was done. Following R98's readmission to the facility (status [REDACTED]. On 05/13/19 at 08:57 AM a record review was done. A review of the physician's orders [REDACTED]. magnesia (MOM) suspension 1200 mg/15 ml, give 30 ml by mouth as needed for constipation if no bowel movement for 2 days (start date 03/06/19). A review of the Medication Administration Record (MAR) found [MEDICATION NAME] suppository was provided on the following days: 03/09/19 at 07:21 AM (effective); 03/12/19 at 02:36 AM (ineffective); 03/19/19 at 02:32 PM (effective); 03/23/19 at 05:05 AM (effective); 03/27/19 at 10:08 PM (unknown); 03/28/19 at 02:43 PM; 04/03/19 at 10:30 PM (effective); 04/07/19 at 06:47 AM (effective); and 04/10/19 at 06:50 AM (effective). There was no documentation for administration of MOM. A review of the progress note dated 03/28/19 documents [MEDICATION NAME] suppository was given for no bowel movement for five days. There was no documentation of R98's refusal of MOM. On 05/13/19 at 09:20 AM, Registered Nurse (RN)11 reported the residents' Certified Nurse Aide (CNA) will document when residents have bowel movement and inform nurses when a resident does not have a bowel movement. RN11 confirmed there is no documentation a prn of MOM was provided before administering the [MEDICATION NAME] suppository. RN11 explained if the resident refused the MOM, the nurse would place an X on the date in the MAR and notates the refusal in the progress notes. RN11 was agreeable to review the resident's record for refusal of MOM. At 09:58 AM, RN11 confirmed there was no documentation of refusal of MOM. On 05/13/19 at 11:07 AM, the facility provided a copy of the Bowel Continence Management Program. The guideline was developed to assure accurate assessment and tracking of resident's bowel function and timely, consistent implementation of bowel protocols to maintain optimum bowel function. The program includes: 3. The following bowel protocol will be implemented as established by physician's orders [REDACTED]. Administration of laxatives/bowel stimulants; and c. Administration of enema and if the routine bowel regimen protocol is followed and the resident has not had a bowel movement, the resident's physician will be notified.",2020-09-01
148,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2019-05-14,755,D,0,1,DZSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to monitor for expired medications for Residents(R) 34, 54, 67, 108 and 191. The deficient practice could have potentially affected five of 35 sampled residents. The deficient practice had the potential of these five residents not receiving medications that are not potent as ordered by their physician. Findings include: In Piikoi wing, 2nd floor, from locked Medication cart #2 it was observed R34's supply of [MEDICATION NAME] 2 mg as needed for diarrhea, expired 05/18. Observed R54's supply of [MEDICATION NAME] 0.125 mg as needed for excessive secretions, expired 01/2018. Observed R84's supply of [MEDICATION NAME] 0.125 mg as needed excessive secretions, expired 05/18. Observed R108 supply of [MEDICATION NAME] 25 mg, twice a day, expired 09/18. Staff(S)14 validated that the medications were expired. In Piikoi wing, 2nd floor, from locked Medication cart #1, it was observed R67's supply of [MEDICATION NAME]-S Tab 2 tabs twice a day, expired 12/2018. Observed R191's supply of [MEDICATION NAME] 10 mg, three times a day, expired 03/2019. Staff(S)15 validated that the medications were expired.",2020-09-01
149,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2019-05-14,761,D,0,1,DZSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with staff member, and a review of the pharmacy chart, the facility failed to properly label medications with discard dates for insulin and an inhaler. Findings include: On 05/09/19 at 09:23 AM observation was made with RN11 of the medication cart (Pensacola, Cart #2) found an opened vial of Humalog for Resident (R)76. The box was labeled with a blue label, documenting the open date of 04/10/19. There was no documentation of a discard date. Also found a box containing [MEDICATION NAME] (an inhaler) for R70. There was documentation on the box with a handwritten date of 04/27/19. There was no documentation of a discard date. Queried RN11 regarding labeling of multi-use medications, RN11 reported when a multi-use medication is opened/used it is labeled with the opened date and also the discard date. The RN reported insulin and inhalers are to be discarded after 30 days. RN11 wrote discard date for insulin as 05/10/19 and 05/27/19 for the Ambient. On 05/09/19 at 09:36 AM, Unit Manager(UM) 5 reported there are some medications that are to be discarded in 28 days. UM5 stated the medication label will indicate medications that are to be discarded in 28 days and if not indicated, it would be 30 days. Concurrent observation of the aforementioned medications was done with UM5. UM5 confirmed the labels did not indicate whether medication (insulin and inhaler) is to be discarded after 28 days. UM5 confirmed licensed nurses are to label medications to include open and discard date. UM5 was agreeable to follow up on a policy and procedure for labeling medications and how long before insulin and inhalers are to be discarded. On 05/09/19 at 10:00 AM, UM5 provided a chart from the pharmacy entitled Medication with Shortened Expiration Dates. UM5 stated RN11 was asked to change the date for the insulin in accordance with the guidelines to discard the insulin on 28th day. Further review of the grid with UM5 found no guidance regarding discard date specifically for Ambient; however, UM5 stated, the Ambient will be discarded on the 30th day.",2020-09-01
150,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2019-05-14,912,D,0,1,DZSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview with the Administrator on 05/14/19 at 10:00 AM , the facility currently has twelve rooms with a waiver for being less than 80 square feet per resident in a multiple resident bedroom. Findings Include: The facility has a waiver for the following twelve rooms, which did not meet the 80 square feet per resident in multiple resident bedroom requirement: Pensacola 1 wing: room [ROOM NUMBER] for 3 residents = 215 sq ft. room [ROOM NUMBER] for 3 residents = 213 sq ft. room [ROOM NUMBER] for 3 residents = 214 sq ft. room [ROOM NUMBER] for 3 residents = 213 sq. ft. room [ROOM NUMBER] for 3 residents = 215 sq. ft. room [ROOM NUMBER] for 3 residents = 210 sq ft. room [ROOM NUMBER] for 3 residents = 215 sq. ft. Pensacola 2 wing: room [ROOM NUMBER] for 3 residents = 212 sq. ft. room [ROOM NUMBER] for 3 residents = 213 sq ft. room [ROOM NUMBER] for 3 residents = 213 sq. ft. room [ROOM NUMBER] for 3 residents = 212 sq. ft. room [ROOM NUMBER] for 3 residents = 213 sq. ft.",2020-09-01
151,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,578,D,0,1,SGUT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain a current, accurate Advanced Directive (AD) for Resident (R)81. As a result, there is potential that the wishes for healthcare for R81 may not be honored at the end of life. Findings Include: On Record Review 06/13/18, it was noted that R81 had an AD and Provider Orders for life-sustaining treatment (POLST) in the medical record. The POLST is a form designed to improve patient care by creating a portable medical order form that records the residents wishes so that healthcare personnel know what treatments the patient wants in the event of a medical emergency. A POLST is not an advance directive. R81's AD was signed and dated 06/20/16. It designated a friend as Health Care Power of Attorney and was marked to instruct health care providers to do the following: 1 [NAME] Choice Not To Prolong Life. I do want artificial nutrition and hydration regardless of my condition and regardless of the choice I made in question 1A/1B. I do want treatment to alleviate pain or discomfort even if it hastens my death. The POLST orders in the medical record were incomplete. The POLST form was initiated on 04/04/17. It was signed by the physician, but was not signed by R81, or the designated Power of Attorney. These orders conflicted with the instructions for care outlined in the AD, and did not contain an order for [REDACTED]. 06/19/18 AM, the Staff (S)10 sought writer out to inform me the friend of R81 would be coming in today to sign the POLST. I asked S10 if she was aware of the discrepancy of the content of the documents, and she replied that she was not. S10 stated, I met with R81 and reviewed his wishes which are reflected correctly in the POLST. S10 stated she would follow up with the AD.",2020-09-01
152,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,608,D,0,1,SGUT11,"During an investigation of a Facility Reported Incident (FRI), based on record review, and staff interviews, the facility failed to report a reasonable suspicion of a crime against a resident by an employee. The outcome was that the employee, Staff (S)12 (S12) who was investigated and determined by the facility to have committed financial exploitation was not reported to law enforcement. The deficient practice was only applicab to resident (R)78. Findings include: FRI dated 01/06/17 which stated, Upon questioning of the Unit staff, the only knowledge they have is resident is looking for staff and he wants to give her a check, then later of the week he is telling them that he gave her money that range from $100 to $2,000.00. Financial abuse confirmed. Interview on 06/15/18 at 02:24 PM with Staff3 (S3), S4 and S2 was conducted. S3 confirmed that law enforcement was never contacted by calling the Director of Nursing who oversaw the investigation at that time. Per S3, R78's sister, and Power of Attorney (POA) insisted not to press charges, because she did not want to aggravate resident's well being. S3 said that since R78's POA decided not to press charges, the facility decided not to contact law enforcement. Per telephone call on 06/18/18 08:02 AM with R78's sister and POA, she denied insisting that she did not want to press charges against S12. In summary, the facility did not contact law enforcement about the financial exploitation because they claimed that the resident's POA did not want to press charges, this is a claim that was later refuted.",2020-09-01
153,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,655,D,0,1,SGUT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR) and staff interview the facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident (R111) who was readmitted to the facility from an acute hospital with a stage 2 pressure ulcer (PU). Findings Include: On 06/15/18 at 09:40 AM during RR of R111 Electronic Medical Record (EMR) found that R111 returned to the facility on [DATE] with a principal [DIAGNOSES REDACTED]. Upon further review it was found that R111 was discharged from the facility from 03/28/18 - 04/24/18, while he was admitted to an acute hospital and treated for [REDACTED]. RR of R111 care plan (CP) did not show any baseline CP for the stage 2 PU. Interviewed S15 who confirmed that there was no baseline CP in place for R111 within 48 hours after readmission to the facility. During this time it was noted that R111's CP for stage 2 PU was initiated on 4/30/18, which was 6 days after admission to the facility. RR of R111's Minimum Data Set (MDS) found that there was a Significant Change in Status Assessment documented in R111's EMR dated 4/29/18. Interviewed S16 who stated that CP for pressure ulcers are normaly started right away upon return from the acute hospital. S16 did not know why the CP for R111 was not started within 48 hours of readmission to the facility. When quiered about why R111 had a significant change in status, dated 4/29/18, S16 stated it was due to the new stage 2 PU on sacrum, decline in function, significant weight loss and R111 returned to facility with a Gastric Tube which was new.",2020-09-01
154,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,685,D,0,1,SGUT11,"Based on observation, record review, and staff interview, the facility failed to ensure that Resident (R)60 receive a device to maintain hearing abilities. The outcome is that R60 continues to struggle with any/all activities that require unimpaired hearing, including everyday communication. The deficient practice was only applicable to R60. Findings include: Interview with R60 on 06/12/18 at 02:18 PM who surveyor informed she is hard of hearing, and needs a hearing aid, asked about an hearing aid in the first month she was admitted but no follow up as far as she knows. Review of electronic health record reflected that on 04/11/18, staff (S)13 spoke to social worker regarding R60's hearing aid request. Interview with S14 on 06/15/18 at 10:41 AM who confirmed that she was assigned to R60 during (MONTH) (YEAR), but did not recall R60 requesting a hearing aid. After S14 reviewed S13's 04/11/18 progress note, she explained that she recalled other details reflected in the progress note that day, but may have forgotten she was informed of the request for hearing aid. In summary, R60 did request for a hearing aid, communicated this need to S13, staff to staff communication documented resident's desire for a hearing aid, and S14 did not follow through on resident's request for hearing device.",2020-09-01
155,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,689,D,1,1,SGUT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interview and record review, the facility failed to ensure the resident's environment is free of accident hazards, adequate supervision and assistance to prevent accidents. Findings Include: 1) During an observation of the Soiled Utility Room(SUR) (located on Piikoi two unit) on 06/12/18 at 09:48 AM, it was noted that the door to enter the room was not locked and anyone could have entered freely. There was also no staff in the immediate vicinity to prevent anyone from entering the room. The room had two large containers for soiled utility, three sharp containers; filled with sharps, two spray bottles of cleaning solution, and a four liter container of GaviLyte; which is a bowel prep solution used before medical test such as a colonoscopy. Any of these items would have put the safety of the residents and the public at risk for accident hazards. During an interview with Staff (S) on 06/12/18 at 09:55 AM, S7 stated that the door to the SUR should have been locked and secured. S7 also acknowledged the risk for accident hazards if the residents or the public got ahold of any of the items in the room. 2) Resident (R) 184 is a [AGE] year-old with a [DIAGNOSES REDACTED]. R 184 had a change in behavior with hallucinations and sleeping patterns on 02/15/18. On 02/16/18, Provider (P)1 ordered lab work to rule out infection or metabolic condition. P1 examined R184 that day. P2 also notified on 02/16/18 of R184's behavior. RR further reveals R184 had hallucinations and/or talking to himself every day the next ten days, as well as episodes of afraid/panic, angry, danger to self, danger to others, as noted on behavior form. P3 examined R184 sometime the morning of 02/26/18. Provider notes: Assessment/Plan: .seeming to be in acutely manic, psychotic episode, r/o [MEDICAL CONDITION] d/t acute change last 10-14 days Not currently evidencing imminent danger to self /others but will need CLOSE MONITORING of behaviors-pt lacks decisional capacity re: medical conditions as his judgement appears skewed by thinking that is not reality based. New orders were provided. 02/26/18 11:05 RR: Resident sits in way of middle of hallway and refuses to be moved by staff for public to get by. Resident wheeled himself by the fire extinguisher . and CNA staff reported him punching the glass. P1 notified and ordered an increase in the current medication ([MEDICATION NAME]), and added [MEDICATION NAME], which is used for psychotic conditions. RR 02/27/18 07:50 Nurses note: P2 updated regarding current condition (hurting self, yelling to kill, attempting to punch 2 residents and stood up without assistance) with order to give [MEDICATION NAME] . P2 visited R184 that morning and wrote new orders. At 15:00 R 184 yelled at a resident who passed by, and he was moved away from that resident . At 16:10 R184 got out of his wheelchair and struck R19. R19 was not injured and R184 was immediately removed from R19.",2020-09-01
156,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,700,E,0,1,SGUT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess eight residents (R15, R74, R81 R104, R107 R111, R116, and R544) for risk of entrapment from bed rails prior to installation, and failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. Findings Include: 1) On 06/12/18 observed grab bars installed on the beds of Resident (R)74, R81, R107, R116, and R544 located on Piikoi 1. Record Review revealed no documentation of assessment for risk of entrapment, review of risks and benefits, or consent of resident or resident representative for use of grab bars for R74, R81, R107, R116, and R544 . On 06/13/18 at 9:30 AM, an interview was conducted with the Staff (S) 5, who said the facility just started a new program for grab bars last week Friday, and just started to call families and talk to residents. S5 validated the assessments and consents were not completed for R74, R81, R107, R116, and R544 . S5 provided a copy of the Informed Consent and Bed Rail Screen forms, and the Clinical Services Policy and Guidelines #700 dated 02/2018, Bed Rails. The policy statement is The facility will attempt to use alternatives prior to installing a bed rail, including side rails, grab bars and other assist rails. Prior to implementing a bed rail, the facility will assess the resident for risk of entrapment, inform the resident and/or representative of the risks and benefits of bed rails and obtain consent . In addition, to not being compliant with the regulation, the facility did not follow their own policy. 2) On 06/12/18 at around 09:30 AM while screening residents on Pensacola 2 observed that 3 residents (R15, R104 and R111) had grab bars installed on their bed frames. During record review (RR) it was discovered that these residents had a history of [REDACTED]. On 06/13/18 at 10:01 AM during RR found that R111 had a fall on (MONTH) 7, (YEAR), at 1430 and this was an unwitnessed fall. Upon further RR found that R111 does not have a risk assessment completed for the use of bedrails and risk for entrapment and there was no informed consent for bed rail use completed by the facility with R111 or resident representative prior to grab bars being installed to R111's bedframe. 3. On 06/13/18 at 01:50 PM during RR found that R15 had a fall during the quarter with no major injury as documented in the progress note dated 5/2/18 by the Interdisciplinary Team (IDT). Further RR found that R15 fell twice out of bed during this time, once when he was reaching for a blanket and once when he was trying to sit up in bed and watch TV. RR found that R15 does not have a risk assessment completed for the use of bedrails and risk for entrapment and there was no informed consent for bed rail use completed by the facility with R15 or resident representative prior to grab bars being installedt o R15's bedframe. 4. On 06/13/18 at 10:41 AM R104 was observed with bruising to left side of his face (forehead and eye) that appears to be healing, when interviewed R104 stated he fell , on the floor near his bed, while trying to pick up something for his roomate. RR found that R104 fell on (MONTH) 20, (YEAR) and (MONTH) 9, (YEAR). On 06/15/18 03:45 PM RR found that R104 had an unwitnessed fall early morning on (MONTH) 9, (YEAR) and neuro checks were normal, R104 was not sent out to emergency room , no reported pain, R104 was documented being confused when asked why he fell he stated he was looking for his classmates. RR found that R104 does not have a risk assessment completed for the use of bedrails and risk for entrapment and there was no informed consent for bed rail use completed by the facility with R104 or resident representative prior to grab bars being installed to R104's bedframe. On 06/19/18 at 02:10 PM prior to leaving the facility S3 requested time to gather documents (risk assessments for bed rail use and informed consents) for R15, R74, R81 R104, R107 R111, R116, and R544. S3 came back and confirmed that these residents, R15, R74, R81, F104, R107, R111, R116 and R544 did not have these documents completed. S3 did state that the facility was in the process of getting this met for all residents who have bedrails.",2020-09-01
157,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,725,E,0,1,SGUT11,"2) Interview on 06/13/18 at 11:28 with Resident (R) 29 stated They never come back. They are so busy. I don't fet my pills on time. They cut the Clinical Nurses Aide staff (CNA). Nurses go to lunch at the same time. I don't get changed until the end of the shift and sometimes I have to go in my diaper. I feel sorry for the girls in the am. They look like they want to cry. They split two CNAs for 20 patients. They used to have three CNAs to handle but two is not enough. Based on resident interview the facility failed to provide sufficient nursing staff to maintain the highest practicable physical, psychosocial well-being for 8 residents who anonymously reported wait times of 30 minutes when using their call light for assistance. Findings Include 1) On 06/12/18 at 10:59 AM met with 8 residents who anonymously reported of having to sometimes wait at least 10 minutes, and also lots of times waiting 30 minutes for staff to respond to their call light. One resident reported that they have seen staff walking in the hallway passing back and forth in front of their room while the resident waited in their bed for assistance. One resident reported that staff give residents a story that they have to go back to another resident who is on the toilet. 2) On 06/14/18 at 10:01 AM interviewed S19 who was able to explain how she does staffing for the facility. When asked how she determines the staffing need S19 stated that staffing is based on the census of the residents at the facility and there is a preset staffing guideline that she works with. S19 also stated that if a nurse calls and requests extra staff because a resident is restless than she tries to fill this need with an extra staff member who is scheduled as a float. When asked if the facility works short staffed S19 confirmed this stating that this is due to staff calling out sick leave, staff on vacation leave, and also emergency leave.",2020-09-01
158,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,760,D,0,1,SGUT11,"Based on observation and staff interview the facility failed to ensure that the one resident (R127) was free from a significant medication error when her Blood Pressure (BP) medication was prepared and ready to be given after R127's BP (118/71) was taken and found to be outside of the ordered parameters that the medication can be given safely. This medication should have been held and documented. Findings Include: On 06/14/18 at 11:05 AM observed S17 pull medications for R127. The following medications were put into a medication cup to be administered to R127: Aspirin 81 mg chewable tablet 1 tab, Losartan-HCTZ 50-12.5 mg tab 1 tab, Tamsulosin HCL 0.4 mg capsule 1 cap and Gavilax powder 17 GM which was mixed with water. S17 stated that R127's BP was 118/71. It was noted that on R127's Losartan HCTZ label that it stated hold for SBP below 120. Quiered S17 about Losartan HCTZ if this medication should be given and she said no and disposed of the medication. On 06/14/18 after lunch requested facility policy on medication administration and this was given promptly by S2. Review of facility policy did not find any guidelines on when to hold medications per parameters that are ordered with blood pressure medications. RR of R127's Medication Administration Record [REDACTED]",2020-09-01
159,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,761,D,0,1,SGUT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review the facility failed to assure all medications were labeled properly with the correct discard by dates for insulin pens and eye drops, that eye drops were labeled with the correct eye that eye drops were to be instilled in. Findings Include 1) On 06/13/18 at 03:02 PM checked medication storage on Pensacola 2 med cart #1 with S18. Found an insulin pen, for R104, Basaglar 100 units/ML KWIKPEN, which was opened on 5/31/18 and had a discard by date of 6/29/18 and the discard label stated to discard this medication 28 days after opening. The correct discard by date is 6/28/18. Found R157 had [MEDICATION NAME] 500 unit/gm opth ointment which was labeled opened on 5/27/18. Label stated to discard 60 days after opening and discard date written was 6/28/18. S18 confirmed that 6/28/18 was not the correct discard by date. The correct discard by date is 7/26/18. Another bottle of eye drops for R157 was labeled with an open on date of 6/11/18 and label stated discard 60 days after opening and the discard by date written on the label was 7/12/18. S18 confirmed that 7/12/18 was not the correct discard date. The correct discard date is 8/10/18. Insulin ([MEDICATION NAME]) for R157 had an opened date of 6/1/18 and had 2 discard by dates, 7/30/18 and 7/9/18 which was written in green. Quiered S18 which was the correct discard by date and she could not state which date was the correct discard by date. 2) On 06/14/18 at 11:27 AM observed S17 gather supplies and medications needed to give R157. S17 stated that she had to give the resident 3 different eye drops and had to wait 3-5 minutes between the eye drops. After medication ([MEDICATION NAME] 25 mg tablet 1 tab) was given to R157, per ordered parameter, (R157 BP was 159/77 and SBP was greater than 100) . S17 administered 3 different eye drops ([MEDICATION NAME] 2.5% ophth drops, Moxifloxacin 0.5% eye drops, and [MEDICATION NAME]-Dexameth ophth susp) to R157's left eye. Afterwards the eye drops were given to copy for this medication administration. It was noted that on the [MEDICATION NAME] 2.5% ophth drops it stated instill 1 drop into right eye 4 times a day. Inquired with S17 why this did not match the Medication Administration Record (MAR) and she took the eye drop to talk with her supervisor. Inquired with S15 why the [MEDICATION NAME] 2.5% ophth drop label did not match the MAR and she stated that the medication came to the facility, from an outside pharmacy, not from PharMerica which is the facility's contract pharmacy, with that label and had not been sent to the pharmacy (PharMerica) for relabeling. S15 was able to print out the medication orders for R157 as requested. R157 had an order written [REDACTED].",2020-09-01
160,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,790,D,0,1,SGUT11,"Based on observation, record review, and staff interview, the facility failed to provide to ensure that Resident (R)60 receive routine dental care. The outcome is that R60 could not receive routine dental care because the annual dental consult was not rendered. The deficient practice was only applicable R60. Findings include: Interview with R60 on 06/12/18 at 02:13 PM who informed surveyor she wants a dental appointment for cleaning, has been begging social worker for toothpaste for sensitive teeth, and dental floss but has not received the service or items yet. Review of R60's electronic health record since admission to 06/15/18 did not reveal any dental services requested or rendered. Interview with Staff#14(S14) on 06/15/18 at 10:41 AM who confirmed that she was assigned to R60 during (MONTH) (YEAR), but did not recall R60 requesting dental services. S14 said that dental consult is performed annually, but could not find that it was rendered in the health record for R60 who has been at the facility for more than a year. In summary, dental consults that are performed annually for routine dental care at the facility were not rendered for R60 who has been a resident at the facility for a year.",2020-09-01
161,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,842,D,1,1,SGUT11,"> Based on staff interviews and a complaint made to the State Department, the facility failed to protect against releasing resident (R) 157's identifiable information. Interview on (MONTH) 13, (YEAR) with complaintee who stated that they gave me the wrong paperwork. I was taking R157 to the doctor and the medical record given to me was on another resident. The paperwork included social security information, medications, personal information. The paperwork was handed back to me and I took it back to the hospital and gave it to the nurse. I pointed out the error. I talked to the woman in charge if social services. This complaintee was informed that any personal information on any other resident in the facility should not be in his possession. Interview on (MONTH) 19, (YEAR) with Staff (S)1 who stated we reported this to our corporate office and he was given the packet of a different patient and there is an investigation going on with this. It was a mistake. We don't have a pattern with this happening here. That was identified by resident's boyfriend and he let the social worker know. He let the unit manager know and the unit manager retrieved it and it was shredded. The clinic did not call us. Instead they gave it back to the boyfriend. The unit manager followed up on this.",2020-09-01
162,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,880,E,0,1,SGUT11,"3) During an observation on 06/13/18, observed a family member (FM) enter a room marked for contact isolation without gowning. The room FM was entering was marked for contact isolation. Family member would go freely in and out of room to go to nursing station to ask questions of patient and step back into room. Upon questioning staff about why does this FM not gown up? Staff replied, she has been doing this for a long time. Based on observation, staff interview, and policy review, the facility failed to perform hand hygiene for one of four residents (Resident (R) 33 reviewed. This deficient practice put all the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: 1) During a lunch meal observation of R33 on 06/12/18 at 12:47 PM, Staff (S) 8 assisted R33. S8 wiped the mouth of R33 with a napkin; however, S8 was not wearing any gloves and did not perform any hand hygiene before or after wiping R33's mouth. S8 proceeded to assist two other residents, again without performing any hand hygiene between residents. Again, this put the residents at risk for the development and transmission of communicable diseases and infections. During staff interview with S9 on 06/12/18 at 1:00 PM, S9 acknowledged that hand hygiene should always be done before and after assisting residents with meals. After review of facility policy on Hand Hygiene, the policy stated that hand hygiene is the primary means of preventing the transmission of infection. Hand hygiene should be done before and after assisting a resident with meals. Hand hygiene should be done upon and after assisting a resident with personal care. This was not done. 2) Observed a man wearing a long sleeve yellow isolation gown and a face mask walking in the hall toward the Piikoi nursing station on 06/13/18 at 10 AM. During an interview on 06/14/18 at 10:30 AM with Staff (S) 5, I was informed the man was a family member of R116, who is on contact precautions for an Extended Spectrum Beta Lactamase (ESBL) infection. Contact precautions are special measures to prevent transmission of the infection which is spread by direct or indirect contact with the resident or resident's environment. S5 was asked what the facility policy was for visitors, and how they educate them on what special precautions they must take. S5 stated, We don't have a written policy about visitors, but we put a sign on the door for them to check in at the nurses' station before entering the room. Every time a visitor comes, we go to the room and help them put on the gown and mask or what they need before going into the room. S5 stated, Every time we remind them they need to take the gown and mask off, and wash their hands before they leave the room. S5 agreed the visitor should have taken off the gown and mask before leaving the room.",2020-09-01
163,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2018-06-19,912,D,0,1,SGUT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview with the Regional Vice President (RVP), the facility has been working on the construction process to decrease the number of bedrooms that required a waiver for being less than 80 square feet per resident in the multiple resident bedrooms. Findings include: The facility has decreased room waivers from 18 bedrooms to 12 bedrooms. The construction started on (MONTH) 20, (YEAR) for 3 additional semi-private rooms that had come to completion. RVP stated that they would be looking at what they needed to do to be in compliance. The facility has a waiver for 12 rooms that did not meet the 80 square feet per resident in multiple resident bedroom requirements as listed here: Pensacola 1 wing: room [ROOM NUMBER] for 3 residents = 215 sq ft. room [ROOM NUMBER] for 3 residents = 213 sq ft. room [ROOM NUMBER] for 3 residents = 214 sq ft. room [ROOM NUMBER] for 3 residents = 213 sq. ft. room [ROOM NUMBER] for 3 residents = 215 sq. ft. room [ROOM NUMBER] for 3 residents = 210 sq ft. room [ROOM NUMBER] for 3 residents = 215 sq. ft. Pensacola 2 wing: room [ROOM NUMBER] for 3 residents = 212 sq. ft. room [ROOM NUMBER] for 3 residents = 213 sq ft. room [ROOM NUMBER] for 3 residents = 213 sq. ft. room [ROOM NUMBER] for 3 residents = 212 sq. ft. room [ROOM NUMBER] for 3 residents = 213 sq. ft.",2020-09-01
164,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2017-07-28,167,D,0,1,8TVX11,"Based on resident interview and observation, the facility failed to ensure the resident's right to examine the most recent facility survey results and place in a location that is readily accessible to the residents (Resident #273). Findings include: During the Resident Council interview conducted 7/27/2017 at 12:40 P.M. with Resident #273, when asked Without having to ask, are the results of the State inspection available to read?, the resident responded that she was not aware the survey results are available for review and where it is posted. Upon observation as to where the survey results were located a binder with the state inspection survey results were located on a shelf on the wall next to the nurses station. The facility failed to ensure residents have the right to examine the results of the State inspection and place the results of the most recent survey of the facility in a location that was readily accessible to the residents.",2020-09-01
165,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2017-07-28,241,D,0,1,8TVX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation and staff interview the facility failed to treat and care for the resident in a manner that promotes privacy and dignity for 3 of 41 residents on the Stage 2 sample resident list. Findings include: 1) On 07/25/2017 a confidential interview was conducted. The resident stated that sometimes I have to move my bowels on the shower room floor, there is no commode under the shower chair and no toilet in the shower room. The resident further stated the staff tell me to go to defecate on the bathroom floor. On 7/27/17 at 8:32 [NAME]M., observation of the shower room found two shower chairs in the room that did not have plastic commode buckets under the seat. At 8:44 [NAME]M., during an interview with Staff #224 stated that sometimes the residents have accidents while showering. The white shower chair comes with a white bucket that is placed under the seat in case the resident needs to have a bowel movement. The blue shower chairs aren't designed with a bucket so a plastic liner/ bag is placed under the seat in place of the bucket. Subsequent observation with Staff #224 found the shower room was not equipped with plastic liners or a trash can. 2) On 07/27/2017 at 10:12 [NAME]M., R#290 was observed being wheeled on a shower chair from his room to the shower room. The resident was draped with linen and passed by 3 residents that were seated in front of the nurses station. The drape only partially covered the resident, leaving the right thigh and buttock exposed. At 10:23 [NAME]M. the resident was wheeled back to his room from the shower in the same manner, only partially covered with the drape leaving the right thigh and buttock exposed. . 3) Observation on 7/27/17 during lunch in R#241's room, the resident was awake when Staff #37 came in and placed the food tray on the bedside table. Staff#37 stated, she's a feeder, I mean we have to feed her, as she set-up the resident's lunch. A review of the Minimum Date Set ((MDS) dated [DATE] for R#241 was done. In Section C. Cognitive level noted the resident was not able to be scored on the Brief Interview for Mental Status (BIMS). C0100 Should brief interview for mental status be conducted? The facility answered No, the resident is rarely/never understood. The facility did not ensure residents were provided care that promotes dignity in recognition of their individuality",2020-09-01
166,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2017-07-28,242,D,0,1,8TVX11,"Based on resident interview, record review and staff interview, the facility failed to ensure the residents right to choose care services that are significant for 1 of 16 residents interviewed (Resident #22). Findings include: On 7/25/17 at 1:28 PM during the resident interview, Resident #22 answered no when asked do you choose how many times a week you take a bath or shower stating, I would like to take a shower 3 times a week but I don't ask the staff because they are too busy and don't have the time. A follow up interview with Resident #22 was conducted on 7/26/17. Resident #22 further stated, it is assumed that everybody takes showers twice a week and she is obeying the rules. The resident also shared that at times, her head perspires and she is conscientious as she receives visitors. On 7/27/17 at 8:51 AM review of the Minimum Data Set (MDS) section F. Preferences for Customary Routine and Activities assessment reference date of 1/9/17 indicated the resident answered that it was very important to choose between a tub, shower, bed bath or sponge bath. Review of the care plan and Kardex dated 7/02/17 did not indicate the resident's preferences for type and frequency of baths. On 7/28/17 at 9:45 AM Staff #111 stated it is the facility's policy that baths are given two times per week. The residents may ask the staff if they want to have a shower or bathe more than twice per week but the staff don't normally ask the residents. In addition, the staff member reported the residents and/ or their representatives are invited to attend the quarterly inter-disciplinary team (IDT) meetings when they can discuss or change any of their care preferences. Staff shared that Resident #22 did not attend the previous previous meetings held in (MONTH) and (MONTH) (YEAR). The facility failed to ensure the resident has a choice on how many times a shower is provided based on their personal preferences.",2020-09-01
167,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2017-07-28,247,D,0,1,8TVX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, and electronic medical records (EMR) reviews, the facility failed to ensure that 3 of 16 residents (R#246, R#339, R#602) interviewed on the Stage 1 census sample were given notice of a new roommate. Findings include: On 07/25/2017 at 11:00 AM R#339 was interviewed during Stage 1 of the survey. When queried whether the resident was moved to a different room and/or had a roommate change in the past nine months and whether he/she received notice, the resident replied that moved from room [ROOM NUMBER] to current room in (MONTH) (YEAR) and also had a roommate change. The resident stated that he/she received notice for room change but was never informed or given notice when a new roommate was admitted to bed B. On 07/25/2017 at 12:27 PM, R#246 was interviewed during Stage 1 of the survey. The resident stated that there was a roommate change within the past nine months but notice was not received for roommate change. On 07/25/2017 at 12:50 PM, R#602 was interviewed during Stage 1 of the survey. The resident stated that there was a roommate change in the last nine months and found out when overheard staff speaking about it in his/her room, but the staff never provided a roommate change notice. On 07/28/2017 at 10:49 AM interviewed Staff#412 and she stated that residents are informed the day of or day before bringing in a new roommate and that the social workers (SW) talk with the individual resident(s) involved with roommate change/new roommate. According to Staff#412 residents should be given notice of roommate change by the assigned SW. Staff#412 went on the EMR to look at whether the residents above received a roommate change notice and could not find any documentation that R#339, R#246 and R#602 were given roommate change/admission notice. Staff#412 stated that sometimes new admits are placed into a room and not sure if residents in the rm are notified and whether notice not required for new roommate. Staff#412 further stated that residents are informed verbally when they are receiving a new roommate by either nurse (new admit) and/or SW. The facility's policy interpretation and implementation for Transfer, Room to Room was provided by Staff#3, and it states under, 4. A roommate will be informed of any new transfer into his/her room. Such information will include why transfer is being made and any information that will assist the roommate in accepting his or her new roommate. The facility failed to provide notice and information to residents that received new roommates.",2020-09-01
168,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2017-07-28,253,D,0,1,8TVX11,"Based on resident interview, observation and staff interview the facility failed to maintain a sanitary, orderly and comfortable interior in good repair. Findings include: 1) On 7/25/17 at 9:45 [NAME]M., 11:10 [NAME]M. and 2:00 P.M. a urine odor was noted in room 212. During lunch, the residents of room 212 were observed dining with the strong foul odor. 2) On 7/25/17 at 10:02 [NAME]M. a strong foul odor was noted on Piikoi 2 near the elevator and nurses station. A soiled laundry cart was observed outside a resident's room in the area. At 11:00 [NAME]M. the foul odor was present in the same area. At 12:30 P.M. the foul odor continued to be present in the same area and near the lunch tray cart. On 7/27/2017 at 8:30 [NAME]M. breakfast trays were distributed by staff and a foul odor was noted near the tray cart and nurses station. At 9:04 [NAME]M. a staff member was observed to open a door and the foul odor came wafting down the hall toward the nurses station. At 9:09 [NAME]M. concurrent observation was done with Staff #97 who unlocked the soiled linen closet near the nurses station and an overwhelming foul odor was immediately noted. The room was observed to contain 6 carts full soiled linen, personal briefs and bed liners. Staff #97 stated that housekeeping removes the dirty items from the room throughout the day. At 9:27 [NAME]M. and 10:15 [NAME]M. the foul odor continued to be present in the same area. 3) On 07/25/2017 at 10:29 [NAME]M. during a confidential interview the resident stated sometimes the floor smells. A previous roommate reportedly had infected leg ulcers that was oozing onto the floor and smelled bad. The resident also noted two soiled laundry carts sitting outside of his room that smelled bad, maybe from sitting too long. On 7/27/17 at 8:35 [NAME]M. a staff member was observed to toss a soiled diaper into a linen cart outside of the resident's room. 4) On 7/25/17 at 10:35 [NAME]M. observation of room 308 on Pensacola, a shower head was noted to have dark black residue and the drain pipe had brown and black residue. A plastic PVC pipe was laying on the shower floor. A visitor mentioned it was a part from a shower chair. The facility failed to ensure the residents have a homelike, sanitary environment free from odor and in good repair.",2020-09-01
169,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2017-07-28,258,D,0,1,8TVX11,"Based on resident interview and observation, the facility failed to ensure the maintenance of comfortable sound levels for 3 of 16 residents interviewed. Findings include: 1) On 7/25/2017 at 1:42 P.M. during the resident interview, Resident #22 stated that the roommate's television is really loud. Resident #22 frequently calls the staff to turn the resident's television down but the resident turns it back up after the staff leaves the room. At 1:45 P.M. the other resident was observed turning the volume up on the television making it difficult to conduct the interview over the sound and hear resident #22. Resident #22 stated that it makes her uncomfortable, making it difficult to sleep or talk on the telephone because of the noise. 2) During a confidential interview on 7/25/17 a resident stated that one of the other residents in the room is very noisy. The resident is very foul mouthed and frequently spits. In the room across the hall, another noisy resident yells loudly, uses foul language toward the staff and many other residents. It causes mental anguish for me and all of the other people. On 07/27/2017 at 8:21 [NAME]M. a resident was observed in the hallway near the same room yelling loudly and swearing. 3) On 07/25/2017 at 12:37 P.M. during the resident interview, Resident #246 stated that one of three of the roommate's in the same room is noisy, often drowns out the sound from the television and frequently wakes the other residents up early in the morning when they're sleeping. The facility failed to ensure the residents have comfortable sound levels that interface with hearing and makes it difficult to have privacy or participate in activities.",2020-09-01
170,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2017-07-28,280,D,0,1,8TVX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and facility policy review, the facility failed to revise/update 1 of 26 care plans (Resident #210) reviewed during Stage 2 of the QIS survey. Findings include: Cross reference to F309. Resident #210 was admitted to the facility on [DATE] for long term care. She was admitted to a Hospice program on 2/26/17 for failure to thrive. A significant change Minimum Data Set (MDS) was completed to reflect Resident #210's change in status with Assessment Reference Date (ARD) of 3/6/17. A medical record review on the afternoon of 7/27/17 revealed two separate care plans: Facility's care plan and the Hospice's care plan. An interview of Staff #205 on the afternoon of 7/27/17 at approximately 3:30 P.M. revealed the Facility staff was unclear of which services and interventions the Hospice staff provided. Staff #205 reported the Facility covered all care areas and when the Hospice staff came in, they may help feed or shower Resident #210. A review of the Facility's policy titled, Hospice Program with revision date of (MONTH) 2014 revealed, 4. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status. The facility failed to update/revise Resident #210's care plan to reflect her current status for end of life care.",2020-09-01
171,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2017-07-28,309,D,0,1,8TVX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interviews and facility policy review, the Facility failed to provide collaborative Hospice services to one resident, Resident (R)#210. Findings include: An observation of R#210 on the morning of 7/25/17 at approximately 10:30 [NAME]M. found her asleep in bed. She appeared comfortable. Observation of R #210 on the morning of 7/26/17 at approximately 9:00 [NAME]M. found her asleep in bed. Observation of R #210 on the afternoon of 7/27/17 at approximately 1:30 P.M. found her laying in bed awake. When spoken to, R #210 did not respond. She appeared comfortable and non-distressed. An interview of Staff #2 on the afternoon of 7/27/17 at approximately 3:06 P.M. revealed that she was responsible for keeping R#210 clean by wiping her down every morning regardless of Hospice staff visiting or not. Staff #2 reported that the Hospice Skilled Nurse and Certified Nurses Aide, (CNA), both came one time weekly. However, Staff#2 wasn't clear of what the Hospice CNA did for R#210 and was unaware of when the Hospice's CNA visited. An interview of Staff #205 on the afternoon of 7/27/17 at approximately 3:10 P.M. revealed her understanding of the Hospice's interventions seemed to be the same as the facility's interventions. Staff #205 reported that the Hospice's skilled nurse came twice weekly. Staff #205 reported that most importantly, she would communicate with the Hospice staff for any changes in R #210's condition. She was unaware of the expectations of the Hospice's staff and how it was incorporated with the Facility's plan of care. Staff #205 noted the Facility and Hospice did not meet to create a collaborated care plan for R #210. Staff #205 further noted that she spoke with the Hospice nurse when he visited. However, the discussion between agencies was not documented in the Facility's electronic medical record (EMR). Staff #205 reported she was unaware if the Facility had copies of the Hospice's progress notes. She understood they left information in a Hospice binder (kept at the nurses station), which Staff #205 admitted she never opened. A review of the Hospice's binder on the afternoon of 7/27/17 at approximately 3:30 P.M. found the skilled nurse and CNA both left progress notes. However, the last skilled nurse's note was dated 4/28/17. The last CNA note was dated 5/26/17. A medical record review for R #210 found she was a long term resident of the facility, admitted on [DATE] with [DIAGNOSES REDACTED]. She was admitted to Hospice on 2/26/17 with a [DIAGNOSES REDACTED]. Review of R #210's care plans found two separate care plans, a Nursing Facility care plan and a Hospice care plan. The Facility's care plan which was dated 3/2/17 noted R #210 had a terminal prognosis related to calorie malnutrition with life expectancy of 6 months or less. The Facility's care plan included interventions related to what the Facility would provide to meet R #210's needs for end of life care. The last intervention stated, Resident is on hospice. See (Hospice Name) care plan for services provided. A Hospice care plan was found in the Hospice binder at the nurse's station. The Hospice's care plan was reviewed/updated on 7/19/17 and noted the Facility was responsible for 24 hour custodial care for the resident and would notify the hospice of changes in condition. The Hospice's care plan further noted the Hospice was responsible for medical management and coordination of care with the Skilled Nursing Facility, SNF. The Hospice's care plan further outlined specific interventions for each discipline: Skilled Nurse; Health Care Aide; Master's degree Social Worker; and Clergy. However, the medical record review did not find a comprehensive/collaborative care plan between the Facility and the Hospice for R #210 related to end of life care. The primary Hospice Nurse was on leave and therefore unavailable for an interview. However, a substitute Hospice Nurse was visiting the Facility on the morning of 7/28/17. An interview of the substitute Hospice Nurse on the morning of 7/28/17 at approximately 11:15 [NAME]M. revealed the primary Hospice Nurse visited R#210 every week. The substitute Hospice Nurse reported the primary nurse attended the facility's daily stand up meeting. She further noted the Hospice started using EMRs as of (MONTH) (YEAR). The substitute Hospice Nurse noted the EMR notes were kept in their own computers. Surveyor pointed out that the Facility's last progress note from the hospice nurse was dated 4/28/17. The substitute Hospice Nurse reported she notified her supervisor, who would be faxing the notes over now. The Assistant Administrator was in attendance during this discussion and joined the conversation to inform the Surveyor that the Hospice staff kept in touch with the Facility's staff. Surveyor informed both the Facility's Assistant Administrator and substitute Hospice Nurse that the collaboration is unclear as evidenced by the Facility staff's lack of knowledge related to what/how the Hospice staff were providing care to their residents. Secondly, the Facility staff did not document discussions between them and the Hospice staff in the facility's EMR. Finally, the Facility did not have a comprehensive, collaborative plan of care which outlined each agency's responsibilities. On the morning of 7/28/17 at approximately 11:45 [NAME]M. a review of the facility's agreement with the Hospice found, Hospice and Nursing Facility shall develop a coordinated plan of care based on the resident's individual needs and unique living situation and in a manner consistent with the hospice philosophy of care and the resident's wish for palliative care. The clinical record of the Hospice and Nursing Facility must evidence the complete coordinated plan of care. A review of the facility's policy titled Hospice Program with revision date of (MONTH) 2014 revealed, 4. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status. The facility and Hospice agency failed to collaborate the necessary care and services to maintain R#210's highest practicable physical, mental and psychosocial well-being.",2020-09-01
172,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2017-07-28,334,D,0,1,8TVX11,"Based on review of the medical record, staff interview and policy review the facility failed to provide information regarding the benefits and potential side effects of the Influenza vaccination for 1 of 5 residents (Resident #66). Findings include: On 7/28/18 at 7:45 [NAME]M. a review of Resident #66's Immunization Consent -V2 form did not show that education about the benefits and side effects of the influenza vaccination was provided to the resident's representative. Staff had checked the box giving consent to administer the vaccine although the box that the information was provided was left blank. Review of the progress notes did not indicate the information was provided to the resident's representative during the phone call. During a staff interview at 9:22 [NAME]M., Staff #111 confirmed there is no documentation that the risks and benefits were provided prior to administration of the flu vaccine. The staff member stated the facility practice is to give the resident's representative the vaccine information by phone and mail the vaccine information sheet, however, the staff was unable to produce this documentation. At 10:00 [NAME]M. the facility's policy and procedures for provision of influenza vaccine was reviewed. The facility's procedure did not include the documentation that the resident or resident's legal representative receives education regarding the benefits and potential side effects of immunizations before the vaccine is administered. The facility failed to ensure resident #66's representative was provided information regarding the benefits and potential side effects of the influenza immunization prior to administering the vaccine.",2020-09-01
173,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2017-07-28,371,F,0,1,8TVX11,"Based on observation, staff interview and record review the facility failed to monitor the dishwasher wash and final rinse temperature and trayline holding temperatures for meals once during each meal period. Findings include: On (MONTH) 25, (YEAR) during the initial kitchen tour, Staff #410 stated that the facility used the dishwasher to sanitize the dishes using heat. On 07/27/2017 at 11:30 AM observed the lunch trayline prep and holding temperatures were taken at that time. After trayline observation with Staff #410, observed that the dishwasher registered washing temperatures between 150-165 degrees F. Requested to review the temperature logs for the trayline and dishwasher from the last 3 months. While reviewing the dishwasher temperature logs it was noted that there were many instances when there were no temperatures logged for the dishwasher wash and final rinse cycles. Upon further inspection there were 2 days in (MONTH) (YEAR), the 6th and 22nd, when there were no temperatures documented for the whole day for the dishwasher use. It was noted on the facility's Dishwashing/Warewashing Machine Temperature Log, Record temperatures, flow pressure (**and ppm, where applicable) once during each meal period. Showed Staff #410 the missing dishwashing temperatures on the log which she acknowledged and stated that the supervisors are supposed to be monitoring the kitchen staff on this. On 7/28/2018 at 8:19 AM requested to have a copy of the (MONTH) (YEAR) menu along with the trayline temperature logs from Staff #410. While looking over the menu and the trayline temperatures it was noted that there were some temperatures missing from the trayline log. When asked, Staff #410 again stated that the supervisors are supposed to be monitoring the kitchen staff on this. The facility failed to check and log all the dishwasher wash and final rinse cycle temperatures and the trayline holding temperatures of food consistently to ensure and prevent the spread of foodborne illness.",2020-09-01
174,HALE NANI REHABILITATION AND NURSING CENTER,125011,1677 PENSACOLA STREET,HONOLULU,HI,96822,2017-07-28,458,E,0,1,8TVX11,"Based on interview with the DON, the facility was in the construction process to decrease the number of bedrooms that required a waiver for being less than 80 square feet per resident in multiple resident bedrooms. Findings include: During the entrance conference, the DON stated that construction started on (MONTH) 20, (YEAR) for 3 additional semi-private rooms. These 3 rooms were being added to the Pensacola building 3rd floor and the Lewalani building 1st and 2nd floors. The facility had a waiver for 18 rooms that did not meet the 80 square feet per resident in multiple resident bedrooms requirement as listed here: Pensacola 1 wing: Room 102 for 3 residents = 215 sq. ft. Room 103 for 3 residents = 213 sq. ft. Room 106 for 3 residents = 214 sq. ft. Room 107 for 3 residents = 213 sq. ft. Room 110 for 3 residents = 215 sq. ft. Room 111 for 4 residents = 273 sq. ft. Room 112 for 3 residents = 210 sq. ft. Room 113 for 4 residents = 270 sq. ft. Room 116 for 3 residents = 213 sq. ft. Room 117 for 3 residents = 215 sq. ft. Pensacola 2 wing; Room 202 for 3 residents = 212 sq. ft. Room 203 for 3 residents = 213 sq. ft. Room 206 for 3 residents = 213 sq. ft. Room 207 for 3 residents = 212 sq. ft. Room 211 for 3 residents = 213 sq. ft. Room 214 for 3 residents = 213 sq. ft. Room 215 for 3 residents = 213 sq. ft. Room 218 for 3 residents = 213 sq. ft. The facility's letter dated 7/13/17, to the State office provided that the facility would start construction on 07/20/17 for the 3 additional semi-private rooms, which would reduce the room waiver request from 18 to 12 rooms not meeting the 80 square feet per resident in multiple resident bedrooms. The DON stated that the facility would apply for a waiver for the existing 12 bedrooms that did not meet the measurement of 80 square feet per resident in multiple resident bedrooms.",2020-09-01
175,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2017-09-01,164,D,0,1,GFIS11,"Based on Resident observation and family interview the facility failed to provide privacy to 1 resident (#134). Findings include: On 08/30/2017 at 11:15 AM During the Resident interview, Resident #134 was observed to occupy the bed closest to the hallway with the privacy curtain open, dressed in a diaper and T-shirt laying on top of his bed. 8/31/17 at 9:45 AM, during the family Interview, Resident #134 Daughter concurred that she has observed Resident #134 exposed wearing only a diaper on several occasions during visits to the facility. She stated that she has repeatedly asked the staff to dress Resident #134 in shorts to provide him with privacy. The facility did not treat the resident in a manner that promotes privacy by leaving the privacy curtain open while the resident rested on his bed undressed in view of people walking by the door.",2020-09-01
176,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2017-09-01,279,D,0,1,GFIS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff members, the facility failed to ensure the development of a comprehensive care plan for Residents #175 #3131 (R#175) of 24 residents who were included in the Stage 2 review. Findings include: 1)R#175 was admitted on [DATE]. On 08/31/2017 7:52 [NAME]M. Resident #175 Observation of Breakfast Watermelon - 25% 1 cup fresh papaya 100% 120 ml Orange juice -100% 120 ml water - 100% 1 cup oatmeal - 100% Egg Mcmuffinn - 25% 240 ml coffee - 25% 08/31/2017 9:31 [NAME]M. R #175 chart review - No careplan on nutrition noted. Doctor's order reveal that R#175 is on a regular diet, regular texture, regular consistency. Weekly weight on admission. Family may bring outside food and dietician may order supplements. 08/31/2017 11:25:16 [NAME]M. Resident #175 interview with Staff #13 stated there was no nutritional consult and no careplan, no supplements. R#175 is eating and varies from 50-75%. R#175 weight on admission was 111.8 and is at 110 lbs per Staff #13. Our nutritionist is a new gentleman stated Staff #13. We communicate with him by email and by phone. 08/31/2017 2:54 P.M. Interview with staff #110 who stated she was on [MEDICATION NAME] for two weeks and just finished it this week. She gets snacks in between meals. She eats about 50-100% of her meals per day. We assess five days and fourteen days, we see a trend, we a lot for the dietician. She drinks over 1000 ml/ day. We use the BMI between 20 and 22. R#175 has a body mass index (BMI) of less than 22. She was low for the family too. Our charting system will calculate the BMI, even with 3% loss. If we see intake for two days that drops, our system will alert us. Nothing is alerting us so we are just monitoring it at this time. Staff #110 was asked why they don't have a care plan. She did not give this surveyor a reason why they don't have a careplan except that they are monitoring her closely. Findings include: 2) Chart review: 09/01/2017 8:26 [NAME]M. Resident #31 (R#31) is on [MEDICATION NAME] 75 mg 1 tablet by mouth one time a day for a history of [MEDICAL CONDITION]. R#31 is at risk for bruising and bleeding due to taking [MEDICATION NAME]. Further review of records, revealed side effects of [MEDICATION NAME] was not care planned for in record. In conclusion, the facility failed to careplan for a high risk drug which could cause bleeding and bruising. Outcome objectives, interventions and monitoring for [MEDICATION NAME] was not noted in the plan of care.",2020-09-01
177,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2017-09-01,309,E,0,1,GFIS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being, in accordance with the comprehensive assessment and plan of care for 3 of 24 residents (Resident #56, #115, #93). Findings include: 1)On 08/30/2017 at 10:04 AM, the MRR on R#93 found that the resident was admitted to hospice on 07/07/17 due to refusing meals and decline in condition. The hospice progress notes docmented that the resident's medication used for gastroesohageal reflux disease (GERD), [MEDICAL CONDITION] ulcers, erosive esophagitis, and Zollinger-Elliso[DIAGNOSES REDACTED] be discontinued as recommended by the hospice MD on 07/25/2017. It was noted in the facility's progress notes that the medication was discontinued on 08/01/2017. On 08/31/2017 at 10:46 AM interviewed Staf f#29 and queried why it took 6 days to discontinue the medication for GERD. According to Staff#29, the nursing staff had to wait for the resident's MD to approve the discontinuation of the medication. Written in the facility's communication book on 07/25/2017 was the recommendation that the medication be discontinued. The resident's MD approved the discontinuation of the medication but did not date his comments. Staff #29 was not sure why it took a week to discontinue the medication and was on vacation during the time period. Staff #29 further stated that the hospice nurse usually writes in the communication book as she came to see R#93 at least 1-2 times a week. When Staff#29 returned from vacation the hospice nurse asked her whether the resident's MD approved to discontinue the medication. Staff #29 looked in the communication book and saw that the resident's MD approved to discontinue the medication so it was discontinued on that date 8/01/17. The facility and the hospice staff failed to communicate with each other when changes were indicated for the discontinuation of medications. Findings include: 2)08/29/2017 at 11:30 [NAME]M. Resident #56 (R#56) in room, Calling out hello. Advised him to press his call light but he was unable to press his call light. Resident asked this surveyor to press call light for him. R#56 had call light in his hand but appears too weak to press it. Stated I'm hungry. This surveyor alerted CNA that he is hungry. 08/29/2017 11:50:07 AM nurse at bedside with medication and to start feeding resident. Res #56 was the last resident to get his tray. 08/31/2017 8:48 [NAME]M. Observation was made of Resident #56 (R#56) in his room. He was dressed in a t-shirt. This surveyor sat with resident. R#56 could not tell me his age. He said his daughter lives in a house. He stated that he was a chemistry teacher. When asked how was your breakfast?, R#56 stated Fine, I survived it. This surveyor noted cards from his daughter on wall and signed Love K___. Also noted two cards at bedside unopened. R#56 confirmed cards were from his daughter. While in his room, there was no TV or radio playing. 08/31/2017 8:57 [NAME]M. R #56 Chart Review: R#56 is on comfort measures only and no transfer to hospital. Careplan I am able to voice my preferences regarding my daily routine - I have a radio in my room and enjoy listening to the radio. Careplan: I have impaired cognition function and thought processes related dementia - I am not always able to use my call light, please check on me hourly if I need assistance. Keep my bed in lowest position call light within reach. A minimum data set (MDS) which is a resident assessment and care screening tool dated 3/14/17 - how important is it to listen to music you like? - very important. Observation made on: 08/31/2017 11:39 P.M. Resident #56 in his room, awake - saying hello I'm thirsty No music playing. Residents served in dining room and R#56 not served yet. No fluids in the room. Resident is not able to use his call bell. 08/31/2017 11:42: P.M. - No tray. Res will talk to you when you go into the room. 08/31/2017 12:02 P.M. - no tray, no music. Asked Staff #89, how do they determine who will get their tray and she stated that they are assigned to residents and the CNA who will feed R#56 is still feeding someone else, so he has to wait. No fluids in the room. 08/31/2017 12:11 P.M. R #56 received his tray from Staff #24, R#56 was the last to receive his tray. Observation made on 08/31/2017 2:53:08 PM R#56 No music playing in room. Observation on 09/01/2017 8:11 [NAME]M. R#56 in his room with lights off. Other residents in dining area eating breakfast. R# 56 still in hospital gown in his room with lights off. No radio playing. Staff nurse was asked why he hasn't eaten - Staff nurse replied no, the aide will feed him. 09/01/2017 8:24 [NAME]M. Interview with Staff #13 According to Staff #13. Daughter lives on the mainland. She calls once or twice month. He has a son who lives here. We have not seen his son in a long time. What does comfort measures mean in his case? Staff #13 stated it means we get him up usually after he eats breakfast and after lunch, we put him back to bed. We do not document this. Explained to Staff #13. Observation was made of two unopened letters on his bedside table and the resident has been observed to be the last one to eat on his floor. Mentioned to Staff #13 that resident has told this surveyor on two occasions that he was hungry and that he was thirsty and he is not able to push his call light although the call light is in his hands. He has been hungry before the time he is scheduled to eat and there is no water in his room. This surveyor did not observe him in a chair during visits to the room during survey dates. Staff #13 stated Usually the aides get up all the people who are eating in the dining area and they are assigned. Other staff come to help and after the dining is served, then they feed the people in the room. Interview with Staff #1 on 09/01/2017 8:38 [NAME]M. - Activity aides don't have have assigned floor, if he refuses to get up, they will do bedside activities. R#56 will have an assigned aide. In the afternoon, we have a room visit called extra special attention(ESA). As much as possible, we conduct an activity at 10:00 on the 2nd floor. It's not really all the responsibility of the activity aide to open letters. We communicate with the nurses aides too. We focus more on the resident who does not come out of their room and R#56 is on the list for ES[NAME] R#56 was the the last to eat on several observations and would tell surveyor that he was thirsty and that he was hungry. He was not able to use his call bell to alert staff that he was hungry and thirsty and did not have fluids at the bedside. His care plan and MDS preferences state that it is important for R#56 to have the radio playing; however, no observation of radio playing on multiple visits. Lastly, two unopened letters at bedside table that were not opened on observations. In summary, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Based on observations, record review, resident and staff interviews, the facility failed to ensure the resident receives the highest practicable physical, mental, and psychological well-being through comprehensive resident assessment and by recognizing and competently and thoroughly addressing the physical, mental or psychosocial needs of the individual. Findings include: 3)Staff interview: 08/31/2017 1:27 PM met with Staff #67 from 3rd floor area to go over Hospice Care. Facility policy for Hospice Care was provided. Noted the Hospice/Nursing Facility Collaboration form provided from Bristol dated 6/6/17. Also saw the Nursing Facility Coordination form. Staff #164 from Bristol Hospice assesses R#115 every Tues and Thurs and Staff #169 comes Tues and Thurs as well. Staff #67 was able to show me the Care Plan from Bristol. When asked if they invite Bristol to their care plan review staff stated that they have access on the computer to their treatment plans. Later Staff #67 stated that they do care plan review with Hospice staff. Interdisciplinary note from Bristol Hospice dated 6/6/17-9/3/17. Last facility careplan (CP) meeting for R#115 was (MONTH) 20, (YEAR) and Staff #164, Staff #167 and Staff #166 from Bristol attended the meeting. 08/31/2017 2:00 PM Staff #67 stated the facility communicates with Bristol by calling Bristol anytime and Bristol also calls them. Staff #67 said that the Bristol staff stops by and talks to the staff about any changes. Record review: 08/31/2017 1:55 PM of Bristol binder stated that R#115 was accepted to Bristol Hospice for protein malnutrition and underlying [MEDICAL CONDITION] disease. Med record discharge forms from Kuakini medical on 6/6/17 showed that R#115 had intractable vomiting due to distal esophogeal obstruction due to presbysesophagus/aggravated by [MEDICATION NAME]. 08/31/2017 2:18 PM reviewed R#115 med record and there is a progress note from 6/20/17 for last CP review. CP review was done with the following: Nursing, social services, hospice SW and resident family X2. Res did not attend the meeting. R#115 had a Pre-Admission Screening/ Resident Review done on 5/27/17 by Staff #170, PhD who recommended Psychology support to educate, problem solve, goal set. On Mental status exam, it was documented that R#115 is alert, oriented and cognitively intact. Further review of this form showed that Pt would benefit from psychology follow-up. 08/31/2017 2:57 PM review of res chart shows that an assessment was completed by Staff#165 from Bristol hospice on 6/6/17 with a Care Plan initiated and revisit planned interventions. Review of res chart from Bristol shows that Staff #164 spoke with Staff #67. Discussion if psychology consult would not be covered by hospice and notified Staff #67 that patient did worry about the cost and if she could speak with patient about whether or not she still wanted to see a psychologist. Asked Staff #67, if she did anything regarding this matter and nothing was documented. Spoke with Staff #134 who stated that the facility has something in place for res who can't afford to see a psychologist--- Nevada Moore Trust Assistance. Staff would help R#115 apply for this and then Staff #34 would either approve or not approve. Staff #67 did not meet with the R#115 and nothing more was done with this matter such as filling out the Nevada Moore Trust Assistance sheet to see if the facility would be able to provide psychology appointments for R#115 who cannot afford these appointments.",2020-09-01
178,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2017-09-01,371,D,0,1,GFIS11,"Based on direct observation and staff interview, the facility failed to control the time and temperature of the second floor nourishment refrigerator. Findings include: On 09/01/2017 at 9:25 AM the second floor nourishment refrigerator temperature registered at 48 degrees Fahrenheit. Contents inside the refrigerator included resident juice, milk, fruit cups and yogurt. The refrigerator's temperature log was reviewed noting elevated temperatures on the following days: 8/04/17, 46 degrees Fahrenheit; 8/09/17, 44 degrees Fahrenheit; 8/10/17, 44 degrees Fahrenheit; 8/11/17, 46 degrees Fahrenheit; 9/13/17, 42 degrees Fahrenheit; 9/18/17, 46 degrees Fahrenheit. Manual adjustment of the temperature control inside the refrigerator was documented as action taken by staff. At 9:36 AM during a staff interview, staff #10 concurred that the thermometer should read in the green zone between 35 and 41 degrees Fahrenheit. Staff #10 turned the temperature control inside the refrigerator to the coldest setting. The facility failed to store foods in accordance with professional standards for food service safety placing the Residents at an increase risk for food borne illness",2020-09-01
179,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2019-09-16,561,D,0,1,SLKG11,"Based on observation, interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident's choice. Findings include: Interview on 09/10/19 at 11:00 AM, R340 stated, They are supposed to give me a sponge bath every day but I haven't been getting that. That's a problem. Nobody likes to do that. The resident preferred a sponge bath because had a leg cast, and stated that no one had asked about his preference for shower and/or bath. On 09/12/19 at 08:51 AM while observing medication pass, R340 asked registered nurse (RN)5 Do you arrange showers? RN5 stated Yes I do and I'll make sure you get a shower today. Observed RN5 tell certified nursing assistant (CNA)6 to give a shower to R340. RN5 stated to surveyor We have a schedule for showers. On 09/12/19 at 12:29 PM during record review on R340, and concurrent interview with CNA7, reviewed the shower schedule. The monthly shower schedule was last done for the month of August, and R340 was not on the shower schedule. According to CNA7, the (MONTH) schedule was not done, and R340 was not on the shower schedule because recent admit to facility. CNA7 further expressed that the CNAs ask residents their preference. On 09/12/19 at 12:36 PM, interviewed CNA6 who stated that the (MONTH) schedule is the same for September. When asked about R340's preference, CNA6 stated that R340 needs supervision for bathing but able to tell us what he wants. 0n 09/12/19 at 01:00 PM R340 stated that his cast got all wet because they gave him a shower. I don't think they know how to properly handle this kind of shower.",2020-09-01
180,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2019-09-16,658,D,0,1,SLKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and a review of the facility's policy and procedure, the facility failed to document urine output in the Treatment Administration Record (TAR) as ordered for resident (R)22 to monitor for signs and symptoms of infection and complications of long-term catheterization. Findings include: Per record review on 09/16/19 at 11:23 AM for R22 documented that R22 has a suprapubic catheter. R22's care plan reports that R22 is At risk for UTI (urinary tract infection) Monitor and document urine output. A review of the physician's orders [REDACTED]. A progress notes on 06/07/19 documented that a urine analysis reported R22 had a urinary tract infection [MEDICAL CONDITION] and on 08/20/19 a finding of an encrustation of the catheter was documented. A review of the Treatment Administration Record (TAR) showed that there were 13 occurrences in which the urine output related to the use of a suprapubic catheter was not documented as ordered. The missing documentation occurred on various shifts: day shift (05/03/19, 05/14/19, 05/16/19, 05/24/19, 07/20/19); evening shift (05/09/19, 05/28/19, 7/02/19, 07/03/19, 07/28/19, 08/31/19, 09/07/19); and night shift (05/26/19). A review of the facility's nursing policy on documentation states, All staff must sign or initial for procedures rendered promptly during their shift to indicate that services were received.",2020-09-01
181,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2019-09-16,684,D,0,1,SLKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, the facility failed to provide services for assessing, monitoring and determining the efficacy of physician prescribed interventions for one of 29 sampled residents (R71), to maintain the resident's highest physical capacity. Findings Include: On 09/10/19 at 09:01 AM, observed R71 sitting in assigned room, on the side of the bed with both feet on the ground, wearing white [MEDICAL CONDITION]-embolic-deterrent (TED) hose on both legs, and notable swelling in both ankles. R71 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 09/10/19 at 02:32 PM, interviewed R71 and inquired about the use of the TED hose and notable swelling, R71 responded, The nurses put on the TED hose in the morning and take it off at night. Inquired if and how facility staff check the swelling, and R71 responded, No they never check, if they do, they don't tell me anything about it. On 09/12/19 at 02:27 PM, interviewed registered nurse (RN)1 regarding the use of TED hose for R71. RN1 responded, R71 had [MEDICAL CONDITION] and there is an order for [REDACTED]. RN1 looked in the electronic medical record (EMR), and shared that in (MONTH) 2019, R71 received [MEDICATION NAME] 20 mg 1 tab by mouth 1 time a day for 14 days. Inquired of RN1 how staff assessed, monitored and communicated the efficacy of the use of TED hose to the physician. RN1 responded that it should be in the progress notes. RN1 navigated the progress notes in the EMR, RN1 could not verify that staff communicated results of their assessments and monitoring of the use of the TED hose. RN2 further assisted in reviewing R71's EMR, and confirmed that there was no care plan to routinely address the problem of R71's [MEDICAL CONDITION]. Interviewed nursing administrator (NA)1 on 09/16/19 at 08:50 AM, inquired how staff evaluate [MEDICAL CONDITION]. NA1 replied staff verbally updates the physician and the physician performs a physical exam, normally staff will chart when there is [MEDICAL CONDITION]. Inquired if NA1 could verify that facility staff monitored R71's [MEDICAL CONDITION]. NA1 navigated the EMR and replied that on 06/12/19 there was a progress note in which staff charted R71's [MEDICAL CONDITION] was a +1, NA1 could not confirm any additional notes. Inquired of NA1, how staff know when to assess for [MEDICAL CONDITION]. NA1 responded, When the registered nurses put on the TED hose they will check, and acknowledged that there was no charting regarding the resident's [MEDICAL CONDITION]. Inquired when should staff alert the physician regarding the resident's [MEDICAL CONDITION], and NA1 replied, When there is [MEDICAL CONDITION] and if the [MEDICAL CONDITION] is not relieved by the TED hose. A record review of R71's orders showed that there were two orders addressing interventions for R71's [MEDICAL CONDITION], 1) Elevate legs when in a chair; 2) TED hose every shift for bilateral [MEDICAL CONDITION], on when out of bed off/ remove at bedtime, both of which are monitored on the treatment administration record from (MONTH) 2019 through (MONTH) 2019. There was no care plan with interventions to include the assessment and monitoring of R71's [MEDICAL CONDITION], or the efficacy of the ordered intervention.",2020-09-01
182,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2019-09-16,761,D,0,1,SLKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and the review of the facility's policy and procedure, the facility failed to secure medications and label open stock medication. Findings include: 1) On 09/11/19 at 08:03 AM, observed registered nurse (RN)1 prepare resident (R)22's medication; [MEDICATION NAME] 25 mg, [MEDICATION NAME] 300 mg, Losartan 100 mg, [MEDICATION NAME] 500 mg, and Senna 1 tab, and entered R22's room with the medications in a white disposable medication cup. Upon entering the room R22 was seated in a wheelchair and told RN1 doo doo (defecate), RN1 reminded R22 that resident used the toilet earlier. RN1 then placed R22's medications on the bedside table to assist R22 with adjusting the resident's shirt and blanket. RN1 was observed to leave R22's medication on the bedside table to go into the bathroom to perform hand hygiene, leaving the medication unattended. On 09/16/19 at 09:05 AM, interviewed the nursing administrator (NA)1 and shared above observation on 09/11/19 at 08:03 AM. Inquired on the facility's standard of practice regarding placing medications on the resident's bedside table and assisting the resident. NA1 responded that staff should acknowledge the resident, label and place the medication securely into the medication cart, assist the resident, and administer the medication after the appropriate care is provided. On 09/13/19 at 11:49 AM, a review of the facility's Medication Administration, General Principles policy, states .10. No medication will be left of resident's bedside table or meal tray. 2) On 09/12/19 at approximately 09:00 AM, inspected the medication storage room on the 3rd floor with RN2, and found a tube of topical anesthetic ([MEDICATION NAME]) opened and placed on top of unopened boxes of the same topical ointment. There was no label on the tube indicating when the tube was opened. Inquired of RN2 regarding the opened tube of anesthetic topical ointment, and RN2 replied, Normally when you open a tube it is placed in the cart and labeled with a date.",2020-09-01
183,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2019-09-16,803,D,0,1,SLKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of 24 residents (R16, R340) in the initial pool sample, received their food preferences. Findings Include: 1) On 09/10/19 at 11:01 AM, observed and interviewed R340 and he stated, I don't get my food I want and it happens every day. At a later interview with R340, he stated Everything is good except for the food. This morning, they brought me something else other than what I ordered. No butter or syrup and it is checked off. I wanted orange juice and they gave me prune juice. They didn't bring me my hard boiled egg. R340 showed the meal ticket delivered with his meal on 09/10/19 for breakfast. Meal ticket had butter and syrup marked and orange juice written as a request. R340 stated that he requested a hard boiled egg, these items were missing. R340 was admitted on [DATE]. On 09/12/19 at 0830 AM interviewed R340 who stated, It still is happening. I don't know what they do. It's mysterious. On 09/12/19 at 0930 AM interviewed registered nurse (RN)5 who stated There is a menu they fill out every week and then they pick the alternate meal. If they don't like that, the dietician says they can pick sandwiches. Occasionally, I will pass a tray out and they will say I want this and the dietary will make them a new tray. There is also a pink slip we can fill out or call them on the phone. RN5 was then told that R340 had filled out his menu but complained that keeps getting the wrong food. RN5 stated that she would talk with R340. Interview on 09/12/19 at 12:51 PM with the registered dietitian (RD) who stated that We get the menu and the kitchen aide completes the ticket and the night crew fills out the tickets for the day meal. 2) On 09/10/19 at 12:00 PM observed R16 eating lunch and she stated that chose breaded pork cutlet but got the fish nitsuke instead. R16 couldn't understand why staff always changed her food choice. On 09/12/19 10:30 AM interviewed certified nursing assistant (CNA) 6 and CNA8 and inquired how residents requested menu choices. According to CNA6, if the resident requested a specific food item he would tell the nurse. CNA8 stated that there is request form that goes to the kitchen and the kitchen manager provides the meal choice. 09/12/19 at 12:38 PM interviewed the RD and inquired how residents are provided their food choice. According to the RD, residents are given the week's menu to mark their choices. Inquired what happened when kitchen staff received the marked menus, and the RD stated that the food service workers (FSW) would then make out meal tickets for each resident's tray. The RD provided R16's weekly menu that was marked with a circle around breaded pork cutlet for lunch, and not the fish nitsuke that was observed on her lunch tray. R16's menu also confirmed that she did not circle shrimp fried rice for dinner on 09/09/19, as she also mentioned that did not get the honey ginger glazed chicken choice on the menu. The RD had the FSW1 explain the process, and he stated that the resident's menu choice would be written on their meal ticket, and that the night shift FSWs completed the meal tickets for the following morning and lunch meals. The RD acknowledged that the FSWs were not completing the meal tickets accurately based on the resident's marked menu choices and actual meal provided.",2020-09-01
184,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2019-09-16,880,D,0,1,SLKG11,"Based on observations, staff interview, and review of the facility's policy, the facility failed to ensure that staff clean/disinfect reusable items used between residents, and that staff perform hand hygiene between task. Findings include: On 09/12/19 at 08:21 AM, observed registered nurse (RN)3 using a blood pressure cuff and pulse oximeter on resident (R)70. After obtaining R70's vitals, RN3 did not perform hand hygiene, exited R70's room and proceeded to use the phone located at the Castle wing nurse's station. RN3 returned to the medication cart, prepared R70's medications and administered R70's medication without performing hand hygiene. RN3 performed hand hygiene after exiting R70's room. RN3 then entered R24's room and used the same blood pressure cuff and pulse oximeter on R24 without cleaning/disinfecting the equipment after using on R70. Inquired of RN3 regarding the policy and procedure of cleaning/disinfecting the blood pressure cuff and pulse oximeter between residents. RN3 responded that the blood pressure cuff and pulse oximeter are only cleaned in between residents with sanitizing wipes or alcohol if the residents have an infection. RN3 went to the nurse's station to double check the policy. RN3 returned and replied that the blood pressure cuff and the pulse oximeter should be cleaned/disinfected between each resident use. Reviewed the facility's nursing policy and procedure, and found on Infection Control- Cleaning and Disinfection of Resident Care Items and Equipment; . d. Reusable items are cleaned and disinfected between resident use.",2020-09-01
185,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2019-09-16,908,D,0,1,SLKG11,"Based on observation, staff interview, and review of policy, the facility failed to properly maintain and label a nebulizer treatment (NEB TX) air/oxygen tubing for one resident (R240) out of three residents reviewed. Findings Include: During an observation of R240's NEB TX air/oxygen tubing on 09/10/19 at 09:12 AM, the following were noted: 1. it was kinked in two places and did not appear to be functional; 2. there was no label indicating a date (put in use) or initial (as indicated per facility policy). During a second observation of R240's NEB TX air/oxygen tubing on 09/11/19 at 09:30 AM, the same finding, as previously noted, remained unchanged. Registered nurse (RN)3 was queried and acknowledged the finding. A review of facility policy titled Schedule for Resident Care Equipment Change, Cleaning and Calibration, stated the following under the paragraph for Policy; Residents' personal items, medical supply and equipment used in resident care shall be maintained, cleaned or changed at regular intervals to ensure proper functioning, resident comfort, and to reduce incidents of irritation .; under the paragraph for Procedures; Respiratory Care Equipment, Oxygen Tubing, Updraft Tubing . 1. Change every week and PRN by Mid-shift CNA or license nurse; 2. Date and initial tubing with adhesive label at time of change.",2020-09-01
186,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2018-09-27,574,E,0,1,5L7411,"Based on interview and record review the facility failed to orally provide the location of the contact information for the long-term care ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended (YEAR) (42 U.S.C. 3001 et seq). Findings include: During a resident council interview on 09/26/18 at 10:11 AM with the resident council president and the following residents (R)31, 85, 59, and 9 answered no when asked if they knew the location of the contact information for the state long term care ombudsman. An interview was conducted with the community life director on 09/26/18 at 10:45 AM who showed the location of the state ombudsman contact information posted on the third floor dining room bulletin board and stated that the volunteer ombudsmen comes to the monthly resident council meetings and answers questions for the residents. The resident council meeting minutes dated 09/08/17 to 09/07/17 were reviewed. No documentation was found to indicate that the contact information for the state long term care ombudsman was discussed or provided to any of the residents during the resident council meetings.",2020-09-01
187,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2018-09-27,577,D,0,1,5L7411,"Based on interview and record review the facility failed to post the results of the most recent survey of the facility in a place readily accessible to residents, family members, and the residents' legal representatives. Findings include: During a resident council interview on 09/26/18 at 10:11 AM with the resident council president and the following residents (R)31, 85, 59, and 9 answered no when asked if they knew the location of the most recent state survey results. An interview was conducted with the community life director on 09/26/18 at 10:45 AM who showed the surveyor the location of the most recent state survey results located on the desk in the third floor library. Reviewed the resident council meeting minutes dated 09/08/17 to 09/07/18. No documentation was found to indicate that the state survey results or where they can be found were discussed with the residents during the resident council meetings.",2020-09-01
188,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2018-09-27,640,D,0,1,5L7411,"Based on interview and record review, the facility failed to ensure the required Minimum Data Set (MDS) assessments were encoded and transmitted for two of 36 sampled residents (R4 and R140). This deficient practice had the potential to affect payment, quality measure monitoring, and the facility's ability to better monitor the residents' progress over time. Findings include: 1. Per the 09/25/18 electronic medical record (EMR) Profile, the facility admitted R4 on 11/14/16. R4's 08/25/18 quarterly Minimum Data Set (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, was signed as completed on 09/10/18 per section Z0500B. Per the EMR MDS tab, the status of the quarterly MDS was Export Ready. On 09/25/18 at 3:26 PM, the MDS Coordinator (MDSC) stated R4's quarterly assessment should have been submitted within 14 days of completion, but it had not yet been submitted. The MDSC stated, it is late. 2. Per the 09/25/18 EMR Profile, the facility admitted R140 on 08/21/18. R140's 08/28/18 admission MDS assessment was signed as completed on 09/04/18. Per the EMR MDS tab, the status of the admission MDS was Export Ready. Per section V0200C2, the care plan completion date was 09/04/18. On 09/25/18 at 3:26 PM, the MDSC stated R140's admission assessment should have been submitted within 14 days of completion, but it had not yet been submitted. The MDSC stated, it is late. On 09/25/18 at 3:26 PM, the MDSC stated, From the completion date, we have 14 days to submit the assessment. She added that assessments with an Export Ready status have not yet been submitted. She stated the assessments were held for quality assurance, but they should have been submitted within the required timeframes. On 09/26/18 at 1:48 PM, the MDS Manager stated the assessments should have been submitted within 14 days of the completion dates, but sometimes some were missed. Per the (MONTH) (YEAR) Centers for Medicare and Medicaid Services 'Resident Assessment Instrument (RAI) Version 3.0 Manual,' All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system . Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date ((section) V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date ((section) Z0500B + 14 days). The facility's 05/11/18 policy addressing MDS completion documented, Electronic transmission of MDS shall be in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations.",2020-09-01
189,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2018-09-27,692,D,0,1,5L7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a nutritionally at risk resident, R192 maintained an acceptable parameter of nutritional status which resulted in a severe weight loss of eight pounds in two weeks. The deficient practice had the potential to place the resident at a high risk of developing a pressure injury. Cross reference to F803 menus and nutritional adequacy. Findings include: During observation on 09/25/18 at 11:50 AM Family Member (F)1 was assisting R192 to eat his pureed meal. Stating that he doesn't like the pureed food and has lost weight. The EMR revealed that R192 was admitted on [DATE] with a [DIAGNOSES REDACTED]. R192 was ordered a cardiac, low cholesterol/ low fat diet with pureed texture. Weight gain equal or more than five pounds (lbs.) in 1 week to be reported. [MEDICATION NAME] (a diuretic) 40 milligrams (mg) tab give 1 tab every day for hypertension. On 09/10/18 the speech language pathologist (SLP) recommended little supervision due to prolonged liquid hold in mouth while eating. Weight records revealed the following: R192's admission weight on 09/06/18 was 160.4 lbs. On 09/20/18 R192's weight was 152 lb, an eight lb weight loss. The dietary assessment dated [DATE] was reviewed. The registered dietitian (RD) noted R192 was at risk for inadequate oral intake continue current dietary orders. Nursing notes dated 09/22/18 were reviewed, R192 with an eight lb. weight loss in two weeks since admission. Buttock/ anal excoriation noted. R192's diet changed to regular diet pureed texture, regular consistency. Resource 2.0 60 milliliters (ml) twice per day (BID) with medication pass. Magic cup as extra dessert with meals. Snack in between meals: pureed banana, 2000 kcal pudding. two soups and a side tofu with lunch & dinner. Physician's note dated 09/24/18 was reviewed, R192 has lost weight recently, ordered 240 ml water every day and evening shift due to not meeting daily fluid goal. Meal intake and hydration flow sheet's revealed from 0 9/06/18 to 09/27/18 R192 ate >75% of the meal 36% of the time and did not meet the fluid goal of 1700 ml. During an interview with LN1 on 09/26/18 at 1:51 PM who stated if there is a significant weight loss of five percent or greater the doctor and dietitian are notified by the nurse. During an interview with the community life director on 09/27/18 at 11:45 AM who stated R192 is not on the nutrition at risk (NAR). On 09/27/18 at 12:08 PM R192 was sitting at the table with the SLP who was conducting a trial to advance his diet with chopped and minced texture. R192 appeared to be sleeping and the SLP placed an ice cube on his lip to try to rouse him. The SLP was unable to complete the trial for R192 who was sleeping. During a telephone interview with the registered dietitian (RD) consultant on 09/27/18 at 01:10 PM who stated that he was notified via e-mail on 09/22/18 of R 192's eight lb. weight loss. R192 should be monitored for NAR and that he would also recommend to hold the [MEDICATION NAME] to see if the weight loss is actual weight loss or fluid loss. R192 should be on the NAR.",2020-09-01
190,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2018-09-27,697,D,0,1,5L7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with resident and staff members, the facility did not ensure R190 received treatment to manage pain. The facility did not ensure R190's pain regimen was administered in accordance with the facility's pain numeric scale. Also, the LN was not aware of the parameters of the pain numeric scale. Findings include: R190 was admitted to the facility on [DATE] following a hospitalization . The admission [DIAGNOSES REDACTED]. On 09/24/18 at 09:30 AM an interview was conducted with R190. R190 reported she has pain to her right arm and leg. R190 states she is provided with pain medication; however, at times the medication is ineffective. The R190 stated that she is given tylenol, then four hours later provided with another dosage of tylenol. R190 acknowledged running hot water on her arms helps to alleviate the pain; however, she will still request a pain killer. R190 reported sometimes the pain is excruciating. R190 also states the pain and swelling interferes with her ability to perform activities of daily living. On the morning of 09/27/18, R190 was observed during physical therapy. R190 was asked whether she received pain medication prior to therapy. R190 responded she did not receive pain medication and does not experience pain during therapy. R190 reported she thinks movement helps her with the pain and this is why she has pain while asleep (due to lack of movement). On 09/26/18 at 7:55 AM a record review found the physician order [REDACTED]. The admission pain assessment dated [DATE] notes R190 has times when her pain is horrible or excruciating at least three times daily. R190's pain was noted to be to her right arm and leg which increases with movement. Subsequent pain assessment done on 09/11/18 notes R190 has occasional pain which does not affect her sleep and the pain intensity was three. A review of R190's care plan found the facility developed a care plan which focuses on pain to R190's right arm/leg due to history of right [PR[NAME]EDURE] with chronic [MEDICAL CONDITION]. The interventions include R190's current pharmacological pain regimen as ordered by the physician. Also included are the following interventions: use of the numeric pain scale to monitor pain daily; monitor pain level during care and as needed with report to Charge Nurse when complaint of pain or signs and symptoms of pain is noted; pain to right arm/leg comes and goes and is not associated with movement or any particular position; assist with repositioning as needed to maintain proper body alignment for comfort; and diversify attention to interest of activities as tolerated. The care plan did not define the parameters for administering prn medication for pain. On 09/26/18 at 8:59 AM an interview was conducted with the DON and licensed nurse (LN) 1. The staff members were asked what are the numeric parameters for mild pain, LN1 responded 1 to 3, the DON clarified parameters for mild pain is 1 to 4; moderate pain is 5 to 7; and severe pain is greater than 7. R190's Medication Administration Record [REDACTED]. A review of the MAR indicated [REDACTED]. The record notes R190 was given prn of tylenol for pain level of 5 on the following dates: 09/12/18 at 0112; 09/15/18 at 0058; and 09/26/18 at 0130. R190 received tylenol on 09/19/18 at 0028 for pain level of 6. The administration of the tylenol given on 09/26/18 at 0130 for a pain level of 5 was noted to be ineffective. R190 was then provided with 2.5 mg of [MEDICATION NAME] at 0405. On 09/15/18 the efficacy of the tylenol was documented as U, undetermined. Further review found administration of 5 mg of [MEDICATION NAME] for severe pain with numeric rating of 5 was administered on 09/24/18 at 0139. R190 was also provided 5 mg of [MEDICATION NAME] on 09/20/18 at 0844 and 09/23/18 at 0148 for numeric rating of 6. R190 was provided [MEDICATION NAME] for severe pain, numeric rating of 7 on the following dates: 09/05/18 at 0859; 09/14/18 at 0038; 09/22/18 at 0048; 09/25/18 at 2214. On 09/26/18 the policy for pain was provided by the facility. The policy documents tylenol is administered for mild pain with a numeric scale of 1 to 4; opiods, [MEDICATION NAME] and [MEDICATION NAME] is administered for moderate pain with a numeric scale of 5 to 7; and opiods, [MEDICATION NAME] for severe pain with a numeric scale of 7+ (seven plus). On 09/27/18 at 9:30 AM an interview and review of R190's MAR indicated [REDACTED].",2020-09-01
191,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2018-09-27,791,D,0,1,5L7411,"Based on resident observation, resident interview, record review, and staff interview, the facility failed to refer one resident (R31) of 36 sampled residents for dental services for denture replacement in a timely manner. This deficient practice had the potential to affect R31's access to needed dental services. Findings include: Per the EMR Profile, the facility admitted R31 on 07/25/18. R31's 07/14/18 quarterly Minimum Data Set (MDS), a comprehensive assessment completed by facility staff that drives the care planning process, indicated R31 did not have broken teeth or loose-fitting dentures (Section L: Oral/Dental Status). A Care Plan addressing performance of activities of daily living, revised on 07/11/18, documented the interventions, I go to VA (Veteran's Administration) dentist as needed. Call my wife for scheduling as I need someone to go with me and I can brush my teeth after set-up. I use an electric tooth brush. On 09/24/18 at 1:23 PM, R31 was observed with no upper teeth and several missing teeth on the bottom. He stated he used to have dentures, but no longer had them; he was unsure what had happened to them. He stated he was interested in getting new dentures and would like to see the dentist. A 04/18/18 Dental Progress Note documented, Pt (patient) has no pain. Pt has no teeth on the uppers and pt lost his FUD (full upper denture) been missing 5 months. Pt wants a new upper denture. Pt needs a good cleaning - black calculus supragingival. Pt interested FUD and a PLD (partial lower denture) metal. Pt states never fit well. Pt states he has dental (insurance), and wants a FUD. On 09/26/18 at 1:38 PM, the admissions manager (ADM) was asked to provide any follow up done to the resident's request for dentures on 04/18/18. A 09/26/18 Nursing Note, written at 2:19 PM, documented, Resident was interviewed today (to determine) if he has any pain when eating, said 'no.' Observed still with natural teeth, multiple missing teeth upper and lower. Asked if he wants dentist to make dentures for him, said 'no, I used to have partial dentures maybe 2-3 years ago, I don't need it. I usually see my VA dentist.' Agreeable to have wife schedule him for dental cleaning with V[NAME] Action: Called his wife, said that she will arrange for VA dental cleaning. Per wife, last time done was December. Response: Wife was appreciative of call. On 09/26/18 at 3:53 PM, the ADM stated she spoke to the nurse, who wrote a note today about the resident's dental needs. She stated she would have expected the nursing staff to follow up on the dentist's note from 04/18/18 at the time, and the resident's request for dentures should have been addressed sooner. On 09/27/18 at 8:24 AM, the second-floor unit manager (UM2) stated R31 reported to her he had dentures 'maybe two or three years ago', but she had never seen him with them. UM2 called R31's wife who reported he did used to have dentures, but she was unsure where they were currently. UM2 reported R31 stated he was not interested in dentures anymore and stated, we agreed to a cleaning with the V[NAME] UM2 stated, I did not know anything about the dental consult on 04/18/18; this is the first time I've heard of it. Medical Records receives the consults and puts them in the chart . the dentist used to tell us if there were any concerns . but now we may have to revisit our process. UM2 stated R31 was someone who changes his mind a lot. Typical of his personality . Could be attention-seeking behaviors.",2020-09-01
192,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2018-09-27,803,F,0,1,5L7411,"Based on observations, record review, and staff interview, the facility failed to ensure correct portion sizes were served according to the menu for 83 of 90 facility residents (19 receiving a pureed diet, 55 receiving a chopped or regular diet, and 16 receiving a minced diet). This deficient practice had the potential to affect the provision of adequate meals to meet each residents' nutritional needs. Findings include: Observation of the lunch service in the main dining room on 09/26/18 from 11:33 AM to 12:00 PM, revealed the following: 1. Puree Cook1 served the following portion sizes for a pureed diet: Pureed chicken, #24 scoop (1.33 ounces (oz.)) Pureed rice, 2 oz. scoop Pureed vegetables, 2 oz. scoop Per the 09/26/18 tray card for a regular pureed diet, the required portion sizes were: Pureed chicken, 3 oz. Pureed rice, #10 scoop (3.2 oz.) Pureed vegetables, 4 oz. 2. Regular/Chopped Cook1 served the following portion sizes for a chopped and regular diet: Regular chicken, 3 oz. scoop Regular rice, #16 scoop (2 oz.) Regular vegetables, 3 oz. scoop Per the 09/26/18 tray cards for regular and chopped diets, the required portion sizes were: Chicken, 4 oz. Rice, 4 oz. Vegetables, 4 oz. 3. Minced Cook1 served the following portion sizes for a minced diet: Minced chicken, #24 scoop (1.33 oz.) Minced vegetables, 2 oz. scoop Rice, #16 scoop (2 oz.) Per the 09/26/18 tray card for a minced diet, the required portion sizes were: Ground chicken, 4 oz. Ground vegetables, 4 oz. Rice, 1/2 cup (4 oz.) On 09/26/18 at 11:33 AM, Cook1 stated the tray card for each resident documented the appropriate portion size for their prescribed diet. Cook1 stated he was unsure of the sizes of the scoops he was using to serve all the foods. On 09/26/18 at 3:23 PM, the registered dietitian (RD) stated the cook should have served the portion sizes documented on each tray card. He was unsure whether the scoop size correlated with the actual weight of the foods, and would have to look into the matter. He stated, It could be because of different weights of different foods . A 2 oz. scoop of rice may be a different size than 2 oz. scoop of vegetables. He stated he was unsure whether the facility had menus that specified the scoop size to use when serving foods. The RD stated he visited the facility about twice weekly, but did not evaluate the portion sizes and serving process during the meals. He stated he did not provide education to the dietary staff regarding portion sizes. On 09/26/18 at 4:20 PM, Cook2 stated the scoop size, in ounces, correlated with the portion sizes listed on the tray cards. For instance, for a 4 oz. portion of a food, the #8 scoop which has a 4 oz. capacity should be used. The facility's 09/23/18 policy addressing Resident Meals and Portion Sizes documented the purpose was, To provide all residents with a nutritious, tasty meal with standardized portions. The procedure was to serve 3 oz. of meat, 1/2 cup of rice, and 1/2 cup of vegetables. The policy documented, Monitoring: Will be done by Dietary Manager (and the) Lead Cook.",2020-09-01
193,MAUNALANI NURSING AND REHABILITATION CENTER,125013,5113 MAUNALANI CIRCLE,HONOLULU,HI,96816,2018-09-27,812,E,0,1,5L7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to ensure foods were stored, distributed, and/or served at appropriate food holding temperatures and in a sanitary manner. This deficient practice had the potential to propagate an outbreak of foodborne illness. Findings include: 1) Observation of the lunch service in the main dining room on 09/26/18 from 11:33 AM to 12:00 PM revealed the following: Chicken salad sandwiches were stacked three to four sandwiches high in a pan sitting over ice behind the steam table. Cook1 monitored the temperature of the sandwiches at 49 degrees Fahrenheit (F). He stated it was monitored at 42 degrees F when brought out from the kitchen. The cook stated he expected cold foods to be below 45 degrees F. The cook began to serve the chicken salad sandwiches at 11:46 AM without cooling them to the appropriate temperature first. Cook1 served approximately nine sandwiches during the meal. Review of the 09/26/18 food temperature log revealed the chicken salad sandwiches were monitored at 42 degrees F. On 09/26/18 at 3:23 PM, the registered dietician (RD) stated he visited the facility two times a week, where he conducted kitchen inspections and spent time in the dining room in addition to completing resident assessments. The RD stated he did not look at food temperatures as part of his inspections. The RD stated Cook1 should have disposed of the sandwiches that were above the appropriate holding temperature and should not have served them to residents. He stated cold foods should be 41 degrees F or below. The facility's 09/21/18 policy addressing Food Temperatures documented, Cold Food Serving Temperatures shall be 41 (degrees F) or below according to the Department of Health guidelines. 2) On 09/24/18 at 11:25 AM During dining observation on second floor outside Orchid dining room door, observed female family member of R16 pouring juice from juice cart. Same family member then opened metal food tray cart with other residents' lunch trays inside and subsequently took out one tray and left. A few minutes later, observed another female family member coming from room [ROOM NUMBER] to the metal food tray cart and proceeded to take two lunch trays out and headed back to room [ROOM NUMBER]. This family member also poured juice from the juice cart. On 09/24/18 at 04:35 PM Interview with DON and Assistant Director of Nursing (ADON) who confirmed that residents' family members should not be taking food trays out from the food tray cart by themselves. No one but staff should be distributing out food trays.",2020-09-01
194,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2017-03-24,257,D,0,1,ATLR11,"Based on observations, staff interviews, and resident interview, the facility failed to provide comfortable and safe temperature levels for one resident interviewed in Stage 1 of the survey. (Resident #86) Finding includes: On 3/21/2017 at 9:16 AM interviewed Res #86 on anything that affects the resident's comfort. Res #86 stated Its always cold, I told them to adjust it, and they don't adjust it. On 3/22/2017 at 12:01 PM a concurrent visit was made with Staff #9 to test the temperature in Res #86's room. The temperature gun pointed to the wall where the room air conditioner is located registered at 56 to 57.5 degrees Fahrenheit. The temperature gun pointed to the back of the room furthest from the air conditioner registered at 72.5 degrees Fahrenheit, a 15 degree difference in readings. The air conditioning control was checked. It was set at low. Staff #9 stated the temperature would be adjusted. On 3/23/2017 at 9:58 AM an interview with Staff #1 was conducted. Staff #1 was informed of the temperature differences in Res #86's room. Staff #1 agreed, the temperature difference was big and would look into this. Comfortable and Safe temperature levels may affect the quality of life for residents.",2020-09-01
195,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2017-03-24,279,D,0,1,ATLR11,"Based on observations, interviews, and record reviews the facility failed to use the result of a fall assessment to develop, review and revise the resident's comprehensive care plan for one (1) of the 38 residents in the Stage 2 Census Sample. (Resident # 98 for Event Report #4082) Finding includes: Cross reference to F 323 In the morning of 3/22/2017 Resident #98's record review found that Res #98 had two unwitnessed falls after admission to the facility, both causing injury. The first fall was on 1/28/2017 near the bathroom door and the second fall on 2/18/2017 in the bathroom. After the first fall on 1/28/2017 the resident's Care Plan Update Sheet, Action Plan stated: Frequent visual checks, call light within reach, instructed resident to call for assistance, bed in lowest position, frequent checks/observation; assess pain level and medicate as needed; wellness exercises for gait/balance. After the second fall on 2/18/2017 a review of the resident's Care Plan Update Sheet, Action Plan stated: Daily dressing to scalp; neuro checks x 6 shifts; geomattress to side of bed and offer bedside commode. On 3/22/2017 a concurrent record review was done with Staff 4. Staff #4 stated a fall analysis was done after the 2/18/2017 fall and it was determined that the fall was unavoidable due to the resident's ischemic changes in the brain the resident will continue to fall and be a risk for repeat fall. Staff #4 was not able to provide evidence of a fall care plan revision based on the current fall risk analysis and medical report. Later that morning Staff #4 provided a copy of an updated entry made to the resident's Care Plan Update Sheet dated 3/22/2017 at 10:23 AM for the fall that occurred on 2/18/2017. The revised fall interventions stated, repeat falls and serious injury related to falls. Revised intervention #1: continue to provide supervision to limited 1 person assistance with ambulation with cane and provide frequent reminders and verbal cues to use cane at al times and to activate call light for assistance. Provide frequent visual checks every 2 hours to inquire on needs and offer/assist with toileting every 2 hours while awake and every 4 hours during sleeping time. Respond to calls promptly. On 3/22/2017 at 11:46 AM a concurrent review of the Fall Risk Analysis report after the 2/18/2017 fall was done with Staff #2. The analysis states resident fell in the bathroom with BM on the floor. The fall analysis documents Resident #98 had a scalp laceration and a skin tear to the left arm. In the Probable Cause of Adverse Event it documents, resident stated, I fell down hitting my head on the floor. Staff #2 was asked to show evidence in the fall analysis of investigation on the cause of the laceration to the resident's scalp. Staff #2 stated there was BM on the floor but was unsure of the cause of the laceration. Timely fall interventions and finding the root cause of a fall related injury may contribute to a reduction in falls.",2020-09-01
196,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2017-03-24,309,D,0,1,ATLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and record review the facility failed to ensure that all aspects of resident care needs are addressed for residents who require such services, consistent with professional standards of practice, and the comprehensive person-centered care plan for 1 of 38 residents in the Stage 2 sample. (Resident # 71) Finding includes: On 3/20/2017 at 9:20 AM observed Resident #71 (Res #71) sitting on the edge of a lounge chair in her room. Res #71's right leg was stretched out with her right hand on her right hip. Res # 71 stated, help me, no one is responding to me. They used to. Prompted Res #71 to ring a bell located on a table next to her. Res #71 rang the bell and no one responded. Res #71 stated, my pain. Observed the resident's call light attached to the resident's bed. The call light was activated for the resident. Staff #16 entered the room in response to the call light. Staff #16 asked Res #71 what was wrong, if she wanted to go into her wheelchair or go to activity. During the observation there was no inquiry by Staff #16 of pain. At 9:55 AM the same morning a concurrent review of the resident's medication Administration History for (MONTH) was done with Staff #14. Res #71 was given a routine dose of [MEDICATION NAME] at 9:48 AM. The last dose of Tylenol given routinely for pain was the night before at 19:00 PM on 3/19/2017. There was no Tylenol given as needed for the resident's complaint of pain that morning. Staff #14 was asked if she knew about the resident's pain this morning Staff #14 did not reply. When asked how pain is assessed for Res #71 Staff #14 responded, the resident grimaces and points. On 3/23/2017 at 8:51 AM observed Resident #71 in her room wearing a necklace and a larger bell at her bedside. At 13:50 PM the same day a concurrent Electronic Health Record Review (EHR) was done with Staff #5. Staff #5 had just completed Res #71's quarterly Minimum Data Set (MDS) pain assessment. For the MDS question, Have you had pain or hurting at any time in the last five days? the resident had answered yes. The pain was occasional, the resident was not able to give a number but the resident's verbal description was moderate. Staff #5 shared that Res #17 had not been having pain on previous assessments. A second review of the resident's medication Administration History for (MONTH) found a new entry entered showing Res #71 received Tylenol 650 mg at 10:23 AM for complaint of pain that morning. An assessment note entered at 13:46 PM that afternoon on the effects of the Tylenol was written, states feels better and pain Scale was 0. The time difference between administration and post administration assessment was nearly 4 hours. A careplan review for right hip pain states the intervention: Pain is monitored when passing meds and when vital signs are taken. The review found no documentation for monitoring of pain when the resident was administered the [MEDICATION NAME] or when the Staff #14 answered the call light on 3/20/2017. Failure to address the residents complaint of pain and to monitor for pain in a timely manner may affect the quality of care provided to the resident.",2020-09-01
197,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2017-03-24,323,D,0,1,ATLR11,"Based on observations, record reviews, and interviews the facility failed to ensure the residents environment remains as free from accident hazards as is possible and that each resident receives adequate supervision and assistance devises to prevent accident, for 2 of 38 Stage 2 sampled residents. (Resident # 98 for Event report #4082 and Resident #103). Findings include: Cross reference to F279 1) In the morning of 3/22/2017 Resident #98's record review found that Res #98 had two unwitnessed falls after admission to the facility, both causing injury. The first fall was on 1/28/2017 near the bathroom door and the second fall on 2/18/2017 in the bathroom. After the first fall on 1/28/2017 the resident's Care Plan Update Sheet, Action Plan stated: Frequent visual checks, call light within reach, instructed resident to call for assistance, bed in lowest position, frequent checks/observation; assess pain level and medicate as needed; wellness exercises for gait/balance. After the second fall on 2/18/2017 a review of the resident's Care Plan Update Sheet, Action Plan stated: Daily dressing to scalp; neuro checks x 6 shifts; geomattress to side of bed and offer bedside commode. On 3/22/2017 a concurrent record review was done with Staff #4. Staff #4 stated a fall analysis was done after the 2/18/2017 fall and it was determined that the fall was unavoidable due to the resident's ischemic changes in the brain the resident will continue to fall and be a risk for repeat fall. Staff #4 was not able to provide evidence of a fall care plan revision based on the current fall risk analysis and medical report. Later that morning Staff #4 provided a copy of an updated entry made to the resident's Care Plan Update Sheet dated 3/22/2017 at 10:23 AM for the fall that occurred on 2/18/2017. The revised fall interventions stated, repeat falls and serious injury related to falls. Revised intervention #1: continue to provide supervision to limited 1 person assistance with ambulation with cane and provide frequent reminders and verbal cues to use cane at al times and to activate call light for assistance. Provide frequent visual checks every 2 hours to inquire on needs and offer/assist with toileting every 2 hours while awake and every 4 hours during sleeping time. Respond to calls promptly. On 3/22/2017 at 11:46 AM a concurrent review of the Fall Risk Analysis report after the 2/18/2017 fall was done with Staff #2. The analysis states resident fell in the bathroom with BM on the floor. The fall analysis documents Resident #98 had a scalp laceration and a skin tear to the left arm. In the Probable Cause of Adverse Event it documents, resident stated, I fell down hitting my head on the floor. Staff #2 was asked to show evidence in the fall analysis of investigation on the cause of the laceration to the resident's scalp. Staff #2 stated there was BM on the floor but was unsure of the cause of the laceration. Timely fall interventions and finding the root cause of a fall related injury may contribute to a reduction in falls. 2) On 3/20/2017 at 11:47 AM observed Res # 103 ambulating with a Front Wheel Walker (FWW) in the hallway. At 11:50 AM noon observed R #103 in the dining room seated. Res #103 stood up and was escorted back to her chair, stood up again and left the room unescorted; returned to room unescorted; stood up and walked around her table to another resident's table and was directed back to her own table by random staff; stood up and left the room again without using her walker; returned back to her seat; stood up again and left the room with her walker. At 2:30 PM on 3/21/2017 while standing with Staff #6 near the bed of Res #58, Res #103 walked into the room unescorted. Resident #58 was laying in bed furthest from the door. Staff #6 redirected Res #103 to her own room across the hallway. On 3/22/2017 at 12:08 PM met with the Staff #3 to do a care plan review. There was no care plan for wandering. On 3/22/2017 spoke to Staff #2 to discuss the observations and care plan findings. Staff #2 stated there should be an episodic care plan for wandering for the resident's safety. Timely care planning and interventions may contribute to keeping the facility free from accident hazards for residents.",2020-09-01
198,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2017-03-24,441,E,0,1,ATLR11,"Based on observations, staff interviews, and facility policy review, the facility failed to maintain a sanitary environment for staff and residents. Findings include: 1) During observation of medication pass on the morning of 3/22/17 at approximately 11:07 AM Staff (S) #14 had just used an Accucheck machine to check Resident # 33's blood sugar. The S #14 was observed using an alcohol swab to wipe down the Accucheck machine. S #14 was asked if the Accucheck machine was used for other residents, to which she replied, Yes, it was used for other residents, not just (Resident #33). The staff was asked whether the facility's policy/practice was to use alcohol wipes. She replied, Yes, we use alcohol wipes to clean the Accucheck machines. An interview of Staff #2 on the morning of 3/23/17 at approximately 11:30 AM revealed the staff were expected to use the purple top CaviWipes to clean the Accucheck machines between residents. The Staff #2 stated that all staff were trained and should know the expectation. Staff #2 provided a copy of the facility's Glucometer Clinical Competency checklist, which is what they used for training staff and the expectation for sanitizing the Glucometers. The checklist noted, Wipes glucometer off with germicidal disinfectant wipe before and after testing. On the morning of 3/24/17, Staff #14 informed the surveyor that she was, indeed, trained to use the purple top CaviWipes. She stated she wasn't sure why she used the alcohol wipes. 2) On 3/20/2017 at 3:25 PM observed in the bathroom shower stall shared by 2 residents (Resident #95 and #63) an unlabeled bedpan and an unlabeled bath basin resting between the shower grab bar and the shower wall. Random Staff #7 was asked if that was the practice for storage of resident reusable personal equipment. Staff #7 stated no, the items should be labeled with the resident name for infection control. Unlabeled patient personal care equipment may facilitate transmission of infection among residents when used.",2020-09-01
199,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2017-03-24,463,D,0,1,ATLR11,"Based on observations, staff interviews, and record reviews, the facility failed to adequately equip the resident to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 2 of 38 residents in the Stage 2 investigation sample. Findings include: 1) On 3/20/2017 at 9:20 AM observed Resident #71 (Res #71) sitting on the edge of a lounge chair in her room. Res #71's right leg was stretched out with her right hand on her right hip. Res # 71 stated, help me, no one is responding to me. They used to. Prompted Res #71 to ring a bell located on a table next to her. Observed Res #71 ring the bell and no one responded. Res #71 stated, my pain. Observed the resident's call light attached to the resident's bed. The call light was activated for the resident. Staff #16 entered the room in response to the call light. Staff #16 asked the Res #71, what was wrong, if she wanted to go into her wheelchair or go to activity. During the observation there was no inquiry by Staff #16 of pain. On 3/21/2017 at 8:41 AM while standing outside and across from Res #71's room heard Res #71 ring her hand bell. Observed no staff respond to the bell ring. After three minutes, observed Staff #15 who was making her rounds walk into Res #71's room. A record review of the resident's Care Plan Update Sheet dated 3/21/2017 at 9:01AM stated, was given 1 large (louder) bell in addition to usual small bell. Will use it on own discretion and staff will provide frequent checks to inquire on needs. At 8:52 AM the same day spoke to Staff #2 regarding observation on two separate days of Res #71 bell call system not being heard when used by the resident. Staff#2 acknowleded would review plan. 2) On 3/23/2017 at 7:16 AM observed Resident #85 in bed with a breakfast tray set up on the overbed table resting over the resident's lap. Resident #85 looked down at the tray and stated they forgot to give me my oatmeal. Observed on the tray a strip of bacon, a small opened bowl of papaya chunks and no oatmeal. Observed the resident's call light under the resident's head pillow to the left of the resident. The location of the call light was pointed out to the resident. Resident #85 raised her right arm to reach up to the left of the pillow but was not able to reach the call light. Resident #85's care plan was reviewed on 3/24/2017 and stated, Needs assistance with ADLs/mobility due to increased forgetfulness and restlessness. 1. Call bell and personal items within reach at all times. The resident was not able to use the communication system provided to call for staff asistance. Residents must have an communication system to directly contact caregiver in their physical environment.",2020-09-01
200,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2017-03-24,514,D,0,1,ATLR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and a record review the facility failed to maintain medical records that were complete and accurately documented and readily accessible for 1 of 38 residents in the Stage 2 sample investigation. (Resident #94) Finding includes: On [DATE] at 9:52 AM a closed record review found Res #94 was admitted on [DATE] and expired on [DATE]. Admission [DIAGNOSES REDACTED]. Res #94 had a Physician order [REDACTED].#94 had an episode described as petite mal [MEDICAL CONDITION] while receiving physical therapy. On [DATE] at 8:37 AM, Res #94 was assisted to the bathroom. During this time, he appeared weak and skin color started to change (pale). Blood pressure recorded at this time was ,[DATE], resident was noted to have black tarry stool during am care. On [DATE] at 10:44 AM. Staff #1 and #2 were queried regarding any documentation regarding why transfer was not done for hospital evaluation during the course of 13 days that led to the resident's decline and death. At 12:57 PM the same day Staff #1 stated that she had called Staff #8. Staff #8 stated he had spoken to family and had offered to send Res #94 out to be evaluated prior to admission but it was the family and resident's wish to remain in the facility. Family and resident did not want emergency room services. Staff #1 stated that there was no documentation of the decision discussed with Staff#8, family and resident in the resident's record. Resident medical records are legal documents that provide evidence of resident care should be accurate and complete.",2020-09-01
201,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2019-04-11,689,D,0,1,UEUY11,"Based on observations, staff interview, review of instruction manual, and review of policy and procedures, the facility failed to identify the following potential accident hazards. 1. A electrical power strip should not have been used with medical devices, and 2. An electrical panel box was not properly secured. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards. Findings Include: 1. During an observation of Resident (R) 58's room on 04/09/19 at 11:00 AM, two medical devices were plugged in to an electrical power strip instead of being plugged directly in to the wall outlet. The two devices were an air mattress pump, and the resident's bed. The electrical power strip was not marked with any labels and it was difficult to determine if the facility inspected it prior to use. During a second observation of R58's room, done with the Maintenance Supervisor (Supvr) on 04/10/19 at 11:56 AM, the Supvr acknowledged that the electrical power strip should not have been used with the medical devices. The Supvr immediately removed the electrical power strip and plugged the medical devices directly in to the wall outlet. A review of the instruction manuals for the resident bed and the air mattress pump revealed a Warning: Possible Shock Hazard, ensure to unplug the power cord from the wall outlet before performing any maintenance, cleaning or service to the bed. It also states to plug the power cord into an electrical outlet before turning the main power switch on. A review of the facility policy titled Electrical Safety for Residents stated the following: Power strips shall not be used as a substitute for adequate electrical outlets in the facility. Power strips shall not be used with medical devices in resident-care areas. 2. On 04/10/19 at 09:00 AM during an observation of the Ewa wing hallway on the second floor, the electrical panel box was not secured. There was a pad lock in place but that pad lock was not locked. No staff members were in the immediate vicinity to prevent any residents and/or visitors from accessing the box. During a second observation of the Ewa wing hallway on the second floor, done with the Maintenance Supervisor (Supvr) on 04/10/19 at 11:45 AM, the Supvr acknowledged that the electrical panel box supposed to be secured and the pad lock should have been locked. The Supvr inspected the panel and was unaware who may have left the pad lock unlocked. Supvr then locked the pad lock and secured the electrical panel. A review of facility procedure titled Monthly Safety Checklist stated the following: Lobby Lounge, Lights/Floors/Ceilings/Walls, Electrical panel box accessible, clearly visible, locked and has proper clearance . Again, the electrical panel box pad lock was not locked.",2020-09-01
202,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2019-04-11,812,F,0,1,UEUY11,"Based on observation, interview and document review, the facility failed to ensure food safety was maintained. The food line preparation area was not free of dust. Because of this deficient practice, there was potential of contamination via dust to the food, that could result in foodborne illness to all residents, and others who were served meals from the food line. Findings Include: 1.On 04/10/19 at 10:58 AM, during a visit to the kitchen, observed a large amount of dust on an electrical power box, and electrical cords located on the top shelf above the food line. The pole adjacent to the shelf had dust on it, and one of the two oven vents that faced the food line was dirty. 2.On 04/10/19 at 12:50 PM, during an interview with the Food Services Supervisor (FSS), he said the facility had a contract with an outside vendor for cleaning some areas of the kitchen. The FSS said the vendor had recently changed staff assigned to the facility, and that he had reviewed the expectations of cleaning with the assigned employee. The FSS agreed the oven vent and dust located near the food line needed to be cleaned. At the time of the survey, the FSS was not able to provide documentation when the vendor last cleaned these areas. The FSS was asked if he knew when they had last been cleaned, and he replied, No. 3.Review of the vendor contract, Customized Service Plan and Proposal, dated (MONTH) 14, 2014, Exhibit A, Vendor services and how often they will be done at your facility, revealed the vendor would do the following: .Dust all high and low vertical and horizontal surfaces and corners not cleaned in the normal dusting, .1 times (sic) per month, and Clean oven .to remove visible soil, clean inside and out . As trained & directed to by Chef .1 times (sic) per month. Dust is a physical source of contamination that may inadvertently fall in the food on the tray line and could potentially cause a foodborne illness. Nursing home residents' risk serious complications from foodborne illness because of their compromised health status.",2020-09-01
203,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,550,D,0,1,Y42W11,"Based on observation, staff and resident interview, the facility failed to treat residents with respect and dignity when a resident (R5) felt that staff didn't listen and rushed her and another resident (R64) had to ask housekeeping staff for assistance with his lunch. Findings include: 1. Cross reference to F725 An interview of R5 on the morning of 5/29/18 at 11:02 AM found the residents expressing, I feel like I'm being pushed around. Like I don't have a choice. R5 reported that the Certified Nurses Aides (CNAs) did not listen to her. R5 stated that the CNAs will tell her that if she needs something at a certain time, she'll have to wait because they're busy. 2. Cross reference to F725 On 05/29/18 at around 1245, while walking in the hallway past R64's door, R64 was overheard talking with the housekeeper asking for assistance, asking for his lunch and stating that he was hungry. R64 was seen earlier in the dining room but he had not eaten his lunch when the meal trays were delivered and was now watching tv in his room. Asked a passing CNA if resident was going to be assisted with his lunch and she stated right after I help this resident as CNA walked into the other resident's room who had pressed the call light. R64 was assisted with his lunch at 1259 after licensed staff was asked if R64 was going to be assisted with his meal. Licensed staff thought R64 had eaten earlier in the dining room. Facility reported lunch time for third floor was 11:45 AM. This day it was noted that trays were delivered to the units later than usual, per facility stated lunch times, as the kitchen reported problems with their warmers.",2020-09-01
204,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,565,E,0,1,Y42W11,"Based on interview and a review of the Resident Council Minutes, the facility failed to ensure the resident council meets regularly and grievances or recommendations provided by the council were discussed. Findings include: On 5/30/2018 at noon, as requested, Staff Member 37 (SM37) provided copies of the resident council minutes for (MONTH) 31, (YEAR); (MONTH) 28, (YEAR); (MONTH) 30, (YEAR); and (MONTH) 27, (YEAR). A review of the minutes found there was no documentation related to residents' concerns or recommendations. The minutes for (MONTH) (YEAR) found one participant in the meeting and an agreement that the resident council meeting will occur quarterly instead of monthly. On 5/31/2018 at 2:30 PM a meeting was held with the resident council. There were five participants. When asked whether the council meets regularly. One participant reported that she was not aware of resident council meetings and this was the first time she was attending a meeting. Another participant stated that the council doesn't meet too often. On 6/1/2018 at 8:15 AM an interview was conducted with SM37. SM37 reported that at the last council meeting it was decided to meet quarterly. The staff member shared that it is sometimes difficult to engage the residents as they prefer to be passive participants and enjoy having presentations. The staff member also shared that sometimes they have participants that have dementia.",2020-09-01
205,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,572,E,0,1,Y42W11,"Based on interview with residents and a review of the resident council minutes, the facility failed to provide ongoing communication to residents regarding their rights. Findings include: On 5/31/2018 at 2:30 PM an interview was done with the resident council representatives assembled by Staff Member 37. The representatives were asked whether the staff review the rights of residents in the facility. One representative reported, she recalls receiving the rights when admitted to the facility. However, the other residents could not recall whether their rights were periodically reviewed with them. A review of the Resident Council Minutes provided by the facility on 5/30/208 found documentation of six rights that were reviewed with the residents on 11/28/2017. The residents in the interview were not participants in the resident council meeting in (MONTH) (YEAR).",2020-09-01
206,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,574,E,0,1,Y42W11,"Based on interview with resident council member representatives and a review of the resident council minutes, the facility failed to ensure residents are aware of how to contact the Ombudsman and State Agency to file a complaint. Findings include: On 5/31/2018 at 2:30 PM an interview was done with representatives of the resident council. The representatives were not aware of how to contact the Ombudsman or State Agency to file a complaint. A review of the Resident Council Minutes found no documentation of contact information for the Ombudsman or State Agency. The representatives were not aware of the location for the posting of this information.",2020-09-01
207,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,577,E,0,1,Y42W11,Based on interview with resident council representatives and a review of the council minutes found the residents were not aware of how to examine the results of the most recent survey conducted by the State surveyors. Findings include: On 5/31/2018 at 2:30 PM an interview was conducted with representatives from the resident council. The representatives were not aware of where to locate the findings of the most recent survey conducted by the State surveyors.,2020-09-01
208,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,580,D,0,1,Y42W11,"Based on interview with family member and staff member, record review and review of the facility's incident report, the facility failed to notify resident's representative of the allegation of abuse. Findings include: On 2/24/2018, the facility submitted a completed Event Report via facsimile to the State Agency of an allegation of physical abuse. The allegation involves, Staff Member 144 (SM144) slapping Resident 23 (R23) in the face after the resident bit SM144. A review of the event report documents on 2/20/2018 at 11:14 AM a message was left for R23's son. On 5/29/2018 at 3:45 PM an interview was conducted with R23's son. Queried resident's son if he was aware of any incidents of abuse. The resident's son stated that he has received report of his parent biting somebody and he had to talk to his parent. The son further recalled that he believes his parent bit a manicurist downstairs but his parent does not remember what happened. A record review could not find documentation in the electronic medical record (EMR) of notification to the resident's son regarding the allegation of physical abuse. Further query was made to Staff Member 136 (SM136) on 6/1/2018. The staff member reported there is no documentation of the notification to the resident's son regarding the alleged abuse in the EMR; however, the Event Reportdocuments a message was left for the resident's son on 2/20/18 at 11:14 AM.",2020-09-01
209,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,583,D,0,1,Y42W11,"Based on observation, the facility failed to ensure a resident's right to personal privacy was provided for Resident 68. Findings include: On 5/30/2018 at 9:00 AM, Resident 68 (R68) was found in a sitting position with her knees up to her chest scooting on the floor in the direction of the door. The resident was asking for help as she wanted to use the toilet. Upon discovering the resident on the floor, assistance was requested of staff member, two staff members assisted the resident off the floor and the Certified Nurse Aide placed the resident on the toilet. At 9:15 AM a male staff member from maintenance entered the resident's room to check on the inoperable call light. Upon entering the resident's room with the male staff member, it was observed the bathroom door was left ajar and R68 could be seen sitting on the toilet.",2020-09-01
210,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,607,E,0,1,Y42W11,"Based on a review of the facility's policy and procedures for abuse, neglect, exploitation of residents and misappropriation of resident property, the facility failed to ensure the policy and procedures included training and oversight and supervision of staff in order to assure that its policies are implemented. Findings include: On 5/29/2018 the facility provided a copy of the policy and procedures entitled Residents' Rights - Freedom from Abuse, Neglect and Exploitation Policy. A review found the policy did not address the training of new and existing staff members and how the facility will provide ongoing oversight and supervision of staff to assure its policies are being implemented. On 6/1/2018 a review of the facility's policy was done with the Administrator. The Administrator acknowledged the facility's policy does not address the training of new employees and existing staff members.",2020-09-01
211,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,609,D,0,1,Y42W11,"Based on interview with family member and staff members and a review of the facility reported incident, the facility failed ensure that all staff are aware of reporting requirements and alleged violation is reported to the State Agency and adult protective services within 24 hours. Findings include: On 2/20/2018 at 11:18 AM a facsimile was sent to the State Office regarding an allegation of staff to resident abuse. The documented date of event was 2/18/2018 at 9:30 AM. The alleged violation was that Staff Member 144 (SM144) slapped Resident 23 (R23) in the face. An interview was done with Staff Member 136 (SM136) on 5/31/2018 at 7:56 AM. Inquired how the facility became aware of the incident. SM136 replied the alleged perpetrator was the final reporter when a text was sent to the Director of CNA Services on 2/18/2018 at 5:31 PM to inform staff that R23 bit him on the arm during transfer. A review of the completed Event Report submitted by the facility notes on 2/19/2018 at 8:00 AM an interview was conducted with Staff Member 145 (SM145). It was during this interview that SM145 reported witnessing SM144 slapping R23 across her face during transfer. SM144 also reported she did not witness R23 bite SM144 as he had reported. Although SM145 witnessed SM144 slap the resident, this was not identified as physical abuse therefore, it was not reported as required. A review of a written witness statement dated 2/21/2018 by Staff Member 104 (SM104) notes she was asked by SM145 to assist with the transferring of R23. At this time SM104 reports SM145 informed her that SM144 slapped R23. There is no documentation of SM104 reporting this allegation to anyone. Subsequently, the facility reported the alleged incident of 2/18/2018 at 9:30 AM to the State Agency on 2/20/18 at 11:18 AM via facsimile. On 5/31/2018 at 7:56 AM further queried SM136 whether a report was made to adult protective services. SM136 replied a report was not made to adult protective services as the facility did not confirm the allegation of abuse.",2020-09-01
212,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,610,D,0,1,Y42W11,"Based on interviews with staff members and review of the facility's incident report, the facility failed to have evidence that an allegation of abuse was thoroughly investigated and ensure appropriate corrective action was taken in response to the facility's findings. Findings include: 1) On 2/24/2018 (Saturday) at 12:53 PM the facility sent an Event Report to the State Agency via facsimile regarding an allegation of staff to resident abuse. The facility reported on 2/18/18 at 9:30 AM two Certified Nurse Aides (CNA), Staff Member 144 (SM144) and Staff Member 145 (SM145) were transferring Resident 23 (R23) to the chair for a shower. R23 reportedly bit SM144 and in turn the staff member slapped R23's face. On 5/30/2018 a request was made to Staff Member 136 (SM136) to review the facility's documentation of their investigation. On the afternoon of 5/30/18 SM136 provided the following documents: Accident Report Form and Incident Witness Statements. The witness statements were written and submitted by Staff Members 104 and 145. SM136 reported the Director of Compliance was consulted and the documentation in the Event Report summarizes their investigation findings. Further review of the Event Report documents the CNA Supervisor was notified that R23 bit CNA while transferring the resident. On 219/18 at 8:00 AM the CNA Supervisor interviews the witness, SM145 and learns that SM144 slapped R23. The interviews were initially conducted by the CNA Supervisor and Director of CNA Services. An interview was conducted with the alleged perpetrator, witness and R23. The interview conducted by the Director of CNA Services on 2/19/18 at 11:30 AM with R23 found the resident reporting SM144 is a nasty guy with further clarification that SM144 is not a nice person and is rough. However, the resident answered that she feels safe. A review of the Incident Witness Statement by SM145 documents, SM145 requested assistance from SM144 to transfer R23. When SM144 entered the room, R23 reportedly said to SM144 don't touch me, don't go near me and the resident tried to hit SM144. SM144 reportedly grabbed R23 by the arm a couple of times but R23 was trying to take the staff members hand off her arm. SM145 reports after the resident was transferred to the shower chair, SM144 slapped the resident on the left side of her face. As SM144 was leaving the room, he reportedly states that's what she get because she (hit or bit) me. When SM144 checked on the resident and inquired whether she was okay, the resident replied that's the reason why I get bruises over here, (pointing to her right upper arm). A review of the Accident Report Form completed by the alleged perpetrator documents upon mid-transfer, resident became suddenly combative, reach mouth to my upper right arm, clenched down and attempted to pull skin simultaneously. The date of injury was 2/18/2018 and the injury was reported to the employer on 2/19/2018. SM144 reportedly had abrasion/bruise/swelling to the back of the arm as a result of R23 biting him. On 5/31/2018 at 7:56 AM an interview was conducted with SM136. Inquired why the facility was unable to substantiate the allegation of physical abuse. SM136 replied during the investigation, SM145 revealed being in a relationship with SM144 and later found SM144 had a girlfriend and the girlfriend was calling. Therefore, the investigation team surmised SM145 was retaliating against SM144 with the allegation of abuse. Inquired whether the investigation team asked SM145 if the allegation of abuse was being made in retaliation. SM136 replied, this question was not asked of SM145. Further queried how the facility first learned of this incident, SM136 replied, it was based on a text that was sent from SM144 to the Director of CNA Services regarding his injury. Further queried whether the facility assessed SM144's injury related to the bite from the resident. SM136 reported SM144 sent a picture via text to the Director of CNA Services on 2/18/2018 at 5:31 PM. Subsequently the investigation team assessed SM144's injury in person on 2/20/2018 (one day after the alleged incident occurred). SM136 stated the bruise appeared old and fading, it was circular with no teeth marks and with a scab in the middle of the bruise. The facility's investigative team were unable to substantiate the allegation of abuse. SM144 and SM145 resigned from their positions at the facility. 2) The investigative team was unable to substantiate the allegation of abuse; however, as a corrective action, the facility provided in-service to their staff. A request was made for the attendance of the in-service. On 6/1/2018 at 2:35 PM the attendance list for the Mandatory Staff Meeting dated 3/2/2018 at 8:15 AM, 2:30 PM and 4:15 PM was provided by SM136. A review of the document found missing signatures of staff members. On 4/1/2018 at 4:23 PM an interview was conducted with the Administrator. The Administrator was queried regarding the missing signatures, the Administrator was agreeable to follow up with SM136. On 6/1/2018 at 4:41 PM, the Administrator confirmed not all employees completed the abuse/neglect in-service provided at the mandatory staff meeting. However, the Administrator reported all employees receive annual training for abuse/neglect. The Administrator provided documentation of the completed annual employee training.",2020-09-01
213,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,655,D,0,1,Y42W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure a baseline care plan was developed and implemented for Resident #55 to address the resident's high risk for development of a pressure injury. Findings include: Resident 55 was re-admitted to the facility on [DATE] following a hospitalized from [DATE] through 4/19/2018. The resident was admitted to the hospital for further evaluation and treatment, IV dieresis, placement of a pacemaker, and antibiotic treatment for [REDACTED]. A review of the Pressure Injury Risk assessment dated [DATE] notes the resident did not have an actual pressure injury; however, was determined to have a total score of 17 (high risk) for development of pressure ulcer related to being chair fast, probably inadequate nutrition related to consuming less than 50% of meals and needs assistance for moving. A review of the Admission Care Plan dated 4/20/2018 found a care plan was not developed to address the prevention of a pressure ulcer for a resident identified as high risk for pressure injury. On 6/1/2018 at 6:50 AM, Staff Member 103 (SM136) provided a copy of the Pressure Injury Tracking Form. R 55 was found to have a Stage 2 pressure injury to the right heel on 4/27/2018. The resident was noted to be weak with a loss of appetite, related to change of food consistency (dysphagia). On 6/1/2018 at 7:44 AM an interview was conducted with Staff Member 134 (SM134). The staff member reported upon readmission R55 had poor intake and stayed in bed most of the time. SM134 reported the resident did not have redness before she developed a blister on the right heel. Concurrent review of the pressure injury assessment and Admission Care Plan was done with SM134. Inquired whether based on the pressure injury risk assessment (high risk) whether interventions were indicated for R55. SM134 confirmed a care plan for pressure injury was not developed as part of the Admission Care Plan; however, the facility already had the resident on a turning schedule and was addressing the resident's poor intake.",2020-09-01
214,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,656,D,0,1,Y42W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR), staff and resident interview the facility failed to develop and implement a comprehensive person-centered Care Plan (CP) for 2 residents (R40, R58) of the 32 residents sampled. R40 reported that she had diarrhea for 2 days from 05/26/18, R58 was observed with 1+ [MEDICAL CONDITION] of his feet on 05/29/18 which was also documented by facility staff on 04/11/18. Findings Include: 1. On 05/29/18 at 10:04 AM during interview with R40, she stated that she had diarrhea for two days over the past 3 days, last diarrhea bowel movement (BM) was yesterday, and that she was able to stop it by monitoring her diet, she stated that she drank liquids, and did not eat papaya as she usually does with breakfast. R40 confirmed that she reported this to staff when she first started having diarrhea. On 05/31/18 at 11:18 AM reviewed R40's progress notes in her EMR and found that R40 vomited X2 on 5/26/18 and this was documented at 11:32 PM and she had one loose BM that day, small amount and res reported feeling dizzy(feel like she was tilting upside down). R40 had documented low grade fever 99.2-100.5 and was treated for [REDACTED]. Urine analysis with culture and sensitivity was done and came back negative. RR found that R40 did not have a CP in place for diarrhea. 2. On 05/29/18 at 11:35 AM while interviewing R58 noted that he had [MEDICAL CONDITION] in both hands and feet, when quiered about the swelling R58 stated that he puts his legs up after lunch. R58 stated that staff remind him to elevate his legs when he is sitting down. R58 stated that he puts his legs up after lunch when he sits in his bed and prefers not to put his legs up while he is sitting in his wheelchair as it is uncomfortable. R58's admitting [DIAGNOSES REDACTED]. On 06/01/18 at 08:53 AM during RR of clinical progress notes in R58's EMR found that facility staff had documented, on 4/11/18, +1 [MEDICAL CONDITION] in R58's feet. Interviewed S103 about R58's CP, which was effective from 5/9/2018-present, and found that there was no CP in place for R58's [MEDICAL CONDITION] in hands and feet. Escorted S103 to see R58 who was sitting up in his chair in his room with socks on. [MEDICAL CONDITION] in his hands and feet were very noticeable at 1+. S103 spoke with R58 and assessed the [MEDICAL CONDITION] in R58's hands and feet. S103 confirmed that R58 did have [MEDICAL CONDITION] in his hands and feet.",2020-09-01
215,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,689,G,0,1,Y42W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record review and facility policy review, the facility failed to ensure five residents (R62, R68, R77, R36, and R45) were free from avoidable falls. Actual harm was identified after review of R62's fall which resulted in a fracture of her fourth finger on her left hand. Findings include: 1. Cross reference to F690 and F725 Resident 62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R62 was reviewed for a Facility Reported Incident (FRI) submitted to the State Agency. The FRI noted R62 experienced a fall which resulted in a fractured finger. Observation of R62 on the morning of 5/30/18 at 10:30 AM found her seated in a wheelchair across the nurses station, outside of her room. Upon approaching R62, there was an odor of feces. Moving away from R62 the odor faded away. Upon return to R62, the feces odor returned. R62 appeared restless as she attempted to get out of her wheelchair and appeared to want to say something. Two Certified Nurses Aides (CNAs) wheeled R62 into her room, assisted her out of her wheelchair and walked with her to the toilet. There was a cushion wrapped in a white pillow case on the seat of R62's wheelchair. The entire pillow case and cushion were soaking wet. CNA 99 stated R62 had a bowel movement (BM) and she therefore needed to shower the resident. R62 wore a personal incontinence brief. Observation of R62 on the morning of 5/31/18 at 9:00 AM found the resident seated across the nurses station outside her room. She appeared to be getting restless: Attempting to stand while seated in the hallway in her wheelchair; Waving her hands around; and Appearing as though she wants to say something or do something. CNA 99 recognized R62 was getting restless so she offered to take her to the bathroom. CNA 99 wheeled R62 into her room and assisted her out of her wheelchair and into the bathroom. The seat cushion on R62's wheelchair was wrapped in a white pillow case and was wet in the center - an area of approximately 16 inches x 8 inches. R62 wore a personal incontinence brief. Observation of R62 on the afternoon of 5/31/18 at 2:00 PM found her seated in a wheelchair across the nurses station outside her room. R62 appeared sleepy as she was falling asleep in her wheelchair. The Licensed Nurse (LN 86) recognized R62 was falling asleep and offered to take her back to bed which the resident agreed to. The LN asked CNA 99 to assist her with placing R62 back to bed. R62 was returned to bed where she immediately fell asleep. R62's wheelchair cushion was dry. The LN 86 stacked two Geomatts next to R62's bed. On the morning of 5/31/18, a medical record review found the most current quarterly Resident Assessment Instrument (RAI) dated 4/12/18 which noted R62 had a short term memory problem and moderately impaired cognitive skills for daily decision making. The 4/12/18 RAI further noted R62 required extensive assistance with toileting with one person physical assist. The 4/12/18 RAI noted R62 was frequently incontinent of bladder and always incontinent of bowel. The 4/12/18 RAI noted (since previous assessment) R62 had two falls without injury, two falls with injuries (except major) and one fall with major injury. Under Section N (Medications), R62 was noted to be on antipsychotics and antidepressants for the seven days prior to the assessment. Previous assessment noted she was only receiving antipsychotics. On the morning of 5/31/18, a review of the latest comprehensive RAI (significant change) dated 10/16/17 found R62's cognitive ability was the same (as 4/12/18 RAI) - short term memory and moderately impaired cognitive skills for daily decision making. R 62's bowel/bladder status was the same (as 4/12/18 RAI). The comprehensive assessment (10/16/17) noted R62 previously required limited assistance with one person assist, where most current (4/12/18) RAI noted she requires extensive assistance with one person assist. The 10/16/17 RAI noted R62 had one fall without injury and one fall with injury (except major). Under Section N (Medications), R62 was noted to be on antipsychotics for the seven days prior to the assessment. The facility did a fall risk assessment for R62 on 1/19/18 and 4/16/18, which noted a score of 10 (8-16=High risk) on each assessment. Despite R62's high risk for falls, she continued to experience multiple falls since her re-admission to the facility on [DATE] (Previous admission 3/6/17). The R62 experienced falls on: 10/12/17; 10/14/17; 10/22/17; 10/28/17; 11/4/17; 12/15/17; 2/2/18; 2/4/18; 2/10/18; 2/23/18; 2/27/18 (two falls); 3/9/18; 3/14/18; and 3/24/18. On 5/27/18 R62 fell while seated at the nurses station. On the morning of 5/31/18 a review of R62's care plan found a plan for Impaired mobility/falls. Interventions included maintaining close supervision and frequent checks to ensure resident safety. Following a fall on 2/2/18, the facility revised R62's care plan to include, Educate staff not to leave residents until another staff is present to supervise. On the morning of 5/31/18 a review of the FRI for R62 found she was seated at the nurses station on the afternoon of 2/27/18 at approximately 2:50 PM. R62 was seated in her wheelchair next to the charge nurse (CN) at the nurses station. The CN turned to one side to make a phone call when R62 attempted to get up and the CN was unable to stop her. R62 fell and landed on her left side. At the time of the fall, R62's wheelchair brakes were not engaged. The CN assessed the resident and found swelling, bruise and pain to her her left thumb, left 4th and 5th fingers. A physician was on site and assessed R62 with orders for an X-ray. The X-ray revealed an acute fracture to the left fourth digit. The facility's root cause analysis (RCA) of R62's fall on 2/27/18 revealed that environmental factors may have contributed to the incident. The FRI noted, Brakes of her wheelchair were not locked and when she stood up the wheelchair possibly moved which contributed to her fall due to increased unsteadiness and poor balance. On the same day R62 sustained the finger fracture on 2/27/18 at 5:15 PM, she was seated in her wheelchair in the dining room. A CNA was seated next to her, feeding her soup. The CNA left R62 at the dining table when the CNA was asked to assist with pushing meal carts into the dumbwaiter. The CNA turned back to the resident and found R62 standing. The CNA was unable to get to R62 in time and the resident fell . The licensed nurse on duty responded to find R62 sitting on the floor with her back resting against the wheelchair, both knees flexed with arms resting on her sides, and facing the table approximately 2 feet away from her. The licensed nurse assisted R62 to the bathroom and she voided and 3 drops of fresh bright red blood was noted. The licensed nurse instructed the CNA to supervise the R62 at all times. The physician was notified and he notified the resident's daughter. The physician recommended a surgical procedure related to R62's finger fracture but the family refused further treatment. An interview of CNA 99 on the afternoon of 5/31/18 at 2:00 PM found her description of R62 is she sometimes get restless and occasionally has behaviors. She reported R62 often tries to get up from her wheelchair without assistance. CNA noted R62 is sometimes continent of bladder and will attempt to get up to go to the bathroom. CNA 99 noted, We don't always have enough staff to help us and therefore we have to leave residents at the nurses station. An interview of CNA 84 revealed R62 is sometimes continent of both bowel and bladder. The CNA reported the resident's brief sometimes has something on it and will still go when placed on the toilet. The CNA 84 noted R62 is often restless. The CNA reported they leave her at the nurses station for the nurse to watch while we're providing care to residents. CNA 84 works day shift and noted that each CNA will have seven residents. An interview of Licensed Nurse (LN 87) on the morning of 6/1/18 at 11:18 AM revealed the nursing staff assist with watching R62 since she's restless. LN 87 noted the nurses help the CNAs when they're busy. To keep R62 safe, all of the staff checks on her frequently, every two hours. An interview of the Director of Nursing (DON) on the afternoon of 5/31/18 at 3:41 PM found the facility was aware that R62 was at high risk for falls prior to the 2/27/18 fall. The DON described the 2/27/18 incident as noted above. The DON stated that the facility determined the root cause analysis was that R62's wheelchair brakes were not engaged. The DON explained that R62 is capable of unlocking her wheelchair brakes. On 2/27/18 the DON was unable to determine whether staff failed to lock R62's brakes or whether the resident unlocked the brakes after a staff member locked them. The DON explained that no one observed R62 unlocking the wheelchair brakes. The DON further noted that a fracture was identified after X-ray. The DON noted R62's family refused further treatment, only agreeing to taping of her fingers to immobilize them. When asked her expectation of staff when managing R62's restlessness, the DON stated she expected staff to provide close supervision. When asked what close supervision meant, the DON stated, Have her sitting next to the nurse and she can self propel to the hallway. When asked if R62's fall was avoidable or unavoidable, the DON reported, If you ask me, every fall is avoidable. The DON was informed that the survey team was looking at harm based on avoidable falls with subsequent major injury. The DON responded that the facility coordinated a family meeting with the physician present to discuss R62's multiple falls. The DON noted the physician identified R62's advanced dementia and instability of her gait. The DON noted the facility, along with the physician, ruled out medications as the cause for gait instability and resultant falls. The DON reported that R62's family is aware of the risks/benefits and the potential outcome of major injury. The DON was asked to provide all the supporting documentation to demonstrate the family's understanding of the risks versus benefits. Additionally, the DON was asked to provide documentation that the family participated in the discussion and signed documents with the risks/benefits outlined for them. On the morning of 6/1/18 at 9:12 AM, a meeting with the DON, Administrator, and Administrator in Training revealed the facility's stance on the family's awareness of R62's fall risks versus benefits. The DON provided a copy of a meeting conducted on 2/9/18 which noted the facility's discussion with the family. The discussion included the use of antipsychotics and the possible negative outcomes which included sedation, weight gain, irreversible abnormal involuntary movements, confusion, death and gait instability/falls. Despite the facility's discussion with R62's family, the facility failed to provide adequate supervision and implement all safeguards (locking of wheelchair) to maintain R62's safety which thereby caused actual harm. 2. Cross Reference to F690, F725 and F919. Resident 68 (R68) was admitted to the facility on [DATE]. R68's [DIAGNOSES REDACTED]. On 5/30/2018 at 9:00 AM while walking through R68's unit, a voice was heard calling out for help. Upon arrival to R68's room, the resident was observed sitting on the floor with legs bent to her chest and scooting on her buttock toward the door. The resident's face was contorted and she kept repeating please help me and stating that she had to use the toilet. The resident's undergarment could be seen which was not soiled. There was no staff member in the hall, assistance was requested at the nurses' station. Staff Member 131 (SM131) accompanied the surveyor to R68's room where she was found at the threshold of the door. SM131 requested assistance from a Certified Nurse Aid (CNA). They were able to assist the resident to stand and ambulate to the bathroom with a forward wheel walker. R68 was placed on the toilet. Further observation found the resident's bed was in a low position with a thick blue pad next to the resident's bed. The floor was not wet or soiled. The call light was placed on the resident's bed and was found to be inoperable. On 5/31/2018 at 3:29 PM a record review found a quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 3/18/2018 noting R68's cognitive ability is moderately impaired. In Section [NAME] Health Condition, R68 is noted to have had falls since admission or prior assessment (ARD of 12/18/2017). R68 is documented as having one fall without injury and one fall with injury (i.e. skin tears, abrasion, superficial bruises, etc.). A review of the resident's care plan (provided by the facility on 5/31/2018) notes R68 had falls on the following dates: 9/15/2017; 9/18/2017; 9/21/2017; 9/21/2017; 9/22/2017; 9/23/2017; 1/24/2018; and 2/20/2018. There is notation that the resident tends to scoot herself down from bed to floor but usually does not sustain any injury and is at risk for repeat falls and serious injury related to falls. The interventions include frequent checks on resident at least hourly and as frequently as every 15 minutes due to her tendency to sit at the edge of the bed, roll off on to geomatt to move about on the unit scooting in sitting position. And when staff is available, station a staff member by resident's doorway to anticipate her needs. Also included is to place the geomatt on the floor as the resident frequently rolls herself off the bed wanting to go out or wanting to go the the toilet by herself without waiting for assistance. 3. Cross Reference to F690 and F725. Resident 77 (R77) was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R77 was discharged from the facility on 3/11/2018. On 5/31/2018 at 10:04 AM a record review was done for R77. R77 was admitted to the facility following a hospitalized from [DATE] to 1/19/2018. The resident resided in an assisted living facility where he fell , sustaining an [MEDICAL CONDITION] following a fall with multifocal intracranial contusions. A review of the admission MDS with ARD of 1/26/2018 notes R77's cognition is moderately impaired. In Section [NAME] Functional Status, R77 requires extensive assistance with one personal physical assist for toilet use. R77 was also coded to be occasionally incontinent of bladder and continent of bowel. In Section [NAME], the resident was noted to have a fall in the last month prior to admission. The resident did not have any falls since admission. A review of the progress notes found an entry for 3/1/2018 at 10:34 AM noting R77 was found out of bed/chair calling for assistance. The staff member found the resident crawling on the floor with right foot still on the geomatt, the resident reported he was trying to go to the bathroom. The resident sustained [REDACTED]. Another entry for 3/1/2018 notes R77 was calling for help every five minutes, wanting to get up to the bathroom, when offered, the resident refused. The resident was noted to inform the staff that he will get up by himself and crawl on the floor if staff members don't come right away. A subsequent progress note of 3/3/2018 documents R77 was heard yelling for help at approximately 10:00 AM. The resident was found lying on the floor at the entry to the bathroom and front door. The resident was founding lying face up. At this time the resident reported he was going to the bathroom. The resident was asked why he did not call for assistance, he responded he did. 4. Cross reference F700 On 05/30/18 at 11:36 AM during RR it was noted that R36 was admitted on [DATE], [DIAGNOSES REDACTED]. It was noted that R36 fell on [DATE] and 12/31/2017, both near her bed. On 06/01/18 at 09:55 AM during RR and staff interview with S103 it was noted on the Care Plan Update Sheet that R36 fell on [DATE], Found resident sitting on the floor between the bed and the chair facing foot part of the bed . Also on 12/31/2017, per Care Plan Update Sheet, Resident activated the bedside call light and LN found her on the floor facing her bed, right hand holding the siderail and left hand holding the call light. No visible injury sustained and offers no complaint of pain. Per resident, she hit her head on the bedside mattress . Complete review of R36 CP with S103 found that R36 had fallen 9 times over the past year (June (YEAR)- (MONTH) (YEAR)). S103 stated that after each fall there was a review of R36's CP and updates made to the intervention(s) in the CP as needed and a root cause analysis was done for each fall by the IDT.",2020-09-01
216,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,690,E,0,1,Y42W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff members, the facility failed to ensure residents who are continent of bladder and bowel receives assistance to maintain continence and failed to ensure a resident with frequent/occasional urinary incontinence and continence of bowel was provided with services to prevent urinary tract infections and restore continence to the extent possible for 1 of 3 sampled residents (Resident 62) and two add-on residents (Residents 68 and 77) which resulted in falls. Findings include: 1. Cross Reference F689, F725, and F919. Resident 68 (R68) was admitted to the facility on [DATE]. R68's [DIAGNOSES REDACTED]. On 5/30/2018 at 9:00 AM while walking through R68's unit, a voice was heard calling out for help. Upon arrival to R68's room, the resident was observed sitting on the floor with legs bent up to her chest and scooting on her buttock toward the door. The resident's face was contorted and she kept repeating please help me and stating that she had to use the toilet. The resident's undergarment was visible, she was not wearing a personal incontinence brief and she was not soiled. There was no staff member in the hall, assistance was requested at the nurses' station. Staff Member 131 (SM131) accompanied the surveyor to R68's room where she was found at the threshold of the door. SM 131 requested assistance from a Certified Nurse Aid (CNA). They were able to assist the resident to stand and ambulate to the bathroom with a forward wheel walker. R68 was placed on the toilet. Further observation found the resident's call light was not working. Also, the floor was not wet or soiled. A record review was done on 5/31/2018 at 3:29 PM. A review of the resident's quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 3/18/2018 notes R68's cognition is moderately impaired. A review of Section H. Bladder and Bowel, the resident was coded as always continent of bowel and bladder. The resident was also coded as requiring extensive assistance with one person physical assist for toilet use. The resident's care plan provided by the facility on 5/31/2018 at 10:40 AM notes interventions to offer and assist with toileting as scheduled during rounds to maintain continence; encourage use of call button for assistance (resident is able to verbalize her need to void; and respond promptly to calls for assistance. 2. Cross Reference to F689 and F725. Resident 77 (R77) was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R77 was discharged from the facility on 3/11/2018. On 5/31/2018 at 10:04 AM a record review was done for R77. A review of the admission MDS with ARD of 1/26/2018 notes R77's cognition is moderately impaired. In Section [NAME] Functional Status, R77 requires extensive assistance with one personal physical assist for toilet use. R77 was also coded to be occasionally incontinent of bladder and continent of bowel. A review of the progress notes found an entry for 3/1/2018 at 10:34 AM noting R77 was found out of bed/chair calling for assistance. The staff member found the resident crawling on the floor with right foot still on the geomatt, the resident reported he was trying to go to the bathroom. The resident sustained [REDACTED]. Another entry for 3/1/2018 notes R77 was calling for help every five minutes, wanting to get up to the bathroom, when offered, the resident refused. The resident was noted to inform the staff that he will get up by himself and crawl on the floor if staff members don't come right away. A subsequent progress note of 3/3/2018 documents R77 was heard yelling for help at approximately 10:00 AM. The resident was found lying on the floor at the entry to the bathroom and front door. The resident was founding lying face up. At this time the resident reported he was going to the bathroom. The resident was asked why he did not call for assistance, he responded he did. 3. Cross reference to F689 and F725 Resident (R62) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R62 was being reviewed for a Facility Reported Incident (FRI) submitted to the State Agency. Observation of R62 on the morning of 5/30/18 at 10:30 AM found her seated in a wheelchair across the nurses station, outside of her room. Surveyor noted a malodorous smell when getting close to R62. R62 appeared restless as she attempted to get out of her wheelchair. Two Certified Nurses Aides (CNAs) wheeled R62 into her room; Assisted her out of her wheelchair; and Walked with her to the toilet. CNA 99 stated R62 had a bowel movement (BM) and she therefore needed to shower the resident. A wheelchair cushion was wrapped in a white pillow case and the cushion and pillow case were completely soaked. R62 wore a personal incontinence brief. CNA 99 stated R62 is sometimes continent of bladder. Observation of R62 on the morning of 5/31/18 at 9:00 AM found the resident seated across the nurses station outside her room. She appeared to be getting restless: Trying to get up; Waving her hand around; and Appeared as though she wanted to go somewhere. The CNA 99 recognized R62 was getting restless so she offered to take her to the bathroom. CNA 99 wheeled R62 into her room and assisted her out of her wheelchair into the bathroom. The seat cushion on R62's wheelchair was wrapped in a white pillow case and was wet in the center - an area of approximately 16 inches x 8 inches. R62 wore a personal incontinence brief. Observation of R62 on the afternoon of 5/31/18 at 2:00 PM found R62 seated in a wheelchair across the nurses station outside of her room. R62 appeared sleepy as she was falling asleep in her wheelchair. The Licensed Nurse (LN 86) recognized R62 was falling asleep and therefore offered to take her back to bed, which the resident agreed to. The LN asked CNA 99 to assist her to return the resident to bed. R62 was returned to bed and she immediately fell asleep. A medical record review found the most recent comprehensive RAI for a significant change dated 10/16/17. The 10/16/17 RAI noted R62's cognitive patterns indicated she had short term memory problem and moderately impaired cognitive skills for daily decision making. Under Section G Functional Status, R62 required: Supervision with setup to walk in room; Limited assistance with one person assist for toilet use; and Not steady (but able to stabilize without staff assistance) for moving on and off toilet. The RAI (10/16/17) further noted R62 was frequently incontinent of urine and always incontinent of bowel. A medical record review found the most recent quarterly Resident Assessment Instrument (RAI) dated 4/12/18 which noted R62 had short term memory problems and moderately impaired cognitive skills for daily decision making (same as 10/16/17). Under Section G Functional Status, R62 required: Extensive assistance with one person physical assist to walk in her room (decline from 10/16/17); Extensive assistance with one person assist for toilet use (decline from 10/16/17); and Not steady (only able to stabilize with staff assistance) for moving on and off toilet (decline from 10/16/17). The RAI (4/12/18) further noted R62 was frequently incontinent of urine and always incontinent of bowel (same as 4/12/18). A review of R62's care plan found one for Bowel and Bladder. The problem stated R62 was always incontinent of bowel and bladder. The problem further noted that R62 was unaware of her toileting needs and uses incontinence products. The facility noted the possible primary contributing factor was impaired cognition related to progression of dementia. The interventions included that staff continue to provide routine incontinence checks regularly. The care plan did not define what routine incontinence checks included. A review of the nurses notes on the afternoon of 5/31/18 found a note dated 3/14/18 which indicated R62 was found lying on the Geomatt next to her bed. According to the note, R62 had been toileted at approximately 9:30 AM prior to going to bed for a nap. The CNA noted R62 was already incontinent of urine but she was assisted to the toilet and voided a moderate amount of urine. A review of R62's output on the morning of 6/1/18 at 8:48 AM found R62 experienced occasional continence of both bowel and bladder over the two weeks before and during survey, 5/21/18 to 5/31/18. R62 was more incontinent than continent of bladder on most days. R62 was continent of bowel on 5/23/18, 5/24/18, and 5/28/18. An interview of LN 86 on the afternoon of 5/31/18 at 1:45 PM revealed her expectation was that CNAs round with residents every two hours. When asked about R62's frequent falls, LN 86 reported all staff helped each other with supervising residents. An interview of CNA 99 on the afternoon of 5/31/18 at 2:02 PM revealed R62 is sometimes continent of urine but always incontinent of bowel. CNA 99 reported they round with R62 every two hours. When asked about R62's frequent falls, CNA 99 replied the staff were expected to keep the resident's bed in a low position, place the Geomatts next to her bed and provide frequent checks. An interview of CNA 84 on the morning of 6/1/18 at 11:47 AM found her understanding was that R62 was sometimes continent of both bowel and bladder. She reported that R62 sometimes soiled her brief prior to being placed on the toilet. When R62 gets on the toilet, she still has to void or have bowel movements. CNA 84 noted that all staff help each other. CNA 84 noted that R62 is often restless. The CNAs leave R62 at the nurses station for the nurse to watch her while they perform their tasks. An interview of the RAI Coordinator on the morning of 6/1/18 at 8:32 AM revealed she was unaware that R62 is sometimes continent of urine. An interview of the Director of Nursing (DON) on the afternoon of 5/31/18 at 3:41 PM revealed her expectation was for the CNAs to provide frequent rounds with R62. When asked what frequent rounding was, the DON replied every two hours. When asked about R62's frequent falls and restlessness, the DON replied that she required close supervision at all times. The DON was informed about the observations where R62's cushion was soaking wet on the morning of 5/29/18 at 9:00 AM. The DON was informed of the observation of R62 on the morning of 5/30/18 at 9:00 AM when the wheelchair cushion was wet in the center of the seat. When asked if R62 wore personal incontinence briefs, the DON confirmed she did.",2020-09-01
217,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,700,D,0,1,Y42W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review (RR) and staff interview the facility failed to obtain informed consent for bed rail use with 2 of 32 residents (R36 and R45) Sampled prior to bed rail use. Findings Include: 1. Cross reference F689 On 05/30/18 at 11:36 AM during RR it was noted that R36 was admitted on [DATE], [DIAGNOSES REDACTED]. It was noted that R36 fell on [DATE] and 12/31/2017, both near her bed. On 06/01/18 at 09:55 AM during RR and staff interview with S103 it was noted on the Care Plan Update Sheet that R36 fell on [DATE], Found resident sitting on the floor between the bed and the chair facing foot part of the bed . Also on 12/31/2017, per Care Plan Update Sheet, Resident activated the bedside call light and LN found her on the floor facing her bed, right hand holding the siderail and left hand holding the call light. No visible injury sustained and offers no complaint of pain. Per resident, she hit her head on the bedside mattress . Quiered if R36 had an informed consent for bed rail use and S103 was unable to find this and confirmed that there was no consent for bed rail use for R36. 2. Review of Facility Reported Incident (FRI) found that R45 was sent to the emergency room (ER) after resident sustained [REDACTED]. On 05/31/18 at 04:59 PM interviewed S105 about R45's ability to walk and use the call light. S105 stated that R45 is stand by assist when she walks and uses a walker and that R45 can use the call light when she remembers to use it. S105 stated that R45 sometimes forgets to use the call light. S105 stated that facility staff check on R45 frequently to see if she needs help with walking. R45's bed was observed up against the wall and she had 2 upper quarter side rails up. On 06/01/18 at 11:49 AM RR of R45's EMR with S103 found that R45 has a CP in place for falls, had interventions and falls listed with changes made to CP, and had a risk assessment done for use of bedrails on 2/26/18. Upon further RR there was no informed consent from R45 or her representative for bed rail use. Quiered S103 if R45 had an informed consent for bed rail use and S103 was not able to find this and confirmed that there was no informed consent for bed rail use for R45. On 06/01/18 at 04:36 PM met with R45 and asked if she remembered the fall on 03/02/2018, res shook her head no, asked if she was trying to go somewhere when she fell and resident stated no, R45 was calm and pleasant enough but unable to say anything more regarding the fall.",2020-09-01
218,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,725,F,0,1,Y42W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR) , staff and resident interview the facility failed to provide sufficient nursing staff to assure the residents live a dignified existence, provide resident safety from falls with significant injury, to maintain highest practicable physical and psychosocial well-being of their residents who depend on staff for assistance at meal times and to maintain bowel and bladder continence. Findings Include: 1. Cross Reference F550 . An interview of R5 on the morning of 5/29/18 at 11:02 AM found the residents expressing, I feel like I'm being pushed around. Like I don't have a choice. R5 reported that the Certified Nurse Aides (CNAs) did not listen to her. R5 stated that the CNAs will tell her that if she needs something at a certain time, she'll have to wait because they're busy. 2. Cross Reference F550 On 05/29/18 at around 1245, while walking in the hallway past R64's door, R64 was overheard talking with the housekeeper asking for assistance, asking for his lunch and stating that he was hungry. R64 was seen earlier in the dining room but he had not eaten his lunch when the meal trays were delivered and was now watching TV in his room. Asked a passing CNA if resident was going to be assisted with his lunch and she stated right after I help this resident as CNA walked into the other resident's room who had pressed the call light. R64 was assisted with his lunch at 1259 after licensed staff was asked if R64 was going to be assisted with his meal. Licensed staff thought R64 had eaten earlier in the dining room. Facility reported lunch time for third floor was 11:45 AM. This day it was noted that trays were delivered to the units later than usual, per facility stated lunch times, as the kitchen reported problems with their warmers. 3. Cross Reference F689 and 690. Observation of R62 on the morning of 5/30/18 at 10:30 AM found her seated in a wheelchair across the nurse's station, outside of her room. Upon approaching R62, there was an odor of feces. Moving away from R62 the odor faded away. Upon return to R62, the feces odor returned. R62 appeared restless as she attempted to get out of her wheelchair and appeared to want to say something. Two Certified Nurse Aides (CNAs) wheeled R62 into her room, assisted her out of her wheelchair and walked with her to the toilet. There was a cushion wrapped in a white pillow case on the seat of R62's wheelchair. The entire pillow case and cushion were soaking wet. CNA 99 stated R62 had a bowel movement (BM) and she therefore needed to shower the resident. R62 wore a personal incontinence brief. Observation of R62 on the morning of 5/31/18 at 9:00 AM found the resident seated across the nurses station outside her room. She appeared to be getting restless: Attempting to stand while seated in the hallway in her wheelchair; waving her hands around; and appearing as though she wants to say something or do something. CNA 99 recognized R62 was getting restless so she offered to take her to the bathroom. CNA 99 wheeled R62 into her room and assisted her out of her wheelchair and into the bathroom. The seat cushion on R62's wheelchair was wrapped in a white pillow case and was wet in the center - an area of approximately 16 inches x 8 inches. R62 wore a personal incontinence brief. On the morning of 5/31/18, a medical record review found the most current quarterly Resident Assessment Instrument (RAI) dated 4/12/18 which noted R62 had a short term memory problem and moderately impaired cognitive skills for daily decision making. The 4/12/18 RAI further noted R62 required extensive assistance with toileting with one person physical assist. The 4/12/18 RAI noted R62 was frequently incontinent of bladder and always incontinent of bowel. The 4/12/18 RAI noted (since previous assessment) R62 had two falls without injury, two falls with injuries (except major) and one fall with major injury. Under Section N (Medications), R62 was noted to be on antipsychotics and antidepressants for the seven days prior to the assessment. Previous assessment noted she was only receiving antipsychotics. The facility did a fall risk assessment for R62 on 1/19/18 and 4/16/18, which noted a score of 10 (8-16=High risk) on each assessment. Despite R62's high risk for falls, she continued to experience multiple falls since her re-admission to the facility on [DATE] (Previous admission 3/6/17). The R62 experienced falls on: 10/12/17; 10/14/17; 10/22/17; 10/28/17; 11/4/17; 12/15/17; 2/2/18; 2/4/18; 2/10/18; 2/23/18; 2/27/18 (two falls); 3/9/18; 3/14/18; and 3/24/18. On 5/27/18 R62 fell while seated at the nurse's station. On the morning of 5/31/18 a review of R62's care plan found a plan for Impaired mobility/falls. Interventions included maintaining close supervision and frequent checks to ensure resident safety. Following a fall on 2/2/18, the facility revised R62's care plan to include, Educate staff not to leave residents until another staff is present to supervise. On the morning of 5/31/18 a review of the FRI for R62 found she was seated at the nurse's station on the afternoon of 2/27/18 at approximately 2:50 PM. R62 was seated in her wheelchair next to the charge nurse (CN) at the nurse's station. The CN turned to one side to make a phone call when R62 attempted to get up and the CN was unable to stop her. R62 fell and landed on her left side. At the time of the fall, R62's wheelchair brakes were not engaged. The CN assessed the resident and found swelling, bruise and pain to her left thumb, left 4th and 5th fingers. A physician was on site and assessed R62 with orders for an X-ray. The X-ray revealed an acute fracture to the left fourth digit. The facility's root cause analysis (RCA) of R62's fall on 2/27/18 revealed that environmental factors may have contributed to the incident. The FRI noted, Brakes of her wheelchair were not locked and when she stood up the wheelchair possibly moved which contributed to her fall due to increased unsteadiness and poor balance. On the same day R62 sustained the finger fracture on 2/27/18 at 5:15 PM, she was seated in her wheelchair in the dining room. A CNA was seated next to her, feeding her soup. The CNA left R62 at the dining table when the CNA was asked to assist with pushing meal carts into the dumbwaiter. The CNA turned back to the resident and found R62 standing. The CNA was unable to get to R62 in time and the resident fell . The licensed nurse on duty responded to find R62 sitting on the floor with her back resting against the wheelchair, both knees flexed with arms resting on her sides, and facing the table approximately 2 feet away from her. The licensed nurse assisted R62 to the bathroom and she voided and 3 drops of fresh bright red blood was noted. The licensed nurse instructed the CNA to supervise the R62 at all times. The physician was notified and he notified the resident's daughter. The physician recommended a surgical procedure related to R62's finger fracture but the family refused further treatment. An interview of CNA 99 on the afternoon of 5/31/18 at 2:00 PM found her description of R62 is she sometimes get restless and occasionally has behaviors. She reported R62 often tries to get up from her wheelchair without assistance. CNA noted R62 is sometimes continent of bladder and will attempt to get up to go to the bathroom. CNA 99 noted, We don't always have enough staff to help us and therefore we have to leave residents at the nurses station. An interview of CNA 84 revealed R62 is sometimes continent of both bowel and bladder. The CNA reported the resident's brief sometimes has something on it and will still go when placed on the toilet. The CNA 84 noted R62 is often restless. The CNA reported they leave her at the nurse's station for the nurse to watch while we're providing care to residents. CNA 84 works day shift and noted that each CNA will have seven residents.\ 4. Cross Reference F689 and 690. On 5/30/2018 at 9:00 AM while walking through R68's unit, a voice was heard calling out for help. Upon arrival to R68's room, the resident was observed sitting on the floor with legs bent to her chest and scooting on her buttock toward the door. The resident's face was contorted and she kept repeating please help me and stating that she had to use the toilet. The resident's undergarment could be seen which was not soiled. There was no staff member in the hall, assistance was requested at the nurses' station. Staff Member 131 (SM131) accompanied the surveyor to R68's room where she was found at the threshold of the door. SM131 requested assistance from a Certified Nurse Aid (CNA). They were able to assist the resident to stand and ambulate to the bathroom with a forward wheel walker. R68 was placed on the toilet. Further observation found the resident's bed was in a low position with a thick blue pad next to the resident's bed. The floor was not wet or soiled. The call light was placed on the resident's bed and was found to be inoperable. 5. Cross Reference F689 and F690. A review of the progress notes found an entry for 3/1/2018 at 10:34 AM noting R77 was found out of bed/chair calling for assistance. The staff member found the resident crawling on the floor with right foot still on the geomatt, the resident reported he was trying to go to the bathroom. The resident sustained [REDACTED]. Another entry for 3/1/2018 notes R77 was calling for help every five minutes, wanting to get up to the bathroom, when offered, the resident refused. The resident was noted to inform the staff that he will get up by himself and crawl on the floor if staff members don't come right away. A subsequent progress note of 3/3/2018 documents R77 was heard yelling for help at approximately 10:00 AM. The resident was found lying on the floor at the entry to the bathroom and front door. The resident was founding lying face up. At this time the resident reported he was going to the bathroom. The resident was asked why he did not call for assistance, he responded he did.",2020-09-01
219,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,761,D,0,1,Y42W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to correctly label discard by dates for 2 residents (R73, R229) insulin pens. Findings Include: 1. On 05/31/18 at 09:29 AM checked the 3 Ewa medication cart for medication storage and labeling and found that an insulin pen was labeled with the incorrect discard by date. [MEDICATION NAME] prefilled syringe was labeled with open date of 05/17/18 with discard by date of 06/21/18 for R229. Label on insulin pen states to discard after 28 days. Correct discard date is 06/14/18. 2. On 05/31/18 at 10:16 AM checked the 2 Ewa medication cart for medication storage and labeling and found that a Tresiba Flextouch 100 units/ml insulin pen had an open date of 5/24 and a discard by date of 6/20/18 for R73. S108 found in the unit binder that this medication has a discard by date of 56 days. The labeled discard date of 6/20/18 was incorrect and the correct discard date is 07/19/18.",2020-09-01
220,ARCADIA RETIREMENT RESIDENCE,125014,1434 PUNAHOU STREET,HONOLULU,HI,96822,2018-06-01,919,D,0,1,Y42W11,"Based on observation and interview with staff members, the facility failed to ensure a call system was functioning properly. Findings include: On 5/30/18 at 9:00 AM while walking on the unit a voice was heard, asking for help. On approach to Resident 68's (R68) room, the resident was observed sitting on the floor with legs bent at the knee and scooting on her buttock toward the door. The resident's undergarment was visible and she was not wearing an incontinence brief. The resident has a low bed with a mat on the floor. The resident's face was contorted and kept repeating please help me. The resident continued to request assistance to go to the toilet and asking please take me. There was no staff in the hall, assistance was requested at the nursing station. The licensed nurse, Staff Member 131 was notified and upon approach to the room, the resident was at the threshold of the door. The staff member asked a certified nurse aide (CNA) for assistance. The CNA retrieved the resident's walker and both staff members assisted the resident to stand and ambulate with the walker to the bathroom and assisted to the toilet. The CNA left the bathroom ajar. R68 was observed to have a round disc call light. The call light was pressed and the light above the resident's door did not activate, nor did the red light on the wall switch covering. The call light was pressed again and appeared inoperable. SM131 was asked whether the R68 is able to use the call light, the response was it is 50-50, the resident forgets sometimes. Inquired whether the call light was operational. The staff member pressed the light and stated it was not working and a call will be made to maintenance. As we walked out of the resident's room, Staff Member 121 (SM121) was in the hall. SM131 asked for the call light to be checked. SM121 checked the call light and stated that the call light was not working and would change it. Subsequent observation found the call light was working.",2020-09-01
221,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,550,D,0,1,MTD611,"Based on observations, the facility failed to ensure that Resident #23 was cared for in a manner that respected they dignity. Findings: On 09/11/2018 and 09/13/2018 at approximately 11:00 AM, Resident #23 was observed lying in their bed with the head of the bed raised at approximately a 30 degree angle. Her hair appeared unkept, it was not combed or brushed and appeared oily and/or greasy. On 09/14/2018 at approximately 07:30 AM Resident #23 was observed in her bed and her hair was combed but still appeared to be oily and/or greasy. The care plan reviewed in Resident #23's medical record had in place a care plan for impaired ADL's with a goal that the resident will appear neat and comfortable. Observations on 3 occasions did not find the resident presenting as neat with her hair unkept and oily/greasy in appearance. Resident #23 did not present in a manner that she had been cared for in a dignified manner.",2020-09-01
222,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,558,D,0,1,MTD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with resident, the facility did not ensure reasonable accommodation was provided to a resident. The resident's bed side rails were covered with a netting which hinders his access to his bed controls and call light. Finding includes: On 09/11/18 at 1:48 PM during the initial tour, Resident 10 (R10) reported the facility placed a netting on the bed side rails which interferes with his ability to use the call light and the controls for his bed. The resident further reported it is especially difficult at night as there is no light to ensure he is pressing the correct controls. R10 further reported if he was not alert he would understand why the netting is needed; however, he is alert and the spacing in the side rail does not pose a danger for him. A record review was done on 09/12/18 at 2:11 PM. R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set with an assessment reference date of 08/04/18 found the resident yielded a score of 15 (cognitively intact) on the Brief Interview for Mental Status. In Section P. Restraints, R10 was not coded for use of restraints.",2020-09-01
223,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,561,E,0,1,MTD611,"Based on interviews with residents, the facility did not ensure residents were provided the right to make choices regarding bathing/showering. Findings include: On 09/13/18 at 10:00 AM an interview was conducted with six resident council representatives. The representatives reported they receive only two showers a week. One resident reported that she does not have a choice whether she receives a shower or bed bath. The resident stated she has been receiving bed baths and has been told by staff members that the hoyer lift is broken; therefore, she cannot be transferred for a shower. Another resident reported she receives showers twice a week and wonders why she cannot get a shower daily when she has observed that the showers are not always in use. Another resident reported he receives a shower twice a week. He also commented that it has been so hot and would like to have a shower more often. The resident shared that he did not think he could request more showers and all residents receive two showers a week. The residents were asked if they were provided a choice of the frequency of showers/bed bath or what their preference is for shower or bed bath. All the residents responded that they were not asked about showers.",2020-09-01
224,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,574,E,0,1,MTD611,"Based on resident interviews, the facility did not ensure residents of the facility were provided with the name, address and telephone number of the State Survey Agency to file a complaint. Findings include: On 09/13/18 at 10:00 AM an interview was done with six resident council representatives. The residents were asked whether they have been informed of their right and provided information on how to formally complain to the State Agency. The residents present were not aware of this right or had knowledge of where this information is posted. One resident asked for the telephone number of the State Agency and one resident wrote down the phone number in her note book.",2020-09-01
225,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,577,E,0,1,MTD611,"Based on interview with the resident council members, the facility failed to ensure the results of the most recent survey of the facility conducted by the State surveyors with the facility's plan of correction is available for review. Findings include: On 09/13/18 at 10:00 AM an interview was conducted with the resident council members. The members were asked without having to ask, are the results of the State inspection available to read. A resident responded she thinks residents can get the folder to look at it. Another resident reported the binder is located by the bulletin board and secured by a chain to the bulletin board. The remaining residents did not have knowledge of the location or are aware of their right to review the results from the most recent survey.",2020-09-01
226,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,578,E,0,1,MTD611,"Based on medical record reviews and interviews, the facility failed to ensure that 3 residents (R6, R19, R50) out of 38 residents were informed of the right to accept or refuse the right to formulate an advanced directive. Findings include: 1. A medical record review for R19 on the morning of 9/12/18 at 10:23 AM did not find Advanced Directives in her record. An interview of the Social Worker on 9/14/18 at 12:04 PM revealed she did not have an Advanced Directive for R19 nor did she have a POLST for her. 2. A medical record review for R50 on the morning of 9/12/18 at 10:58 AM did not find Advanced Directives for the resident. An interview of the Social Worker on the morning of 9/14/18 at 8:44 AM found she may not have documented her conversation with the resident/representative on options to formulate an advanced directive. The Social Worker returned on 9/14/18 at 12:07 PM when she stated she did not document anything about advanced directives for R50. 3. On 09/11/2018 a record review was conducted for R6. No advanced directive was found and no documentation was found in the medical record that R6 had been provided with information about the formulation of an advanced directive. An interview was conducted with the Social Workers on 09/12/2018 in regards to the advanced directives. One of the Social Workers displayed on the Electronic Medical Record (EMR) where information of the advanced directive could be found. For R6 no information on advanced directives was found.",2020-09-01
227,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,580,D,0,1,MTD611,"Based on record review, interview with staff member and resident's representative, the facility did not ensure a resident's representative was informed of alteration to skin integrity for Resident 40. Findings include: On 09/11/18 at 1:18 PM an interview was conducted with Resident 40's representative. The representative was asked whether the facility notifies her of any changes. The representative replied the facility may have forgotten to inform her of her husband's pressure ulcer. On the morning of 09/14/18 a record review found no documentation the resident's representative was notified of an alteration to his skin integrity (pressure ulcer/moisture associated skin damage). On the morning of 09/14/18 an interview was conducted with LTC Coordinator 1 (LTCC1). LTCC1 confirmed there was no documentation Resident 40's representative was notified of the change in the resident's skin integrity.",2020-09-01
228,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,584,E,0,1,MTD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with the resident council representatives, the facility did not ensure the residents were provided with a homelike and comfortable environment. Findings include: 1. On 09/13/18 at 10:00 AM an interview was conducted with the resident council representatives. The residents reported the facility is hot which interferes with their ability to sleep at night. One resident reported the heat causes him to sweat and he would like to have more showers; however, he is unable to get more showers. One resident reported that the council and residents have been trying to get air conditioning for the past two to three years. The resident expressed concern regarding the use of fans and the spreading of germs by the fan. The same resident reported that the fans are not effective as odors travel in the wind stream. The resident explained that there are odors when her roommate has a bowel movement and the staff keep the door open, then the odor travels via the fan. The resident further explained that this has occurred while she is eating lunch in her room. 2. An interview of Resident (R38) on the morning of 9/13/18 at 9:18 AM found the resident sitting up in bed. He reported he has experienced warm temperatures over the past 6 years. He stated his air conditioning (AC) vent in his room does not work properly and barely blows any air through. The resident asked the Surveyor to place her hand near the vent to demonstrate the low pressure air coming from the vent. The Surveyor noted there was a very slight pressure of air blowing out. R38 further noted he has difficulty breathing when the temperature is warm. 3. An observation of a dressing change for R50's pressure injury on the morning of 9/13/18 at 11:AM found the non-interviewable resident in a private room. R50's bed was placed close to the windows where the temperature was warmer. A rotating fan was on and situated in the corner of R50's room. The LN1 stated R50's room, is hot. R50 was on contact isolation for [MEDICAL CONDITION] (MRSA) in a wound on her right heel. 4. An interview of R25 on the afternoon of 9/11/8 at 1:41 PM found she feels hot during the day. She reported the hallway is cool but her room is very hot. 5. An interview of R13 on the morning of 9/12/18 at 9:00 am found he feels warm in his room, particularly when the sun is shining into his windows. 6. An interview of the Assistant Director of Nursing (ADON) on the morning of 9/14/18 at 10:00 AM revealed the facility was in the process of ordering parts for the air conditioner. The parts, according to the ADON, are on order and will take several weeks to arrive.",2020-09-01
229,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,625,D,1,1,MTD611,"> Based on interviews and a medical record review, the facility failed to provide written information to the resident's representative about the bed hold policy prior to the resident's transfer to an acute hosptial. Findings: R63 was admitted to an acute hospital 06/14/2018. A nursing progress note dated 06/16/2018 had stated that they received a phone call from the daughter of R63 to state that her mother was in ICU. It was verbally explained to the daughter during that phone call that per the facility's protocol they could only hold her bed for 72 hours. During an interview with the daughter of R63 on 9/11/2018, she state she had not been informed in writing of the bed hold policy. She stated if she had of know that she could have paid to hold the bed for her mother, she would have done so. On 09/13/2018 the administrator was interviewed at approximately 08:00 AM. The administrator confirmed she was aware that the daughter of R63 had not been appropriately informed about the bed hold policy prior to R63 being admitted to an acute care hospital.",2020-09-01
230,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,656,D,0,1,MTD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff members, the facility failed to develop a comprehensive care plan for 1 (Resident 21) of 16 residents reviewed. The facility did not develop a care plan for prn use of oxygen. Findings include: Cross Reference to F695. The observations of Resident 21 on 09/11/18 and 09/12/18 found the resident in her room using oxygen via nasal cannula. The record review found a physician's orders [REDACTED]. The record review found there was no development of a care plan for the use of oxygen.",2020-09-01
231,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,657,D,0,1,MTD611,"Based on observation, record review and interview with staff members, the facility failed to revise the comprehensive care plan for 1 (Resident 31) of 16 residents with moisture associated skin damage. Findings include: Cross reference to F684. A review of Resident 31's quarterly Minimum Data Set with an assessment reference date of 07/06/18 found the resident was coded in Section M. Skin Conditions with moisture associated skin damage (MASD). On 09/13/18 at 1:33 PM a concurrent record review and interview was conducted with LTC Coordinator 1 (LTCC1). The coordinator confirmed the care plan did not include a goal and interventions/tasks to treat the MASD. The LTCC1 reported interventions to address the MASD would include applying a moisture barrier, frequent changing after bowel incontinence, and decrease the use of linens.",2020-09-01
232,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,677,D,0,1,MTD611,"Based on direct observations, the facility failed to ensure R23 recieved the necessay services to maintain grooming and personal hygiene. Findings: On 09/11/2018 and 09/13/2018 at approximately 11:00 AM, R23 was observed lying in their bed with the head of the bed raised at approximately a 30 degree angle. Her hair appeared unkept, it was not combed or brushed and appeared oily and/or greasy. On 09/14/2018 at approximately 07:30 AM R23 was observed in her bed and her hair was combed but still appeared to be oily and/or greasy. The care plan reviewed in R23's medical record had in place a care plan for impaired ADL's with a goal that the resident will appear neat and comfortable. Observations on 3 occasions did not find the resident presenting as neat with her hair unkept and oily/greasy in appearance. R23 did not receive the necessary care services to ensure her grooming and personal hygiene were maintained.",2020-09-01
233,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,684,D,0,1,MTD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not ensure 1 (Resident 31) of 2 residents sampled Resident 31 received treatment for [REDACTED]. Findings include: Cross Reference to F657. Resident 31 (R31) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 09/11/18 at 11:14 AM an interview was conducted with R31. The resident reported that he has red marks on his buttock related to his mattress which is broken. He reportedly had an air mattress and now he can feel the metal brackets of the bed frame. On 09/13/18 at 1:00 PM a record review found a quarterly Minimum Data Set with an assessment reference date of 07/06/18. R31 was found to have a score of 15 (cognitively intact) when the Brief Interview for Mental Status was administered. In Section M. Skin Conditions, R31 was coded with moisture associated skin damage (MASD). The resident was also coded as having a Foley catheter and always incontinent of bowel. A review of the Weekly Skin Assessment - V4 dated 07/05/18 documents the resident has MASD to buttock which was first observed on 09/28/17. The progress noted, is unchanged in 1 week. A review of the resident's care plan found a focus area for potential impaired skin integrity related to moderate rashes to left anterior knee; history of pressure injury, deep tissue to bilateral malleolus-resolved; extensive assist with bed mobility; and bowel incontinence. The care plan was not updated to address the MASD. On 09/13/18 at 1:33 PM a concurrent record review and interview was conducted with LTC Coordinator 1 (LTCC1). The coordinator confirmed the care plan did not include a goal and interventions/tasks to treat the MASD. The LTCC1 reported interventions to address the MASD would include applying a moisture barrier, frequent changing after bowel incontinence, and decrease the use of linens. The LTCC1 reported the resident brought his own air mattress; however, the facility is unable to repair his personal property. Also, the resident reportedly does not want to change the mattress. On 09/13/18 at 1:56 PM LTCC1 was found in R31's room with the curtain drawn. LTCC1 reported the resident's skin was checked and stated the resident does not have a MASD, it appears to be [MEDICAL CONDITION].",2020-09-01
234,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,686,D,0,1,MTD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff and family member, the facility failed to provide care consistent with professional standards of practice for 1 of 3 residents sampled for pressure ulcer review. The facility did not assess Resident 40's skin integrity as evidenced by the conflicting assessments by the hospice entity and the facility. The facility also did not ensure the care plan was being implemented for prevention of skin breakdowns. Findings include: Resident 40 (R40) was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 09/11/18 at 1:18 PM an interview was conducted with R40's representative. The representative reported the facility did not notify her of R40's pressure ulcer (Cross Reference to F580). A record review was conducted on the afternoon of 09/13/18 and morning of 09/14/18. A review of the quarterly Minimum Data Set with an assessment reference date of 07/13/18 notes the resident's cognition is severely impaired. Also, in Section M. Skin Condition the resident is coded as having moisture associated skin damage (MASD). R40 was admitted to hospice on 10/26/17. A review of the progress notes found documentation by the hospice entity on 04/04/18 of R40 with excoriation to buttock and noted shearing to coccyx due to moisture measuring 2 cm. x 0.8 cm. Subsequent entry by the hospice entity on 05/23/18 notes Stage 2 pressure ulcer to the coccyx and buttock. A subsequent note on 06/29/18 notes resolved pressure ulcer to the buttocks. On 07/23/18 the hospice entity notes collaboration was done with the facility staff member on 07/20/18 regarding R40's open Stage 2 pressure ulcer to the right buttocks. At this time [MEDICATION NAME] was applied with 4x4 [MEDICATION NAME] dressing with dressing change every three days or when skin is soiled. The hospice entity documents on 08/27/18 healing of pressure injury to coccyx and buttock. A review of the facility's weekly skin assessment was done. On 05/24/18 the assessment documents a new skin condition to the sacrum/coccyx and open area to the sacral area. The physician was notified with no new orders and no previous orders updated and continuation of turning/repositioning program. The subsequent evaluation of 06/07/18 notes the skin condition (MASD) first observed on 04/04/18 to the sacrum/coccyx was unchanged. Also noted is MASD first observed on 05/29/18 to the buttock (right and left) was unchanged. The assessment dated [DATE] notes no changes to the MASD to the sacrum/coccyx and buttock (right and left). The skin assessment dated [DATE] documents no change in the resident's skin condition (MASD) to the sacrum/coccyx (right, left, midline). Further review found an entry for 05/29/18, Skin/Wound Progress Note, documenting the facility was notified by the hospice nurse of R40's Stage 2 pressure injury to bilateral buttocks. The nurse documents there is a chronic area of denudement due to moisture, not pressure related. There was also an open are to left buttock with no [MEDICATION NAME] dressing. On 09/14/18 at 9:45 AM concurrent record review and interview was conducted with LTC Coordinator 1 (LTCC1). The coordinator acknowledged the discrepancy in the documentation by the hospice entity and the facility nursing staff. A review of the resident's care plan found intervention for skin care (use mild soap and tepid water for bathing, apply mositurizing lotion to dry skin at least once a day, apply moisture barrier/ointment to areas in contact with moisture after each incontinence care). The coordinator reported the use of barrier cream/ointment does not have to be ordered by the physician; however, it would be noted in the Certified Nurse Aide's kardex. A review of the kardex found no instructions to apply the barrier cream/ointment.",2020-09-01
235,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,692,D,0,1,MTD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, family interview and staff interview, the facility failed to maintain an effective system for monitoring hydration for one resident (R62) of one resident (R62) reviewed for hydration. Findings include: An interview of R62's granddaughter on the morning of 9/11/18 at 8:51 AM found her seated next to R62's bed. R62 was nonverbal with Surveyor. R62 was finishing her breakfast and her granddaughter assisted as needed. R62's granddaughter reported R62 was previously sent to the facility's emergency room (ER) (facility is attached to a hospital) for dehydration, pneumonia, and urinary tract infection [MEDICAL CONDITION]. R62's granddaughter stated the facility does not bring R62 water between meals unless the family asks for it. Observation of R62 on 9/11/18 at 8:51 AM found she did not have water or other beverages at her bedside. On the morning of 9/12/18 at 10:34 AM, R62 did not have water or other beverages at her bedside. On 9/13/18 at 9:35 AM R62 did not have water or other beverages at her bedside. On 9/14/18 at 9:33 AM a water pitcher was at R62's bedside. Interview of R62's granddaughter on 9/14/18 at 9:33 AM revealed her papa asked the staff to bring the water pitcher this morning. A medical record review for R62 found she was transferred to the emergency roiagnom on [DATE] for altered mental status. She was treated with intravenous (IV) fluids and IV antibiotics and transferred back to the facility. A nurses note dated 5/31/18 at 15:37 noted R62 was back in the facility and, Now on IV fluids for 7 days for hydration and IV [MEDICATION NAME] (antibiotic) 250mg/50ml every 24 hours for aspiration pneumonia and urinary tract infection [MEDICAL CONDITION] for 14 days. The ER did a basic metabolic panel and noted R62's sodium was normal. A review of physician's orders [REDACTED]. A review of R62's care plan found one for nutritional risk with suboptimal fluid intake. The Registered Dietician (RD) recommended that nursing staff monitor R62's daily fluid intake to meet estimated needs range 1500-1800ml/day (last revised 8/28/18). A review of R62's intake records found she was not meeting her recommended daily fluid intake. From 4/30/18 through 5/30/18, R62 met her fluid intake goal on one day, 5/23/18, when she got 1560 ml. Over the course of 31 days, R62 averaged 1135ml/day or 365ml/day less than her daily recommended intake. During that time, six of thirty one days had a recorded fluid intake of 960 ml. On 5/27/18, R62's fluid intake was recorded as 900 ml. On 5/30/18, R62's fluid intake was 840 ml. On 5/31/18 R62 was transferred to the emergency room and diagnosed with [REDACTED]. An interview of the Director of Nursing (DON) on the morning of 9/14/18 at 10:08 AM revealed the Assistant Director Of Nursing (ADON) was responsible for monitoring residents' fluid intake. The DON stated the Certified Nurses Aides (CNAs) record R62's fluids and when she doesn't meet her goals, the CNAs are expected to notify the licensed nurses. When asked who ensures residents meet their daily fluid goals, the DON stated the CNAs were responsible for ensuring the necessary/required fluid intake. The ADON stated the Charge Nurse was responsible for monitoring daily fluid intake. However, she was unable to show documentation of the Charge Nurse's review and possible interventions when R62 does not meet her fluid goals. The DON repeated several times that residents who are defined as nutritional risk were reviewed weekly in a meeting with the Registered Dietician.",2020-09-01
236,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,695,D,0,1,MTD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff member, the facility did not ensure 1 (Resident 21) of 2 residents in the sample received respiratory care consistent with the comprehensive person-centered care plan. Findings include: Cross Reference to F656. The facility failed to develop a care plan to include the prn use of oxygen for the resident. Cross Reference to F880. The facility failed to label the oxygen tubing to indicate the date of first use to ensure the tubing is changed every seven days for the prevention of infection. On the morning of 09/11/18 during the initial tour, Resident 21 was observed to be asleep. The resident was receiving oxygen via nasal cannula. There was no labeling of the tubing to document the date of first use. Subsequently an interview was conducted with R21, the resident was observed to be on oxygen via nasal cannula. An observation at lunch found the resident dining in her room, laying in bed using oxygen. On the morning of 09/12/18, R21 was observed asleep in bed with oxygen being administered. A record review done on 09/12/18 at 01:25 PM found a physician's orders [REDACTED]. A review of the resident's care plan found no interventions for the use of oxygen. On 09/12/18 at 01:47 PM an interview was conducted with the Director of Nursing (DON), LTC Coordinator 1 (LTCC1), and Licensed Nurse 2 (LN2). Inquired how does the facility monitor the resident's oxygen saturation. The LN2 responded at least daily and as needed, which is then documented in the resident's electronic medical record. The LN2 also reported the resident is checked twice daily as she receives blood pressure medication. The LN2 was able to show documentation of the O2 saturation results. Further queried how is it determined when to administer the oxygen and when to discontinue. Also, how is it determined whether the resident requires oxygen at all times. The DON replied the oxygen is for the resident's comfort. The LTCC1 responded the nurses will use their observations to determine the need for oxygen. A concurrent review of the resident's care plan was done and the DON confirmed the facility did not develop a care plan for the resident's use of oxygen. The DON acknowledged a care plan was indicated for this resident. LN2 was able to provide an O2 sats Summary. A review of the summary from 06/05/18 through 09/12/18 found documentation the resident met the goal of oxygen saturation above 92% on room air for the following dates: 06/23/18 at 15:50; 07/10/18 at 07:31; 07/11/18 at 07:09; 07/15/18 at 08:07; 07/19/18 at 11:22; and 07/25/18 at 10:59. There are two entries of the resident not meeting the goal on room air for the following dates: 06/23/18 at 15:50 (90%); 07/08/18 at 1652 (85%); and 07/27/18 at 1613 (88%). The remaining O2 sats were taken while the resident received oxygen via nasal cannula.",2020-09-01
237,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,725,E,0,1,MTD611,"Based on interviews with residents the facility failed to ensure there are sufficient numbers of staff to provide nursing care to all residents. Findings include: On 09/13/18 an interview was done with the resident council representatives. The council representatives were in agreement that there is not enough staff available to provide the help and care needed without having to wait a long time. The resident council members reported that the facility is short on staff and they are requesting to the facility to hire floaters so that when the aides are on break there is staff to go in between the units, ensuring there is enough staff to provide assistance. The council members clarified that there are times when residents are unable to get assistance to use the restroom. One resident reported he requires assistance to change his brief after a bowel movement, the call light is pressed and staff will tell him to wait as his aide is busy. The resident reported waiting an hour for assistance after having bowel incontinence. This resident also reported that he will press the call light for his roommate as the roommate is unable to press the call light. The resident further reported that his roommate has to wait long to be cleaned after bowel incontinence. A resident reported upon admission she did not know how to use the call lights so she would just yell and continue to yell until someone would answer. Another resident reported she will use the call light, a staff member would respond informing her that she needs to wait. The resident reported this would result in bowel and bladder incontinence. On 09/11/18 at 10:53 AM a confidential resident interview was done. The resident reported there is not enough staff at the facility to provide assistance. He further explained that staff will respond to the call light and at times is informed that his assigned staff is busy; therefore, he will need to wait. The resident estimated he will wait approximately 45 minutes, this usually occurs during the day and night shift; however, the graveyard shift is fast.",2020-09-01
238,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,756,D,0,1,MTD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to perform monthly medication reviews for 2 of 5 residents (R48 and R59) reviewed for unnecessary medications. Findings include: 1. R48 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R48's orders found she was taking insulin for diabetes mellitus and [MEDICATION NAME] for anxiety. A medical record review for R48 did not find a monthly medication review (MMR) by the Pharmacist. An interview of the Pharmacy Manager on the morning of 9/14/18 at 9:19 AM revealed the long term care Pharmacist was on leave and therefore the Pharmacy Manager stated he completed the MMR for August. On 9/14/18 at 10:00 AM, the Pharmacy Manager provided a copy of a Pharmacy Requisition dated 8/16/18 which listed R48's allergies [REDACTED]. The Pharmacy Requisition did not discuss R48's medications in reference to irregularities, possible duplicate therapy and consideration of a gradual dose reduction for the [MEDICATION NAME]. The Pharmacy Requisition did not indicate whether the Pharmacy Manager reviewed R48's medical record to obtain an accurate picture of R48's current clinical status. 2) Resident 59 (R59) was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. count; and [MEDICAL CONDITION], unspecified. A record review was done on the morning of 09/12/18. A review of the physician order [REDACTED]. at bedtime for appetite stimulant. A review of the Minimum Data Set with assessment reference date (ARD) of 08/03/18 found in Section N. Medications the resident received an antidepressant seven times and opiods twice during the ARD period. A review of the medication regimen review by the pharmacist found no review for (MONTH) (YEAR). On 09/14/18 at 10:00 AM the Pharmacy Manager provided a copy of the Pharmacy Requisition (v2) which was dated 08/23/18 and stated he did the medication regimen review. The review addressed the orders for the following: senna tablet and [MEDICATION NAME] sodium; however, did not address all the resident's medications and the use of an antidepressant with consideration for dose reduction.",2020-09-01
239,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,812,E,0,1,MTD611,"Based on observation and interview with staff members, the facility failed to ensure food was stored at the proper temperature and sanitarily and chemical solution for sanitizing food preparation equipment and utensils was monitored for appropriate levels. Findings include: 1. On the morning of 09/11/18 at 8:45 AM an initial tour of the kitchen was done with the Regional Director of Operations (RDO) and Director. Concurrent observation with staff members found the tray line refrigerator was 58 degrees Fahrenheit. A second observation was done on 09/13/18 at 9:20 AM. The RDO confirmed the tray line refrigerator was 50 degrees Fahrenheit. The items in the tray line refrigerator were removed and placed in the refrigerator. The trays were found in the refrigerator, the sliced oranges was 46 degrees Fahrenheit and the carton of thickened liquids was 45 degrees Fahrenheit. The Director confirmed the holding temperatures for these items should be 40 degrees Fahrenheit. 2. On 09/11/18 during the initial tour, further observation found two bins, one containing flour and the second containing sugar. The scoopers were stored atop the flour and sugar paper bags. The Director reported the scoopers should not be stored in the bins atop the flour and sugar. 3. During the tour, the RDO demonstrated testing of the chemical in the three compartment sink. The testing found the sanitizing solution at the level required per the manufacturer's instructions. A request was made to review the log which documents the testing of the sanitizing solution, the kitchen staff member stated that a new log was not posted so there is no documentation of the results from the testing. 4. On 09/11/18 observation with the RDO and Director found the walk-in refrigerator containing dairy products. At the back of the refrigerator clear liquid was dripping onto crates of individualized milk cartons. The RDO and Director removed the cartons that were under the dripping liquid. There was water on the floor under the palettes of milk.",2020-09-01
240,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,880,F,0,1,MTD611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility policy review, the facility failed to maintain an effective infection control program. Findings include: 1. An interview was conducted with two Infection Control Preventionists (ICPs) on the afternoon of 9/13/18 at 1:00 PM. ICP1 was the supervisor and was responsible for the Infection Prevention Program (IPP) within the attached hospital and oversight of the ICP2. The ICP2 worked half time for the hospital and half time for the long term care (LTC). When asked about infection surveillance, the ICP2 stated he spends a small amount of time surveying infections. The ICP1 stated they are working on completing their infection control policies and procedures. Their surveillance did not include placing residents in the same rooms to cohort infections. The ICPs responded they weren't actively looking at room assignments related cohorting and history of illness. They further noted they don't get involved with room assignments. The ICP1 noted the facility is in the process of revising their policies and procedures and have not yet gotten them approved. The ICP1 and ICP2 were unable to describe their process for data collection and trending of the data. They were unable to show the Surveyor their surveillance program and how they manage and track infections. They discussed pieces of an infection control program but were unable to pull together the large picture of infection tracking and surveillance. Additionally, their policies were in development but incomplete. ICP1 noted they've identified increased numbers of residents with hospital acquired infections. Her response to this trend was to provide staff education on handwashing. This was a one time occurrence and no further education/training was done. She reported they were in the process of developing a quarterly inservice for the long term care facility. At this time, ongoing education/training is not provided. The ICP1 reported the LTC facility recently obtained a part time person in charge of infection control. Previously the LTC did not have a person dedicated to them. The ICP1 and ICP2 were questioned about residents with CDiff infections who want to attend activities. The ICP1 reported that persons infected with CDiff are expected to remain in their rooms on contact isolation. The treatment is from 7 to 14 days. The ICP1 reported that if the resident isn't experiencing watery diarrhea they are able to leave their room. When the resident does go out of the room, they are expected to maintain a safe distance from others, at least 6 feet away and limit their contact with other people. The ICPs were informed about the Resident Council meeting on 9/13/18 at 10:00 AM when R4 attended. She had been diagnosed with [REDACTED]. The ICPs stated they would have to remind staff of the contact isolation expectations. The ICPs were informed of an observation of a dressing change for R50 on 9/13/18 at 11:10 AM. R50 was on contact isolation for positive [MEDICAL CONDITION] (MRSA) in a pressure injury on her right heel. R50's room was very hot and there was an oscillating floor fan on in her room. The Licensed Nurse 1 (LN1) left the fan on during the dressing change. The LN1 was observed walking into the room with her gloves on. She proceeded to measuring R50's wound without removing her gloves, sanitizing her hands, and regloving. The fan was on during the entire procedure. After measuring the wound, the LN1 pickedup R50's right foot to look at the wound, which was located on the inner aspect of her right heel. The fan was blowing from the corner of the room, blowing past R50's heel and into the face of the LN1 and a Certified Nurses Aide (CNA1), standing next to her. The ICPs reported the LN1 should have turned the fan off for the dressing change. Additionally, the ICP1 stated the LN1 should have put a mask on since she brought the resident's heel up next to her face. A review of the facility's policy titled, Care of the patient with multi drug resistant organisms and [MEDICAL CONDITIONS], including guidelines for discontinuing isolation with revision date of 10/15, noted, For patients with diarrhea from confirmed [MEDICAL CONDITION] the diarrhea should be gone for 48 hours before discharge from contact isolation. A review of the facility's policy titled, Pressure injury management, long term care from Lippincott manual noted the process included removal of old dressings, removal of gloves, hand hygiene, and re-gloving before proceeding with clean dressing supplies. 2 ) On 09/11/18 and 09/12/18 observations were made of Resident 21 (R21). The observations found R21 receiving oxygen via nasal cannula. There was no labeling which documented the date the tubing was first used. A record review done on 09/12/18 at 1:25 PM found a physician's orders [REDACTED]. On 09/12/18 at 1:47 PM an interview was done with Licensed Nurse 2 (LN2) and LTC Coordinator 1 (LTCC1). The staff members were asked whether the oxygen tubing requires labeling to document the date first used and when is the tubing changed. The coordinator reported the tubing requires labeling; however, the LN2 was not aware of labeling or the requirements for changing the tubing. The Director of Nursing (DON) joined the interview and confirmed the oxygen tubing requires labeling and the tubing requires changing every 7 (seven) days. Concurrent observation was done with the DON. The DON confirmed there was no labeling of the resident's tubing. The facility was unable to provide a policy and procedure for the labeling of the tubing.",2020-09-01
241,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,908,E,0,1,MTD611,"Based on observation and interview with staff members, the facility did not ensure the freezer and refrigerator in the kitchen was maintained in safe operating condition. Finding includes: On 09/11/18 at 8:45 AM an initial tour was done of the kitchen with the Regional Director of Operations (RDO) and Director. The observation found the freezer had ice build up on the floor at the entrance and around the door. The RDO reported that the ice build up is caused by improper seal of the door. The observation of the walk-in refrigerator found liquid dripping onto the cartons of individualized servings of milk and the liquid was pooling on the floor by the palettes holding the milk.",2020-09-01
242,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2018-09-14,923,E,0,1,MTD611,"Based on interview with residents, the facility failed to ensure there is proper air circulation in the facility as evidenced by lingering odors. Findings include: Cross Reference to F584. On 09/13/18 at 10:00 AM an interview was done with the resident council representatives. A resident reported that the air does not circulate in the facility and it is malodorous. The resident reported she feels embarrassed when there are visitors at the facility.",2020-09-01
243,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,156,B,0,1,3X5E11,"Based on record review and interview with staff members, the facility failed to provide information regarding Medicare and Medicaid non-coverage for 2 (Residents #2 and #21) 3 residents in a timely manner. Findings include: A record review done on the afternoon of 9/14/17 found documentation of the Notice of Medicare Non-Coverage (NOMNC) was issued and signed by Resident #2 on 4/24/17 at 8:00 [NAME]M. The resident was notified effective 4/25/17 therapy services will be discontinued and the deadline for the appeal is noon on 4/24/17. A review for Resident #21 found the NOMNC was issued on 5/18/17 at 9:40 [NAME]M. to notify the resident effective 5/19/17 therapy services will be discontinued and the deadline for the appeal was noon on 5/18/17. On 9/14/17 at 2:20 P.M. an interview was conducted with Staff Member #5. The staff member reported the NOMNC is issued at least 48 hours prior to a level of care change (SNF to ICF). However, the facility tries to issue the notice as soon as there is confirmation of a downgrade. The staff member confirmed Residents #2 and #21 were not given 48 hours notice before the discontinuance of therapy services. A request was made for the facility's policy and procedures for the issuance of the NOMNC. At 2:52 P.M. Staff Member #5 returned and reported the facility does not have a policy regarding NOMNC; however, provided a copy of the slide presented in a training. The slide documents the following: NOMNC must be issued no less than two days prior to the last covered day of Med A services. The staff member confirmed the two residents were not given 48 hours prior to the issuance of the NOMNC.",2020-09-01
244,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,164,D,0,1,3X5E11,"Based on resident interview and record review the facility failed to provide privacy to 1 (one) resident during personal care (Resident #46). Findings include: On 09/12/2017 at 10:23 AM during the resident interview Resident #46 responded that he often has to remind staff several times to close the curtain during and after he receives personal care. People come in to visit the other guy and sometimes the curtain is either open or not closed all the way when I'm naked and uncovered. Resident #46 added that he is very self conscious and very uncomfortable when left exposed. Review of the Care plan dated 12/22/16 states that Resident #46 is totally dependant on staff due to impaired physical mobility and activities of daily living (ADL) functions. Resident #46 is alert and oriented to person, place, time and situation. Per review of the Minimum Data Set (MDS) Resident #46 is cognizant with a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact). The facility did not treat the resident in a manner that promotes privacy by leaving the privacy curtain open while providing personal care leaving the resident exposed.",2020-09-01
245,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,170,B,0,1,3X5E11,"Based on resident and staff interviews the facility failed to ensure residents' right to promptly receive mail upon delivery. Findings include: On 09/14/2017 at 12:50 PM interviewed the facility's resident council president (R#73), and when queried whether residents could receive mail on a Saturday, she responded, No. The R#73 elaborated that mail is not delivered on Saturdays because only receives mail Monday through Friday. On 09/14/2017 at 1:37 PM interviewed Staff#55 and she stated that everyday including on Saturdays, a facility staff will pick-up resident's mail from the hospital mail room and mail is delivered to resident's room. Staff#55 further stated that there are times when there is only one unit clerk working and mail doesn't get delivered for several days. Staff#55 elaborated that often only one unit clerk on Saturdays, so mail probably delivered on Monday. Staff #55 also stated that a unit clerk is currently on maternity leave and the newly hired unit clerk is in training, to replace herself whose last day of work is on Friday (09/15/2017). Staff#55 stated that currently there isn't enough staff to ensure residents' mail gets delivered promptly.",2020-09-01
246,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,246,D,0,1,3X5E11,"Based on resident observations, interviews and record review, the facility failed to provide reasonable accommodation of resident needs and preferences for 1 (one) resident (Resident #46). Findings include: 1) On 9/12/17 at 10:23 [NAME]M. Resident #46 was observed laying in his bed. The bed appeared too small for Resident #46, both of his arms were hanging off each side of the bed preventing proper support and alignment while Resident #46 is laying or sitting up in bed. Resident #46 stated that his bed is too small which makes him uncomfortable and his arms sore. The resident further reported, in order for the staff to turn and provide personal care for me, one staff stands at each side of the bed to roll me up on my side and support my weight. 2) On 9/15/17 at 8:52 [NAME]M. Resident #46 stated that he wears size 3X brief but he has been receiving a size 2X instead. Resident #46 further reported he was told that the size 3X is too expensive and the supply clerk is looking for a new vendor. Resident #46 stated he complained about it many times to the staff because the brief is tight and uncomfortable. On one occasion about three months ago Resident #46 stated that he didn't have any briefs for one whole week and had to use only a chux pad. The resident was told that the purchasing clerk didn't order the briefs and the facility ran out. It was further reported that sometimes on the weekend there are no briefs because the supply room is locked and the certified nurse aides can't get any briefs or supplies. Review of the Care Plan dated 12/22/16 stated that Resident #46 will receive clean hospital shorts as requested daily and Facilities Manager to send size 4 hospital shorts to 1st floor on a daily basis. At 9:30 [NAME]M. Staff #76 stated only the size 2X are available adding that we need to find a new supplier for the larger 3X brief. The facility failed to assist the resident in maintaining well-being to the extent possible in accordance with the resident's own needs and preferences by accommodating Resident #46 with the correct size shorts and equipment (personal briefs).",2020-09-01
247,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,252,D,0,1,3X5E11,"Based on confidential resident interview, the facility failed to ensure 1 of 15 interviewable residents was provided with a comfortable homelike environment. Finding includes: A confidential resident interview was conducted on 9/13/17 at 8:30 [NAME]M. The resident reported discomfort in his home when the roommate has a bowel movement. The resident reported it is malodorous and affects her/his discomfort especially during mealtimes. The resident further reported the roommate does not leave the room and eats and defecates all day.",2020-09-01
248,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,272,D,0,1,3X5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and medical record reviews (MRR), the facility failed to ensure that 2 of 21 residents (R#5 and R#73) on the Stage 2 Resident Sample list, were comprehensively assessed as part of an ongoing process through which the facility identifies the resident's functional capacity and health status. Findings include: Cross to F323 1) On 09/12/2017 at 10:14 AM during Stage 1 of the survey, observed that R#5 was lying in bed with bilateral half old metal type side rails (SRs). The SRs were shaky and there was space between the SRs and mattress. On 09/13/2017 at 3:11 PM,discussed with Staff#22 and Staff#79 of SRs and resident safety to prevent entrapment, and shared FD[NAME]gov website on bed rail safety to show examples. Both staff members accompanied surveyor to R#5's room to look at the SRs, and the resident was lying prone in bed with the SRs up. On 09/14/2017 at 10:28 AM observed R#5 lying prone and apparently sleeping; there were no SRs and the bed was at the normal height. On 09/14/2017 at 10:30 AM review of R#5's EMR found that the Side Rail/Device Assessment was done quarterly with the last dated 7/10/2017 and documented: Type of Bed Side Rail: half rail top right; half rail top left; Bed side rails assist the resident with bed positioning and mobility; Daily Care (holding of SR); time of day and circumstances when device will be used,: When in bed; The bed side rail is not a restraint because the : Res can't move, so the bed rails are not restraining her; Final determination : Side rails and/or Other Device are NOT a restraint, The care plan (CP): Potential for falls or fall related injuries related to generalized weakness, impaired sitting/standing balance, use of [MEDICAL CONDITION] medication with its possible adverse reaction; [DIAGNOSES REDACTED].Keep bed in low position with brakes on at all times; For resident who are utilizing bilateral half rails for mobility and transfers, keep upper half rails up; Pad side rails as indicated to prevent injury during episode of [MEDICAL CONDITION] activity; Observe for possible occurrence of [MEDICAL CONDITION] staring into space, tremors or shakiness; Take note of duration of [MEDICAL CONDITION] activity and notify MD when [MEDICAL CONDITION] activity occur . On 09/14/2017 at 1:27 PM observed R#5 lying prone in bed with Staff#107 finished taking vital signs. Queried Staff#107 if resident's bed in lowest position. Staff#107 used bed controls at foot of bed, lowered bed, and then stated this is the lowest position. When queried Staff#107 whether R#5's bed should be in low position, she replied, they all should be at lowest position. On 09/14/2017 at 1:52 PM discussed with Staff#79 bed rail assessment for R#5. According to Staff#79, the resident's SRs were removed because the resident was assessed and cannot move. Queried whether the staff looked at R#5's CP before removing SRs to ensure resident's safety. Staff#79 conferred with Staff#76 and inquired of her if SRs removed and assessment done. Staff#76 stated that she didn't make that decision to not use SRs because didn't contact family yet. Informed staff that according to the resident's CP, padded SRs are required due to a [MEDICAL CONDITION] disorder with bed lowered. Staff#79 stated that she was unaware because inquired of CNAs whether the resident moved around in bed, and assessed that resident cannot move. Staff#79 stated that R#5 has history of [MEDICAL CONDITION] but had no [MEDICAL CONDITION] in the facility since admitted in 01/2015. Discussed that the last IDT meeting on 7/13/2017 and CP documented SRs with [DIAGNOSES REDACTED]. 2) On 09/12/2017 at 1:10 PM observed R#73 smoking in the facility's parking lot. The resident stated that she bought pack of cigarettes last month and still had 10 cigarettes left. The resident further stated that she feeds the birds outside in the parking lot, and that she doesn't always smoke because trying to cut down. On 09/13/2017 at 12:30 PM the EMR for R#73 noted on the CP: The resident is at risk for noncompliance with smoking (past history of smoking), was witnessed smoking outside with other residents; the goal was for the resident not suffer injury from unsafe smoking practices through the review date. The CP interventions included: 11/23/16 Resident signed Risks vs Benefits form; Instruct resident about smoking risks and hazards and about smoking cessation aids that are available; Instruct resident about the facility policy on smoking: locations, times, safety concerns. On 09/13/2017 at 12:43 PM interviewed Staff#79 and shared observations of R#73 smoking at designated smoking area that was not wheelchair accessible due to concrete curbing of parking lot. The resident was sitting in her wheel chair smoking in the parking lot where vehicles enter and exit. Staff#79 stated that she would discuss with Staff#22 about inaccessible designated smoking area. According to Staff#79, R#5 is A/O x 4 and able to make needs known. The Smoking policy was provided to the resident and she was also assessed for smoking safety. The resident had a BIMS score of 15. On 09/13/2017 at 1:00 PM, Staff#79 reported that she spoke with Staff#22 and the plan is to make the designated smoking area wheel chair accessible. During the construction period, the 3 smoking residents that use a wheel chair will be supervised to a wheel chair accessible smoking area. On 09/13/2017 at 2:16 PM, Staff#108 stated that a concrete slab at the designated smoking area was being planned to make area wheelchair accessible. According to Staff#108, concrete curbing would have to be removed and will start pricing with contractors to complete task. The facility failed to address all needs and strengths of residents whether the issue is included in the MDS or CAAs.",2020-09-01
249,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,278,D,0,1,3X5E11,"Based on medical record review and facility staff interview, the failed to accurately assess three residents (Resident #58, Resident #38, and Resident #131) on the Minimum Data Set (MDS). Findings include: 1) During stage 2 of the QIS survey, Resident #58 was triggered for nutrition due to unplanned significant weight loss. However, Resident #58 was admitted to hospice on 3/16/17 and therefore his weights would not have been required during the stage 1 medical record review. On the morning of 9/13/17 at approximately 10:00 [NAME]M. a review of the Minimum Data Set (MDS) for Resident #58 found his most recent quarterly MDS with assessment reference date (ARD) of 6/9/17 noted under item J1400 Terminal Prognosis - No. However, the previous MDS with ARD of 3/22/17 was for a significant change and item J1400 noted Terminal Prognosis - Yes. An interview of one of the MDS Coordinator on the afternoon of 9/13/17 at 2:40 P.M. revealed an error in the coding. The MDS Coordinator noted that Resident #58 was on hospice since 3/16/17. The MDS Coordinator acknowledged that J1400 on the quarterly MDS with ARD 6/9/17 was incorrectly coded. 2) During stage 2 of the QIS survey, Resident #38 was coded as having vision impairment without corrective lenses. An interview of the MDS Coordinator on the afternoon of 9/13/17 at 2:40 P.M. revealed the vision coding for Resident #38 was incorrect. She noted he did not have visual impairment. 3) During stage 2 of the QIS survey, Resident #131 was coded as having vision impairment without corrective lenses. An interview of the MDS Coordinator on the afternoon of 9/13/17 at 2:40 P.M. revealed that Resident #131 did have visual impairment but had his own glasses. She noted the coding for corrective lenses was incorrect.",2020-09-01
250,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,279,D,0,1,3X5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with facility staff, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 13 sampled residents (Resident #76) of 27 residents in the Stage 2 sample. Findings include: Cross Reference to F313. Resident #76 was admitted on [DATE] to the facility with [DIAGNOSES REDACTED]. On 9/14/17 at 12:30 P.M. a review of the quarterly Minimum Data Set (MDS)with assessment reference dates of 5/26/17 and 8/18/17, Resident #76 yielded a score of 2; moderately impaired-limited vision, not able to see newspaper headlines but can identify objects and not having corrective lenses. On 9/14/17 at 2:40 P.M. Resident #76's care plan was reviewed indicating there were no goals or interventions to address the vision deficit documented in the quarterly assessments. At 1:48 P.M. during an interview with Staff #2, when asked if Resident #76 was able to see, Staff #2 responded that Resident #76 can't see very well and could benefit from the use of glasses. At the request of the surveyor, Staff #76 reviewed the Electronic Medical Record and stated there was no Ophthalmology consultation for Resident #76 for a vision exam. At 1:52 P.M. the MDS Coordinator reviewed the care plan and concurred with Staff #2 that there is nothing written in the care plan to address the vision deficit. Staff #67 stated that the care plan will be updated and the family contacted to assist the resident with an eye exam and to obtain glasses. The facility failed to provide necessary care and services to attain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.",2020-09-01
251,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,280,D,0,1,3X5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and medical record reviews, the facility failed to ensure that 3 of 21 residents (R#103, R#73 and R#3), were accommodated to exercise the resident's rights and the resident's health, to explore care alternatives through a thorough care planning process in which the resident may participate. Findings include: 1) Based on F441, R#103 continued to place his urinal on the overbed table and the CP: Impaired ADLs/Mobility R/T: generalized weakness associated with exacerbation of [MEDICAL CONDITION], HTN, A-fib, Vit D deficiency, Gout, and hx of [MEDICAL CONDITION]-L sided [MEDICAL CONDITION]/paresis; M/B: res requiring ext to total asst in ADL functions. Non-ambulatory. w/c primary mode of locomotion. bedfast per preference. The CP further documented that, Prior level of function was independent with the use of cane to ambulate as reported by resident; Strengths: alert and oriented to name, place and times as well as situation; able to make his needs known. Note: refuses to get out of bed to sit up in w/c and to transfer during shower days thus bed bath provided. The goals were that the resident would maintain level of ADL performance from extensive asst in most areas like bed mobility, personal hygiene, toilet use, dressing, bathing through next review. The resident preferred to keep his urinal on the overbed table next to his water pitcher and had meals served on overbed table as well. The facility did not explore other options for R#103 to keep his urinal in a sanitary manner that was separate from a clean area for eating and drinking. 2) Based on F309, R#73 CP was not revised to reflect that hemodialyis (HD) was on Mon, Wed, Fri. from 4:45-8:30 PM. On 09/15/2017 at 9:34 AM, MRR on R#73 found that a, Risks v. Benefits form was signed by the resident on 10/10/14 and witnessed. On this form for area of concern was regarding food and resident's occasional refusal to go to [MEDICAL TREATMENT]. Besides changing the days and times for [MEDICAL TREATMENT], there were no documentation on whether the facility explored other alternatives to accommodate both the exercise of the resident's rights and the resident's health. 3) Cross Reference to F314. Based on an assessment, the facility failed to revise Resident #3's care plan to develop interventions to prevent further skin breakdown following the presence of a Stage 3 pressure ulcer to the lower posterior of the right leg. The staff member reported the resident's skin breakdown was related to crossing of his legs while seated in the wheelchair. However, there was no intervention identified to address this issue. The staff member added the intervention to the resident's care plan during the survey.",2020-09-01
252,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,309,D,0,1,3X5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and facility staff interviews, the facility failed to ensure the highest practicable psychosocial, mental and physical well-being for two residents, Resident #38 and Resident #76. Findings include: 1) Resident #38 was admitted to the facility in (MONTH) 2010. He was admitted with [DIAGNOSES REDACTED]. The facility failed to maintain his highest practicable mental, psychosocial and physical well-being as evidenced by his poor hygiene, poor self awareness, aggressiveness, and uncontrolled auditory and visual hallucinations. Observation of Resident #38 on the morning of 9/12/17 at approximately 10:30 [NAME]M. found him lying in bed in his private room with the door closed. Observation of Resident #38 on the afternoon of 9/12/17 at approximately 2:00 P.M. found him lying in bed with the door closed. Three elderly residents were seated close to the nurses station. One staff member was at the nurses station seated at a computer. Observation of Resident #38 on the morning of 9/13/17 at approximately 9:30 [NAME]M. found him lying in bed with the door closed. Observation of Resident #38 on the afternoon found him sitting on his bed in his room with the door closed. Two elderly female residents were seated in the hallway near the nurses station and approximately four rooms lengths from Resident #38's room. All staff members were busy and no one was around. Observation of Resident #38 on the morning of 9/14/17 at approximately 8:15 [NAME]M. found him sitting up in bed with the door closed. Observation of Resident #38 on the afternoon of 9/14/17 at approximately 1:50 P.M. found resident lying in bed with the door closed. A concurrent record review and staff interviews on the morning of 9/15/17 at approximately 9:00 [NAME]M. revealed Resident #38 gets agitated, has auditory and visual hallucinations and often refused daily care. The nurses' notes indicated that Resident #38 was observed taking the yellow Wet Floor sign from the cleaning cart and chasing the staff with the sign on several occasions over the past 6 months. According to the nurse's notes, Resident #38 is often observed responding to internal stimuli. He often gets agitated and begins yelling. Sometimes the resident yells at staff. Other times, he is observed yelling at persons who aren't there. The nurses' notes further indicated Resident #38 was routinely observed to have dried feces on his shorts and on his bed linens and his room had a strong odor of feces. The fecal odor from Resident #38's room can be smelled in the hallway when the resident opens the door and goes out into the hallway. Staff #80 reported that Resident #38 preferred staying in his room. He has a long history of attacking staff members. Staff #80 reported the facility made an agreement with their Facilities staff to come over once per week to encourage Resident #38 to shower. Resident #38 was more inclined to obey the Facilities' staff members as they were larger in stature. Staff #80 reported that Resident #38 is ambulatory and continent of bowel and bladder. Staff #80 reported that he thought Resident #38 has bowel movements and doesn't know how to clean himself as the feces was noted to be in the back center area of his shorts. Resident #38 is able to use the toilet to urinate without problems. Staff members in the nursing facility had been attacked by Resident #38 on multiple occasions. Interview of Staff #87 on the morning of 9/15/17 at approximately 9:30 [NAME]M. revealed Resident #38 last attacked her on 9/3/17 when she called the police. Staff #87 stated that the resident said he wanted to kill her and he attempted to hit her but she got out of the way. Another staff member intervened to stop him. Resident #38 was given [MEDICATION NAME] prior to the police arriving. Staff #87 stated that when police arrived they refused to take Resident #38 into custody stating the facility was the best place for him. The police apparently informed the facility that Resident #38 was not with it mentally and therefore they couldn't take him into custody as the police wouldn't know how to care for him. Staff #87 reported feeling afraid of Resident #38. She reported the facility has offered psychiatric and psychological counseling for Resident #38 and he has refused all services. Staff #87 stated the facility has attempted to transfer Resident #38 to other long term care facilities, acute care facilities and foster/care homes but none of those agencies were willing to take him. Staff #87 stated that Resident #38's family (parents and a sibling) occasionally visited the resident but refused to take him into their homes. Staff #87 noted the family visits less frequently and his parents reported feeling afraid of Resident #38. An interview of Staff #94 on the morning of 9/15/17 at approximately 10:00 [NAME]M. found she made multiple attempts to find alternative placement options for Resident #38. Staff #94 reported that she's had many conversations with the police. The police informed the facility that they were unable to take the resident out of the facility as it was the best placement option for him. Staff #94 noted that she made attempts to transfer Resident #38 to other acute care psychiatric facilities when he's had psychotic episodes in the past. The acute psychiatric facilities deny the transfer with differing reasons. One acute care facility stated their patient population was admitted via the police department after being arrested and therefore Resident #38 would be at risk of getting injured. Another acute care facility informed Staff #94 that they only took patients referred through their acute care hospital. Staff #87 reported that when Resident #38 gets aggressive, the nurses give him an antianxiety medication via injection which calms him down before the police arrive. When the police arrive, Resident #38 appears calm and cooperative and therefore the police refuse to take him. An interview of Staff #73 on the morning of 9/15/17 at 10:25 [NAME]M. revealed the staff consistently offered daily care for Resident #38 but she stated he always refused. Staff #73 stated that the Administration will ask the Facilities staff to help and the resident will agree to a shower. Staff #73 reported that Resident #38 yells at the staff. In the past, Resident #38 hit Staff #73. She reported feeling afraid of the resident. Staff #73 said the police often come when Resident #38 gets aggressive but they never take him into custody. The police consistently tells the staff that Resident #38 is already in an institution. Staff #73 stated Resident #38's room has a strong foul odor. She noted seeing feces from his bed to the bathroom. Staff #73 said Resident #38 can toilet himself but he doesn't really know how to clean himself and refuses to allow the staff to help him. Staff #73 further added when they try to assist Resident #38, he yells at the staff and slams the door. Staff #73 sometimes enter Resident #38's room alone but if possible will go with another staff member. In addition to his aggressiveness, Resident #38 frequently refuses medications and daily care. On the morning of 9/15/17, a review of the nurse's notes found Resident #38 refused medications eight times over the past month (8/16/17 to 9/15/17). A review of Resident #38's Activities of Daily Living (ADLs) over a period of one month (8/16/17 to 9/15/17), found he had 3 showers and 4 bed baths. Staff offered Resident #38 a bed bath on every shift every day but he refused most of the time. The staff offered him showers on his scheduled days which he also refused. Aside from the 3 showers and 4 bed baths in 30 days, Resident #38 had refused all other opportunities for bed baths and showers. A review of Resident #38's annual Minimum Data Set (MDS) on the morning of 9/15/17 at approximately 9:30 [NAME]M. with an Assessment Reference Date (ARD) of 8/11/17 noted under Section C. Brief Interview of Mental Status (BIMS) score of 12/15 indicating moderately impaired cognitive status. Section E. Behavior noted that during the look back period, Resident #38 experienced: Hallucinations; Verbal behavioral symptoms toward others 1-3 days; Behaviors significantly interfered with resident's care; Behaviors put others at significant risk of physical injury; Rejection of care for 4-6 days; and Resident has wandered on 1-3 days. Section [NAME] Functional status noted Resident #38 only required supervision with Activities of Daily Living (ADLs). Exceptions included: Dressing - activity occurred only once or twice; and Bathing with which he was totally dependent requiring one person physical assistance. A review of Resident #38's care plan noted Resident's long history with aggressive behaviors, including: Yelling and threatening staff; Hitting staff with a cane (6/25/16); Hitting staff with his fist (6/27/16); Held a cane and went to another resident's room yelling, That man used to be next to my room and I hate him (11/17/16); Held a removable IV pole and refused to give it back (11/9/16); Held a wet floor sign, yelling many times (11/10/16); Held an IV pole in hallway and was yelling (11/14/16); Verbal altercation with another resident (3/9/17); Threatened to hit staff (3/20/17). Although not listed in Resident #38's care plan, his aggressive/disruptive incidents continued on a regular basis. On the morning of 9/15/17, a review of the nurse's notes revealed Resident #38's hallucinations and aggressive behaviors regularly occurred up until the time of survey. Resident #38 refused medications at least once per week and displayed aggressive behaviors almost daily. The nurse's notes demonstrated Resident #38 gets agitated and or aggressive with staff and or other residents at least one time per week. The staff attempts to redirect the resident but are not always successful. An interview of the Administrator on the morning of 9/15/17 at approximately 10:00 [NAME]M. revealed her knowledge of Resident #38's medical and behavioral history. She reported the facility's frustration with getting help for this resident, whom the facility was not equipped to care for. She stated the facility has had lengthy discussions of options for Resident #38 and have concluded they would maintain him at his current level of functioning. She noted that she provided Resident #38's parents with a discharge letter informing them that the facility would discharge him in 30 days from the date of the letter. The resident's parents never responded to the discharge letter and the facility did not pursue discharge of the resident. At the time of survey, the facility was unable to provide the necessary care and services for Resident #38, despite their efforts and attempts. The facility staff did not have the necessary training and skills to care for Resident #38. Additionally, the facility was unable to provide the necessary environment to maintain Resident #38's highest practicable behavioral, physical and psychosocial well being. 2) On 09/13/2017 at 12:22 PM reviewed R#73's EMR as the resident was sampled for [MEDICAL TREATMENT] in Stage 2 of the survey. The care plan (CP): The resident needs [MEDICAL TREATMENT] related to [MEDICAL CONDITION], noted that the resident was alert and able to make decisions for daily needs; resident is noncompliant at times to diet; and refusing [MEDICAL TREATMENT] due to diarrhea or pain, related to constipation. The interventions included: assist resident to go for the scheduled [MEDICAL TREATMENT] appt; Resident receives [MEDICAL TREATMENT] TTH and Sat, . On 09/13.2017 at 12:24 PM interviewed Staff#87 and she stated that R#73 goes to [MEDICAL TREATMENT] on Mon, Wed and Fri from 4:45 - 8:30 PM. In the residents EMR under the Orders tab was documented, [MEDICAL TREATMENT] Mon, Wed, Fri. On 09/13/2017 at 1:17 PM reviewed R#73's EMR with Staff#76 to clarify where the nursing staff documented patency of resident's fistula. Staff#76 found under the Progress Note tab a template, Assess patency of fistula; Fistula location: Left arm; Every shift document bruit - strong, faint or absent; Document thrill - strong, faint or absent. Discussed with Staff#76 template documented as above, with bruit and thrill (B/T) characteristics not underlined or circled, and not specific for exactly what the nurses assessed. Staff#76 stated that treatment administration record (TAR) was used to document B/T per shift. Looked at TAR with Staff#76 and found documentation on: 9/11/17 N[NAME] no fistula assessment for Bruit/Thrill; 8/3/17 N[NAME] and 8/7/17 N[NAME] Bruit/Thrill =0; 8/20/17 N[NAME] no fistula assessment. Staff#76 made note of missing documentation and stated that will be discussed with nursing staff that progress note template needs to be specific. On 09/14/2017 at 2:42 PM the medical record review (MRR) on R#73 found that the interdisciplinary (IDT) meeting on 8/18/16 documented, CP# Health Care deficit [MEDICAL TREATMENT] - Tue, Thur, Sat r/t [MEDICAL CONDITION] tolerating well, Tues, Thurs, Sat was crossed out and MWF was written above in ink). The facility did not ensure that R#5 received [MEDICAL TREATMENT] care that was consistent with professional standards of practice.",2020-09-01
253,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,313,D,0,1,3X5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident observation and staff interview the facility failed to ensure that 1 of 3 sampled residents (Resident #76) received proper treatment and assistive devices to maintain vision ability. Findings include: Cross Reference to F279. Resident #76 was admitted on [DATE] to the facility with a [DIAGNOSES REDACTED]. On 9/13/17 at 9:30 [NAME]M. Resident #76 was observed to be awake and alert and resting in bed. On 9/14/17 at 12:30 P.M. a review of the quarterly Minimum Data Set (MDS) with assessment reference dates of 5/26/17 and 8/18/17, Resident #76 yielded a score of 2; moderately impaired-limited vision, not able to see newspaper headlines but can identify objects and not having corrective lenses. On 9/14/17 at 2:40 P.M. Resident #76's care plan was reviewed indicating there were no goals or interventions developed to address the vision deficit documented in the resident's assessment. At 1:48 P.M. during an interview with Staff #2, when asked if Resident #76 was able to see, Staff #2 responded that Resident #76 can't see very well and could use glasses. At the request of the surveyor, Staff #2 reviewed the Electronic Medical Record and revealed there was no Ophthalmology consultation for Resident #76 for a vision exam. At 1:52 P.M. the MDS Coordinator reviewed the care plan and concurred with Staff #2 that there is nothing written in the care plan to address the resident's visual deficit. Staff #67 stated that the care plan will be updated and the family contacted to assist the Resident with an eye exam and to obtain glasses. The facility failed to provide necessary care and services to ensure Resident #76 received proper treatment and assistive devices to maintain his vision.",2020-09-01
254,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,314,G,0,1,3X5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff, the facility failed to ensure 1 (Resident #3) of 1 residents selected for pressure ulcer investigation developed an avoidable pressure ulcer. Findings include: Resident #3 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. On the morning of 9/12/17 a record review and interview with staff member found Resident #3 with a Stage 3 pressure ulcer to the right posterior shin. Further review documented on 4/2/17, Resident #3 had a Stage 2 pressure ulcer to the right heel which was now suspected deep tissue injury. On 9/12/17 at 9:55 [NAME]M., Resident #3 was observed asleep in bed laying on his back. Subsequent observation at 2:00 P.M. found the resident asleep with bilateral upper rails raised. On 9/13/17 at 1:48 P.M. Resident #3 was observed lying in bed asleep, on his right side, a pillow was placed under his back on the left. The resident's left leg was bent up toward his torso with the right leg under the left. On 9/14/17 at 9:25 [NAME]M. Resident #3 was observed with the therapist. The resident was awake lying in bed. The therapist confirmed they were working on a way to float the resident's heels and demonstrated the use of three pillows; however, the resident's heels still touched the mattress. Inquired where the resident had a Stage 3 pressure ulcer, the therapist looked at the back of the resident's calf, the skin was observed to be mottled with brown spots, the therapist located a small scab and surmised this was the healing pressure ulcer. Subsequent observation at 10:31 [NAME]M. found the resident asleep with pillows under his legs and a pillow between his legs. Observation on the morning of 9/15/17 found the resident sitting in his wheelchair with rolled up towels between his knees/calves. On the afternoon of 9/13/17 a record review found a physician's orders [REDACTED]. A review of the progress note dated 8/6/17 documents a Certified Nurse Aide (CNA) notified the nurse of a wound on the resident's lower leg. The nurse documents finding a wound with irregular edges with cream colored tissue on the center. No bleeding noted. The area was cleansed with normal saline and covered with a dry dressing. Further review found Weekly Pressure Ulcer/Wound Assessment - V1 dated 8/6/17, initial assessment. The wound measured 2 cm (length) x 2 cm (width). This wound was documented as a new pressure ulcer which was healthcare acquired. There was yellow drainage noted to the wound and the plan was to consult the wound nurse. Subsequent assessment was done on 8/9/17 by the wound nurse. The assessment documents the pressure ulcer is new and was healthcare acquired. Listed under the cause of skin problems included: pressure and [MEDICAL CONDITION] with left-sided weakness and resident tends to cross his legs while up in the wheelchair. The site identified was right lower leg (rear) with the following measurements: 1.5 cm (length) x 1.5 cm (width) x 0.3 cm (depth). Also noted was a scant amount of serosanguineous drainage. The wound was 90% pink-reddish and 10% subcutaneous tissue. The wound was assessed as a Stage 3 pressure ulcer. A review of the weekly skin assessment for 7/26/17 notes the resident sits in his chair most of the time and no skin condition noted. The subsequent weekly skin assessment dated [DATE] documents no skin conditions. A review of the skin assessment dated [DATE] notes resident is non-compliant with heel protectors and stays up in the wheelchair for long periods. The assessment also documents two skin conditions, the right leg (8/6/17) and the left leg which was first noted on 8/1/17. A review of the Minimum Data Set (MDS) for significant change with an assessment reference date of 8/18/17 documents in Section M. Skin Conditions, Resident #3 was coded with one unhealed Stage 3 pressure ulcer. Resident #3 was also coded with functional limitation in range of motion on one side of the upper extremities and bilaterally to the lower extremities. In Section [NAME] Functional Status, Resident #3 is noted to require extensive assistance with one person physical assist for bed mobility (how the resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture). A review of the care plan found a focus for actual impaired skin integrity, fungal rash to groin, denudement to scrotum and left lateral upper thigh. Also noted the following: 4/22/17 Stage II right heel pressure injury; 5/19/17 Stage II right heel pressure injury now deep tissue injury; 6/27/17 right heel deep tissue injury healed; and 8/9/17 Stage 3 pressure injury right posterior lower extremity. Interventions included: referral to therapy as appropriate; cleanse right lower extremity wound with normal saline, apply [MEDICATION NAME] ointment, apply dry gauze, wrap with kerilix daily; juven 2 packets daily unit pressure ulcer is healed; document compliance an/or adherent to wound care regimen; assess for pain using 0-10 rating on numerical pain scale or by noting non-verbal cues every shift with wound care; administer pain medication as ordered; monitor site of impairment for signs and symptoms of infection such as swelling [DIAGNOSES REDACTED], increased drainage and pain during each treatment; apply pillows under calves to off load heels while in bed; and monitor effectiveness of treatment. There was no documentation of an interventions to address prevention of further skin impairment to the right lower extremity. Further review found care plans to address mobility deficit related to stroke and activities of daily living self-care performance. Interventions include: using a hoyer lift for transfers; therapeutic exercise; recommend rolling schedule with patient in bed to prevent bed sores with two person transfer with hoyer lift; restorative upper extremity range of motion program (passive range of motion to left upper extremity and a resting hand splint. The review of the kardex/task section in the electronic medical record included a list of tasks for the aides to perform. The tasks included: restorative nursing aide to perform lower body program 2-3 times a week to start on 10/14/16 for passive range of motion to include bilateral lower extremity, hip extension/flexion/abducter/adducter, bilateral knee extension and bilateral ankle dorsiflexion/extension with focus on passive range of motion for right knee extension with gentle stretching. A review of the last 30 days found documentation on 8/18/17 that the restorative nursing program was performed. On 9/14/17 at 9:30 [NAME]M. an interview and concurrent record review was done with Staff Member #87 (Wound Consultant). Staff Member #87 reported Resident #3's pressure injury was related to crossing his legs while sitting in the wheelchair, the shin bone pressing on the back of the resident's posterior leg. The staff member also reported the resident is not always compliant with repositioning. Further queried the staff member whether the weekly skin assessment would identify pre-existing signs of a skin breakdown as upon discovery of the wound, it was already assessed as a Stage 3 pressure ulcer. The staff member reported the signs of a skin break down if assessed early would prevent the advancement to Stage 3. The signs of the breakdown would include redness and advance to an open area, Stage 2 (affecting the first two layers). The staff member also identified skin impairment is more difficult to detect on fatty areas as opposed to bony areas. A review of the kardex/task section in the electronic medical record was done with Staff Member #3. The staff member confirmed the inclusion of the restorative nursing program. The staff member also confirmed a review of the last 30 days found documentation restorative nursing program was performed on 8/18/17. The staff member was asked whether the restorative nursing program would assist in the prevention of a pressure ulcer, the staff member replied a restorative nursing program would help in the prevention of a skin breakdown and for Resident #3 the passive range of motion would help to relieve the pressure and his muscles would not be so tight. A request was made to Staff Member #3 to provide documentation of the restorative nursing program for the last three months. On 9/14/17 at 3:35 P.M. the facility provided a copy of the task grid for (MONTH) (YEAR) through (MONTH) (YEAR) which documents when the restorative nursing program was done. A review of the documentation found the restorative nursing program was performed on 6/14/17; 7/7/17, 7/11/17, 8/3/17, 8/4/17 and 8/18/17. On 9/14/17 at 12:50 P.M. further review and interview was done with Staff Member #87. Queried whether Resident #3's care plan was revised based on an assessment to identify possible contributing factors leading to the resident's identified pressure ulcer on 8/9/17. The staff member confirmed the care plan was not revised to include interventions to prevent further pressure related injuries. At this time the staff member added the following position resident with use of pressure reducing devices (i.e. pillows, wedges) to prevent further pressure injury to Resident #3's care plan. The facility failed to accurately perform a weekly skin assessment to identify the early stages of a skin breakdown which eventually was identified as a Stage 3 pressure ulcer acquired in the facility. The skin assessments done on 7/26/17 and 8/2/17 documents no skin conditions. On 8/6/17 Resident #3 is noted with a wound and subsequently assessed as a Stage 3 ulcer. The facility also failed to implement the resident's restorative nursing program as evidenced by the documentation provided by the facility. The restorative nursing program was documented to be done two to three times a week and over a period of three months, it was done six times. Subsequently, the facility did not revise the resident's care plan based on the identified causal factors that contributed to the Stage 3 pressure ulcer to the right lower posterior leg for prevention of another skin breakdown.",2020-09-01
255,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,323,J,0,1,3X5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record reviews, the facility failed to identify hazard(s) and risk(s) in the use of old metal side rails (SRs) for 2 of 21 residents (R#5 & R#103); and, evaluate and analyze hazard(s) and risk(s) of smoking for 1 of 21 residents (R#73) on the Stage 2 Sample Resident list. Findings include: 1) On 09/12/2017 at 10:08 AM, observed R#103 awake in bed with old metal SRs with peeling paint and rust showing. The SRs were shaky with space between the SRs and mattress for limb entrapment. On 09/13/2017 at 3:09 PM interviewed Staff# 22 and #79 and shared FD[NAME]gov website for SR safety and resident assessment guidelines. Both staff member went to R#103 bedside and observed resident in bed with SRs up and demonstrated to them how the SRs were shaky and with rust spots. On 09/14/2017 at 9:33 AM , EMR on R#103 found under the, Orders tab: DME: wheelchair, jay prevention cushion, bilateral elevating leg rests, brake extension and buckle seat belt, semi electric hospital bed with half siderail. The quarterly Fall Risk assessment dated [DATE], documented that R#103 was at moderate risk with a score of 7.0. The Rehab Services Screening done 7/28/2017 noted, No skilled intervention at this time for ST/OT/PT. The resident required total assist for functional mobility with wheelchair and extensive assistance for activities of daily living (ADLs). The resident was alert and oriented to person, time and place. The quarterly Side Rail/Device Assessment done 8/3/2017 for type of bed side rail, documented that R#103 used bilateral half side rails. The SRs were to assist the resident with bed positioning and mobility and daily care (holding of SR). The SR assessment was primarily to determine whether the SRs were a restraint or not as it noted, The bed side rail is not a restraint because the resident can move in bed, but can't get out of bed on his own. Final Determination Side rails and/or other device are NOT a restraint. 2) On 09/12/2017 at 10:14 AM during Stage 1 of the survey, observed that R#5 was lying in bed with bilateral half old metal type side rails (SRs). The SRs were shaky and there was space between the SRs and mattress. On 09/13/2017 at 3:09 PM interviewed Staff# 22 and #79 and shared FD[NAME]gov website for SR safety and resident assessment guidelines. Both staff member went to R#5 bedside and observed resident in bed with SRs up and demonstrated to them how the SRs were shaky and with space between the SRs and mattress for limb entrapment. On 09/14/2017 at 10:28 AM observed R#5 lying prone and apparently sleeping; there were no SRs and the bed was at the normal height. On 09/14/2017 at 10:30 AM review of R#5's EMR found that the Side Rail/Device Assessment was done quarterly with the last dated 7/10/2017 and documented: Type of Bed Side Rail: half rail top right; half rail top left; Bed side rails assist the resident with bed positioning and mobility; Daily Care (holding of SR); time of day and circumstances when device will be used,: When in bed; The bed side rail is not a restraint because the : Res can't move, so the bed rails are not restraining her; Final determination : Side rails and/or Other Device are NOT a restraint, The care plan (CP): Potential for falls or fall related injuries related to generalized weakness, impaired sitting/standing balance, use of psychotropic medication with its possible adverse reaction; [DIAGNOSES REDACTED].Keep bed in low position with brakes on at all times; For resident who are utilizing bilateral half rails for mobility and transfers, keep upper half rails up; Pad side rails as indicated to prevent injury during episode of seizure activity; Observe for possible occurrence of seizure like staring into space, tremors or shakiness; Take note of duration of seizure activity and notify MD when seizure activity occur . On 09/14/2017 at 1:27 PM observed R#5 lying prone in bed with Staff#107 finished taking vital signs. Queried Staff#107 if resident's bed in lowest position. Staff#107 used bed controls at foot of bed, lowered bed, and then stated this is the lowest position. When queried Staff#107 whether R#5's bed should be in low position, she replied, they all should be at lowest position. On 09/14/2017 at 1:52 PM discussed with Staff#79 bed rail assessment for R#5. According to Staff#79, the resident's SRs were removed because the resident was assessed and cannot move. Queried whether the staff looked at R#5's CP before removing SRs to ensure resident's safety. Staff#79 conferred with Staff#76 and inquired of her if SRs removed and assessment done. Staff#76 stated that she didn't make that decision to not use SRs because didn't contact family yet. Informed staff that according to the resident's CP, padded SRs are required due to a seizure disorder with bed lowered. Staff#79 stated that she was unaware because inquired of CNAs whether the resident moved around in bed, and assessed that resident cannot move. The facility failed to implement a system that address resident's risk in use of old metal SRs to minimize the likelihood of accidental limb entrapment. The facility also did not properly evaluate and analyze R#5's use of SRs to develop targeted interventions to reduce the potential for accidents. 3) On 09/12/2017 at 1:10 PM observed R#73 smoking in the facility's parking lot. The resident stated that she bought pack of cigarettes last month and still had 10 cigarettes left. The resident further stated that she feeds the birds outside in the parking lot, and that she doesn't always smoke because trying to cut down. On 09/13/2017 at 12:30 PM the EMR for R#73 noted on the CP: The resident is at risk for noncompliance with smoking (past history of smoking), was witnessed smoking outside with other residents; the goal was for the resident not suffer injury from unsafe smoking practices through the review date. The CP interventions included: 11/23/16 Resident signed Risks vs Benefits form; Instruct resident about smoking risks and hazards and about smoking cessation aids that are available; Instruct resident about the facility policy on smoking: locations, times, safety concerns. On 09/13/2017 at 12:43 PM interviewed Staff#79 and shared observations of R#73 smoking at designated smoking area that was not wheelchair accessible due to concrete curbing of parking lot. The resident was sitting in her wheel chair smoking in the parking lot where vehicles enter and exit. Staff#79 stated that she would discuss with Staff#22 about inaccessible designated smoking area. According to Staff#79, R#5 is A/O x 4 and able to make needs known. The Smoking policy was provided to the resident and she was also assessed for smoking safety. The resident had a BIMS score of 15. On 09/13/2017 at 1:00 PM, Staff#79 reported that she spoke with Staff#22 and the plan is to make the designated smoking area wheel chair accessible. During the construction period, the 3 smoking residents that use a wheel chair will be supervised to a wheel chair accessible smoking area. On 09/13/2017 at 2:16 PM, Staff#108 stated that a concrete slab at the designated smoking area was being planned to make area wheelchair accessible. According to Staff#108, concrete curbing would have to be removed and will start pricing with contractors to complete task. The facility failed to implement a system to address resident's risk and environmental hazards for wheel chair bound residents to smoke in designated smoking area.",2020-09-01
256,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,325,D,0,1,3X5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and staff interviews, the facility failed to ensure a safe, detailed and monitored approach to physician prescribed weight loss programs for two residents, Resident #165 and Resident #188. Findings include: 1) Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #165 was a patient at the sister hospital of the long term care facility. Upon admission to the hospital, Resident #165 weighed more than 500 pounds. Upon admission to the long term care facility, Resident #165 weighed 445 pounds. On 7/17/17, Resident #165 weighed 429 pounds or 4% loss since admission. On 8/14/17, Resident #165 weighed 383 pounds or 14% since admission to the long term care facility. On the Resident Assessment Instrument (RAI), Resident #165 was coded as a nutrition risk due to her dramatic weight loss since admission. An observation of Resident #165 on the morning of 9/12/17 at 10:00 [NAME]M. found her lying in bed watching TV. She stated that she's made several requests for food preferences but the kitchen continues to send the wrong foods. An observation of Resident #165 on the morning of 9/13/17 at 11:30 [NAME]M. found her lunch tray untouched on the bedside table. The resident reported she wasn't feeling hungry. A review of Resident #165's medical record found a physician's orders [REDACTED]. On 7/11/17, the physician ordered, Physician prescribed weight loss. The Physician prescribed weight loss order did not provide details on Resident #165's planned weight loss program. A review of Resident #165's care plan found, (6/22/17) Nutritional risk related to Body Mass Index (BMI) too high (morbidly obese). The goals included, Resident's weight will remain stable or minus up to or >10% over 180 days through review date 9/2017; and Resident's weight will remain stable or minus up to or >5% over 30 days through review date 9/2017. Interventions included: Encourage resident to consume all meals and provide assistance as needed; Notify MD if any changes in condition e.g. poor oral intake, significant weight loss. The care plan was not consistent with the Physician prescribed weight loss. Additionally, the facility did not provide details of a safe, monitored, and paced weight loss for Resident #165. The physicians orders and care plan did not describe a goal weight for Resident #165. A review of the Dietician's notes on the morning of 9/13/17 at 10:00 [NAME]M. found a note dated 7/10/17 which stated, BMI >35: MD Please order 'physician prescribed weight loss' to allow significant weight loss to be correctly coded in section K of the MDS document. An interview of the Registered Dietician (RD) on the afternoon of 9/14/17 at 1:45 P.M. revealed her recollection that Resident #165 was on a physician prescribed weight loss plan due to [MEDICAL CONDITION]. The RD did not provide details of the weight loss plan. The facility failed to utilize an appropriate care plan for a safe physician prescribed weight loss plan for Resident #165. The care plan contradicted the goal of weight loss. Additionally, the facility failed to identify a safe, effective weight loss plan that would be monitored and evaluated as the resident slowly and gradually lost weight. 2) Resident #188 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was a patient at the facility's sister hospital prior to admission. A review of the RD's notes found a note dated 8/31/17 which noted Resident #188 experienced a 5% weight loss since his admission to the hospital. The RD noted Resident #188 had a BMI >35 and noted, MD please order 'Physician prescribed weight loss' to allow significant weight loss to be correctly coded in Section K of the MDS document. The RD note dated 9/13/17 found, Resident (#188) had a 3% weight loss over the past 30 days - physician prescribed weight loss ordered. However, on the morning of 9/14/17 at 10:00 [NAME]M., a review of the physician's orders [REDACTED]. An interview of the RD on the afternoon of 9/14/17 at 1:48 P.M. found the RD was unaware that the nursing staff did not follow through on her recommendation for a physician prescribed weight loss program. She further stated she thought it has been ordered and admitted that it was her responsibility to ensure the order was in place. A care plan review for Resident #188 found a Nutritional Risk care plan with interventions which included: Encourage resident to consume all meals and provide assistance as needed; Notify MD of any changes in condition e.g. poor oral intake, significant weight loss; Offer and provide alternatives for meal consumption less than 50%. Resident #188's Nutritional Risk care plan further noted the following goals: Resident's weight will remain stable or minus up to or >5% over 30 days through review date 12/2017; and Resident's weight will remain stable or minus up to or >10% over 180 days through review date 12/2017. The goals and interventions included in Resident #188's care plan were inconsistent with the Physician prescribed weight loss program. Additionally, the care plan failed to address the a safe, monitored, and paced weight loss for Resident #188. The facility failed to utilize an appropriate care plan for a safe physician prescribed weight loss plan for Resident #188. Resident #188's care plan contradicted the goal of weight loss. Additionally, the facility failed to identify a safe, effective weight loss plan that would be monitored and evaluated as the resident slowly and gradually lost weight. In conclusion, the facility failed to provide clear and specific goals and interventions for physician prescribed weight loss programs for both Resident #165 and Resident #188.",2020-09-01
257,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,371,E,0,1,3X5E11,"Based on direct observation, staff interview and a review of the facility's policy and procedures and maintenance records, the facility failed to properly sanitize dishes and utensils during the final rinse cycle. Findings Include: On 9/12/17 at 8:45 [NAME]M. Staff #107 ran the dish washer. The wash temperature gauge for the dishwasher read 140 degrees Fahrenheit during the wash cycle and the temperature gauge for the final rinse cycle did not register. Staff #107 stated that the temperature gauge was broken and the Ecolab T-sticks were used to record the final rinse temperature. Staff #107 attached the Ecolab T-stick to a fork, placed the fork in the dish rack and ran the dish washer a second time. The Ecolab T-stick registered a dark brown color that indicated the correct temperature of 170 degrees Fahrenheit. On 9/15/17 at 10:05 [NAME]M. the Dishmachine Temperature Log Policy was reviewed. The Dishroom Employee: 2. Responds to an inappropriate temperature: a. make sure all control switches are turned on; b. re-check temperatures; and c. notify supervisor if temperatures are not in the acceptable range. Supervisor: 3. Notify Maintenance for corrective action. 4. Follow up to verify repairs were effective. At 11:30 [NAME]M. the temperature log was reviewed. On the following dates: 8/20/17; 8/30/17; 8/31/17; 9/02/17; 9/03/17; 9/04/17; 9/05/17; 9/06/17; 9/07/17; 9/08/17; and 9/14/17 the T-sticks placed on the log sheets were clear indicating the temperature did not reach the required 170 degrees Fahrenheit. At 12:50 P.M. the Food Services Manager (FSM) stated that if a T-stick does not register the correct temperature, the Dishroom staff must re-run the strip a second time. If it still does not indicate the correct temperature staff will report the discrepancy to the FSM who will contact the manufacturer to come service the machine. The FSM further stated that there is no documentation of communication with the dishwasher maintenance company that there is a problem with the temperatures and that maintenance was performed on the machine for the past few weeks. The facility failed to properly sanitize dishes and utensils to ensure sanitary conditions and safe food handling.",2020-09-01
258,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,441,D,0,1,3X5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure that infection prevention practices are followed for the use of a urinal at the bed side for 1 of 21 residents (R#103) on the Stage 2 Sample Resident List. Findings include: On 09/14/2017 at 10:18 AM observed R#103 sleeping in bed and urinal filled with urine on overbed table. On 09/14/2017 at 1:31 PM observed R#103 in bed watching TV, urinal with urine on overbed table. Queried resident if staff didn't empty urinal from that morning and he replied that urinated in urinal just little while ago. Queried whether resident was instructed to keep urinal on overbed table next to water pitcher and where ate his meals. R#103 stated that urinal should be hung from side rail (SR) but he had difficulty reaching for urinal if placed on SR. On 09/14/2017 at 1:46 PM interviewed Staff#33 regarding R#103 filled urinal on overbed table. According to Staff#33, the resident's urinal is emptied before breakfast, lunch and in the afternoon before 3 PM. The resident preferred to keep urinal on overbed table even though told to hang it from the SR. R#103 didn't use call-light for staff to empty the urinal, so staff had to check. R#103 was considered A/Ox4 and able to make needs known. The nurses also knew of this behavior, but the resident preferred that urinal stay on his right (R) side next to the water pitcher. On 09/15/2017 at 12:09 PM the electronic medical record (EMR) found that R#103 [DIAGNOSES REDACTED]. On the care plan (CP), Impaired ADLs/Mobility related to generalized weakness associated with exacerbation of CHF, HTN, A-fib, Vit D deficiency, Gout, and hx of CVA-L sided [DIAGNOSES REDACTED]s/paresis, it was noted, refuses to get out of bed to sit up in wheel chair (w/c), and to transfer during shower days thus bed bath provided. The CP interventions included, RNA program for maintenance 3-5x week revisit resident when he refuses RNA program and explain the risk for being steadfast. According to Staff#71, the EMR task bar tab for bladder continence/toilet use documented the times that the urinal was emptied. From 09/11-13/2017, the urinal was emptied 6-8 times a day and at various times of day. The annual minimum data set (MDS) 3.0 for R#103 dated 5/16/17 documented that the resident required extensive assistance with 1 person physical assistance when using the toilet, moving in bed, dressing and performing personal hygiene. The resident was coded for functional limitation in range of motion in the lower extremity (hip, knee, ankle, foot; with impairment on both sides. The facility did not follow standard precautions for infection prevention practices by continuing to allow the resident to store his urinal after use on the same overbed table where meals were served and eaten, and placed right next to his water pitcher.",2020-09-01
259,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2017-09-15,520,D,0,1,3X5E12,"Based on interview with staff member, the facility failed to develop, implement and monitor appropriate plans of action to correct identified quality deficiencies. Findings include: On 11/17/17 at 11:03 [NAME]M. an interview was done with the Administrator and the Director of Nursing (DON). On 11/16/17 at 11:30 [NAME]M. the State Agency identified Immediate Jeopardy for Resident #38. During the refortification survey, the facility was cited for Resident #38 related to his behaviors. The corrective plan included providing one to one supervision for this resident. However, during the revisit survey, the State Agency found the staff member providing the one to one supervision did not ensure this was being done. Resident #38 was observed out of his room and entering another resident's room unbeknownst to the staff member providing the one to one supervision. Immediate Jeopardy was identified at F323, Accidents (Cross Reference F323). Queried the staff members regarding how the deficient practice related to residents on physician prescribed weight loss are being addressed by the committee. The Administrator reported the nutritional risk committee meets weekly to discuss the residents, newly admitted residents are reviewed for the first four weeks on admission. The Administrator reported residents on a physician prescribed weight loss are placed on the list to be reviewed and monitored. During the onsite revisit survey, the State Agency identified the deficient practice related to nutrition was not corrected. The facility was re-cited at F325 for two of the three residents in the sample. The facility failed to develop care plans with specific goals and interventions based on a resident assessment. Cross reference to F325. The QAA/QAPI committee failed to ensure the plan for improvement related to the deficiencies cited during the recertification survey was implemented and monitored. Overall, the facility's failure to monitor the plan for improvement resulted in repeat deficiencies at F323 and F325.",2020-09-01
260,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-09-26,657,D,1,0,NR2S11,"> Based on interview and record review, the facility failed to develop a resident centered care plan that addressed an injury of unknown origin. Furthermore, the care plan did not include members of the residents (R)1 family who were assisting in the range of motion and care of the resident. Findings include: During a Record Review (RR) of the Care plan dated 07/18/19, noted Restorative Nurse Aide (RNA) for passive range of motion (PROM) as the primary focus on the care plan. The interventions/tasks dated 10/05/17 states RNA program for mobility of the bilateral upper and lower extremities, contractures management and activities of daily living (ADL)s. Provide RNA program as tolerated three to five times per week. The Careplan did not show any education for the family in regards to R1's restorative care. In addition, the Care plan showed no collaboration between Nursing and Rehab Department and instead worked independently of each other. During an interview on 09/25/19 at 10:33 PM with staff (S)22 stated there was restorative care going on and the certified nurse aide (CNA) providing it was trained by the Rehab department on how to do ROM. For basic ROM, I train the CNA's, and, in this case, I trained S55 on the restorative program. The hard part is when S55 is not here there is no one except the Occupational (OT) and physical therapist (PT). The incident may have occurred if the ROM was done improperly by the CNA who provided it when S55 wasn't here. Now if S55 sn't here to do the ROM, S62 will do it. If S62 isn't here then I will do it. The CNA's can do the ROM if it is routine. They can bring them to the gym and do regular ROM, flexion, elbow flexion, shoulder flexion and prevent contractures. (F689) During an Interview with Director of Rehab (DOR) on 09/25/19 at 10:47 AM stated we do a competency checklist with the staff once per year and meet the RA's two to three times per week. We do in-service training about restorative care. The certified nurse aide (CNA)s and restorative aide's (RA's) can do transfers and range of motion (ROM). We need to train all the CNA's how to do the restorative care for the complex residents. We trained two RA's who provide more complex care and they cover for each other if one is absent. Since the incident, either S55, S62 and S22 or other therapist for the complex ones. We have five residents who receive complex care. R1 is one of those complex residents. I wanted to make sure that we had a system in place to provide the complex care as well as the routine care. A licensed therapist will only provide the care for the complex residents now. We screen quarterly and I ask the nurses to give us a heads up for any changes in positioning, meal issues, or skin. (refer F689) During an interview with the Interim Director of Nursing (IDON) on 09/26/19 at 11:30 AM when asked if the facility included the family in the Care planning stated we told Family member (F)1 that his father (F2) was doing ROM. IDON stated further that she did not know that the restorative care for R1 was being done only by Rehab Department and not the CN[NAME] She was also not aware that the Rehab department had identified R1 as a complex resident and needed the RA, PT or OT to do her restorative care in order to prevent injury. IDON was not able to state if a care plan was developed for R1's complex restorative care or if the family was trained in doing range of motion. IDON agreed that there was a disconnect with communication between nursing and rehab departments. (F689)",2020-09-01
261,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-09-26,684,D,1,0,NR2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure resident centered care in accordance with professional standards of practice when a resident received an injury of unknown origin. Findings include: A Record Review (RR) revealed that Resident (R)1 is an [AGE] year old female with an admitting [DIAGNOSES REDACTED]. R1 sustained an injury of unknown origin to the left upper arm on 07/20/18. The facility failed to thoroughly investigate the cause of the injury and update the plan of care. (refer F689) During an interview with R1's son (F)1 at R1's bedside on 09/24/19 at 01:15 PM. During the interview, F1 showed a photo of his mother's grimacing face on his phone which he said he reported to the facility on [DATE]. He said that R1 was not offered pain medication. He showed more pictures of R1's swollen left arm, dated (MONTH) 20, (YEAR). The picture is evident of swelling to the left anterolateral biceps, triceps, elbow, and frontal forearm. There was no swelling to the left shoulder. F1 stated that at the time of the alleged incident R1's husband (F2) was at the bedside and observed the certified nurse aide (CNA) who was providing the range of motion (ROM) exercises was rough. Refer (F689) During a Record review (RR), reviewed the facility's investigation paperwork. The RR revealed a statement by staff (S)62 stating Today 07/20/18 at 0945 AM, I went to provide restorative nurse's aide (RNA) treatment to R1. I noticed her left upper arm was swollen and notified S59. S59 stated S62 alerted me this morning about the swollen arm of R1 while doing RNA exercises. When I went to the room, noted both arms were covered with a stockinet. When the stockinet's were removed I noticed the left upper arm was swollen. The left arm is bigger compared to the right arm. The area was tender to touch upon assessment. No reports received from night shift about the swelling. Husband was at the bedside. Registered Nurse (RN) supervisor and DON were notified. Physician notified at 10:55 AM and an order was obtained for an X-ray of the left arm. Informed F1 of the plan at 10:40 AM. On 07/20/2018 at 11:03 AM, an X-ray was obtained for [MEDICAL CONDITION], swelling of R1's left humerus. Impression: 1) There are no fractures or dislocation of the left humerus. 2) There are mild [MEDICAL CONDITION] changes of the left acromioclavicular joint and glenohumeral joint. 3) There is possible calcific tendinitis of the distal left rotator cuff. During an Interview with Director of Rehab (DOR) on 09/25/19 at 10:47 AM stated we do a competency checklist with the staff once per year and meet the RA's two to three times per week. We do in-service training about restorative care. The certified nurse aide (CNA)s and restorative aide's (RA's) can do transfers and range of motion (ROM). We trained two RAs who provide more complex care and they cover for each other if one is absent. Since the incident, either S55, S62 and S22 or other therapist for the complex ones. We have five residents who receive complex care. R1 is one of those complex residents. I wanted to make sure that we had a system in place to provide the complex care as well as the routine care. A licensed therapist will only provide the care for the complex residents now. We screen quarterly and I ask the nurses to give us a heads up for any changes in positioning, meal issues, or skin. (refer F657) During an interview on 09/26/19 at 11:30 AM with Interim Director of Nursing (IDON), she stated that she is not aware that the RA and licensed therapist are the only staff who can provide restorative care to complex residents. Although, a sign was visible on the wall stating CNA will do the ROM when the RA is not here. IDON agreed that there was a disconnect with communication for this resident's restorative care. (refer F689)",2020-09-01
262,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-09-26,689,D,1,0,NR2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to appropriately investigate an injury of unknown origin to rule out accidents. In addition, the facility also failed to update the residents plan of care to ensure that accidents were prevented and family members were properly trained how to provide safe range of motion exercises. This deficient practice placed one resident (R)1 at risk for injury. Findings include: A Record Review (RR) revealed that Resident (R)1 is an [AGE] year old female with an admitting [DIAGNOSES REDACTED]. R1 sustained an injury of unknown origin to the left upper arm on 07/20/18. The facility failed to thoroughly investigate the cause of the injury and update the plan of care. (refer F684) During an interview with family member (F)1 on 09/24/19 at 01:15 PM, F1 showed a picture of R1's grimacing face that was taken on 07/24/18 with his cell phone. He stated he reported to the facility on [DATE]. F1 stated further that R1 was not offered any pain medicines and he had to finally ask for her to receive the pain medication. F1 showed many additional pictures on his cell phone of the swollen arm. The picture is evident of swelling to the left anterolateral biceps, triceps, elbow and frontal forearm. The left shoulder does not appear to be swollen. F1 also questioned why the facility did not want to see the pictures or why the facility did not question R1's husband (F2) about the incident since he was at the bedside during the alleged incident. F2 stated to F1 it was rough when the certified nurse aide (CNA) did the exercises with R1. Refer (F684) Facility investigation paperwork was provided by the administrator on the swelling of R1's left arm. A thorough investigation was done regarding the swelling stated administrator. A statement by staff (S)62 stating Today 07/20/18 at 0945 AM, I went to provide restorative nurse's aide (RNA) treatment to R1. I noticed her left upper arm was swollen and notified S59. S59 stated S62 alerted me this morning about the swollen arm of R1 while doing RNA exercises. When I went to the room, noted both arms were covered with a stockinet. When the stockinet's were removed I noticed the left upper arm was swollen. The left arm is bigger compared to the right arm. The area was tender to touch upon assessment. No reports received from night shift about the swelling. Husband was at the bedside. Registered Nurse (RN) supervisor and DON were notified. Physician notified at 10:55 AM and an order was obtained for an X-ray of the left arm. Informed F1 of the plan at 10:40 AM. On 07/20/2018 at 11:03 AM, an X-ray was obtained for [MEDICAL CONDITION], swelling of R1's left humerus. Impression: 1) There are no fractures or dislocation of the left humerus. 2) There are mild [MEDICAL CONDITION] changes of the left acromioclavicular joint and glenohumeral joint. 3) There is possible calcific tendinitis of the distal left rotator cuff. During an interview with S55 at 10:15 AM on 09/25/19 when asked how does the restorative aide (RA) program work? stated that It starts off with occupational therapy (OT) or physical therapy (PT). They will work with the resident for a defined period and turn it over to the restorative aides (RA)'s. Speech and OT assess and treat the upper half of the body. The CNA's do the range of motion (ROM) to make sure they don't degrade. PT is from the hips down and depending on what type, they do the ambulation, passive or active ROM. Passive is when the resident cannot do anything. Active and semi-active is when the resident can do some movement. Passive is indicated when a resident has had a stroke. S55 stated that the difference between the CNA and the RA is that the RA has a job description that doesn't include nursing care. My manager is from the rehab department. We do assist the CNA with mobility. I got on-the-job training by the PT and OT. I have been an RNA from 2005 to (YEAR) and an RA for less than a year. They deemed me restorative with the collaboration of the therapy programs. The RA program just started almost a year ago when the union approved the title. When asked what you do if you note any concerns during care, like a bruise, how is it reported, is there a process to report pain, swelling, bruises responded that normally, I will tell the CNA and tell the charge nurse. If the charge nurse requires me to document it, I will. I am hoping the CNA will document it too. If there is an incident report involved, I do it. During an interview with S22 on 09/25/19 at 10:33 PM stated there was restorative care going on and the CNA providing it was trained in ROM. Was its ROM or was it restorative care. I'm trying to remember. For basic ROM, I would train the CNA's, and, in this case, I trained S55 on the restorative program for R1. The CNA who was providing the care when the alleged incident occurred may have caused an injury if it was not performed properly or rough. If S55 isn't here, then S62 (the other RA) would provide the care. If neither of them are here, then I would provide the care. For ROM, the CNA's can do the ROM. They can bring them to the gym and do regular ROM, tendon flexion or elbow flexion, shoulder flexion and prevent contractures. During an interview with the Director of Rehab (DOR) on 09/25/19 at 10:47 AM. stated I am the manager and I oversee the ER, SNF, acute sides of the hospital. As far as the SNF goes, there is usually a flow. We have short term rehab and long-term residents. The therapists will usually work with the residents for short-term. If they convert to long term, they set up program, it's individualized per person. R1 is lower level - ROM. She is a little bit frail so it's doing but not overdoing it, working the ROM and not pushing past the resistant point. She is not verbal, so watching for facial grimacing is very important. At the time the incident occurred, if the RA wasn't there, the CNA's would carry out the ROM. CNA's tend to carry ROM out when they are changing clothes. So, a lot of times, the CNA's don't do ROM every day. On the day of the incident, the RNA's were not here, S126 said she can carry out the restorative care. The RNA's do a competency checklist once a year and two or three times a week. The CNA's have annual training, we do a periodic thing like transfers and ROM. They do a competency checklist once per year. We meet with the RA's two to three times per week. We do in-services about restorative care. The CNA's and RA's can do transfers and ROM. We trained two RA's. If one RA is not here, the other RA will cover for them. Since the incident only the RA's or licensed therapists work with the residents who are complex. We have five complex residents who are receiving restorative care here. R1 is included. I wanted to make sure that we had a system in place to meet the restorative needs for complex and those who are routine. This was not in play at the time. We screen quarterly and I ask the nurses to give us heads up, positioning change, meal issue, skin or addressing. So, switching to RA, we are more over the Restorative aides. During an interview with S114 on 09/25/19 at 02:49 PM when asked if there had been anytime that the facility suspected abuse from staff or family members, responded that if the CNA's saw something new to them, they would report to the licensed nurse. If the CNA's see something new, they mark it on the task bar. What I know, they would try to collect a statement from the CNA's for any bruising that occurred before and after, especially after R1's shower day. I know the family would come every morning to feed her, help with care, sit on one side of her bed and help with her exercises. The bruising and swelling has never been looked at as abuse. There was no root cause analysis done and it never came up during the quality assurance and performance improvement (QAPI) meetings. When asked if you ever witnessed mishandling of R1's from F2 responded no, he was caring and takes his time feeding her and talk's to her. Her husband was not trained on the ROM exercises that he does while at the bedside. We have a monitor log to write down what kind of care the family does, i.e. activities of daily living (ADL) care, transfers and feeding. She gets transferred at any time using a Hoyer sling and her showers are done on Thursday and Sunday evening so so the family is here to watch. When asked for any other information about the swelling of her left arm replied that the RNA was not there and was on vacation and I know R1 did not get her treatment. Her husband said something and so the CNA did the treatment. Apparently the next day was when the pain and swelling was noted. During an interview with the Interim Director of Nursing (IDON) on 09/26/19 at 11:30 AM stated that she was not the acting DON, at the time R1's arm was swollen in (MONTH) (YEAR). I do remember that they talked to S126 and the previous DON was handling it at that time. What I know at that time according to our long term care coordinator, swelling was reported, and they got an order to take an x-ray. F1 had a lot of concerns. It looked like the swollen arm was a continuing complaint from the F1. Adult protective services (APS) came in to investigate. The CNA noted some roughness from the husband, stretching, cutting toenails. One time F2 placed a stool on top of R1 while she was sitting in the wheelchair. Staff would see him exercising the arm. We told F1 that his father was doing ROM to his mother. In fact, the DON mentioned that our CNA will do the ROM when the RA is not here. IDON was not aware that Rehab Department had arranged for the RA's to do R1's restorative care and looked surprised. IDON was informed that PT stated that if RA's were not available that R1's restorative therapy would be done by rehab department to prevent any further incidents. IDON was not able to state if a care plan was developed for R1's complex restorative care or if the family was trained to do range of motion. IDON agreed that there was a disconnect with communication for this resident's restorative care. On 09/26/19 at 11:53 AM interview was done with the administrator. The question was posed to the administrator Did the facility investigate the swelling as possible abuse? Administrator stated We didn't have a suspicion of abuse. When we got the xray result it said there were [MEDICAL CONDITION] changes so we didn't view it as an abuse injury. It was an unknown origin. Queried if the investigation was looked at as swelling from unknown origin of possible abuse. If not abuse, an accident? How did it occur? Was there a nursing assessment done? There was no documentation. They called a physician to get the order. Queried if there were interventions in place. Administrator stated We did a lot of education for the bathing and transferring. If there is any indication of a bruise, it is documented. The staff are keeping logs since (YEAR). We did not look at it as abuse or an accident. The xray stated it was [MEDICAL CONDITION] disease and calcific tendonitis. RR revealed in a statement by S126 On (MONTH) 19, (YEAR) the night shift CNA help me to give morning care to the patient. No swelling was observe on left arm. Even when I was exercising. She had no swelling and after after the shift. Endorsement was done to the next shift. Body check was also done and no swelling observe. S126 conducted the RNA program because the family asked about it. S126 was not trained and not deemed competent by the Rehab Department. Furthermore, the Rehab Department and Nursing Department were conducting different programs for restorative care. R1 has been identified by Rehab as a complex, frail patient who needs special care. On 07/19/18, S126 conducted restorative care and on 07/20/19, R1 exhibited swelling of the left arm of unexplained origin.",2020-09-01
263,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-10-02,561,D,0,1,HX9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the resident had a choice of his bathing (shower) frequency for one resident (Resident (R) 129) selected for review. This deficient practice has the potential to affect all residents residing in the facility. Findings Include: Resident (R) 129 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R129 was receiving skilled rehabilitation services with a goal to discharge back to the community. During a family interview on 09/27/19 at 12:25 PM, the family member (FM) stated R129 likes to have daily showers, but was not sure how often he was being showered since his admission. R129 was unable to be interviewed as he was very sleepy. The FM said he had some days when he was alert and some days when he was sleepy, but that he still liked having a shower every day. The FM said if he was too sleepy, then a shower at least every other day would be fine for him. Review of R129's admission information found he had a care plan related to activity based on his short term rehab which stated, daily preference: very important to choose shower for a bath. It did not include a frequency, but that R129, . is able to choose his own daily routine and activity for the day. On 09/30/19 at 02:29 PM, an interview with certified nurse aide (CNA) 101 was done. She said they had a shower schedule for the residents and said, It's twice a week, but when a resident want it more, we try our best to give, but it's not like the regular time, so we usually give after lunch, afternoon. R129's shower schedule for the 2nd floor was provided and at 02:40 PM, CNA101 verified R129's shower schedule was on Mondays and Thursdays. The shower schedule was found to be set depending on each resident's room number for the entire facility; thus each resident received showers twice a week with this pre-set schedule. On 09/30/19 at 03:12 PM, R129 said he was not sure if he received a shower today (Monday), although it was his shower day. He vocalized, Yes, that he would like a shower every day when asked. R129 was tired since he just completed an occupational therapy session, but his response affirmed what the FM said about wanting a daily shower. On 09/30/19 at 03:44 PM, during an interview with CNA24, she confirmed she had given R129 a partial bed bath at 07:36 AM, and not a shower. CNA24 said although she tried to offer it again after lunch, R129 refused it so she was going to endorse it to the evening shift. CNA24 said if the resident refused, the charge nurse would be told, and the charge nurse would document it. Interview with the charge nurse, RN72 at 03:45 PM revealed she was aware that R129 had refused his shower and was informed by CNA24 about it, but stated she forgot to document it. When RN72 was asked who was tracking the amount of showers and refusals, she replied there was a way to look at the trends if a resident refused and it was in their system. On 10/01/19 at 02:11 PM, during an interview and concurrent record review with RN 103, she confirmed R129 had received a shower on 09/11/19 and 09/21/19, and on the evening of 09/30/19, and said, the rest are bed baths or partial bed baths. RN103 was asked what R129's preference for how often he would like a shower was, and she said she would have to ask. Review of R129's admission checklist was done and RN103 acknowledged R129's bathing preference was marked as shower, but there was no documentation as to the amount/frequency of showers he would prefer. RN103 said if the resident refused, the CNA could endorse it to the evening shift (similar to what CNA24 had stated), but RN103 said the CNAs should also be documenting the shower refusals as well. RN103 pointed to a column where the CNA could chart the shower refusals. RN103 said if R129 refused the shower, the CNA should have documented it. The facility failed to proactively ask R129 and/or the FM about his shower preference, which was to have a daily shower. Instead, R129's shower schedule was pre-set according to his room number, without the resident's or his family's input. Additionally, although the bathing schedule shows only two showers had been given prior to the State Survey Agency's (SA) inquiry about R129's showers, he was being provided bed/sponge baths or partial bed baths, to which RN103 said, Seems like he gets more bed baths or partial bed bath--like to the face, peri area, or when he may have gotten soiled. These were not the showers which R129 said he would like to have on admission.",2020-09-01
264,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-10-02,584,E,0,1,HX9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and document review, the facility failed to ensure a homelike environment with housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. The facility's water also did not warm to a comfortable temperatures in Room (RM) 154,155 and two shower rooms. Findings include: 1)Observation upon entrance to the facility, on 09/27/19 noted the ceiling near the main activity room in the was exposed. The ceiling tiles were wet and leaking and some tiles were water-stained. On the floor beneath the ceiling leak was a catch water wheelbarrow system. The next day, observation on 09/28/19 at 0900 AM, it was noted that a few of the ceiling tiles near the main activity room were replaced. On 09/30/19 at 1100 AM surveyor was approached by a family member (FM) who showed time/date stamped photos of the same ceiling leak. FM states that this has been going on for a year. On 10/01/19 at 10:46 AM Interview with Maintenance Director (MD). Facility staff changes the ceiling tiles. If it's pouring rain we put a bucket underneath for water catchments and housekeeping maintains it. We put the wet floor signs down for safety. Housekeeping will check it every one two hours. We thought it was due to the air handler but it wasn't, so now, in the last three weeks, it's coming from the roof drain so we just finished re-routing the two roof drains. On 10/01/19 received work order records from maintenance director for ceiling tile work that dates back to (MONTH) 02, (YEAR). 2) On 09/27/19 at 10:00 AM, during initial walk through of facility, spoke with R35 in room [ROOM NUMBER]-2. R35 states everything is fine but it gets really hot in here at about 2:30 to 03:30 PM. My blinds are broken and they try to cover the window as best as they can. On 10/01/19 at 02:00 PM conducted a walk through and interview with maintenance director of facilities to test room temperatures. The first room tested was room [ROOM NUMBER] and it was 72 degrees F. Maintenance director explained that about a month ago the facility got the air handler which is on the roof now. The air handler cools the building down. room [ROOM NUMBER]'s temperature was 72 degrees. room [ROOM NUMBER]-2's temperature was 66.2 degrees. room [ROOM NUMBER]'s temperature was 72 degrees but the on/off button was turned off which controls the temperature. Maintenance director states that we placed locked boxes on the thermostats but somehow staff are finding ways to get into the box. This is resulting in some of the temperature boxes accessible and not locked. In room [ROOM NUMBER], the thermostat box was broken. Maintenance director stated that if the box is broken, then the staff can adjust the temperature on floor by the thermostat controls. The other problem is the on/off switch which is not covered. It seems that the staff is turning this switch off when it gets cold at night. This is also a problem when we start to get complaints that it is too hot. In the am, facilities will come to check because of complaints too hot, or too cold. When staff touch adjustments, it will take a longer time to cool a room down when daylight comes. Because we know the temperature controls may have been adjusted, the maintenance staff will usually go to all the rooms in the am to check the off/on switch and thermostat controls. On 10/01/19 at 2:39 PM, R35 stated that her daughter had bought a fan for her because of the heat and her room felt cooler. 3) During initial tour, ran the water in the sink Rm 154 and 155 to check the temperature. The sinks had hot and cold handles and after quite a while, the water was still cool to touch. During an interview with Resident (R)3, she stated the water in the shower was always too cold. Inquired if she had reported it to staff, and R3 said she had reported it several times, but hasn't been fixed. On 09/30/19 at 04 :00 PM completed a tour with the Maintenance Director, and requested water temperature check in Rm154, Rm 155, shower Rm in back hall, and shower Rm 178. The maintenance director said the water flow in Rm 154-2 was low, so called staff to turn the flow up. After an extended period of time, the water fluctuated between warm and cold, and the highest temperature reached was 102.8. The highest water temperature reached in Rm 155 was 99 degrees. The back hall shower temperature reached 104.8 degrees, and shower Rm 178 reached a temperature of 102 degrees. Maintenance director said she would call plumbing out tomorrow to look at it. On 09/30/19 at 04:30 PM, the maintenance director spoke with R3 and informed her the shower temperature had reached 104.8 and asked if that was warm enough. R3 replied no, she would like it warmer. 4) During the initial tour of R132's room on 09/27/19 at 08:40 AM, it was found the window next to his roommate's bed had white towels on the window sill and large bed bath type blankets on the floor below it. The white towels were felt and they were damp. RN8 said it had been raining and the window, it's leaking because of the rain. At 08:41 AM, CNA106 along with RN8 were then observed carrying the wet towels and blankets out of the room and placed them into a hamper. CNA106 said it had rained hard so, it got wet by the window. On 10/01/19 at 09:40 AM, during a second observation of the window area in R132's room, there was an accumulation of water drops on the lower window blinds. Staff (S) 1 came into the room and said, there's water, its leaking, and was going to follow-up with maintenance. S1 shortly thereafter produced a work maintenance order to repair the window for a water leak. S1 said he did not think this was done the day it was identified on 09/27/19.",2020-09-01
265,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-10-02,656,D,0,1,HX9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safely monitor the side effects of diuretics for two of five Residents (R)34 and R67 reviewed for unnecessary medications. The deficient practice has the potential to increase the resident's risk for illness or injury. Findings include: 1) Electronic medical record (EMR) reviewed: R34 is a [AGE] year-old female with a [DIAGNOSES REDACTED]. Medication Administration Record [REDACTED]. [MEDICATION NAME] tablet 40 milligram (mg) give 40 mg orally in the morning and afternoon for [MEDICAL CONDITION] hold for systolic blood pressure (SBP) R34 received [MEDICATION NAME] every (Q) day in (MONTH) 2019. MDS reviewed section N- medications. Received anticoagulant and diuretic 7 days. Care plan dated 09/30/19 reviewed. No Diuretic precautions noted on care plan. Pharmacy notes reviewed. Medication regimen review (MRR) dated 09/17/19, states no irregularities. MRR dated 08/21/19, no irregularities. During an interview with Registered Nurse (RN)96 on 10/01/19 at 02:07 PM, when asked how are you monitoring R34 for adequate hydration with use of the [MEDICATION NAME]? Responded we check her blood pressure, we check for swelling, and we check the daily fluid intake to see what her intake is. She's on hospice so we aren't checking her labs. 2) EMR reviewed for R67, a [AGE] year-old male with a [DIAGNOSES REDACTED]. end stage [MEDICAL CONDITION], stage 5, and dependence on [MEDICAL TREATMENT]. Medical Doctor (MD) orders reviewed. [MEDICAL TREATMENT] every Monday, Wednesday and Friday. [MEDICATION NAME] tablet 80 mg give 1 tab by mouth one time a day for [MEDICAL CONDITION] hold for SBP MAR for (MONTH) 2019 reviewed. [MEDICATION NAME] 80 mg given daily for month of (MONTH) 2019. Care plan dated 09/31/19 reviewed. There is no intervention on the care plan to monitor the electrolyte levels for the Diuretic, or the side effects of the medication. During an interview with the registered nurse (RN)114 on 10/01/19 at 02:25 PM, stated his I/O's are being monitored when he goes to [MEDICAL TREATMENT]. At the [MEDICAL TREATMENT] center, the staff monitor R67's levels routinely. When he goes to [MEDICAL TREATMENT], the MD orders labs. The [MEDICAL TREATMENT] staff send the lab results to us with the recommendations and we follow up with the MD.",2020-09-01
266,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-10-02,657,E,0,1,HX9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility failed to review and revise by an interdisciplinary team composed of individuals who have the knowledge of the resident and the resident's needs in a timely manner. The interdisciplinary team's communication to assure person-centered care plan is failing between departments for four (Residents (R) 35, 59, 3 and 69) out of sample size of 20. Findings include: 1) Interview on 09/27/19 at 01:10 PM with R35 who stated I can't stand. Occupational therapy tried. I don't get range of motion (ROM) exercises. Record review on 09/27/18 reveals on the Kardex that R35 is tasked with restorative nursing assistance (RNA): Active upper extremity (UE) ROM . Start date: 07/15/19, 3x a week. 1)Trunk flexion with sheet and assistance 3x10. 2) Shoulder flexion 5#dowel 3x10 . 3)Biceps curls 5# dowel 3 x 10. 4)Shoulder press. 5)#dowel 3 x 10. Kardex states: RNA PT RNA program to start after 07/12/19 for up to 3x per week. Passive and active assisted LE ROM Ankle pumps knee flex, hip flex, abduction to tolerance. Weight bearing as tolerated. Interview on 10/01/19 at 10:35 AM interview with Long term care coordinator LTCC114 and registered nurse, (RN)103 and IDON. LTCC114 printed the RNA therapy sheet which shows she has not gotten therapy in one month. IDON and LTCC114 stated the CNA's with the activities of daily living (ADLs). So when they change their clothes, they will lift their arm. Further questioning and sharing that the residents say they are not getting ROM. Surveyor discussed difference between doing repetitions of 3 sets of ROM (as per RNA orders) and lifting a persons arm to wipe them down during a bed bath. LTCC114 stated I see what you mean. IDON acknowledged. Interview with restorative assistant (RA)55 on 10/01/19 at 01:39 PM who states the workload is so heavy and Rehab Director (RD) determines what my list and that's what I go by. We are also tasked to help with nursing, lifting, transport, dining 730 to 830 and lunch time is 11:45 until when the resident gets done. Our time is being eaten up . We are supposed to do 8 residents and then we have admissions, we have to provide wheelchair service. We only have 8 hours during the day. Clinical nursing assistants are not doing ROM. The nursing department asks for us to help the nursing. How is the communication for the day handed down to you? Like I talk to the DR if there is a change. I ask if there are recommendations. I ask the therapists what can be done and then it comes back to me. There are so much RNA orders that need to be done. We prioritize which ones have to be done and the initiative comes from physical therapy (PT). Sometimes it's our job to prioritize. The doctor normally does the ordering. We got more work than we got people to do it. The therapists tells us what to do. Restorative assistant (RA) will meet with Rehab weekly and adjust programs accordingly. The rehab will meet monthly with nursing. Interview on 10/02/19 at 09:04 AM with DR Trying to tie all the pieces together is tricky. I feel between the therapists and RA it is ok. Between the nursing and rehab there is a missing piece. What is the process when you develop a Careplan or the aide comes to you and says their hurting? A lot of time, I send a therapist to see what the rehab part of it is. We will ask nursing to see if there is anything they can do on their end. Changes in status, and then from there updating the program . There are inconsistencies. I think it is moving forward but it happens, when things are done verbally. I meet with RAs on Fridays and we go over the clients. I give an update to the interim director of nursing (IDON) but I feel there is still a missing gap. We need to find a way to get more involvement. I don't know who is exactly responsible for updating the Careplan. We try to update to the coordinator on the floor and we are not sure how it is being done on the nursing side. The breakdown occurs when people are not here. For ROM, the RAs will talk to the CNAs. We don't have a good formalized process. When you say ROM, what is your expectation? . ROM is basically meant to be passive movement of the extremities, usually arms and legs. We want to make sure people don't get severe joint limitations. I think if the PT, RA or CNA but if there is a more complex patient then it may be something not meant to be aggressive. We had an OT who was training the staff. That was the main topic about ROM and she actually gave me feedback that it was inconsistent. I do believe that their are are some CNAs that do ROM while doing their ADLS but there are some CNAs just putting on their shirt and counting it as ROM. We have to do a program for the CNAs on the same page because of the inconsistency. Regarding R35, there is some miscommunication that she was declining everything. I would agree it's not an all inclusive. Do you get a list from short term and long term - where is the pickup. We tend to communicate more verbally. Can't put everybody in an RNA because there are too much people in this building. I make the RA schedule, sometimes people will come up and then get off depending on the PT or R[NAME] Before there was no list. This is a starting list. The problem is that if we had a specific list of people . We need a little more help. It's tricky with one RA being on vacation and the other RA is not able to do all the residents. There is not a clear back up system. I've talked with the administrator. We want to treat all the clients. Some staff are capable of doing their own work. It's hard to decide who to put on the list. It's nice to put people on the list who are motivated. It's hard to work with people who like you are pulling teeth to work with. Even when we communicate it properly, some CNAs work with us and some don't. Interview on 10/02/19 at 10:27 AM with the IDON and inquired how changes made by PT are communicated and integrated into the Nursing CP. Surveyor shared the process as described by DR. DR says that they discuss the plan with IDON, if there are changes. Also quoted the policy that was issued 08/17/2018, it stated, It is the policy the Rehab Service Manager will meet monthly with DON, ADON or designee for program review. IDON stated so the plan is active in nursing plan for the CNAs to see. RA55 says he meets with you and how does the nursing Careplan get changed. If RA55 will meet with me, I will change the Careplan but I only became interim DON recently. RA55 also goes to to the administrator. and also with LTCC114. It should be communicated to the LTCC so that they can follow through on it. RNA program was not done by the facility for R35 for one month. The Careplan was not discontinued nor revised to include maintenance services to the R35. 2) R3 was admitted to the facility 02/20/17. She had mobility deficit due to [MEDICAL CONDITION] following a stroke affecting her Left (L) side. R3 requires extensive assist in the areas of dressing, bed mobility, transfers, personal hygiene and toileting. On 09/27/19 at 09:00 AM, during an interview with R3, observed she was unable to move her Left (L) arm. Asked R3 if she was getting physical therapy (PT), and she said, No. Inquired if staff did range of motion (ROM) exercises with her, and she said they did not. R3 demonstrated how she was able to lift her L arm hand using her right hand/arm to pull it up. Asked if staff encourage her to do that, and she replied, No. Record review (RR) of R3's Care Plan (CP) revealed an active intervention of Passive LE (left extremity) ROM 2-3x's to start 07/09/18 to include: B (Bilateral) foot stretch in the direction of dorsiflexion 30 sec. (seconds) hold x3 sets or to patient tolerance. The responsible staff designated to complete the therapy was the RA (Restorative Assistant). The current Kardex (used by staff for reference of tasks) also indicated R3 was receiving these exercises. RR of the Rehab (rehabilitation) Services Screen dated 03/28/19 documented, No PT/OT (occupational therapy) indicated. Currently on RNA (RA) program. On 10/01/19 at 01:38 PM during an interview with RA55, inquired what therapy R3 was currently receiving. RA55 stated, Use to do the stretches of her feet, but she complained it hurt. If continues to say it hurts, we stop and report it to Director of Rehabilitation (DR). It was decided to put a bolster at the foot of her bed (helps prevent foot drop). Asked if ROM was being done on R3's L extremities, and RA55 said no, it's a package. We aren't doing the stretches, so don't do the ROM. Review of the facility policy number RS-GEN-48 titled, Transition of care following termination of therapy services dated (MONTH) (YEAR) states, the following: C. The new or updated FMP (functional maintenance program) or restorative program will be entered into Point Click Care (electronic medical record) to be executed by certified nursing assistants or restorative aides. D. The new or updated FMP or restorative program will be entered into that resident's care plan and reviewed by rehab department and restorative nurse or designee on a monthly basis. On 10/02/19 at 10:31 AM during an interview with IDON reviewed R3's active CP that indicated R3 was to receive passive LE (Left extremity) ROM, and foot stretches. Informed IDON that the DR, and RA55 said R3 was no longer receiving the exercises listed in the CP. Inquired how PT staff communicate therapy changes to nursing, and how they are integrated into the CP. The IDON said, it should be communicated to the Long-Term Coordinators (LTCC), who would update the nursing CP and Kardex. Informed IDON that DR said he meets with IDON about changes to therapy, but unsure how the CP was updated. IDON said if he meets with me, I will change the CP, but I only became interim recently. He (DR) goes to Administrator and talks her, and sometimes he talks to the LTCC's. It should be communicated to the LTCC so they can follow through on it. IDON agreed the process needed to be improved and that R3's CP had not been revised. 3) R69 was admitted to the facility on [DATE]. He had impaired mobility related to generalized weakness and right(R) arm, R hip and left leg pain associated with muscle spasm and neurological damage due to lumber and cervical spine [DIAGNOSES REDACTED] (disease of the spinal cord). R69 had potential for impaired skin integrity related to his lack of mobility and had a history of [REDACTED]. On 09/27/19 at 13:30 PM during an interview with R69, noticed a deflated air mattress on the bed and asked him if he knew it was deflated and why. R69 said the mattress and pump had been given to him by someone and that he didn't think the pump was working. R69 said it use to work and they have looked at it a couple of times. RR revealed on page 11 of R69's CP an active intervention to prevent skin breakdown was to Apply pressure relieving devices while in bed. Page 12 of the CP states, (MONTH) have low air loss replacement mattress .provide pressure relieving devices for bed and wheelchair. On 10/30/19 at 02:00 PM, during an interview with LTCC114, she said, the air mattress R69 has on the bed was given to him and I believe the pump is broken. It works for awhile, and then doesn't. Proceeded to R69's room and confirmed the pump was not working. LTCC114 said the maintenance department couldn't work on it because it's not ours. Reviewed R69's CP with LTCC114 and asked why R69 didn't have a working air mattress since it was in his CP. LTCC114 explained R69 use to have a PU but it resolved a long time ago. The CP should have been updated. We use the air mattress's when they have a PU. 4 ) R59 was admitted to the facility on [DATE] after an acute hospital stay and started long term care (LTC) skilled rehabilitation services (physical and occupational therapy (PT/OT)) for short stay rehabilitation . One care plan was for mobility deficit related to activity tolerance, disease process, generalized weakness, impaired balance and pain. The goal by the PT was that R59 would improve in his level of function in bed mobility from moderate assist to minimum assist by review date. This care plan was revised 8/13/19 (the date of admission) by PT, with a target date of 11/14/19. The OT therapy care plan also had the same revision and target dates. Review of the facility's policy, issued 8/17/2018, it stated, It is the policy that there shall be a Restorative Assistant (RA) program to assist and guide residents following the completion of skilled rehabilitation. Areas cover include but not limited to ambulation, UE/LE exercises, range of motion (ROM), and restorative dining . Upon discharge from skilled rehabilitation, therapists will design appropriate RA program for Resident as needed . Rehab Service Manager will meet monthly with DON, ADON, or designee for program review. On 10/01/19 at 02:30 PM, during an interview with RN103, she was asked whether R59 was receiving any restorative or maintenance therapy since his skilled rehabilitation (skilled rehab) ended. RN103 said she did not see any orders for it and verified he was discharged from skilled rehab on 08/25/19. Upon further query as to what happened when a resident was discharged from skilled rehab services and if maintenance therapy was provided, RN103 said there would be an order for [REDACTED]. On 10/02/19 at 09:09 AM, during an interview with the Director of Rehab (DR), he said, I do think there's still a gap between nursing and the restorative program. The DR also said he did not know what happened to the transitional part for R59, but that it was important and for the PT/0T care plan, since R59 was no longer receiving skilled service, that it should have been discontinued. Per the DR, The whole process needs changing. During an interview with RN103 on 10/02/19 at 09:40 AM, she verified R59's skilled rehab care plan were no longer current since he was discharged from rehab therapy for PT and OT services. RN103 concurred that nursing has to look at the transition process when rehab services ended. This was not done by the facility for R59. In addition, R59's PT/OT care plans were revised on the date he was admitted (08/13/19); however, on the date he was discharged from PT/OT services on 08/25/19, the two care plans were not discontinued nor revised to include any transitional or maintenance services to be provided to him.",2020-09-01
267,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-10-02,688,E,0,1,HX9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) On 09/27/19 at 12:05 PM, during an interview with R59, he stated he could walk with the use of a walker, but also used a wheelchair for mobility. When R59 was asked about maintenance exercises, he said that he was just doing it, on my own. When I stay inside this room, I wiggle my legs and push it off . When he was asked if he could walk at all, R59 said he could with the walker, and then sat in the wheelchair when he tired. R59 said at this time the staff were not encouraging him with his exercises and reiterated he did them by himself by wiggling his legs and toes. R59 was admitted to the facility on [DATE] after an acute hospital stay and started long term care (LTC) skilled rehabilitation services (physical and occupational therapy (PT/OT)) for short stay rehabilitation . One care plan was for mobility deficit related to activity tolerance, disease process, generalized weakness, impaired balance and pain. The goal by the PT was that R59 would improve in his level of function in bed mobility from moderate assist to minimum assist by review date. This care plan was revised 8/13/19 (the date of admission) by PT, with a target date of 11/14/19. The OT therapy care plan also had the same revision and target dates. On 10/01/19 at 09:56 AM, during an interview with CNA104, she said the resident improved in his functional level a lot. CNA104 said when he was first admitted , R59 needed another person to move him, position him and pull him up. CNA104 verified R59 had received PT and OT, and said, It's already ended. Yes, he's been doing exercises on his own, and if we change him, we tell him to do like move his arm around, leg around, so he doesn't like. I was telling him earlier, to exercise his legs. She said they have a restorative aide (RA) program, but was not sure if R59 was enrolled in it. During an interview with RA55 on 10/01/19 at 01:47 PM, he said R59 was not on his list for restorative services. RA55 said the PTs were the ones to write the RA orders and they just followed it. On 10/01/19 at 02:30 PM, during an interview with RN103, she was asked whether R59 was receiving any restorative or maintenance therapy since his skilled rehabilitation (skilled rehab) ended. RN103 said she did not see any orders for it and verified he was discharged from skilled rehab on 08/25/19. Upon further query as to what happened when a resident was discharged from skilled rehab services and if maintenance therapy was provided, RN103 said there would be an order for [REDACTED]. Record review found for R59, from 09/19/19 - 10/2/10, his walk in room self performance (how resident walks between locations in his/her room), showed this activity did not occur. For his transfer self performance (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position, excluding to/from bath/toilet), this activity also did not occur for these days, except on 09/24/19. There also were no specific range of motion exercises (ROM) to be done, although CNA104 said in her interview she would instruct R59 to do arm and leg exercises. Review of the facility's policy, issued 8/17/2018, it stated, It is the policy of . that there shall be a Restorative Assistant (RA) program to assist and guide residents following the completion of skilled rehabilitation. Areas cover include but not limited to ambulation, UE/LE exercises, range of motion (ROM), and restorative dining . Upon discharge from skilled rehabilitation, therapists will design appropriate RA program for Resident as needed . Rehab Service Manager (Director of Rehab) will meet monthly with DON, ADON, or designee for program review. On 10/02/19 at 09:09 AM, during an interview with the Director of Rehab (DR), he said, I do think there's still a gap between nursing and the restorative program. The DR also said he did not know what happened to the transitional part for R59, but that it was important and for the PT/0T care plan, since R59 was no longer receiving skilled service, it should have been discontinued. Per DR, The whole process needs changing. During an interview with RN103 on 10/02/19 at 09:40 AM, she verified R59's skilled rehab care plan were no longer current since he was discharged from rehab therapy for PT and OT services. RN103 concurred that nursing has to look at the transition process when rehab services ended. This was not done by the facility for R59. 2) R3 was admitted to the facility 02/20/17. She had mobility deficit due to [MEDICAL CONDITION] following a stroke affecting her Left (L) side. R3 requires extensive assist in the areas of dressing, bed mobility, transfers, personal hygiene and toileting. On 10/01/19 at 10:15 AM observed a sign taped on the wall across from R3's bed. The sign was a picture of a wedge foot bolster (used to keep feet in functional position and prevent foot drop) and how R3's feet should be positioned. At that time observed that neither of R3's feet were touching the bolster as in the picture, and in fact one leg was crossed over the other. Interviewed R3 and asked if she could move her feet to touch the bolster, and she replied, No. R3 said, RA55 put the sign there, and when he finds it not in place, points to it and says picture, picture. Asked if RA55 was aware the nursing staff were not consistently positioning her as recommended, and she said, yes. On 10/02/19 at 11:00 AM second observation that the wedge bolster was not in place. Record review (RR) of R3's CP directed staff to, Apply footdrop wedge bolster to feet. On 10/01/19 at 01:41 PM during an interview with RA55 inquired what R3's restorative care program currently was. RA55 said, Use to do the stretches of her feet, but she complained it hurt. If continues to say it hurts, we stop, and report it to DR. The DR would document and determine the next step. It was decided to put a bolster at the foot of the bed. Reviewed the Nursing Care Plan (CP) and Certified Nursing Assistant (CNA) task list with RA55. RA55 said, Ours is totally different, now only has the bolster.Asked if ROM was being done on R3's L extremities, and RA55 said no, it's a package. We aren't doing the stretches, so don't do the ROM. Informed RA55 that R3 shared he (RA55) often checks on her, and was aware nursing was inconsistent using the bolster as recommended. RA55 stated, Yes, I check on her daily cause not doing the exercises. Sometimes it's (bolster) there, and sometimes its not even on the bed. Asked RA55 if he had brought this to the attention of the nursing staff, and replied he had several times. On 10/02/19 at 09:05 AM during an interview with Director of Rehab(DR), he stated R3 had been in and out of the program (Restorative Assistant Program). She started getting weaker and showing some decline, so started Range of Motion (ROM) and stretching, mostly to try to position her correctly in bed. She would sometimes tell the RA she didn't need it today .I think we should have looked at it differently, and find out why not wanting to do the program. It's going to be uncomfortable sometimes. I think I'm going to take another look at it. Inquired why they stopped doing R3's ROM exercises to the L extremities when the foot stretches were discontinued. DR said, I was under the impression that she had declined. Informed DR that RA55 said the program was a package so the ROM exercises too. DR agreed the R3's program was not a package and the other exercises should not have been discontinued. Asked how often the Rehab Services Screenings are completed, and DR replied usually quarterly. RR revealed P3's last Rehab Services Screening was dated 03/28/19. DM confirmed R3's screening was overdue. There was no documentation provided that R3 declined the ROM exercises.",2020-09-01
268,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-10-02,700,D,0,1,HX9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review (RR), the facility failed to obtain informed consent for the installation of an assist bar (grab bar) on one of one Resident (R) 69 sampled. As a result of this deficient practice, there is the potential that R's with grab bars were not provided the information needed to make an informed decision and provide consent for use of the grab bar. In addition, R69's quarterly assessments for use of the grab bar, but did not identify they were not meeting his specific needs. Findings include: 1. On 09/27/19 at 10:04 AM observed R69 to have several bruises on both arms. During an interview at that time, R69 said, I have sensitive skin and bruise easily. I hit them (arms) on these things (demonstrated hitting his arms on the grab bars attached to the bed). These don't help me. R69 demonstrated how he had to turn and awkwardly twist to reach the grab bar in order to reposition or turn himself. R69 said,They are too high (placement of grab bar on the bar). No matter how flat I put the bed, they are still too high. When they transfer me to a gurney, they have to pull me down in bed with my legs over the footboard to slide me over. R69 stated I asked them why they have these things (grab bar) on, and they told me the State said we have to have them. The grab bars were observed to be bolted on, unable to be released, and located in a place on the bed that was difficult for R69 to reach. 2. RR of R69's active Care Plan (CP) revealed, (MONTH) use grab bars to assist with mobility and transfers. RR of the Side Rail/Device assessment dated [DATE] indicated the use of Grab bars, to assist the resident with: 1. Bed positioning and mobility, 2. Transferring in and out of bed, 3. Daily Care, and 4. Ability of rising from a supine position and or standing position. The effectiveness of the grab bar as an enabler to reposition self was limited by the location of the bar. 4. On 09/30/19 at 10:30 AM during an interview with Certified Nursing Assistant (CNA)92, asked how they move R69 to a gurney. CNA92 said they pull him down for clearance of the bar and then slide him over. Asked if his legs extended past the foot board and she said, yes. CNA92 went on to say the grab bar made it more difficult sometimes to provide care because it could not be released. 5. On 09/30/19 at 11:45 AM, during an interview with LTC (Long Term Care Coordinator)114, asked if she was aware of R69's concerns about his grab bar and that he had been told the State required them. LTC114 was not aware of his concerns, and felt he probably misinterpreted a conversation with someone about why this grab bar replaced the old one. 6. Review of the Bed Rails policy number NRS-LTC-021 revised 09/06/19 revealed the policy definition of bedrails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eight lengths. Also, some bedrails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of the bed. The policy also states, The facility must obtain an informed consent from the resident . 6. On 10/02/19 at 11:05 AM during an interview with the Interim Director of Nursing (IDON) she said, The previous bedrails had to be replaced because the spacing was not correct. We replaced them with the grab bar. The IDON was aware how staff transfer R69 to a gurney, but said he usually is transferred to a wheelchair. IDON was not aware R69 had expressed concerns about the grab bars, and that they were not meeting his needs. IDON said, R69 needs them for positioning. Discussed the need to assess that the grab bar meets the residents needs, and that they are considered a side rail that requires informed consent. IDON was not aware a grab bar was considered a siderail.",2020-09-01
269,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-10-02,726,D,0,1,HX9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and document review, the facility failed to assure that all nursing staff possessed the knowledge necessary and develop consistent behavior to label control solutions for blood sugar monitoring. As a result of this deficient practice, there is the potential to get inaccurate blood sugar readings. In addition, the facility did not provide staff with education needed to properly use a new urinary bag that resulted in urine leaking out of bag. There is the potential that all residents could be affected if staff do not have the knowledge to perform roles successfully. Findings include: 1) During an observation on the 2nd floor nursing unit on [DATE] at 02:57 PM, it was found there were two Accu-chek glucose control solutions with handwritten labels on it. These labels were dated, [DATE] - [DATE]. Per Registered Nurse (RN)103, she verified both of the control solutions were outdated and had to be discarded. RN103 said this was their hospital policy. Review of the hospital policy, Accu-chek Inform II Glucose Monitoring System, Policy No. NRS-GEN 124, last revised ,[DATE], stated, Reagents are not used past their expiration date. Accu-chek Inform II control and linearity solutions expire on the date printed on the vial label, or 3 months from opening, whichever comes first. Whenever an operator opens a vial of controls or linearity solution, he/she must handwrite the expiration date on the vial. That date will be either 3 months from opening or the date printed on the vial label, whichever comes first. This was not followed by the nursing staff on the second floor. On [DATE] at 10:20 AM, the interim Director of Nursing (IDON) submitted an in-service education record, which was titled, Glucometer control solutions; Change control solutions to glucometer every 90 days. The IDON said she started her in-service on this for the nurses due to the finding of the expired control solutions. 2) On [DATE] at 10:00 AM, noted yellow liquid on the floor in Room ,[DATE] under R69's urinary catheter bag (foley). The fluid extended approximately one foot from the bed, and there was a disposable wipe in the middle of it that was soaked. At that time, interviewed R69 who said, I think they got a bad batch of bags (foley urine bags). It leaks all the time. They cleaned it up this morning. Is it leaking again? Then asked R69 if he knew why it kept leaking, and he said, they change bags a lot, but it keeps happening. On [DATE] at 10:15 AM, interviewed Certified Nursing Assistant (CNA)29, who stated she would clean the floor up and check R69's foley bag. CNA29 said she was a floater, and wasn't aware of any specifics regarding his foley bag, or issues of it leaking. On [DATE] at 02:59 PM, during an interview with first floor Long Term Care Coordinator (LTCC)114, she said the unit recently had a new foley bag that had been sent to them. She said, It just showed up on the floor. We use what they bring us. LTCC114 further explained the hospital purchasing department orders the supplies and, we use whatever they bring. Inquired if the staff are informed when a product/equipment change is made so they can assess if education needs to be done on the new product. LTCC114 replied, Not to my knowledge. When I saw it, I had to ask one of the Certified Nursing Assistant how to use it. The new foley bag (Steri-Gear The fig leaf) was examined. The foley back has a blue cover with a fig leaf that hides the urine bag and makes it less identifiable as a urine bag. The drain valve on the outlet tube to drain the urine from the bag is different from the other foley bag that clamped to close off the tube. The new foley does not have a clamp and the drain valve needs to be positioned correctly to close off the outlet tube to prevent drainage of urine out of the bag. On [DATE] at 03:00 PM, during interview with Interim Director of Nursing (IDON), she said they changed products and switched to a foley bag that has a cover so you can't see the urine in the bag. Inquired if staff are notified if a product is changed, and the IDON said, The hospital purchasing department is suppose to email me. The IDON was unable to locate an email about the product change. Due to this finding, the IDON started staff education on the new foley bag.",2020-09-01
270,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-10-02,761,E,0,1,HX9X11,"Based on observation and interview, the facility failed to properly store a medication for a resident that was unlabeled in a medication cart. The facility also failed to appropriately discard an open can of thickener that was stored in the medication cart. This deficient practice has the potential to increase a risk for illness for residents residing in the facility. Findings include: During a random inspection of the medication cart on 2nd floor C on 10/02/19 at 01:27 PM an unlabeled medication cup containing four pills was found in the medication cart drawer. Registered Nurse (RN)40 responded, that medication is for a resident who was sleeping during the med pass, I put it in the cart to give later. I forgot to label it. In the same cart, an opened can of thickener was found in the bottom drawer with an opened label dated 06/16/19. When asked when the opened medications and/ or supplements get discarded RN96 responded I think it needs to be thrown away monthly. Unfortunately, when we open a can of thick it, much of it gets wasted since we don't have too many residents who use it, we need to use the smaller packets, it would be better. 2) Review of the facility's policy, Storage of Medications, Policy No. WNRC-RX-021, last reviewed, 08/23/2019, stated, Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations . The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized authorized to administer medications. During an observation of RN8 on 09/27/19 at 01:16 PM, there were three pre-filled normal saline (NS) syringes left in the IV pole tray which was at R128's bedside. The State Survey Agency (SA) asked RN8 to verify what those were, and she said those were the NS syringes used to flush the resident's intravenous (IV) line. RN8 said, I unwrapped one, and confirmed the other two NS syringes had been unwrapped and left there. It was not certain whether the two NS syringes had been used or not. RN8 said, Yes, it's not a good practice, and said the NS syringes were probably left there for staff convenience. RN8 acknowledged it also would not be safe practice to leave it unattended at the bedside and that she would not have used the two syringes that had been unwrapped. RN8 stated she would be discarding those.",2020-09-01
271,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-10-02,803,E,0,1,HX9X11,"Based on observation, resident interview and record reviews, the facility failed to provide the residents with local foods they have specified are important to them. This deficient practice doesn't allow the resident to have food choices that meet their cultural preferences. Findings include: 1) On 09/27/19 at 01:03 PM, R35 stated I dont like my food. It's the taste. I cant stand chicken anymore. I asked for small portions but still I cant. Its just the way they prepare it. I have gout so I cant eat pork and fish - I used to eat my fish at home. 2)On 09/30/19 at 10:33 AM interview with R54 who states I feel like the food needs to be geared more towards local people. It cannot be always pasta, pasta, pasta. 3) During the initial tour and interview with Resident (R)34on 09/27/19, who said, the food is not so good. It's chicken, chicken, chicken every time, just the gravy is different. We're eating things we never had before like ravioli. I want like stuff cabbage. Electronic Medical Record (EMR) reviewed. The Dietary progress note dated 08/07/19 stated, Nutritional risk note. Current body weight (CBW): 100.8 pounds (lbs.). Noted resident is under hospice care. Weight has been stable between 100-105 lbs. continue to monitor per care plan. Continue to provide nutrition as comfort. Review of the dietary menu's revealed a variety of food choices with the main course foods like chicken, fish and pasta. The carbohydrates are most often potatoes. During an interview with the Dietary manager and Chef on 10/02/19 at 12:39 PM, when asked if they receive feedback from any of the residents about the food, the chef stated that yes, there are a few residents who complain, and we have been working on the new menu, should be rolling it out in another month. The dietary manager added that they have said that they would like to have more local food. We have asked the residents to choose a local favorite and we had a vote. Last month the residents chose chicken long rice. We have been working on the menus, and have offered selections like Chicken Hekka, chicken long rice, etc. It went okay but we needed to improve the recipe. We are still working on the menus. During a discussion with Registered Nurse (RN)103 and RN40 on 10/02/19 at 10:45 AM, when asked if the residents have had complaints about the food, they responded, yes, we hear complaints that there is not enough local food being served. The dietary manager has been addressing it with the staff and they are trying to make it better. She added, It's hard to please all of them. The residents would like to eat rice as a regular starch, but potatoes are often provided. Per feedback from the Resident Council meeting on 10/01/19 at approximately 2 pm, it was stated, the dietician used to come to the resident council meetings, but we weren't speaking up very much, so they probably stopped coming. We always have the same food, they have no imagination how to change the menu, (it's always chicken). they are from the mainland and don't know how to cook the local food. Review of the resident council minutes for (MONTH) stated that the new menu is coming up in a few months, the chef asked for recommendations. The residents suggested Hawaiian food like chicken long rice.",2020-09-01
272,WAHIAWA GENERAL HOSPITAL,125015,128 LEHUA STREET,WAHIAWA,HI,96786,2019-10-02,880,D,0,1,HX9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure appropriate hand hygiene was performed before the start of an intravenous (IV) medication for one resident (Resident (R) 128). In addition, the facility also did not change the [MEDICATION NAME] suction catheter timely for one Resident (R63) in the sample, which increased the risk of spreading contaminants that may cause infections or potentially transmit infections. This deficient practice had the potential to affect all residents residing in the facility. Findings Include: 1) 09/27/19 at 01:06 PM, Registered Nurse (RN)8 was observed at the bedside of R128 to prepare and administer an IV antibiotic medication. RN8 set up the IV medication on the IV pole and the IV tubing. However, with her clean gloves on and prior to priming the IV line with the medication, RN8 grabbed the resident's rubbish can to bring it closer to her and set it down. RN8 then turned to get the IV tubing and began priming the line. RN8 failed to change her gloves after touching the rubbish can, and failed to perform hand sanitization before priming the IV line. On 09/27/19 at 01:16 PM, RN8 acknowledged she failed to change her gloves after touching the rubbish can. RN8 said, Thank you, I'm going to remove them right now. Review of the facility's policy, Hand Hygiene, Policy No. IC-006, it stated, All personnel will use the hand hygiene techniques, . recommended guidelines on when to use non-antimicrobial soap and water, an antimicrobial soap and water or an alcohol-based hand rub . After contact with medical equipment/supplies in patient areas. There was a failure by RN8 to discard her gloves after touching the rubbish can and not performing hand hygiene prior to performing a clean technique for medication administration. 2) R63 was severely cognitively impaired with history of dementia, [MEDICAL CONDITION] and was totally dependant on staff for activities of daily living. She had difficulty swallowing and nutritional needs were met by tube feedings. R63 periodically required oral suctioning for secretions. On 09/27/19 at 09:00 AM, observed suction set up on a table next to R63, which included a suction canister to collect secretions, tubing and a [MEDICATION NAME] suction catheter (a hollow rigid tube made of disposable plastic and used to facilitate removal of oral secretions). The Yankhauer catheter can be reused frequently, but must be changed to minimize risk of contamination and infection. The Yankhauer suction was observed to be stored in the original wrapper that was dated 09/11/19. On 09/27/19 at 09:15 AM asked Licensed Practical Nurse (LPN)16 to look at the [MEDICATION NAME] suction in R63's room. LPN16 confirmed the date written on the package was 09/11/19. At that time asked LPN16 how often the [MEDICATION NAME] suction is changed, and she replied, I think it's every week. LPN16 later provided the facility policy and stated, The catheter is suppose to be changed every day. Review of the facility Policy Number NRS-CP-010 titled, Suctioning states, To establish guidelines for the removal of secretions from the patient's airway will be performed using appropriate method and following specific guidelines to minimize the risk of .infection. The policy directs staff to Open catheter kit, or [MEDICATION NAME] package, mark date and time on [MEDICATION NAME]. [MEDICATION NAME] may be reused for 24 hours.",2020-09-01
273,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2019-01-04,689,G,1,0,NTJS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews and facility incident report the facility failed to provide adequate supervision and assistance in use of a Hoyer-lift to transfer a resident (R1) from the wheelchair back to bed. As a result of this deficient practice, R1 slipped out from the Hoyer- lift sling, fell on to the floor and sustained a skull laceration. Findings Include: On 01/03/2019 at 10:15 AM, an abbreviated survey was conducted to investigate an unrelated complaint allegation (#7219) on quality of care issues and observed facility staff on Unit 2. During observations noticed a visitor/care giver (CG) at R1's bedside and another resident in a wheelchair at R1's bedside with the CG tending to both residents. Interviewed the CG and she identified herself as R1's guardian and the resident in the wheelchair was from another room and visiting with R1. The CG explained that both residents roomed together in their previous facility for fifteen years and now resided in this facility in separate rooms. The CG was a retired special education teacher and taught both residents when they were younger, and so familiar with both. The CG stated that she acted as R1's guardian and visited daily from 9:00 AM to 6:00 PM and provided one-on-care to R1. The CG also brought the other resident (former roommate) to R1's bedside for stimulation as both had profound intellectual disabilities. Observed the CG talking to both residents, repositioning R1 in bed with pillows and wedges and called a certified nurses aide (CNA) when needed assistance. Reviewed the electronic medical record (EMR) on R1 to review care plan (CP) interventions. The resident had a CP focus for activities of daily living (ADL) self-care performance deficit due to, PVS, mental [MEDICAL CONDITION], spastic [MEDICAL CONDITION], and Hx of TBI during childhood. Being totally dependent in all ADLs, interventions for R1 included that required mechanical lift with 2 staff assistance for transfers. Under the CP focus high-risk for falls due to functional status, it was noted, 08/27/18 Accidental fall during transferring from wheelchair to bed when res slid off from sling using the Hoyer lift. The intervention section noted Do 2 staff assistance during all transfers using Hoyer-lift. Make sure sling secured prior to lifting Hoyer-lift. Created date: 08/28/18. On 01/03/2019 at 11:00 AM returned to Unit 2 and interviewed R1's CG regarding the fall from Hoyer-lift on 08/27/2018. According to the CG, R1 fell from the Hoyer-lift sling as the resident was lifted from the wheelchair to be placed back to bed. The CG demonstrated how she assisted the CNA by pulling the wheelchair away from R1 as the CNA operated the Hoyer-lift with R1 in the sling. Inquired of CG where the other CNA was standing and the CG stated that there was only one CNA and herself transferring R1. The CG further stated that the left clip of the sling became unhooked and R1 slipped out of the sling and fell approximately 3 feet to the floor. The CG was pulling R1's wheelchair backward away from the resident and was unable to break the fall. The resident was sent to a nearby acute hospital emergency department (ED), and a CT scan was done. According to the CG, R1 sustained a two inch gash to back of the head. In the ED, the wound was glued to hold the skin together because the cut was not deep, and the wound healed within a week. On 01/03/2019 at 11:45 AM interviewed the facility's director of nursing (DON) and requested falls with injury incident reports (IR) in the past 6 months that were not reported to the State agency (SA). The DON provided a batch of IRs but there was none for R1's fall, so honed down request for any accidents that occurred in (MONTH) (YEAR) not reported to the S[NAME] The DON then recalled R1's fall from the Hoyer-lift and stated that the IR was not sent to the SA because it was a witnessed fall. The DON recalled that there were two CNAs at R1's bedside but the CG assisted one CNA with the Hoyer-lift and the other CNA was on the other side of R1's bed. The IR for R1's fall was provided by the DON and documentation of the facility's investigation noted that there was one CNA present with the CG assisting when R1 slipped out of the sling and hit head on floor. The IR also noted that R1 was transferred by ambulance to the ED and was treated for [REDACTED]. Verified IR documentation with the DON and she stated that the IR is accurate. The DON further stated that the CG is with R1 daily and was there with the CNA, so there were two people transferring R1 with the Hoyer-lift. On 01/03/2018 at 3:15 PM interviewed the CG to further verify if there were one or two staff present during R1's fall from Hoyer-lift sling on 08/27/2018. The CG stated that there was only one CNA and herself transferring R1 with the Hoyer-lift. The CG further elaborated that sometimes there are 2 CNAs to transfer R1 with the Hoyer-lift and sometimes just one CN[NAME] Inquired of the CG if she was trained by the facility on use of the Hoyer-lift and she stated, No. The CG stated that after the accident on 08/27/2018, the facility's rehab nursing assistant (RNA) re-educated the two CNAs that were responsible for R1 on 08/27/2018. The CNAs were shown where they should stand when operating the Hoyer-lift. The CG also stated that different size slings were tried on R1, but back to the same size sling on date of fall. Inquired of the CG if she knew how to report to the SA when accidents/incidents occurred. The CG response was that she promised the facility administration that would work with them when issues arose instead of reporting to the S[NAME] The CG further elaborated that R1 needed to be placed into a facility when the previous facility shut-down and R1 was the last resident to find another placement. The CG stated that when she comes to the facility daily, she spends time with three other residents in the facility besides R1, and acts as guardian to a female resident in the room next door to R1. The CG stated that previous reports to the SA were made on behalf of the other female resident she is guardian for, and made agreement with facility administration that would work with facility before reporting to SA so that R1 could also be placed at this facility. Observed the CG suctioning R1's secretions through the tracheotomy (trach) opening and queried if had training. The CG stated that the facility trained her how to properly suction R1 through [MEDICAL CONDITION] was taught proper technique by the respiratory therapist. On 01/04/2019 at 8:34 AM interviewed the RNA who reportedly trained the CNAs on proper Hoyer-lift use. According to the RNA, staff was shown how to properly transfer R1 in the Hoyer-lift per CG request when R1 was transferred from Unit 1 to Unit 2. The RNA stated that he had [AGE] years experience using the Hoyer-lift but the device company provided training to staff on proper use. The RNA stated that staff are corrected if observed using Hoyer-lift to transfer a resident by themselves; and, reminds staff to protect themselves as well as the resident. The RNA could not recall the last time the Hoyer-lift representative came to train staff. The RNA stated that staff should be following the Kardex on the computer and that if a resident is totally dependent that means a Hoyer-lift is needed, and always two staff to use Hoyer-lift. The RNA stated that R1 fell from the sling because one side of the sling became unhooked and the resident slid out. After the fall, different size slings were tried but R1 had the correct size sling on date of the fall. On 01/04/2019 at 9:15 AM interviewed the staff development coordinator (SDC), and he stated that the RNA, the two CNAs responsible for R1 on the day of the accident, besides himself were present when the Hoyer-lift representative came to train on proper usage of the Hoyer-lift. The SDC stated that the CG knew how to use the Hoyer-lift because with R1 for many years. Inquired if the facility allows family/guardians to operate Hoyer-lift, and the SDC stated that should be two trained staff to operate. Requested documentation of staff trained by Hoyer-lift representative and the SDC did not have information on the premises but could provide by the afternoon. On 01/04/2019 at 11:00 AM the DON provided a sign-in signature sheet for, TOPIC: Hoyer-Lift Transfer; DATE: 8/27/18 o 9/2/18, and attached Total Mechanical Lift Competency Checklist, with inservice only written in black ink above the title and the form was not completed for staff, date, etc. The facility did not provide documentation of staff trained by the mechanical lift device representative by the time of the exit conference at approximately 3:00 PM . An avoidable accident occurred because the facility failed to implement interventions, including adequate supervision in use of the mechanical lift device, consistent with R1's needs, care plan and current professional standards of practice.",2020-09-01
274,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,574,D,0,1,5K7411,"Based on observation and interview, the facility failed to provide the information on how to file a grievance and place the forms in an accessible location for the residents residing in the facility. The facility failed to provide the contact information for the State long term care ombudsmen. Findings include: Surveyor and DON did a walk through on 01/31/20 at 0[AGE]0 AM to look for the written forms for the residents to file a grievance. The form on unit (U)3 was located at the nurse's station. DON stated that the form is given out when a resident request it from the staff. So, it is the responsibility of the staff to follow through and give the form to the resident. The family and residents upon admission are educated about the process for filing a grievance. Surveyor shared that the resident's at the resident council meeting reported they did not know about the grievance form or the process. The residents stated that in the past they have taken their concerns to the supervisor or manager and and that it goes nowhere. The DON stated its her goal to educate the residents about the location and use of the grievance form. Surveyor and DON observed the bulletin board located on U4, and VC1. The residents from the other units would have a very difficult time accessing the information posted there due to the pathway to the elevator. The DON agreed that it is not visible for the residents and stated that she would probably be moving the board to a better location. DON agreed that the residents are not aware of the process and need to be educated.",2020-09-01
275,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,576,D,0,1,5K7411,"Based on interviews during a resident council meeting on 01/30/20 at 10:00 AM, and staff interview, the facility failed to provide services for residents to receive mail, letters and packages and other materials on Saturdays. Findings include: Surveyor attended an abbreviated Resident Council (RC) meeting on 01/30/20 at 02:27 PM with 14 residents in attendance. The residents stated We don't get our mail on Saturdays. The front desk does not work. Surveyor interviewed Staff (S)156 on 02/03/20 at 09:39 AM. S156 stated that the mail is distributed from the front desk to the units. One ward clerk distributes the mail. However, on Saturdays, we don't accept the mail. The mail will all be accumulated on Monday and delivered to the units and residents. The mailman does not come Saturday and Sunday because no one will be here to accept the mail.",2020-09-01
276,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,578,D,0,1,5K7411,"Based on interview, record and policy review, the facility erroneously documented that Resident (R) 111 had a copy of an advance health care directive (AHCD) in his medical chart. No current copy of R111's AHCD was found in the resident's medical record as indicated on his admission paperwork dated on 01/06/2020. Findings include: 1. In the Resident Agreement for R111, dated 01/06/20, under Admission Acknowledgements, the box was checked for I have provided an Advanced Healthcare Directive. No AHCD was found in the electronic and paper chart for R111. On R111's care plan, it was stated that R111 declined having an AHCD. In an interview with the social worker (SW) 1, on 01/31/20 at 02:35 PM, she stated that R111 had been declining to complete his AHCD. The facility's Policy & Procedure on Advance Directives state, Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.",2020-09-01
277,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,584,D,0,1,5K7411,"Based on observation and interview, the facility failed to provide necessary maintenance services to ensure a clean, comfortable and appealing room with adequate lighting levels. The deficient practice has the potential to affect the residents highest practicable well being. Findings include: During a tour of Resident (R)122's room on 01/29/20 at 11:30 AM, noted the exterior wall was constructed of several windows. In the center of the windows an air conditioner unit was mounted to a wooden frame. The wood that framed the air conditioning unit appeared unpainted in poor condition with soiled, brown and black debris. The windows had several yellow curtain panels missing which gave the room a tattered appearance. The missing curtains allowed very bright light to shine into the room. During an interview with the Maintenance Supervisor on 02/03/20 at 10:00 AM, revealed the appearance of R122's room, and discussed the concerns with the missing curtain panels and old wood around the air conditioner. The maintenance Supervisor agreed that the room is very bright and adequate curtains are necessary, and a replacement of the the air conditioner frame.",2020-09-01
278,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,585,D,0,1,5K7411,"Based on interviews, observation and record reviews, the facility failed to oversee the grievance process. Because of this oversight, the facility failed to address the residents concerns. In addition, the facility failed to implement a grievances process for the reporting, tracking and resolution of residents concerns. Findings include: An abbreviated Resident Council (RC) meeting was held during the State survey on 01/30/20 at 02:27 PM. There were fourteen in attendance at the RC meeting. Residents shared concerns about the facility not following up or resolving any of their complaints. Surveyor reviewed the RC minutes, which show concerns were addressed in January of 2019, March of 2019, May 2019, June 2019, and November 2019. No concerns noted for the months July to December 2019 were addressed. There were two grievances filed on 11/01/19 - regarding lost monies, and 11/04/19 regarding a personal funds account. Surveyor Interviewed the Director of Nursing (DON) on 01/31/20 at 07:00 AM who stated I came in June and there was not a Grievance procedure in place. Apparently the staff were not bringing concerns forward. Surveyor and DON conducted a walk through to the units on 01/31/20 at 0[AGE]0 AM where the written complaint forms are to file a grievance. The form on unit (U)3 was located at the nurse's station. DON stated, the form is given out by the staff when the resident makes a request. During admission, the family and residents are educated about it. Surveyor stated to the DON that during the resident council meeting the residents did not know about the form to file a grievance. The residents stated they take their concerns to the supervisor or manager and that it goes nowhere. The DON replied that her goal is to educate the residents too. Surveyor observed the bulletin board which on U4. The residents on U3 turn to go to the elevator before they would see the bulletin board on U4. This is a repeat on VC1, as the board is on U2 and the vent VC1 residents would have to go to the next unit. DON agreed it's not visible for both units and stated that she would probably be moving the board to a better location. DON agreed that although the staff have been educated, the residents are not aware of the process and education needs to be provided. Surveyor reviewed the grievance policy and procedure dated 2017. Policy statement says staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her right have been violated. the staff member is encouraged to guide the resident, or person acting on the resident's behalf, as to how a written complaint with the facility.",2020-09-01
279,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,622,D,0,1,5K7411,"Based on interviews, record review, and review of the facility's Transfer Form policy, the facility failed to furnish the appropriate resident information to the receiving provider to ensure the resident's safe and orderly transfer and continuity of care. Findings include: 1. During an interview with R111 on 01/29/20 at 10:40 AM, the resident stated that he went to an acute care clinic because his foot was bleeding. He is unable to recall the reason as to why his foot was bleeding. A record review was done. On 12/25/19, the day of R111's transfer, registered nurse (RN) progress notes state, Oriented to person, place and time. The Physician's Discharge Summary, dated 01/24/20 was handwritten and difficult to decipher to relay necessary information to the receiving provider in order to meet the resident's needs. Transfer Form policy reviewed. The transfer form will be completed by the nurse and will include: .o. All other necessary information, including a copy of the residents discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. Also, 3. A copy of the Transfer Form will be filed in the resident's medical record. On 02/03/20 at 07:45 AM, State Agency (SA) inquired with Licensed Nurse (LN) 17 if the Transfer Form sent to the receiving facility is kept in the resident's chart. LN17 states that she will inquire with the unit manager regarding this. On 02/03/20 at 09:30 AM, SA made a records request for R111's transfer documents with Staff (S) 22. During an interview with LN95 on 02/03/20 at 10:43 AM, LN95 stated that the Transfer Form is done on a case by case basis depending on the acuity of the resident. The records request for R111's transfer form and accompanying documents was made again with LN95. No records were received by 01:30 PM on 02/03/20. LN95 stated that the documents that were sent to R111's receiving provider on his 12/25/19 transfer, were his MAR (medication administration record), labs, face sheet and order summary.",2020-09-01
280,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,623,E,0,1,5K7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to send notices to three residents (R)2, R3 and R33, residents' representatives and ombudsman before transferring and/or discharging a resident. Findings include: 1) Surveyor reviewed Electronic Medical Record (EMR) for R3 who was hospitalized on [DATE] for [MEDICAL CONDITION], aspiration pneumonia and dislocation of left shoulder joint. 2) Surveyor Interviewed R33 on 01/30/20 at 07:23 AM. R33 says he was hospitalized on ce in November but can't remember the date. Surveyor reviewed the EMR for R33 and confirmed he was admitted for [MEDICAL CONDITION] failure on 11/13/19 and re-entered on 11/25/19. Surveyor interviewed Social Services (SS) on 01/31/20 at 01:04 PM. When asked what the facility process for notifying the ombudsman and or representative for Resident transfer or discharge, responded, that she look's through the point click care for any discharges or transfers and send out the letter to the representative. The letters are kept a binder although I do not notify the ombudsman. 3) A review of R2's EMR documented R2 was hospitalized from [DATE] to 10/26/19 for acute hypoxic [MEDICAL CONDITION] due to severe pneumonia and [MEDICAL CONDITION] due to severe pneumonia. Review of the hospital's Final Report confirmed R2 was hospitalized from [DATE] to 10/26/19. The reason for admission to the hospital was documented R2 presented with a low grade fever, low blood pressure, and rapid breathing. R2 was being treated for [REDACTED]. Inquired with SS on 02/03/20 at 10:00 AM, confirmed that the ombudsman was not notified in writing of R2's discharge/transfer to the hospital for 10/19/19 to 10/26/19. Nurse manager (NM)4 provided a Discharge/Transfer Notice (Confidential) form to this surveyor. Information on the form provided by NM4 only contained: SS's name; Facility phone number; Name of facility; Reason for discharge: No longer meeting skilled criteria, patient has plateau and has met rehab goals. The form did not contain any relevant or specific information pertaining to R2 and the reason for discharge did not apply to R2",2020-09-01
281,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,657,E,0,1,5K7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation and record reviews, the facility failed to maintain an updated plan of care for three residents (R)2, and R3, and R111 of 41 sampled residents. The deficient practice fails to implement a current plan of care that is resident centered and meets the needs of the resident. Findings include: 1) Surveyor Interviewed R3's family member who stated on 01/29/20 at 11:24 AM, whenever my family visits, my sisters, my daughter, my son, and me, we check his diaper and there is usually doodoo. He tends to dig, and we clean him up. We can smell it when we come in. Even if they clean it, the doodoo is in the trash can and the room smells. We must ask the janitor to clean. When you enter the room, we can smell the doodoo because they leave the doodoo diaper in the trash and then say they must call the janitor and it smells for a longer period. Surveyor interviewed the clinical nursing assistant (CNA) 157 on 02/03/20 at 11:43 AM, who stated, we have tried mittens and R3 knows how to take off the mittens. We try to check him every 30 minutes. We put the shorts backwards. We are going try long pants. We are not able to stay with him one on one. As soon as his hands are free, he likes to scratch by his doodoo, and we try hard to prevent this. The last time it happened was last week. We told the family that we check, less than 30 minutes at a time and we can't stay with him one on one. Surveyor reviewed R3 Care plan dated 06/15/19 that did not address the digging behavior in his personal hygiene goal and intervention. 2) During an interview will R111 on 01/29/20 at 10:23 AM, he stated that he does not receive [MED] and that the staff do not check his blood sugars. R111's care plan reviewed. Focus initiated on [DATE]20 .has potential having [MEDICAL CONDITION] (high blood sugar). Accucheck (blood glucose monitoring) BID (twice a day) and [MEDICATION NAME]SQ (subcutaneously) as ordered. The Order Listing Report with date range 01/01/2020 to 01/31/2020 was reviewed. It was noted that a Completed status existed for the order Accucheck two times a day for [MEDICAL CONDITION] for 7 days *Notify MD if BS less than 70 or greater than 350mg/dl. The Medication Administration Record [REDACTED]. R111's MAR indicated [REDACTED]*Give before breakfast & before dinner (BID) if BS (blood sugar) is greater than 250mg/dl (milligrams per deciliter). The 02/01/2020 to 02/29/2020 R111's MAR indicated [REDACTED]*Give before breakfast & before dinner (BID) if BS is greater than 250mg/dl. An interview with Licensed Nurse (LN)26 on 02/03/20 @ 09:15 AM, confirmed that R111 is not currently receiving blood glucose monitoring and [MED]. Cross reference with tag 6[AGE] 3) On 02/03/20 at 12:01 PM, a reviewed R2's care plan. The activity of daily living (ADL) portion of the care plan documented created on 02/26/15, listed an intervention which states R2 is able to feed self after set up. However, according to a review of R2's review of R2's Minimum Data Set (MDS) documenting a significant change in condition (readmission to the facility following a hospitalization ) with an Assessment Reference Date of [DATE], documented R2 requires extensive assistance for eating, with one staff assistance. Furthermore, R2 weighed 94 lbs, had loss 5% or more in the last month or loss 10% or more in the last 6 months, and was not a physician prescribed weight loss plan. A review of the electronic medical record (EMR), on 09/09/2019, the R2 weighed 107 lbs and on 01/03/2020, the resident weighed 95.2 pounds which is a -11.03 % Loss. On 02/03/20 at 10:19 AM, reviewed R2's care plan with Nurse Manager (NM)4. NM4 confirmed that R2's care plan was not revised following a significant change in condition to address and implement interventions that were specific and necessary in R2's care.",2020-09-01
282,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,684,D,0,1,5K7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, the facility failed to ensure Two resident's (R)2 and R[AGE] received care that was within professional nursing standards of practice. R2 did not receive the correct texture of food based on nutritional assessment and provided 1:1 supervision with meals according to the comprehensive care plan. As a result of this deficiency, R2 was at risk for choking and inadequate nutritional intake. R[AGE] developed a chronic non-healing Stage four facility acquired pressure ulcer which resulted in infection. Cross reference with F657, F6[AGE], F[AGE]5. Findings include: 1) R2 was admitted to the facility on [DATE]. A review of R2's Minimum Data Set (MDS) documenting a significant change in condition (readmission to the facility following a hospitalization ) with an Assessment Reference Date of [DATE] documents, R2 Brief Mental Status (BI[CONDITION]) score is 00 indicating severe cognitive impairment. R2 requires extensive assistance for eating, with one staff assistance. R2 weighed 94 pounds (lbs), had loss 5% or more in the last month or loss 10% or more in the last 6 months, and was not a a physician prescribed weight loss plan. A review of the electronic medical record (EMR), on 09/09/2019, the R2 weighed 107 lbs and on 01/03/2020, the resident weighed 95.2 pounds which is a -11.03 % Loss. On 02/03/20 at 12:01 PM, a review of R2's care plan documented has an ADL self care performance deficit due to general weakness, limited mobility, dementia, and a history of stroke. been needing more assistance in ADL range with 1-2 person- Eating- The resident is able to feed self after set up- 02/26/15 not updated. Also, R2 is at risk for fluid-nutritional deficit related to: unreliable intake, history of chewing/swallowing deficit. The resident has had a significant weight loss greater than 10% (10/30/19) in 1[AGE] days. Interventions listed included: Encourage cue assist or feed as needed to complete at least 50% of meals, at least 3[AGE] cc fluids with meals, and 120 cc fluid between meals. On 01/29/20 12:53 PM, lunch was distributed to R2. R2 needed assistance setting up removing the covers from food, and no assistance being provided. On 01/29/20 01:59 PM, observed R2 seated in her wheelchair, with lunch set up on a table in front of the resident. Lunch included a bowl of chopped up noodles with 3 large pieces of broccoli. R2 was having difficulty feeding herself and would drop 90% of food from the fork onto the table in front of her. Observed the resident attempted to break the broccoli with her finger but was unsuccessful. As a result of not being able to break apart the broccoli, R2 did not eat any of the broccoli. Furthermore, the over half of the soup which was also served for lunch had spilled onto the tray, when R2 attempted to feed herself. Certified nurse aide (CNA) staff was present in the room, assisting another resident with lunch. R2 was not given any assistance. On 02/03/20 at 11:08 AM, reviewed R2's EMR with Nurse Manager (NM)4. On 01/29/20 at lunch, staff documented R2 ate 1-25% of lunch. NM4 confirmed that staff does not help R2 with lunch. An interview with the Registered Dietician (RD) confirmed the broccoli R2 received should have been chopped into smaller pieces. 2) R[AGE] is an [AGE] year old female with a [DIAGNOSES REDACTED]. During several observation's of R[AGE] on 01/30/20 at the following times: 11:45 AM; 12:30 PM; 01:15 PM; 02:00 PM; noted the resident was laying in bed on her back without being repositioned. During an observation on 01/31/20 at 09:10 AM noted R[AGE] slightly elevated in bed being assisted with her breakfast meal by the RNA. During additional observations at 10:30 AM; 11:00 AM; and 12:15 PM noted R[AGE] sitting in same position with eyes closed. During several observations of R[AGE] on 02/03/20 at the following times: 08:10 AM; 09;17 AM; 10:00 AM; and 11:30 AM noted R[AGE] lying in bed on her back in the same position. During an interview with Licensed Nurse (LN)52 on 01/30/20 at 02:06 PM confirmed that R[AGE] has a stage 4 pressure ulcer to the sacrum acquired in the facility on 03/03/19. LN52 stated that R[AGE] is not receiving the Wound care clinic services because her insurance coverage is with a different provider that won't cover the service. They tried to get it approved but it was denied. There is a Nurse Practitioner who comes 1-2 times per week to look at the wound and write the treatment orders. The dressing is changed in the early morning and evening shift or when she makes a bowel movement (BM). Electronic Medical Record (EMR) reviewed. Following Skin observation tool's reviewed: 03/13/19; open skin to sacral area stage 2 with treatment (tx) of [MEDICATION NAME] covered with foam dressing after cleansing with normal saline (NS). 0[DATE]; open skin to sacral area with tx of [MEDICATION NAME] covered with foam dressing daily & PRN. 05/29/19; stage 4 sacral injury appears moist [AGE] percent (%) slough yellowish-brownish adherent tissue, surrounding skin slightly reddened and partially macerated wound edges. 06/04/19; treatment plan changed to the following: cleansed with dakins solution applied [MED] to slough area and [MEDICATION NAME] to the reddened surface, covered with foam dressing. 06/04/19: Stage 4 wound to sacrum. Low air mattress applied on May 28, 2019. 5.5 cm L x 4.3 cm w no tunneling. Care plan dated 08/01/17 reviewed. -Focus: R[AGE] is high risk for skin breakdown or other pressure ulcer development R/t incontinence, decreased mobility and poor nutrition/ wt. loss. Goal: will decrease risk for pressure ulcer development through next review. Interventions: Avoid shearing resident's skin during positioning, turning, and transferring. Observe skin every shift with special attention to bony prominence and report changes. Turn and reposition at least every 2 hours. Use Air loss mattress in bed. Rojo cushion on w/C at all times Initiated: -Focus: The resident has infection of Sacral wound. date initiated: 07/04/19. Weekly wound assessment dated [DATE] reviewed. Stage 4 pressure ulcer, Length 3 cm x width 4.5 cm x depth 1 cm. with 2.5 cm tunneling and 1 cm tunneling. Progress notes by Advanced Practice Registered Nurse (APRN) dated 01/07/20 reviewed. Chronic pressure ulcer of sacrum with delayed healing, due to overall frailty. Has pressure relieving mattress and staff very aware of need for strict 2 hourly position changes. Weekly wound assessment dated [DATE] reviewed. Stage 4 pressure ulcer. Length 5.0 cm (increased from 3.0 cm on 01/17/20). Width: 4.0 cm (increased from 3.5 cm on 01/17/20) x depth. 0.7 cm. Progress notes reviewed. In March 2019 developed a pressure injury. Superficial pressure sore. By May 17, APRN came to see resident, changed orders and evaluated the wound. Stage 4 pressure injury. Had an infection and fever on May 26, 2019. Treated with antibiotics and ordered a pressure relieving mattress. Nurses notes dated 04/09/19 reviewed. Dietician recommended high protein supplement boost plus vanilla with meals three times per day (TID). Discontinued (D/C'd) the majic cup. Nurses notes dated 03/11/19 reviewed. Sacral open wound, stage 2. Clean with NS pat dry, apply [MEDICATION NAME] ointment and cover with foam, cleanse once daily and as needed (PRN). During an interview with her two Family member (F)1 and F2 on 02/03/20 at 11:54 PM stated that R[AGE] does not mind being turned but I know the staff aren't turning her. I also think they don't give her enough water. F2 added, I know they're not turning every two hours, because I come in early in the morning and sometimes I'm here late at night and I ask the staff why they're not turning her every 2 hours and they make excuses like saying she just ate. 05/17/19: Physician (MD) note dated 05/17/19 reviewed. Wound Care- cleanse with NS [MED] to slough every day (QD) and PRN if excessive drainage or soiled d/t BM. Medi Honey to granulation tissue QD and prn if excessive drainage or soiled d/t BM. Boarded foam dressing. Dx, sacral pressure ulcer. APRN order dated 11/12/19 reviewed. Vitamin C 500 mg po BID, Zinc 220 mg PO daily During an interview with the Registered Dietician (RD) on 02/03/20 at 12:36 PM stated R[AGE] has a history of adult failure to thrive [MEDICAL CONDITION]. Always a challenge to eat and maintain her weight, she had a gradual decline. She was on hospice in 2016 and off in March in 2017 back on august 2017 then discharged from hospice on 2017. She weighed 82 pounds in August of 2017 and in December was [AGE] pounds, January 2018 went up to [AGE] pounds. Last weight for her was 78.4 lbs, she is stable now. She is offered majic cup at meals, and boost plus at meals. Overall she drinks the boost plus and it should be helping with the wound healing. She get's extra vitamins and minerals and she gets a lot of juices on her tray. I see her every three months, or if there was a sudden drop of her weight. During an interview with LN 52 on 02/03/20 at 01:00 PM, was asked how often is R[AGE] turned stated every two hours. The certified nurse aides (CNA's) change the brief at 7 am just before shift change, at 8 am they make first round, at 10 AM they turn again, at 12 they place her in straight position. At 2 PM they turn again. When I change her dressing at 10:00 AM she was on her side. During an interview with an anonymous staff on 02/03/20 at 01:37 PM when asked why R[AGE] has not been turned onto her side every 2 hours and confirmed with surveyor observations over the past few days, quietly stated that with the staff we have here during any shift, we really can only turn her every 2-3 hours, we need more staff to be able to turn her every 2 hours.",2020-09-01
283,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,686,D,0,1,5K7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to turn a resident side to side at least every two hours, and apply the timely use of a pressure relieving device to prevent a facility acquired stage 2 pressure ulcer which worsened to a stage 4 pressure ulcer in 2 months (from March 2019 to May 2019). The deficient practice placed the resident at an increase risk of illness when she acquired a serious infection of the wound. Findings include: R[AGE] is an [AGE] year old female with [DIAGNOSES REDACTED]. During several observation's of R[AGE] on 01/30/20 at the following times: 11:45 AM; 12:30 PM; 01:15 PM; 02:00 PM; noted the resident was laying in bed on her back without being repositioned. During an observation on 01/31/20 at 09:10 AM noted R[AGE] slightly elevated in bed being assisted with her breakfast meal by the RNA. During additional observations at 10:30 AM; 11:00 AM; and 12:15 PM noted R[AGE] sitting in same position with eyes closed. During several observations of R[AGE] on 02/03/20 at the following times: 08:10 AM; 09;17 AM; 10:00 AM; and 11:30 AM noted R[AGE] lying in bed on her back in the same position. During an interview with Licensed Nurse (LN)52 on 01/30/20 at 02:06 PM confirmed that R[AGE] has a stage 4 pressure ulcer to the sacrum acquired in the facility on 03/03/19. LN52 stated that R[AGE] is not receiving the Wound care clinic services because her insurance coverage is with a different provider that won't cover the service. They tried to get it approved but it was denied. There is a Nurse Practitioner who comes 1-2 times per week to look at the wound and write the treatment orders. The dressing is changed in the early morning and evening shift or when she makes a bowel movement (BM). Electronic Medical Record (EMR) reviewed. Following Skin observation tool's reviewed: 03/13/19; open skin to sacral area stage 2 with treatment (tx) of [MEDICATION NAME] covered with foam dressing after cleansing with normal saline (NS). 0[DATE]; open skin to sacral area with tx of [MEDICATION NAME] covered with foam dressing daily & PRN. 05/29/19; stage 4 sacral injury appears moist [AGE] percent (%) slough yellowish-brownish adherent tissue, surrounding skin slightly reddened and partially macerated wound edges. 06/04/19; treatment plan changed to the following: cleansed with dakins solution applied [MED] to slough area and [MEDICATION NAME] to the reddened surface, covered with foam dressing. 06/04/19: Stage 4 wound to sacrum. Low air mattress applied on May 28, 2019. 5.5 cm L x 4.3 cm w no tunneling. Care plan dated 08/01/17 reviewed. -Focus: R[AGE] is high risk for skin breakdown or other pressure ulcer development R/t incontinence, decreased mobility and poor nutrition/ wt. loss. Goal: will decrease risk for pressure ulcer development through next review. Interventions: Avoid shearing resident's skin during positioning, turning, and transferring. Observe skin every shift with special attention to bony prominence and report changes. Turn and reposition at least every 2 hours. Use Air loss mattress in bed. Rojo cushion on w/C at all times Initiated: -Focus: The resident has infection of Sacral wound. date initiated: 07/04/19. Weekly wound assessment dated [DATE] reviewed. Stage 4 pressure ulcer, Length 3 cm x width 4.5 cm x depth 1 cm. with 2.5 cm tunneling and 1 cm tunneling. Progress notes by Advanced Practice Registered Nurse (APRN) dated 01/07/20 reviewed. Chronic pressure ulcer of sacrum with delayed healing, due to overall frailty. Has pressure relieving mattress and staff very aware of need for strict 2 hourly position changes. Weekly wound assessment dated [DATE] reviewed. Stage 4 pressure ulcer. Length 5.0 cm (increased from 3.0 cm on 01/17/20). Width: 4.0 cm (increased from 3.5 cm on 01/17/20) x depth. 0.7 cm. Progress notes reviewed. In March 2019 developed a pressure injury. Superficial pressure sore. By May 17, APRN came to see resident, changed orders and evaluated the wound. Stage 4 pressure injury. Had an infection and fever on May 26, 2019. Treated with antibiotics and ordered a pressure relieving mattress. Nurses notes dated 04/09/19 reviewed. Dietician recommended high protein supplement boost plus vanilla with meals three times per day (TID). Discontinued (D/C'd) the majic cup. Nurses notes dated 03/11/19 reviewed. Sacral open wound, stage 2. Clean with NS pat dry, apply [MEDICATION NAME] ointment and cover with foam, cleanse once daily and as needed (PRN). During an interview with her two Family member (F)1 and F2 on 02/03/20 at 11:54 PM stated that R[AGE] does not mind being turned but I know the staff aren't turning her. I also think they don't give her enough water. F2 added, I know they're not turning every two hours, because I come in early in the morning and sometimes I'm here late at night and I ask the staff why they're not turning her every 2 hours and they make excuses like saying she just ate. 05/17/19: Physician (MD) note dated 05/17/19 reviewed. Wound Care- cleanse with NS [MED] to slough every day (QD) and PRN if excessive drainage or soiled d/t BM. Medi Honey to granulation tissue QD and prn if excessive drainage or soiled d/t BM. Boarded foam dressing. Dx, sacral pressure ulcer. APRN order dated 11/12/19 reviewed. Vitamin C 500 mg po BID, Zinc 220 mg PO daily During an interview with the Registered Dietician (RD) on 02/03/20 at 12:36 PM stated R[AGE] has a history of adult failure to thrive [MEDICAL CONDITION]. Always a challenge to eat and maintain her weight, she had a gradual decline. She was on hospice in 2016 and off in March in 2017 back on august 2017 then discharged from hospice on 2017. She weighed 82 pounds in August of 2017 and in December was [AGE] pounds, January 2018 went up to [AGE] pounds. Last weight for her was 78.4 lbs, she is stable now. She is offered majic cup at meals, and boost plus at meals. Overall she drinks the boost plus and it should be helping with the wound healing. She get's extra vitamins and minerals and she gets a lot of juices on her tray. I see her every three months, or if there was a sudden drop of her weight. During an interview with LN 52 on 02/03/20 at 01:00 PM, was asked how often is R[AGE] turned stated every two hours. The certified nurse aides (CNA's) change the brief at 7 am just before shift change, at 8 am they make first round, at 10 AM they turn again, at 12 they place her in straight position. At 2 PM they turn again. When I change her dressing at 10:00 AM she was on her side. During an interview with an anonymous staff on 02/03/20 at 01:37 PM when asked why R[AGE] has not been turned onto her side every 2 hours and confirmed with surveyor observations over the past few days, quietly stated that with the staff we have here during any shift, we really can only turn her every 2-3 hours, we need more staff to be able to turn her every 2 hours.",2020-09-01
284,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,689,D,0,1,5K7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to maintain an environment that is free of accident hazards for Resident (R)26 and provide the adequate supervision and assistance devices to provide accidents. Findings include: Surveyor observed R26 outside in the front area with another resident on 01/29/20. Noted R26 was by herself and had a pack of cigarettes, and lighter with her. She stated that the nurses hold her pack of cigarettes and lighter at the nurses station and she asks them for it when she goes outside to smoke. Surveyor Interviewed the charge nurse on 01/29/20 at 11:14 AM who stated although this is a smoke free environment, R26 goes and smokes in the front or the back as much as she wants to go. She leaves her pack of cigarettes and lighter with the nurse. Staff was not able to say which nurse holds the cigarettes, there are two nurses on the unit. Surveyor reviewed the Facility smoking policy-Residents dated July 2017. 1. Prior to and upon admission, .facility smoking policy.smoking preferences. 6. The resident will be evaluated on admission. 7. The staff shall consult with the attending Physician and the Director of Nurse Services.8. A resident's ability to smoke safely will be re-evaluated quarterly. Surveyor interviewed the director of nursing (DON) on 01/31/20 at 08:13 AM, who confirmed that the smoking area is out front and the facility is a smoke free facility. Surveyor reviewed R26 record for a safe smoking assessment, physician's orders [REDACTED]. No documentation was found. The Nurse manager concurred with the surveyor that there were no orders, no assessment, and no care plan for R26's smoking.",2020-09-01
285,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,695,D,0,1,5K7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and observation, the facility failed to provide care consistent with the professional standards of practice. The facility provided oxygen therapy to R111 without a physician's orders [REDACTED]. Findings include: 1. On 01/29/20 at 10:46 AM, R111 states that he does not utilize his [MEDICAL CONDITION] mask at night because it is uncomfortable. He prefers to receive oxygen through the nasal cannula (tubing to deliver oxygen into his nose) at 2 liters per minute continuously. Observed R111 using oxygen tubing that was not dated, into his nares. This was connected to a dusty oxygen concentrator with a dirty filter, set at 2 liters per minute. Order Listing Report with date range 01/01/2020 to 01/31/2020 reviewed. There was an Active order for [MEDICAL CONDITION] (bilevel positive airway pressure) @ 22/16 (pressure) with 2 L (liters of oxygen) bleed-in every evening and night shift for OSA (obstructive sleep apnea) *ON: when sleeping. R111's medical record was reviewed. There was no physician's prescription for the oxygen utilized in place of the [MEDICAL CONDITION] machine. There was no nursing or respiratory therapist documentation indicating that the physician was notified for R111's refusal to wear his [MEDICAL CONDITION] machine. Review of R111's current care plan revealed a Focus for .oxygen therapy r/t (related to) Ineffective gas exchange initiated on [DATE]20. Interventions listed OXYGEN SETTINGS: O2 via nasal prongs @ 1 L continuously initiated on [DATE]20. During an interview with the nurse manager (NM) 1 on 01/31/20 at 10:23 AM, the SA informed NM1 that R111 received oxygen at 2 liters/minute with no physician's prescription. NM 1 was also informed of R111 refusal to use his [MEDICAL CONDITION] at night and of his preference to utilize oxygen at 2 liters/minute. SA also indicated that there was no documentation in the medical records that the physician was notified of this.",2020-09-01
286,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,725,E,1,1,5K7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, and interviews the facility failed to develop a facility assessment. The deficient practice were affected Residents (R)148, and R[AGE], when the facility failed to have sufficient staff available to provide nursing care and services to assure resident safety and attain or maintain their highest practicable physical, mental, and psychosocial well-being. The deficient practice potentially increases the likelihood of poor health outcomes, such as incontinence, and one resident, R[AGE] developing a chronic stage 4 pressure ulcer that was acquired in the facility. Findings Include: Cross reference to F[AGE]8. 1) During an interview with R148 on 09/29/20 at 10:30 AM, R148 relayed that he/she had to wait between thirty minutes to one hour for staff to respond to the call bell. R148 said that several times, he/she would be lying in a wet diaper or lying in stool waiting for staff to respond. R148 further stated that this concern had been reported to facility management in the past with little change or improvement. A review of records for R148 showed an admitted [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Resident Assessment Instrument - Minimum Data Set with the Assessment Refence Date 01/16/20, R148 was totally dependent on care. 2) R[AGE] is an [AGE] year old female with [DIAGNOSES REDACTED]. During several observation's of R[AGE] on 01/30/20 at the following times: 11:45 AM; 12:30 PM; 01:15 PM; 02:00 PM; noted the resident was laying in bed in semi fowlers position on her back without being repositioned. During an observation on 01/31/20 at 09:10 AM noted R[AGE] slightly elevated in bed being assisted with her breakfast meal by the RNA. During observations at 10:30 AM; 11:00 AM; and 12:15 PM noted R[AGE] sitting in same position with eyes closed. During several observations of R[AGE] on 02/03/20 at the following times: 08:10 AM; 09;17 AM; 10:00 AM noted R[AGE] lying in bed on her back in the same position. During an interview with Licensed Nurse (LN)52 on 01/30/20 at 02:06 PM confirmed that R[AGE] has a stage 4 pressure ulcer to the sacrum acquired in the facility on 03/3/19. Following Skin observation tool's reviewed: 03/13/19; open skin to sacral area stage 2 with treatment (tx) of [MEDICATION NAME] covered with foam dressing after cleansing with normal saline (NS). 0[DATE]; open skin to sacral area with tx of [MEDICATION NAME] covered with foam dressing daily & PRN. 05/29/19; stage 4 sacral injury appears moist [AGE] percent (%) slough yellowish-brownish adherent tissue, surrounding skin slightly reddened and partially macerated wound edges. 06/04/19; treatment plan changed to the following: cleansed with dakins solution applied [MED] to slough area and [MEDICATION NAME] to the reddened surface, covered with foam dressing. 06/04/19: Stage 4 wound to sacrum. Low air mattress applied on May 28, 2019. 5.5 cm L x 4.3 cm w no tunneling. Care plan dated 08/01/17 reviewed. -Focus: R[AGE] is high risk for skin breakdown or other pressure ulcer development R/t incontinence, decreased mobility and poor nutrition/ wt. loss. Goal: will decrease risk for pressure ulcer development through next review. Interventions: Avoid shearing resident's skin during positioning, turning, and transferring. Observe skin every shift with special attention to bony prominence and report changes. Turn and reposition at least every 2 hours. Progress notes by Advanced Practice Registered Nurse (APRN) dated 01/07/20 reviewed. Chronic pressure ulcer of sacrum with delayed healing.staff very aware of need for strict 2 hourly position changes. Nurses notes dated 04/09/19 reviewed. Dietician recommended high protein supplement boost plus vanilla with meals three times per day (TID). Discontinued (D/C'd) the majic cup. Nurses notes dated 03/11/19 reviewed. Sacral open wound, stage 2. Clean with NS pat dry, apply [MEDICATION NAME] ointment and cover with foam, cleanse once daily and as needed (PRN). During an interview with her two Family member (F)1 and F2 on 02/03/20 at 11:54 PM stated that R[AGE] does not mind being turned but I know the staff aren't turning her. I also don't think they give her enough water. F2 added, I know they're not turning her every two hours, because I come in early in the morning and sometimes I'm here late at night and I ask the staff why they're not turning her every 2 hours and they say she just ate or giving some other excuse. There is difficulty in endorsement to the staff in meeting our mom's needs, we ask the staff to help by making sure she has her sweater on because she gets cold, or putting her sleeves on because she has fragile skin and gets a lot of skin tears and bruises. Many times when I come in she's cold, and she has no sweater on. She needs to wear a sweater or a jacket. I've asked the staff several times but it doesn't seem to be working. It seems like the staff need more training in caring for frail elderly. During an interview with LN 52 on 02/03/20 at 01:00 PM, was asked how often is R[AGE] turned stated every two hours. The certified nurse aides (CNA's) change the brief at 7 am just before shift change, at 8 am they make first round, at 10 AM they turn again, at 12 they place her in straight position. At 2 PM they turn again. When I change her dressing at 10:00 AM she was on her side. During an interview with an anonymous staff on 02/03/20 at 01:37 PM when asked why R[AGE] has not been turned onto her side every 2 hours and confirmed with surveyor observations over the past few days, quietly stated that with the staff we have here during any shift, we really can only turn her every 2-3 hours, we need more staff to be able to turn her every 2 hours. 3) An abbreviated Resident Council (RC) meeting was held during the survey 0n 01/30/20 at 02:27 PM. There were fourteen in attendance to RC meeting. They were resident (R) 22, 148, 14, [AGE], [AGE], 41, 9, 155, 59, [AGE], 98, 143, 130 and 48. The concern regarding the call lights were brought up as a problem. We can wait up to 2 hours for the call light to be answered. This mostly happens during the evenings and when they go to break. R148 stated we have repeated these questions to the management level and there is no improvement. Another resident stated, I talk with the supervisor and nothing happens. Another resident stated, when I go to the bathroom, I page someone on the call button, and I ask them nicely, but they want me to wait. Another resident chimed in about her roommate and says, It's priority calls and they just leave her and attend to something else and sometimes she is waiting a long time. The nurses are short, and it is a priority thing. The clinical nurse assistants (CNA)'s in the am have to bathe people, change people and the nurse comes in and gives us the pills and leave. R14 joins in and voices that On our unit, the respiratory therapists have been told that they have to answer call lights. R[AGE] chimes in and says A lot of times, walking through the hall, staff ignore the lights since we are residents here. Things are talked about but nothing changes. If you want to come back to talk about the call light, they shut you down. We should be able to voice our concerns without being shut down. R48 states In the back, there is 24 patients and sometimes there is only two CNAs and then there is five lights on, and the CNA don't come for one hour. Nobody come and I watched another resident wait two hours for someone to take him/her to their room. They are lacking CNAs. My aunty is on unit 4 and I go up at 2:00 PM to check that her snack has been given to her. A lot of times, the snack is still in the hallway. I was concerned about her because she is only 69 lbs. Residents stated We can talk but we are concerned about the ones that cannot talk and the way people are treated that cannot talk. Residents stated that at dinner, there is only one staff and she cannot handle all the residents in the dining. They drop off the patients and leave them with the one person. The one person cannot help all the residents by herself/himself. Record Review (RR) on 01/30/20 at 01:17 PM of resident council minutes dated November 29, 2020 - talks about - a resident waiting about 2 hours to be assisted back to bed in the evening shift. Action taken by the facility was the assistant Director of Nursing (ADON) explained to the members that evening shift has less staff and that staff may have gone to break during that time. Respiratory therapy, (RT) manager was already aware of the concern and that he will remind respiratory therapists that they are all responsible to answer call lights. Interview with the DON on 01/30/20 at 07:15 AM. DON confirmed that everybody can answer the call lights.",2020-09-01
287,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,726,E,0,1,5K7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews and a review of the facility's records, the facility failed to ensure nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. Findings include: On 02/03/20 01:19 PM, inquired with staff development coordinator (SDC) regarding staff training and competencies conducted by the facility. SDC confirmed the facility does not have a system in place that is able to identify between staff that has completed training versus staff that have not completed training. SDC stated that staff is currently undergoing training. This surveyor requested to review a sample of the completed Annual Mandatory In-Service training. Reviewed staff (S)1's Annual Mandatory In-Service training. On 07/31/19, S1 had completed written training, however, the completed training was not corrected or verified by the SDC. The SDC confirmed the facility is unable to verify the answers provided by S1 on the Annual Mandatory In-Service was correct. Furthermore, the facility was unable to provide documentation ensuring all nursing staff have meet the specific competency requirements as part of their license and certification requirements defined under State law or regulations. A review of the Facility Assessment provided to the surveying team during the entrance conference was dated October 2018. The facility assessment for staff competencies and overall acuity of the units was blank and did not contain any information. On 02/03/20 at 11:17 AM, inquired with the Administrator and the Director of Nursing (DON) regarding the staff training and the ability of the facility to ensure staff have the appropriate competencies and skills necessary to care for the residents of the facility. The DON confirmed the facility does not have a system that can denitrify staff that has completed training versus staff that have not completed training. Furthermore, both the Administrator and the DON confirmed the facility does not use a Facility Assessment when staffing the facility.",2020-09-01
288,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,761,E,0,1,5K7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to properly label a multi dose vial of vaccine with an opened date. The deficient practice has the potential to increase the risk of injury/ illness for residents residing in the facility. Findings include: During a medication storage inspection on [DATE] at 10:26 AM in the Unit 3 medication storage refrigerator, two influenza multi-dose vials were found in refrigerator. One vial had writing on the box that stated opened [DATE], although the bottle in the box is not labeled. The other box was labled opend [DATE], and the bottle in the box was not labeled. During an interview with the Unit Manager, validated that the bottle should have been labeled as well as the box since the vaccine could get placed back into the wrong box and potentially given to a resident after it expired.",2020-09-01
289,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,812,F,0,1,5K7411,"Based on observations and staff interviews, the facility failed to ensure food was properly stored, served, and dishes were properly sanitized in accordance with professional standards for food safety. As a result of this deficiency, residents of the facility were all at risk of potential of of food contamination. Findings include: 1) On 02/29/20 at 08:25 AM, upon initial tour of the kitchen with the Dietary Manager (DM), observed an open box of uncooked Dececco Spaghetti Noodles in the dry storage room. The opened box was not stored in a closed container. DM confirmed according to the facility's policy and procedure, the box spaghetti noodles should have been stored in a sealed plastic bin after opening. 2) On 01/29/20 at 08:33 AM, the Dishwasher Temperature Log for December 2019 and January 2020 staff documented the temperatures of the wash cycle (150-165) Rinse (1[AGE]-195) for breakfast, lunch, and dinner. The Dishwasher Temperature Log consistently logged the wash cycle as 100 degrees. Inquired with DM, about the documented temperatures of the dishwasher. DM stated, They (staff) did not tell me about this. Inquired if temperature logs are monitored by DM, DM stated Only when something is reported to me other than that I don't monitor it. DM confirmed dishes are sanitized by high temperatures (wash - 150-165 degrees F; final Rinse - 1[AGE] degrees F). Inquired with Kitchen Staff (KS)10, who operates the dishwashing machine. KS10 confirmed the temperatures during the wash cycle is consistently at 100 degrees Fahrenheit (F). Requested the DM to test the dishwasher temperature with Dishwasher Sensor Label (Lot # 8105 expiration date 03/19/20). DM conducted 3 separate test using temperature test strips within a 20 minute time period. According to the temperature test strip instructions, the test strip will turn black in color when the temperature of the water reaches 1[AGE] F. DM confirmed all three strips did not turn black, even though the final rinse gauge on the dishwasher indicated the temperature was 204 F. Furthermore, when the dishes came out of the dish washer, the dishes were warm to touch. 3) On 02/29/20 at 09:15 AM, inspection of the manual washing and sanitizing (3-step process is used to manually wash, rinse, and sanitize dishware correctly) with DM. The third step is sanitizing with either hot water or a chemical solution maintained at the correct concentration. Inspection of a 3 compartment sink for , the last compartment (sanitizing compartment) was tested with the DM. The DM grabbed a test strip roll from a window sill ledge near the sink. The test strip was not stored in the appropriate container. Upon testing the sanitizing solution the test strip color did not turn green indicating that the solution was 4) On 01/30/20 in preparation for lunch, observed serving utensils stored in 4 brown open bins. The open bins were stored directly under the steam serving line. The open bins contained various unknown liquids and unidentifiable brown particles in the open bins and on the serving spoons. Inquired with kitchen staff (KS)15, who had cooked and was about to plate the lunch trays with food. KS15 confirmed the utensils in the brown bins were used to serve food onto the resident's trays. KS15 confirmed the liquid and the brown particles in the open bins was food and liquids that fell off the serving area above the bins and there were no covers for the bins to protect the serving utensils from splashes and contaminates. 5) Observed 3 sectioned plate on the serving line that contained dried food particles which were stuck to the corner of the plate. KS15 confirmed staff it was dried food on the plate.",2020-09-01
290,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,838,F,0,1,5K7411,"Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during day-to-day operations. Findings include: A review of the Facility Assessment provided to the surveying team during the entrance conference was dated October 2018. The facility assessment for staff competencies and overall acuity of the units was blank and did not contain any information. During an interview with the Administrator and the Director of Nursing (DON) on 02/03/20 at 11:17 AM regarding the facility assessment, could not provide a current or updated facility assessment which provided information's on the number of residents and the facility's resident capacity; The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; The staff competencies that are necessary to provide the level and types of care needed for the resident population; The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. Additionally, both the Administrator and the DON confirmed the facility does not use a Facility Assessment when staffing the facility.",2020-09-01
291,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,880,E,0,1,5K7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for two of 41 Residents in the sample. Findings include: 1) On 01/29/20 at 09:15 AM, observed the charge nurse, (CN)3, Respiratory director, respiratory staff, medical doctor and a nurse's aide going in rooms and leaving rooms without doing any hand sanitizing (HS) or hand washing. An urgency was occurring at a room located close to the nurse's station and staff were entering the room and exiting the room quickly without hand sanitization. Queried with RN[AGE] why she/he did not hand sanitize, and he/she stated I would to, but they have a hand sanitizer on the cart. Further investigation into the hand sanitizer on the cart shows that the hand sanitizer was only on the nurse's carts and once they took their cart to another room, they could not hand sanitize. It was also noted that not all the rooms on the floor contained a wall unit dispenser for hand sanitization. On entry to isolated room, there was no hand sanitizer available on the Personal Protective Equipment (PPE)cart, and no container to dispose of your gown. RN[AGE] stated the hand sanitizer was on another RNs cart. She passed some hand sanitizer to me and took the cart away. Upon entering the room labeled isolation and gowning up, it was not apparent where the gowns are to be disposed of when leaving the room. Observed a gown rolled up and in the med cart outside the room. There were no gowns in the trash before I left the room. The staff de-gowned outside the room into the med cart. 01/29/20 at 10:00 AM, introduced myself to the staff/manager and shared observations, that staff were walking in and out of the rooms without hand sanitization and inquired about the use of hand sanitization for infection control. 01/29/20 at 10:30 AM Upon return to the floor, a new dedicated isolation cart was placed in front of the resident's room with hand sanitizer on the cart. Policy and procedures were reviewed for Handwashing/Hand Hygiene: The first sentence states 1> All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of health-care associated infections. 7(n) Use an alcohol-based hand rub containing at least 63% alcohol; or, alternatively, soap )(antimicrobial or non-antimicrobial) and water for the following situations: N. Before and after entering isolation precaution settings. 8) Hand hygiene is the final step after removing and disposing of personal protective equipment (PPE). 01/29/20 at 12:10 PM, observed RT hand washing his hands on 1st floor but at room [ROOM NUMBER]. RN staff did not HS upon entering the room of RN but HS on the out. 01/29/20 at 12:17 PM - 2nd floor, observed two CNAs passing trays, entering rooms without HS or hand hygiene at room [ROOM NUMBER] going in. Rm 207 - Observed CNA - no hand sanitization out of the room and went to room [ROOM NUMBER]. 2) During an observation on 01/29/20 at 10:46 AM of R111's private room, it was noted that R111's oxygen tubing was not dated. The oxygen concentrator was dusty and dirty. The filter located on the back of the oxygen concentrator was soiled with dust. The policy for Infection Control - Disposable Equipment Change-Out states that disposable equipment will not be re-used. Table 1 indicates when respiratory equipment needs to be changed. Oxygen tubing is scheduled to be changed every month and as needed. On 01/31/20 at 10:23 AM, SA revealed to NM1, R111's filthy oxygen concentrator and undated nasal cannula, who verified the concern. R111's Admission Memo dated 01/03/20 contains documentation of Contact Iso (isolation) + (positive)[MEDICAL CONDITIONS]. R111's Orders Listing Report with date range, 01/01/2020 to 01/31/2020, revealed an Active order for Contact Precaution (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment), Dx (diagnosis):[MEDICAL CONDITION] to RLE (right lower extremity) wound ordered by the physician on 01/04/20. R111's care plan reviewed and showed, [DATE]20 Contact precaution. [MEDICAL CONDITION] to RLE wound. During frequent observations and interviews with the R111 during the survey period revealed that R111 was not on any contact isolation precautions and that dressing changes were being done to the right lower extremity. R111 states that the staff have not been using gowns consistently. Isolation - Initiating Transmission-Based Precautions and Isolation, Discontinuing policies reviewed. Transmission-based precautions are discontinued when it is determined that the resident's condition no longer indicates such precautions. R111's progress notes reviewed. No documentation was found to indicate whether R111 was discontinued from contact isolation precautions. During an interview with NM1 on 01/31/20 at 10:23 AM, NM1 stated that R111 was previously on contact precaution isolation and believes that it was discontinued. NM1 also states that this error is due to a lack of documentation.",2020-09-01
292,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,881,F,0,1,5K7411,"Based on staff interview, and review of policy, the facility failed to establish an Antibiotic Stewardship Program which includes the development of protocols and a system to monitor antibiotic use. Findings Include: On 01/31/20 at 02:00 PM, the Assistant Director of Nursing (ADON) who is also in charge of the Infection Prevention and Control Program was interviewed about the Antibiotic Stewardship Program. ADON stated that the program had not been started yet and is currently being put together. ADON also stated that the facility received a Medication Regimen Review, that included data about antibiotics, from the Pharmacists but currently there is no process for reviewing that data for antibiotic stewardship. A review of facility policy on monitoring compliance with infection control stated the following: Policy Interpretation and Implementation, the infection preventionist will conduct infection control compliance rounds at least quarterly or at a frequency determined by the Infection Prevention and Control (IPC) Committee. Review of facility policy on infection prevention and control committee stated the following: Duties of the Committee, establish and monitor the facility Antibiotic Stewardship Program.",2020-09-01
293,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2020-02-03,919,D,0,1,5K7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, and record review, the facility failed to provide Resident (R) 14 the call bell mechanism to call for staff assistance. As a result of this deficient practice, there was a potential for health hazards related to R14's total dependence for care. Findings Include: During an interview with R14 on 01/29/20 at 09:45 AM, R14 was asked if he/she had any concerns. R14 replied that the call bell to call for assistance was frequently out of reach and there was no other way to call for assistance. An observation of R14's room during the above interview revealed R14's call bell mechanism was on the bedside table and out of reach of R14. A review of records showed that R14 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 01/29/20 at 10:00 AM, Staff Nurse (Nurse) 1 was asked about the call bell being on the bedside table and out of reach of R14. Nurse 1 acknowledged that the call bell should not have been on the bedside table, but should have been in reach of R14.",2020-09-01
294,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,558,E,0,1,66G811,"Based on observations, and record review (RR), the facility failed to ensure three residents (R72, R95, and R134) of 47 sampled residents selected for review had communication equipment accessible to them to call for immediate help if needed. The facility assessed each resident for limitations and determined the most appropriate type of communication equipment to accommodate their needs, but did not have it accessible for R72, R95, and R134 at all times. This does not meet the standard of care and put R72, R95, and R134 at risk for not being able to obtain help if needed. Findings Include: On 10/23/18 at 02:47 PM, observed R72 did not have a method to call for assistance within reach. R72 is a quadripegic (paralysis with loss of all four limbs and torso), who uses a call light (touch pad), that is placed by his head so he can summon help easily. The call light was located on the bedside stand and not within his reach. RR of R72's Care Plan directed staff to Place call light within easy reach. On 10/24/18 at 04:45 PM, observed R95 did not have a method to call for assistance within his reach. R95 is a quadripegic with limited movement of his arms. He uses a call light (touch pad) which is placed on his chest so he can summon help easily. The call light was hanging on the wall from mounted equipment, and not within his reach. Registered Nurse (RN) 7 was queried about R95's call light and RN7 subsequently placed the call light on R95's chest. RR of R95's Care Plan directed staff to Place call light within easy reach, and noted Pt refused to have call light at times. Continue to offer. There was no evidence of documentation that the call light was offered to R95 and refused. On 10/26/18 at 02:44 PM, observed R134 did not have a method to call for assistance within his reach. R134 is a quadripegic who uses a call light (touch pad) that is placed by his head so he can summon help easily. The call light was on the bedside stand and not within his reach. RR of the Care Plan directed staff to Continue to place call light near him and will be able to address his needs at that time.",2020-09-01
295,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,561,D,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR) and staff interviews, the facility failed to promote and facilitate resident (R)35's self-determination through support of resident choices. Findings include: 1) Record review (RR)/concurrent interview on 10/23/18 - R35 doctor's order written on 07/15/16 is a [DIAGNOSES REDACTED]. No concentrated sweets. Per unit clerk (UC)1, confirmed there has been no psych evaluation. Interview on 10/23/18 08:46 AM, R35 stated look at my breakfast, it is ridiculous, plain bread - no butter. They don't give me anything. I don't get a menu. At least at home, I have bread, its not toasted but they give me no butter. I asked for bacon , eggs and toast. When they came by. They brought me two plain pieces of bread and they brought me maple syrup for the cereal? Very strange. I should ask my family to bring me food if that's the case. Rehab nurses aide (RNA) - at bedside and stated what do you want? She stated that I want bacon and eggs and toast. RNA brought breakfast of choice in 30 minutes. Interview on 10/25/18 at 11:54 AM with the dietician who stated we have a set menu and an alternate list. When they first come in, either dietary manager will get what the residents request. It is on a eight week cycle. We keep it as similar to the menu as possible. Lunch and dinner is with crystal lite for the juice. So with the cycles, we modify it for diets such as no concentrated sweets. We brought back the eight week cycle for the menu. Dietician stated I called dietary and she did get her toast. Informed dietician that she got plain bread, not toasted and without butter. She also received maple syrup and had cereal and no pancakes or waffles. She was not happy with it. 2) During a concurrent interview/observation with R35 on 10/24/18 at 06:43 AM, R35 stated that I wouldn't mind brushing my teeth in the morning but they don't have time. They don't come. At 02:29 PM, re-interviewed R35 who was still in a hospital gown. I would love to brush my teeth in the morning but they don't have time. Observation is R35's hair is not brushed, has some whiskers on chin, teeth not brushed (halitosis noted). I haven't taken a bath. They clean me when I'm wet and they come and change me. I'm like a baby. I would like to walk. If you call them, I cant hold it, so 15 minutes go, 20 minutes and so I just go in my diaper. They are very busy. Observation that R35 still in hospital gown, Hair is not brushed. Chin with a few whiskers. Has not brushed teeth (halitosis). (ref 676) On 10/25/18 at 09:23 AM, this surveyor entered the room of R35. Certified nurse aide (CNA)2 was at the sink in R35's room drawing water into a basin. When asked CNA2, she stated that she did not want to shower. However, R35 stated to this surveyor and CNA2 at that time I would like to shower. CNA2 was surprised. CNA2 went to get the shower chair and was placed at bedside. R35 was assisted to the shower chair and brought to the shower room. R35 was brought by wheelchair (W/C) to the first shower which did not have hot water. Maintenance workers attempting to fix the hot water. R35 was then taken by W/C to the second shower. When she passed this surveyor in the hall she stated a hospital with no hot water. R35 refused to shampoo her hair. I would like to go to the beauty shop once a week to shampoo my hair. CNA2 stated that the beauty shop is only open on Mondays. Interview 10/25/18 at 09:27 AM interview with UC1 who showed this surveyor the beauty parlor's schedule. The schedule states that she was scheduled for a hair cut on (MONTH) 13th and (MONTH) 7, (YEAR), she had a full blowdry and shampoo set. Interview on 10/25/18 09:32 AM at Interview with activity coordinator (AC)- who explained that the beautician comes every Monday and residents need to get scheduled. Beautician washes your hair and can do full set shampoo and blow dry and hair cut. Surveyor asked what has R35 requested? She request for haircut and then she refuses sometimes. We had to have her sister come. When the day comes, she refuses. Surveyor asked - so she has had one haircut on (MONTH) 13th and she refused one time, so that means you don't offer again? No we try but when the day comes, she refuses. Asked for any other documentation regarding refusal or scheduled appointments. None available. Observation of R35 is a woman who is refusing to wash her hair unless she goes to the beauty salon once a week. Resident looks unkempt. R35 is able to make needs known and can be reasonable when talked to in a calm voice.",2020-09-01
296,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,578,E,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review (RR), and review of facility's policy, the facility failed to establish sufficient policies and procedures that delineate the residents' right to formulate an advance directive (AD) for twelve (R18, R29, R36, R43, R65, R79, R93, R106, R111, R119, R141, and R144) of 47 sampled residents selected for review. This deficient practice had the potential to affect all residents without a documented AD such that the residents may not be afforded the right to formulate an AD and/or the right to request, refuse, discontinue treatment, participate in or refuse to participate in experimental research. Findings Include: 1. RR found there was no ADs for R29, R106 and R144 on file. 2) On 10/23/18 at 10:14 AM RR on R111 found no AD only POLST. 3) On 10/24/18 at 11:52 AM RR on R79 found a POLST and no AD. Inquired of WC2 and there was no admission checklist in the record to show that AD information was provided. 4) On 10/24/18 at 11:59 AM RR on R65 found only a POLST and no AD. 5) On 10/25/18 at 11:02 AM RR on R18 found a POLST and no AD. Inquired of WC2 and she could not locate an admission list and/or documentation that AD information was provided to R18 on admission date of [DATE]. The PCP reviewed the POLST with R18 on 03/07/18. 6) On 10/24/18 at 08:21 AM RR for R93 showed only POLST on file, no AD. This was confirmed by[NAME] Clerk (WC)1. 7) During RR, the ADs were not found in R43 or R119's records. On 10/25/18 at 11:06 AM The ADs were requested from the first floor WC3. At 01:50 PM no ADs were provided for either R43 or R119. 8) On 10/24/18 at 10:55 AM RR for R36 and R141 showed no ADs on file, only POLST. On 10/24/18 at 03:28 PM interviewed the DON and she was informed that AD could not be found in the records. The DON stated that she would look for admission checklist and/or documentation on AD for each resident on the list provided. At the exit conference the DON could not provide the necessary AD information for those residents that she was provided a list on.",2020-09-01
297,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,584,E,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not provide housekeeping and maintenance services to provide a clean and sanitary internal enviornment to R146. Findings Include: R146 resides in room [ROOM NUMBER]C which is located by the window. On 10/23/18 at 12:11 PM, an observation was made that the ceiling needed repair and cleaning. There were several areas of the ceiling near the window that were chipped and pealing, and the ceiling behind the window curtains had several areas of distinctive black and green discoloration. On 10/25/18 at 01:17 PM, the Staff Development Coordinator (SDC) was notified of the black and green discoloration on the ceiling of room [ROOM NUMBER]C. The ceiling was viewed together, and the SDC confirmed the presence of the black and green discoloration, and stated That shouldn't be there, I will go tell them right away. On 10/25/18 at 02:45 PM an interview was conducted with the Director of Environmental Services (DES), who stated, Housekeeping uses a form to track dates for detailing each room. When asked what detailing meant, he replied, it is surface cleaning, and if something else needs to be done, housekeeping notifies maintenance. The tracking form indicated room [ROOM NUMBER] was detailed by housekeeping on 10/21/18. The DES said, housekeeping noted it, and notified maintenance. He validated that maintenance had not yet completed the work. There are three ventilator dependant residents including R146) in room [ROOM NUMBER] who are vulnerabe and at high risk for respiratory infections. A clean and sanitary enviornment is critical for prevention of infection.",2020-09-01
298,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,602,D,0,1,66G811,"Based on interviews, record reviews (RR), and review of missing items log, the facility failed to report, investigate and act upon alleged misappropriation of property for two (R91, R93) of 47 residents reviewed for sample. Findings include: 1) On 10/24/18 at 03:30 PM during the resident council meeting, R91 spoke up to report that she had missing clothes that were gifts from her sister. R91 voiced concern of possible theft and a CNA commenting that no one would want to take or wear her clothes anyway. R91 felt that the facility staff didn't care about the missing clothing and felt hurt by comments devaluing her clothing. On 10/25/18 at 09:10 AM interviewed the unit manager (UM)1 on R91's floor and inquired about R91 reportedly missing eleven blouses. Accompanied UM1 to R91's room, as UM1 just returned to unit 3 four days ago, and wanted to interview R91. The UM1 queried R91 about the missing clothing, speaking in R91's native language to clarify specifically what was missing. R91 reiterated to UM1, about the package of clothes that was sent by her sister; and, R91 described how she counted out eleven blouses from the package, then placed the package of blouses onto her wheelchair at the side of the bed. According to R91, she informed CNA1 about the missing clothing, and CNA1 insisted it was in the closet but those particular clothing items were not there. The UM1 removed a big box of clothing from R91's closet and helped R91 look through her clothes but none were identified as the missing clothing. The UM1 stated that he would follow-up with CNA1, because R91's missing clothing were not documented on her personal inventory sheet or the units missing log forms. On 10/25/18 at 10:04 AM reviewed missing items log reports and found that on 03/20/18, R91 reported missing eye glasses to RN16. The report documented that the investigation was still ongoing but results of investigation and notification of results to R91 were left blank. R91 also reported missing sandal, Hello[NAME]black tan pink color but the missing report form had no date and primarily left blank for investigation, results and notification of results. On 10/25/18 at 03:22 PM interviewed CNA1 and he stated that R91 always reports missing items and staff usually find the item(s). CNA1 further stated that R91 continually reports about the missing 11 blouses, but family members have told staff that they brought only two blouses for R91. R91's family members have apologized to staff for R91's accusations and confusion. RN6 validated CNA1's statement, as R91's brother also called her to apologize. Inquired where staff documented complaint of missing blouses and investigation, including the family calls to the staff, and information given to R91. The staff could not provide any documentation and there was no missing item form completed for the missing blouses. 2) During an interview with R93 at 10/24/18 at 09:10 AM. R93 stated some workers are very careless and they mistakenly put my clean clothes in the dirty laundry. I lost my expensive [NAME]et. I told people about it and everybody was looking for it. On 10/26/18 at 12:13 PM. interviewed R93's daughter who stated, That was his favorite [NAME]et, it was a white [NAME]et with green trimmings. I already bought a replacement. The daughter further stated that everybody was aware of it and all the nurses were looking for it. R93 also lost one of his hats and she bought another one. The daughter stated that staff mistakenly mixed R93's clothes up with somebody else's. Interview on 10/26/18 at 01:00 PM with unit manager (UM)2 who stated that there was no report filed. The staff told UM2 that they were looking for the items, according to R93 and R93's daughter. The facility failed to implement policies for investigating theft and/or misappropriation of resident property, complete a thorough investigation, and train staff on procedures for reporting of residents misappropriation of resident property.",2020-09-01
299,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,636,D,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review (RR), and review of facility's policy, the facility failed to ensure a comprehensive assessment for R144's psychosocial well-being was done. The facility also failed to justify the administration of an antipsychotic for R133 without a specific diagnosis. The deficient practice has the potential to affect newly admitted residents with a potential for psychosocial adjustment concerns and resulting in residents receiving unnecessary [MEDICAL CONDITION] medications. Findings Include: 1) Review of facility's policy, Care Plans, Comprehensive Person-Centered, (Revised 12/2016), found: 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. R144 was recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He is a younger, [AGE] years old resident. On 10/24/18 at 09:06 AM, During an interview with R144, who stated his current health condition, went from bad to worse due to his long hospitalization . R144 said, it's messing up my mind, from caring to not caring. R144 said he [MEDICAL CONDITION] and because of strong medications given to him while hospitalized , the blood flow to his hands and feet shut down and became gangrenous. R144 said, look at my hands, wasn't like this before. R144 felt his life was getting worse and that he would not be able to return back home to live independently again with his family. R144 said his humor and his faith help him through, but, it messes with you mentally and emotionally. Although his family was there for him, R144 said he did not want to ask much from them. R144 said no social worker visited him since his admission. R144 said he only talked to the nurse aides caring for him and they would try to make him laugh. On 10/24/18 at 04:50 PM, During an interview with the Assistant MDS Coordinator, she said R144's comprehensive assessment was completed on 10/09/18. On 10/25/18 at 05:11 PM, During an interview with the Social Services Designee (SSD), she stated she updated R144's current care plan for R144's wish to return home to his family when medically stable. The SSD stated if R144 was not able to decannulate (remove his [MEDICAL CONDITION]), then the plan was for him to stay at the facility, and further said, because he thinks that family won't be able to care for him. He would like to return home if can. This was not found in the resident's care plan as part of his assessment which the SSD was aware of. It was also found there was no care plan to support R144's psychosocial adjustment to the facility, with his expression and feelings of loss to the physical appearance of his hands and feet from the gangrene. He also expressed his emotional/psychological state of his mind and being a burden to his family making it potentially difficult for him to return home because of his condition. Thus, although the SSD had weekly meetings to establish a pre-discharge plan with R144 and/or his family, the facility failed to ensure R144's current physical, mental and psychosocial well-being was being thoroughly assessed and the SSD's role was clearly communicated and understood by R144. Cross-reference to F745. 2) During an observation on 10/23/18 at 08:30 AM R133 was observed to be sitting up in bed, leaning to the right side with her eyes closed. On the table in front of her was the breakfast meal. RR states unspecified dementia with behavioral disturbance. [MEDICAL CONDITION] without behavioral disturbance and mood behavioral disturbance. [MEDICAL CONDITION] disorder not found. RR for R133 showed R133 was prescribed [MEDICATION NAME] (antipsychotic) due to [MEDICAL CONDITION] disorder without actually having a documented [DIAGNOSES REDACTED]. Minimum Data Set (MDS) annual review dated 07/05/18 Section [NAME] (Behavior). No symptoms or behaviors noted. Section I (Active Diagnosis). Non-Alzheimer's Dementia. [MEDICAL CONDITION] disorder not found. Section N: (Medications Received). Antipsychotic. 2 days. During an interview on 10/26/18 at 01:18 PM with the DON who stated that R133 was prescribed the [MEDICATION NAME] during a previous admission and it was discontinued on 10/14/16 when she was discharged . R133 was readmitted on [DATE] and the [MEDICATION NAME] was ordered. The DON concurred that she could not find any documentation stating R133 was diagnosed with [REDACTED].",2020-09-01
300,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,656,D,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR), interview, and review of the facility's policy, the facility failed to ensure each resident will have a person-centered comprehensive care plan developed and implemented to meet their preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for two (R4, R106) of 47 sampled residents selected for review. This deficient practice has the potential to affect other residents for whom a comprehensive care plan will be developed. Findings Include: Review of the facility's policy, Care Plans, Comprehensive Person-Centered, (Revised 12/2016), found: 8. The comprehensive, person-centered care plan will: . g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; . k. Reflect treatment goals, timetables and objectives in measurable outcomes; l. Identify the professional services that are responsible for each element of care; . o. Reflect currently recognized standards of practice for problem areas and conditions. 1) During the initial tour on 10/23/18, R4, was found to have an indwelling foley catheter (IDFC) due to a [DIAGNOSES REDACTED]. There was also a 10/18/18 order for another urinalysis with reflex to culture and sensitivity. On 10/25/18 at 10:38 AM, during an concurrent RR with RN1, she stated, I don't see one, when asked about R4's care plan for his UTI. RN1 said the 10/18/18 order was not for another UTI, but for the post-antibiotic urinalysis. RN1 confirmed there should be a care plan for this, but there was none. RN1 said the nurse who received the order should have created the care plan if there was none for the UTI. 2) During the initial tour on 10/23/18, R106 was observed sitting upright in bed and in no distress. She has resided in the facility since (MONTH) (YEAR) and was no longer ventilator dependent. RR however, found an order for [REDACTED]. On 10/25/18 at 01:19 PM, during an interview with RN3, she stated R106's vaginal bleed was a one time occurrence. RN3 said the physician ordered a pelvic ultrasound in (MONTH) of (YEAR), but because the majority of gynecologists did not want to see the resident due to her safety/transfer issues back then, it was discontinued by her attending physician. R106's vaginal bleed was documented in a 08/20/18 nursing note, and RN3 confirmed they were still monitoring the resident for it. RN3 verified there should be an episodic care plan as they are monitoring the resident for it, but acknowledged there was no care plan for it. RN3 said the nurse who wrote the order would have developed the care plan.",2020-09-01
301,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,657,E,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR), interview and a review of the facility's policy, the facility did not ensure a resident's care plan was revised to include her current negative pressure wound therapy (NPWT) treatment for [REDACTED]. This deficient practice has the potential to affect other residents for whom revisions and/or updates to their comprehensive care plans are needed and for newly admitted residents the right to be informed of their plan of care upon admission. Findings Include: 1) Review of the facility's policy, Care Plans, Comprehensive Person-Centered, (Revised 12/2016), found: 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. R107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R107 was observed on 10/23/18 at 12:30 PM upon her return from her weekly NPWT treatment provided at a hospital wound clinic. The 10/23/18 clinic consultation form for R107's wound visit noted her chronic Stage IV wound was improving to her left ischium. The treatment order was to continue to offload and turn (reposition) every two hours on an air mattress. The current NPWT pressure setting was at 125 mmHg (millimeters of mercury). On 10/24/18 at 09:29 AM, RN1 stated the R107's NPWT is a weekly wound vac dressing done at the clinic. RN1 said dressing changes were also done by their evening shift staff on Thursdays and Saturdays or as needed. Review of R107's care plan of 01/30/18, SDTI classified as Stage 4 and last revised on 04/07/18, found the current NPWT treatment modality was from (MONTH) 28, (YEAR). But the care plan had not been updated/revised to include this as part of R107's current wound care plan. On 10/25/18 at 02:11 PM, this was confirmed by the RN MDS coordinator (RN2). RN2 said the R107's wound vac was actually started on 08/07/18 and, Every changes in treatments should be care planned. On 10/25/18 at 05:43 PM, the DON verified the wound vac had been a prior treatment order, had been removed, then reinstated, and said, they did not put it back into the wound care plan. 2) During an interview with R90 on 10/25/18 at 08:52 AM, R90 stated, I do not know what exactly what my care plan is. When asked if he recieved a copy of his care plan shortly after admission, he replied, No. RR revealed no evidence that a written summary of the baseline care plan was provided to R90. During an interview with the MDS Coordinator on 10/25/18 at 12:18 PM regarding the facilities process to ensure that all residents recieve the required written summary of the baseline care plan, she stated, We started a new process about 2-3 months ago. On admit I will meet with the patient and do the baseline care plan. The resident or representative now signs and gets a copy of the plan, and it is in the medical record. R90 was admitted prior to implementing the new process. RR of R134 and R146 also revealed no evidence that a written summary of the baseline care plans were provided to them.",2020-09-01
302,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,676,D,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review (RR), the facility failed to provide services for resident R35 based on the comprehensive assessment of a resident and consistent with the resident's needs and choices. Findings include: Concurrent Interview/observation on 10/24/18 at 02:29 PM, R35 stated I wouldn't mind brushing my teeth. They don't come. I would love to brush my teeth in the morning and the night but they don't have time. I haven't taken a bath. They clean me when I'm wet and they come and change me. I'm like a baby. I would like to walk. If you call them, I can't hold it, so 15 minutes go 20 minutes so I just go in my diaper. Observation that R35 still in hospital gown, Hair is not brushed. Chin with a few whiskers. Has not brushed teeth (Halitosis). Continued interview with R35 who states When I first came in, I could walk. I haven't walked in so long but they yelled at me and now I don't walk. On 10/25/18 at 09:23 AM, this surveyor entered the room of R35. CNA2 was at the sink in R35's room drawing water into a basin. When asked CNA2, she stated that she did not want to shower. However, R35 stated to this surveyor and CNA2 at that time I would like to shower. CNA2 was surprised. CNA2 went to get the shower chair and was placed at bedside. R35 was assisted to the shower chair and brought to the shower room. R35 was brought by wheelchair (W/C) to the first shower which did not have hot water. Maintenance workers were attempting to fix the hot water. R35 was then taken by W/C to the second shower. When she passed this surveyor in the hall she stated a hospital with no hot water. 10/25/18 at 09:55 AM, this surveyor returned to the room for concurrent interview/observation. This surveyor asked R35 if she had a shower and R35 stated she had half a shower because the water is not working. CNA2 entered the room and this surveyor asked CNA2 if R35 had a shower and CNA2 stated she did and when asked how because the water isn't working, R35 chimed in and stated it's half a shower, I got wet but the water is broken. CNA2 did not answer to this. Asked CNA2 if she had brushed her teeth, CNA2 stated she refused. When asked R35 about brushing her teeth, she stated after lunch I will brush my teeth. RR on 10/25/18 - R35 was admitted on [DATE] to the facility. Minimum Data Set (MDS) for resident assessment and care screening with an assessment reference date (ARD) of 08/02/18 was reviewed for coding in section G for functional status. 08/02/18 MDS is coded for: Locomotion in room: Activity did not occur. (8) ADL activity did not occur. Personal hygiene: How resident maintains personal hygiene, including combing hair, brushing teeth, washing/drying face and hands (excludes baths and showers). (2) One person physical assist. Toilet use: Total dependence- full staff performance every time during entire 7-day period. (2) One person physical assist. Walk in room: Activity did not occur. (8) ADL activity did not occur. Bed mobility: Extensive assistance - (3) resident involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance. (2) One person physical assist. Continued RR on 10/26/18 of careplans for focus of ADLs and the goals are: R35 will have bathing, dressing, and grooming needs met as evidenced by lack of unpleasant body odors and a neat and clean appearance daily. Interventions: Allow sufficient time to perform tasks Continue to encourage resident to get out of bed (OOB). Encourage to be involved in care as much as possible. Halo ring as enabler to enhance bed mobility. Offer verbal cues and reminders as needed. Oral care - set up assist with oral hygiene. Personal hygiene - R35 requires extensive assistance by one staff with personal hygiene. Toileting - comfort care. R35 will not participate in toileting program. R35 requires extensive assistance by one staff for toileting. Check every 2 hours and provide incontinent care a needed. 10/25/18 Continued RR of the Therapy communication to nurses flowsheet for the RNA program dated 10/4/18 reveals: Current functional status: Transfers from bed to W/C with minimal assist. Refuses to ambulate. Supine to sitting with stand by assist. Problem /Needs: Decreased strength, balance and endurance. Decline in functional mobility. Goals: Maintain bilateral lower extremity joint mobility and strength. Increase sitting tolerance and out of bed time. Maintain functional mobility. Recommendations/approaches: Follow out of bed schedule. Sit to stand movements 3x10 reps or more per tolerated. Ambulation with front wheel walker x 20-50 feet or more per tolerated. 10/25/18 RR of physical therapy (PT) referral states Nursing reports the need for more assistance to complete functional transfers, and patient exhibits increased motivation to walk. Due to declined functional mobility, this patient will require skilled PT in order to regain supervision levels in transfers and participate in ambulation program with RN[NAME] Interview on 10/26/18 11:16 AM with the Director of Nursing (DON) stated everyone in the Rehab nurses aide program (RNA), I send to rehab. She has been seen by physical therapy almost every year. She has seen physical therapy and occupational therapy for September. (MONTH) is the end of my quarter. That is when I reviewed everybody's decline. R35 is an [AGE] year old with functional decline. R35 needs lots of encouragement, verbal cueing and has a tendency to refuse treatment. However, R35 verbalizes the motivation to want to walk, shower, brush her teeth at sink. R35 also verbalizes that the staff is busy, that she was yelled at once. Observation on 10/25/18 with CNA2 and R35 demonstrates a disconnect in communication. Resident was observed in bed during this survey verbalizing to this surveyor requests to do her activities of daily living (ADLs) but also needing a lot of encouragement and the facility was not able to provide the encouragement needed.",2020-09-01
303,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,690,E,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews (RR), and interviews, the facility failed to ensure four residents (R36, R79, R132, and R134) of 47 sampled residents selected for review with indwelling catheters, received the appropriate care and services to prevent urinary tract infections [MEDICAL CONDITION] to the extent possible. This deficient practice put residents with indwelling catheters at risk for UTI and prevent these residents from attaining their highest physical and psychosocial well being to the extent practicable. Findings include: 1) During an interview with RN15 on 10/23/18 at 02:08 PM who stated that R132 has a UTI. The urine output from the indwelling foley catheter (IFC) appeared to have sediment so a urinalysis was done with culture and sensitivity. The results came back positive for UTI. The care plan was reviewed: R132 has a history of UTI and potential for UTI related to the IFC. The goal is that R132 will be free of UTI complications through the next review. The R132's UTI will resolve without complications by the review date. Give antibiotic therapy as ordered. During an observation on 10/26/18 at 09:15 AM revealed a sign on his door stating see the nurse before entering. Progress notes dated 10/26/18 were reviewed to confirm that R132 has a [DIAGNOSES REDACTED]. R132 is on [MEDICATION NAME] (an antibiotic) and is on contact isolation. During an interview with RN15 on 10/26/18 at 09:39 AM who stated that foley catheter care is done by the certified nurse assistants (CNA's) during perineal care. They wash the genitals with soap and water. The IFC is changed every month. We will follow the date the IFC was initially inserted. It should be documented when to change the bag on the treatment administration record and written on the IFC bag. During an interview with the staff development coordinator (SDC) on 10/26/18 at 10:00 AM who stated that the catheter care training for the nurses and CNA's is completed twice per year during inservice skills and competency training. When they're providing the IFC care they are instructed on how to clean the catheter from the meatus out toward the bag. Sometimes I have seen the CNA's come into the hallway with gloves on. I provide reinforcement teaching and hands on training with spot checks between shifts. During an observation with two CNA16, and CNA17 on 10/26/18 01:15 PM who provided the IFC care during R132's personal care. CNA16 used proper technique to clean the meatus with 1 clean towel at a time carefully starting from the meatus of the penis then cleaning the catheter out toward the bag and dispose of the wipe. CNA16 repeated four times with a clean wipe each time. Review of the treatment plan revealed the catheter was changed on 10/11/18. However the daily/ per shift IFC care was not documented on the treatment administration record that it was being done and the IFC bag did not have a date written on it when it was changed. The progress notes dated 10/13/08 at 00:05 were reviewed stating IFC due for change this shift. No follow up notes were found to verify the IFC was changed. The missing documentation was confirmed with RN15. 2) On 10/24/18 at 02:10 PM interview with R36's mother who stated her son has UTI now and frequently has UTI. On 10/26/18 at 03:10 PM RR under labratory reports showed R36 had UTI on: 09/11/18 (extended spectrum beta lactamase (ESBL)), 09/28/18, and 10/12/18. On 10/26/18 at 03:15 PM interview with SDC who stated R36 does have frequent UTI's. On 10/26/18 at 03:10 PM RR of the Treatment Administration Record (TAR) for (MONTH) (YEAR) under indwelling foley catheter care every shift (DX: [MEDICAL CONDITION] bladder) showed no documentation (blank) by staff for this task. 3)On 10/25/18 at 02:30 PM RR for R79 showed use of an indwelling catheter and R79 had a care plan (CP) for indwelling catheter related to [MEDICAL CONDITION] bladder. The CP goals were for no signs/symptoms of urinary infection and remain free from catheter-related trauma through the review target date of 08/29/18. CP interventions included: .change catheter monthly and PRN (as needed)Fr#16 with 30 cc balloon.check tubing for inspection each shift .Foley bag emptied each shift . The RR for R79 included on the (MONTH) (YEAR) treatment administration record (TAR), Foley Cath change every month and as needed Fr 916 30 ML Bal ( DX: [MEDICAL CONDITION] bladder). The (MONTH) TAR was blank as UM1 stated that staff did not provide indwelling urinary catheter treatment for [REDACTED]. Reviewed R79's previous TARs (July, (MONTH) and (MONTH) of (YEAR)); and, there were no check marks or initials on those previous TARs to indicate that staff provided treatment for [REDACTED]. Also, R79's electronic medical record under the task bar included [MEDICATION NAME] Care - Indwelling catheter (including suprapubic catheter and nephrostomy tube)done per shift; and on 10/17/18 at 03:05 PM it was blank. The UM1 and RN6 could not recall who was on duty for that shift on that date. 4) R134 has a suprapubic catheter (a type of urinary catheter that empties the bladder through an incision in the belly instead of a tube in the urethra) and has a history of UTIs. R134's care plan with start date of 09/20/18, included an intervention to Change catheter every month and as needed (PRN). The TAR for (MONTH) and (MONTH) of (YEAR) showed no documentation (blank) that staff completed this task.",2020-09-01
304,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,697,D,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews (RR) the facility failed to ensure that one of 47 residents (R) 18, sampled for review, received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. Findings Include: On 10/23/18 at 12:48 PM interviewed R18 and when queried on pain, R18 stated that there was intermittent pain in the left (L) shoulder area due to the joint coming out of the socket. R18 was to see a specialist but an appointment was not yet scheduled. On 10/25/18 at 10:14 AM RR on R18 found a radiology report dated 08/10/2018 with findings of advance chronic deformity involving the L humeral head. There were no fractures, normal alignment, normal soft tissues, and normal L acromicoclavicular joint. The occupational therapy (OT) report with start of care date 02/15/2018 documented under current level of function, L shoulder pain rated 5 out of 10 resulting in difficulty maintaining proper positioning of LUE during [MEDICAL TREATMENT] and when standing at FWW. The OT goal was for, Decreased L shoulder pain, rated 2 out of 10 or less, resulting in improved tolerance of proper positioning of LUE during [MEDICAL TREATMENT] and standing at FWW; goal date of 03/31/2018. Another therapy screen form dated 06/25/18 documented that R18 was not indicated for OT/PT/ST. R18 was scheduled for orthopedic surgeon on this date (10/25/18) for L shoulder pain, but had to be rescheduled as R18 had [MEDICAL TREATMENT] on this date. The ward clerk (WC) 2 stated that R18's primary care physcian's office scheduled the appointment with the orthopedic specialist and didn't know R18 was scheduled for [MEDICAL TREATMENT]. On 10/25/18 at 01:27 PM the record review on R18 noted that there was a care plan (CP): . has potential for pain/discomfort due to medical condition. History chronic pain R hand (gout), DM [MEDICAL CONDITION], L LE Phantom limb pain. The (MONTH) (YEAR) physician orders [REDACTED]. Interviewed UM1 and RN6 and queried on last time R18 needed [MEDICATION NAME]/APAP for moderate to severe pain. The UM1 looked in the narcotics log and found that the facility received [MEDICATION NAME]/APAP 5/325 mg tabs; 120 tabs/30 tabs per blister pack on 03/09/18 (4 blister packs) for R18. The first blister pack was started on 10/13/18 and there were 18 tabs left in the pack. Inquired of both UM1 and RN6 on type of pain and pain scale used to determine R18's pain level. They could not provide pain scale but only documentation that [MEDICATION NAME] administered for phantom pain. RN6 stated that R18 had recently been asking for [MEDICATION NAME] pre-[MEDICAL TREATMENT] because R18 stated that the needle sticks hurt his arm. R18 had last requested and was administered [MEDICATION NAME] on 10/23/18 at 11:30 AM and on 10/23/18 at 7:30 PM. The PRN Med form with medication date given on back documented that [MEDICATION NAME] was given on 10/12/18, 10/16/18, and 10/20/18. The nurses did not do pain assessment prior to administering the [MEDICATION NAME], and RN6 stated that R18 is alert and oriented times four (person, place, time, situation), and able to tell staff when there is pain. Inquired on pain management protocol and UM1 went to ask the director of nursing (DON). The DON provided the facility's, Pain- Clinical Protocol, and the paragraph with the heading, Assessment and Recognition . 3. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. a. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The facility failed to implement strategies for R18's pain management; did not identify and use specific strategies for preventing or minimizing pain related to [MEDICAL TREATMENT] treatment; and, did not have a clinical rationale for the use of [MEDICATION NAME] pre and post [MEDICAL TREATMENT] to balance R18's desired level of pain relief with the avoidance of unacceptable adverse consequences.",2020-09-01
305,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,725,D,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR), staff and family interviews, the facility failed to provide sufficient nursing staff with appropriate competencies and skills to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for three R35, R93, and R98 out of 47 residents in the sample size. Findings include: Interview with R98's family member on 10/23/18 at 12:56 PM who stated I think they don't have enough staff. I found my husband wet in shi shi and they didn't have people to move him. His diaper was soaking wet that the urine had gone to the front of the diaper. I called three nurses and they said they couldn't carry him. One calls another one and on and on but they don't come back. Interview with CNA3 at 10/24/18 at 09:19 AM - we have 5 CNAs on the floor today and we should have 8. Census is 42 on unit 4. Sometimes we are short staffed and we just help each other. Concurrent Interview/observation on 10/24/18 at 02:29 PM, R35 stated I wouldn't mind brushing my teeth. They don't come. I would love to brush my teeth in the morning and the night but they don't have time. I haven't taken a bath. They clean me when I'm wet and they come and change me. I'm like a baby. I would like to walk. If you call them, I cant hold it, so 15 minutes go 20 minutes so I just go in my diaper. Observation that R35 still in hospital gown, Hair is not brushed. Chin with a few whiskers. Has not brushed teeth (Halitosis). (refer 676) During an interview with R93 on 10/24/18 at 09:22 AM, R93 stated that I have to dodo in my pants because they don't have enough staff to take me to the bathroom. This surveyor noted that R93's urinal had approximately 300 ml of urine. R93, brought the fact up my urinal will be a problem because when I have to go, it has urine in it. During an interview with the Director of Nursing (DON) on 10/25/18 at 07:41 AM, who stated I base my acuity staffing on California's model. My staff here have been here for [AGE] years and they cover within the facility and help each other out. For instance, if we are short, and a CNA calls out, I will ask for someone to stay over four hours or come in early. We also have call ins. My unit clerks are also CNAs on Unit 3 and Unit 4. I have a rehab nurses aide on each unit assigned to the day shift. A treatment nurse is also assigned to the floors and will do [DEVICE]s and the dressing changes, etc. The DON was told about observations and interviews made during survey. Staffing acuity and policy and procedure regarding staffing was requested and not provided. During an interview on 10/26/18 at 12:13 PM with R93's family member who stated I want to voice out some of my concerns - they have a lot of patient's long term and they are short of nurses there. I feel so sorry for the nurses aides. They are assigned one nurse so if you are in the nursing home, then they are not getting the attention they need. Sometimes, the residents are pressing the call light and they have to wait two hours to wait to see what the patient's needs. It bothers me and that is what my dad complains about. Last night his urinal was almost full. I asked him, why didn't you call them? My dad said that I did and they don't come.",2020-09-01
306,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,745,D,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review (RR), the facility failed to ensure a resident understood he was receiving medically-related social services in order for him to attain or maintain his highest practicable physical, mental and psychosocial well-being for one (R144) of 47 residents in the sample. Findings Include: R144 was recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He is a younger, [AGE] year old resident. On 10/24/18 at 09:06 AM, during an interview with R144, he stated his current health condition, went from bad to worse due to his long hospitalization . R144 said, it's messing up my mind, from caring to not caring. R144 said he [MEDICAL CONDITION] and because of strong medications given to him while hospitalized , the blood flow to his hands and feet shut down and became gangrenous. He said, look at my hands, wasn't like this before. He felt his life was getting worse and that he would not be able to return back home to live independently again with his family. He said his humor and his faith help him through, but, it messes with you mentally and emotionally. Although his family was there for him, he said he did not want to ask much from them. R144 said no social worker visited him since his admission. He said he only talked to the nurse aides caring for him and they would try to make him laugh. On 10/25/18 at 05:11 PM, during an interview with the Social Services Designee (SSD), she stated she updated R144's current care plan for resident's wish to return home with his family when medically stable. The SSD stated if R144 was not able to decannulate (remove his [MEDICAL CONDITION]), then the plan was for him to stay at the facility, and further said, because he thinks that family won't be able to care for him. He would like to return home if can. This was not found in the resident's care plan as part of his assessment which the SSD was aware of. The SSD verified she met with R144 weekly as part of her care plan intervention, but said R144 was more passive with no real concerns to share. The SSD was shown R144's 10/02/18 Patient Transfer Form, that noted his attitude toward placement was scared/anxious and he is a quadraplegic. The other areas on the form such as his adjustment to disability and emotional support from family, were left blank. The SSD said initially the resident came into the facility worried and unsure of where he was at, but was happy after he got placed by the window. The SSD affirmed on his care plan, she is identified by name as a CNA (certified nurse aide) and said, So now I'm thinking, does he identify me as a CNA, or maybe he doesn't know my role? The SSD stated from this interview and questions about R144's adjustment to their facility, that she would be spending more time with him. It was also found there was no care plan to support R144's psychosocial adjustment to the facility, with his expression and feelings of loss to the physical appearance of his hands and feet from the gangrene. He also expressed his emotional/psychological state of his mind and being a burden to his family making it potentially difficult for him to return home because of his condition. Thus, although the SSD had weekly meetings to establish a pre-discharge plan with the resident and/or his family, the facility failed to ensure R144's current physical, mental and psychosocial well-being was being thoroughly assessed and the SSD's role was clearly communicated and understood by the resident.",2020-09-01
307,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,757,D,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR), and interview, the facility failed to adequately monitor R36's mood/behavior on a consistent basis and document the findings. This deficient practice had the potential to affect residents by keeping the residents free from unnecessary drugs through adequate monitoring, monitoring for excessive dose and duration, and adequate indications for its use. Findings include: On 10/26/18 at 01:37 PM RR showed R36 has the following Diagnoses: [REDACTED]. On 10/26/18 at 01:37 PM Medication Administration Record [REDACTED]. On 10/26/18 at 02:00 PM MAR indicated [REDACTED]. According to RN10, the as stated flowsheet should be filled out. RN10 was also unable to provide the Mood/Behavior flowsheet for the previous months.",2020-09-01
308,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,758,D,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review (RR), the facility failed to justify the administration of an antipsychotic to R133 without a specific [DIAGNOSES REDACTED]. R133 was prescribed [MEDICATION NAME] (an antipsychotic) due to [MEDICAL CONDITION] disorder without actually having a documented [DIAGNOSES REDACTED]. Findings include. During an observation on 10/23/18 at 08:30 AM R133 was observed to be sitting up in bed, leaning to the right side with her eyes closed. On the table in front of her was the breakfast meal. Medication Administration Record [REDACTED]. RR, states unspecified dementia with behavioral disturbance. [MEDICAL CONDITION] without behavioral disturbance and Mood behavioral disturbance. [MEDICAL CONDITION] disorder not found. Minimum data set (MDS) annual review dated 07/05/18 Section [NAME] (behavior). No symptoms or behaviors noted. Section I (active diagnosis). Non-Alzheimer's, dementia. [MEDICAL CONDITION] disorder not found. Section N: (medications received). Antipsychotic. 2 days. Care plan reviewed: R133 uses [MEDICAL CONDITION] medications ([MEDICATION NAME]) related to [MEDICAL CONDITION] with behavioral disturbance/ [MEDICAL CONDITION] disorder. Monitor/ record behavior symptoms inappropriate response to verbal communication, aggression towards staff/ others; hitting/ pinching staff, refusal of care etc. and document every shift. Progress notes reviewed from 06/25/18 to 10/25/18, R133 behavior calm and quiet. Aggressiveness not documented Monthly behavior flow sheet for (MONTH) (YEAR) was reviewed, behaviors documented are zeros. During an interview with RN15 on 10/25/18 at 11:17 AM who stated R133 is taking the [MEDICATION NAME] for her behavior. Requested a copy of the psychiatric assessment that includes a [DIAGNOSES REDACTED]. During an interview on 10/26/18 at 01:18 PM with the DON who stated that R133 was prescribed the [MEDICATION NAME] during a previous admission and it was discontinued on 10/14/16 when she was discharged . R133 was readmitted on [DATE] and the [MEDICATION NAME] was ordered. The DON concurred that she could not find any documentation stating R133 she was diagnosed with [REDACTED].",2020-09-01
309,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,842,E,0,1,66G811,"Based on record review (RR) and interview, the facility failed to maintain accurate and complete documentation that R72, R95, and R146 were turned and repositioned as directed in the care plan, or that R72 and R146 were educated and informed of the risks of refusing. The time recorded in the medical record did not always reflect the actual time the care was provided. This deficient practice affected three (R72, R95, and R146) of 47 sampled residents selected for review. Findings Include: On 10/24/18 at 09:00 AM, an observation was made that a binder is located at the bedside of each resident on the ventilator unit. The binder includes a form referred to as the position log, which the Certified Nursing Assistant (CNA) used to document when a resident was turned and repositioned, or if the resident refused to turn. On Review of the POS [REDACTED]. On 10/25/18 at 09:24 AM during an interview with CNA18, she stated, We document when we turn them on the position log. Sometimes we forget if we are busy. We also document in the computer. The position log for R146 was reviewed with CNA18, who confirmed the missing entries. RR of R146's Care Plan directed staff to Encourage turning and repositioning every 2 hours. The plan includes notation that R146 has refusal for turning and repositioning every 2 hours. There is no evidence of documentation that R146 was educated and informed of the risks of refusing to be turned. RR of R72's Care Plan directed the staff to: Turn and reposition at least every 2 hours and as necessary, and to Continue to encourage to reposition side to side in bed at least every two hours and PRN. The plan includes, R72 Prefers not to be waken up at noc, and R72 is resistive to care, verbally abusive, refusing to be turned and repositioned related to adjustment to nursing home. There is no evidence of documentation that R72 was educated and informed of the risks of refusing to be turned. On 10/25/18 the DON was interviewed regarding missing documentation on the position log for turning R72, R95, and R146. The DON stated, Yes, the log is in the room, and hasn't been removed because families like to see it. It is incomplete sometimes, but the CNA documentation of turning and repositioning is in Point Click, the electronic medical record (EMR). When asked if the EMR is the legal record of documentation, she replied Yes. EMR documentation was requested for the following: R72: 10/13/18, 10/16/18, 10/17/18, 10/18/18, and 10/24/18. R95: 10/01/18, 10/03/18 ,10/07/18, 10/17/18, 10/22/18, and 10/23/18. R146: 10/01/18, 10/03/18, 10/15/18, 10/16/18, 10/17/18, 10/18/18, 10/24/18, and 10/25/18. RR revealed missing times, and a pattern that the same time was being recorded several times in a row (for example: 08:00 AM, 08:00AM, 08:00AM). During a brief interview with the DON on 10/26/18 at 03:00 PM she stated, The CNA's don't go to the computer immediately to document every time they turn someone. That wouldn't be feasible with their workload. When they get to the computer to document, they will make an entry for each different time they turned the resident, but because the computer time stamps it in real time, the only time that shows up in the record is the time they are doing the documentation in the computer. It does not show the actual time they turned the resident. The DON acknowledged this was not accurate documentation but did not think they could change the time in the computer. It was determined that the computer program has the feature to change the time to accurately reflect when the care was provided. The DON stated, I will educate everyone how to do that.",2020-09-01
310,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2018-10-26,883,D,0,1,66G811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR) and interviews, the facility failed to minimize the risk of one (R72) of 47 sampled residents selected for review from acquiring, transmitting, or experiencing complications from pnuemococcal disease. The deficient practice had the potential to prevent residents from having the opportunity to recieve the pneumococcal vaccine unless refused or medically contraindicated. Findings include: RR of R72 noted a physcian's order written on 03/05/18 [MEDICATION NAME] if not previously given. There was no documentation if there was a shortage of the vaccine, that R72 was offered and declined the vaccine, had previously received the vaccine, or that the vaccine was administered at the time the order was written. The Medical Administration Record (MAR) indicates the first dose of the pneumococcal vaccine was given on 08/12/18. On 10/25/18 at 12:50 PM, an interview was conducted with the Staff Development Coordinator (SDC), who orders the vaccines. He stated, We sometimes have shortages, but I can't tell if that was why he didn't get it. I use my calender as a reminder to order the vaccine, and ripped that month off already. I just use the calender as a reminder to order. The SDC confirmed the vaccine was given on 08/12/18, and acknowledged if the vaccine is not available due to a shortage, it should be documented in the medical record. Not receiving the pneumococcal vaccine timely put R72 at increased risk.",2020-09-01
311,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2017-11-09,241,D,0,1,3IW611,"Based on observation, the facility failed to care for 2 (Residents #74 and #28) of 27 residents in the Stage 2 sample in a manner that promotes enhancement of his or her quality of life. Findings include: 1) On 11/6/17 at 1105 [NAME]M. observed a staff member transporting Resident #74 from the shower room across the hallway to her room (#229). The resident was seated in a shower chair with a cloth draped over her body; however, the resident was exposed on left side, her bare skin could be seen from the hip to knee. 2) On Monday, (MONTH) 6, (YEAR) observation of the dining was done in the dining room on the 1st Floor. Meals started being served at 11:30 AM. There were a total of 9 residents in the dining room. Resident #28 was sitting at a table by herself. There were three people delivering lunch trays from the food cart. At 11:55 AM Resident #28 was the only resident left to have her lunch tray delivered. At that time, she banged down on the table with clenched fists and stated in a loud voice Hurry up. She had waited 25 minutes for her meal to be delivered to her. As there were 3 people delivering lunch trays and only 9 residents in the dining room, her meal was not delivered in a timely manner with disrespect towards the resident's dignity.",2020-09-01
312,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2017-11-09,278,D,0,1,3IW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the assessment accurately reflects the resident's status for 1 of 18 resident (Resident #69) assessment of the 28 residents in the Stage 2 sample. Findings include: On 11/08/2017 at 3:22 PM review of Resident (Res) # 69's MDS 3.0 found that resident had a significant change in bed mobility from limited assistance to extensive assistance, locomotion on unit: self- performance from supervision to extensive assistance, locomotion off unit- self performance from supervision to extensive assistance, eating: self performance from independent to supervision, and toilet use-self performance from limited assistance to extensive assistance. Interview with staff #50 shared that Res # 69 has had a decline in ADLs over the past year. Staff #50 explained that resident used to wash her face and clean herself up after using the bathroom but now requires staff assistance. Staff also explained that resident could put on her dentures, lipstick, and fix her coffee without staff prompt but now resident requires assistance with these. Staff # 50 also explained that sometimes Res #69 forgets that she just used the bathroom and when she sees the bathroom door, after she exits it, she tells staff that she needs to use the bathroom. On 11/08/2017 at 3:42 PM while reviewing Res # 69's electronic medical record (EMR) it was noted that the Nurse Practitioner documented that Res #69 has Dementia WO (without) behavioral disturbance ICD-10-CM: F03.90. Review of Res #69's MDS 3.0 Quarterly assessment dated [DATE] and Significant Change assessment dated [DATE] did not include a [DIAGNOSES REDACTED].# 12 regarding resident's decline in ADLS confirmed that this was due to her progression of dementia. Staff #12 was shown Res #69's MDS 3.0 Quarterly and Significant Change assessments and that the Dementia [DIAGNOSES REDACTED]. Staff #12 stated that this was an error and that she would be submitting an updated assessment. The facility failed to ensure the assessment accurately reflects the resident's decline in ADLS due to the progression of her Dementia as this was not documented in the resident's MDS 3.0 Quarterly or Significant Change assessments.",2020-09-01
313,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2017-11-09,279,D,0,1,3IW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a comprehensive care plan with measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Residents # 284 and # 307) of 18 care plans of 28 residents in the Stage 2 Sample. Findings include: 1) On 11/07/2017 at 12:44 PM reviewed Resident (Res) #284's Comprehensive Care Plan (CP) for completeness. Res #284's initial admission to the facility was on 08/30/2017 with an unstageable pressure ulcer (PU) on his sacral area. Review of resident's electronic medial record (EMR) found that there was no CP for his unstageable PU. Review of resident's Minimum Data Set (MDS) 3.0, 5 day scheduled assessment, dated 09/06/2017 documented that resident had an unstageable PU that was 8 cm long X 7 cm wide X 0 cm deep with eschar covering the wound bed. Further review of resident's EMR found that resident was sent out to an acute facility on 09/07/2017 and resident was re-admitted to the facility on [DATE] from the acute facility. After resident's return there was an MDS 3.0 Admission Assessment, that was completed on 09/19/2017, that had documented resident had an unstageable PU which measured 8 cm long X 7.2 cm wide by 0.1 cm deep with slough covering the wound bed. On 11/07/2017 at 2:34 PM interviewed staff #145 to verify that she was familiar with resident #284 and she confirmed that she was familiar with his care. Showed staff #145 Res #284's CP and inquired where was the resident's CP to address the unstageable PU. Staff #145 stated she would investigate and find the CP. On 11/08/2017 at 7:49 AM spoke with staff #220 who stated that she had to call the technical support department to get Res #284's CP. Staff #220 stated that her MDS coordinator had made a mistake and changed dates for Res #284 CP to start on 9/21/17 which was actually started when he was initially admitted to the facility on [DATE]. Staff #220 was asked and provided the facility's policy on PU assessment and documentation. It is noted that in the facility's policy, Pressure Ulcer/ Injury Risk Assessment, which was revised on (MONTH) (YEAR), states the following 5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the conditions of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. On 11/09/2017 at 12:51 PM staff #145 gave a copy of Res #284 CP. Staff confirmed that this CP for the unstageable PU was from the resident's second admission (09/12/2017) and initiated on 09/20/2017. Staff #145 confirmed that resident's CP did not have anything in place for the care of the unstageable PU prior to 09/20/2017. On 11/09/2017 in the afternoon inquired with staff #220 if there was a CP for Res #284 for his initial admission for resident's PU and there was none provided. 2) On 11/08/2017 at 4:57 PM review of Res #307 EMR showed that this resident was ordered and receiving [MEDICATION NAME] 10,000 unit/mL inject 0.5 mL (5,000 units) SQ every 12 hours until patient ambulates for Dx: [MEDICAL CONDITION] since the resident's admission on 10/23/2017. Further review of Res #307 EMR and her CP found that there was no care plan for the use of [MEDICATION NAME]. On 11/09/2017 at 10:34 AM interviewed staff #17 who was taking care of Res #307 and this staff was able to state that she would monitor resident for signs and symptoms of side effects from [MEDICATION NAME] such as bruising and bleeding and stated that this information is documented in the nurse's progress note. Interviewed staff #201 right after and he confirmed that there was no CP for [MEDICATION NAME] use for [MEDICAL CONDITION] for Res #307. Further review of resident's hard copy chart found that there were no labs done with this resident since admission to the facility and no orders for labs to be done to monitor resident's platelets. On 11/09/2017 at 11:39 AM continued review of Res #307's medical record found a nutritional assessment completed by RD #1 on 10/27/2017 at 13:27. RD #1 listed pertinent medications: [REDACTED]. RD #1 did not document that the resident was getting [MEDICATION NAME] injections twice a day. [MEDICATION NAME] is an anticoagulant and is considered a high risk medication and there was no diet restriction related to this in this nutritional assessment. On 11/09/2017 at 11:50 AM spoke with staff #263 and when inquired about labs for Res #307 such as a Partial [MEDICAL CONDITION] Time (PTT) he ordered a Complete Blood Count (CBC) with differential and Complete Metabolic Profile (CMP) to be done the next day. On 11/09/2017 at 12:16 PM met and interviewed RD #2, to discuss Res #307's Nutritional Assessment that was completed by RD #1. When asked if this resident had any food restrictions RD #2 stated that the facility's menu is to provide a menu consistent to supply an amount of vitamin K in our menu to support/ balance with medical anticoagulation. Res #307 did not have any food restrictions in place even though she was receiving [MEDICATION NAME] injections twice a day to prevent [MEDICAL CONDITION]. On 11/09/2017 at 1:49 PM spoke with the facility's contract pharmacist, regarding lab monitoring for [MEDICATION NAME] that Res #307 is receiving subcutaneous. Pharmacist stated that this resident does not require PTT lab monitoring for bleeding time, only requires close watch of CBC and H and H. The facility failed to develop a comprehensive care plan with measurable objectives and timeframe to meet a resident's medical needs for an identified unstageable PU and use of a high risk medication ([MEDICATION NAME]) needed to prevent [MEDICAL CONDITION] for 2 of the 28 residents from the Stage 2 sample which may have resulted in injury to these residents.",2020-09-01
314,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2017-11-09,325,E,0,1,3IW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff members and residents, the facility failed to ensure 4 (Residents #92, #14, #3 and #74) of 4 residents in the sample is provided a therapeutic diet. Findings include: 1) Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record review done during the Stage 1 phase found the resident's body mass index was 18.4 and there was no documentation in the medial record of the resident receiving a nutritional supplement. On 11/7/17 at 12:25 P.M. Resident #74 was observed eating in bed. The resident's tray was placed on the bedside tray. The tray consisted of minced chicken, peas and carrots, okai (rice gruel), dessert and hot tea. The resident reported she has okai as the rice gets too hard to swallow. On 11/8/17 at 8:26 [NAME]M. found the resident having breakfast in her room. A concurrent observation was made with Staff Member #164. Inquired whether the resident receives boost. The staff member confirmed the resident had a container of ivory colored liquid on her tray. The staff member reviewed the resident's card and reported the resident's preference for boost is strawberry. Further queried the staff member whether the resident was provided with the strawberry flavored boost. Staff Member #164 stated it was the vanilla flavor and was agreeable to call the kitchen for strawberry flavored boost. The staff member brought the boost liquid and expressed the color was the same as the previous liquid. The two containers were compared and the boost on the tray was labeled with a v and the the new container was labeled with a s. The staff member opened the container and smelled the liquid. Staff Member #164 confirmed it was strawberry. A record review done on the afternoon of 11/7/17 found Resident #74's history and physical dated 6/13/17. The [DIAGNOSES REDACTED]. over the last two months with labs documenting low [MEDICATION NAME] and total protein levels. At this time the resident was prescribed Boost Pudding. A review of the Nutrition assessment dated [DATE] documents the resident was 56 inches in height and weighed 84 pounds. The resident's ideal body weight was 85 to 116 pounds. The dietitian recommended boost plus (preference for strawberry) with meals to support weight gain. Further review found a physician's telephone order dated 6/25/17 for Boost Plus, 120 ml three times a day with meals. A subsequent telephone order dated 7/25/17 was found for Boost VHC (very high calorie), 60 ml with med pass secondary to weight loss and underweight. These orders were handwritten into the physician's orders [REDACTED]. A review of the orders for (MONTH) (YEAR) found no orders for the boost plus and boost VHC and there was no order for discontinuation of these supplements. A review of the facility's documentation of fluid intake consumed was found in a binder. The meal/fluid intake sheet notes codes for items consumed, 1 for milk, 2 for juice, 3 for pudding, 4 for cream, 5 for jello, 6 for coffee, 7 for soup, 8 for teapot, 9 for custard, 10 for small plastic cup and 11 large plastic cup. On the top right corner of the 11/7/17 intake sheet is a handwritten note: B boost, N Novo? (illegible) and R renal. A review of the intake sheet for 11/7/17 found the following: breakfast 6 240, lunch 8 240 and no documentation for dinner. Further review for 10/1/17 through 10/7/17 found no documentation that a supplement was consumed. There is no documentation for breakfast on 10/1/17. There is no documentation for lunch on 10/1/17 and 10/5/17. Overall there is no documentation Resident #74 consumed the prescribed supplement of strawberry flavored boost with her meals. On 11/8/17 at 8:37 [NAME]M. an interview and concurrent observation was done with Staff Member #6. A review of the Medication Administration Record [REDACTED]. The staff member confirmed the order was not in (MONTH) (YEAR) MAR. On 11/8/17 at 8:56 [NAME]M. an interview was conducted with Staff Member #87. Inquired whether the physician order [REDACTED]. The staff member reported that the licensed nurses transcribes the orders to the MAR. At 9:04 [NAME]M. Staff Member #87 provided documentation that the physician's orders [REDACTED]. On 11/8/17 at 12:15 P.M. the Director of Nursing (DON) provided a copy of the intake record from the binder, the resident's meal card and reports of Resident #74's fluid intake from 10/1/17 through 11/7/17. The report documents the amount of fluid the resident consumed during this time period; however, does not document the consumption of nutritional supplement. The facility failed to ensure Resident #74 was provided with a systematic approach to optimize her nutritional status. The facility failed to consistently document the consumption of the prescribed nutritional supplement to ensure the supplement was being offered and consumed by the resident. Based on this inconsistent system for documenting the resident's intake of the nutritional supplement there is a lack of evidence that the facility was monitoring the efficacy of its interventions. 2) Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #14 had physician's orders [REDACTED]. The facility did not have a consistent, accurate system for monitoring and evaluating the use of nutritional supplements for Resident #14. A concurrent record review and staff interview regarding Resident #14's intake of [MEDICATION NAME] Renal was conducted on the morning of 11/7/17 at 10:00 [NAME]M. The Director of Nursing (DON) reported resident's supplement intake was recorded in a binder at the nurses station. The DON and Surveyor reviewed the intake binder for Resident #14 and found the documentation was inconsistent and sometimes blank. During the lunch meal, the Certified Nurses Aides (CNAs) were documenting Resident #14 had juice and tea and the supplement was not documented. The DON reported she knows the resident is receiving the supplement but noted the CNAs were likely documenting using the incorrect item code (ex. juice/tea). She then stated the CNAs also documented supplement intake in the Point of Care system online. The DON was unable to access the Point of Care system and therefore asked a CNA to log on and show the Surveyor. The CNA logged in and pulled up the amount of fluids Resident #14 received over the past 30 days. A numerical value was noted in Point of Care without clearly defining what types of fluids and how much of each item Resident #14 received. The DON was then asked how she monitored her staff to ensure all residents received their nutritional supplements since she was unable to access the Point of Care system. The DON replied that she relied on the CNAs and the Registered Dietician for residents with nutritional concerns. She further noted she spoke with Medical Records to get her access to Point of Care. The RD was present during the Surveyor's interview with the DON. The RD reported that she usually reviewed the intake binder to determine how much food and fluids a resident has received. The RD did not report using the Point of Care system to review supplemental intake. A review of Resident #14's care plan found one titled, Resident at risk for fluid-nutritional imbalance related to End Stage [MEDICAL CONDITION], on [MEDICAL TREATMENT], Diabetes Mellitus, [MEDICAL CONDITION], diuretic use and dysphagia. The care plan for Resident #14 did not include the use of a nutritional supplement. A review of the Registered Dietician's (RD) notes for Resident #14 found the most current note dated 9/12/17 indicating the resident had a history of [REDACTED]. The RD trialed [MEDICATION NAME] Renal during Resident #14's lunch on 9/12/17 when the resident stated he liked the supplement. The RD recommended use of [MEDICATION NAME] Renal 120 ml every day with lunch meals to support his nutritional needs with ongoing [MEDICAL TREATMENT] and to support weight maintenance. On the afternoon of 11/7/17 at 12:40 P.M., the DON provided Surveyor with Resident #14's fluid intake over the past month from Point of Care. She stated to Surveyor, You're confused. I'm confused. The staff was confused. She stated that she interviewed all persons (CNAs, kitchen staff, and nurses) and clarified that the kitchen staff never provided Resident #14 with juice during his lunch meals. The DON reported the documentation for juice in the intake binder was for Resident #14's supplement. However, the DON reported the intake binder was not considered a part of the medical record and instead would consider Point of Care as the medical record. The DON was again asked how she monitored nutritional supplement intake when she was unable to access the Point of Care system. The DON repeated that she relied on CNAs for accurate documentation and the RD to ensure the supplemental intake was meeting residents' needs. The facility failed to clearly document Resident #14's supplement intake. The lack of clarity made it unclear as to whether Resident #14 was receiving his nutritional supplement. The facility failed to have a system in place to ensure accurate documentation of nutritional supplements which placed residents at high risk for nutritional deficits. 3) Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #31 had physician's orders [REDACTED]. The facility did not have a consistent, accurate system for monitoring and evaluating the use of nutritional supplements for Resident #31. A review of Resident #31's fluid intake found inconsistent record keeping. A concurrent record review and staff interview with the DON on the afternoon of 11/7/17 at 2:00 P.M. revealed the facility utilized an intake binder as well as Point of Care to document Resident #31's supplement intake. A review of the intake binder and the Point of Care program found inconsistent, missing and inaccurate documentation of Resident #31's supplemental intake. As with Resident #14, the DON was unable to access the Point of Care and she therefore had a CNA access the program for her. In Point of Care a numerical value was listed but did not specify how much of that was Resident #31's nutritional supplement. A review of the intake binder for Resident #31 found various entries varying from milk, juice, and B. When asked what B stood for, the DON answered Boost (nutritional supplement). The Surveyor asked why Resident #31 was receiving Boost since there was no order for Boost but instead [MEDICATION NAME] Renal. The DON reported the CNAs likely documented B but meant his supplement. In addition to the inconsistencies, the intake binder did not have a section to document Resident #31's order for [MEDICATION NAME] at morning snack. In Point of Care, the numeric values were listed in 3 sections, which the DON explained was separated by shifts (day, evening, night). However, some of the day and evening shifts appeared to be documented at the same time. For example, on 11/5/17, the day shift documented Resident #31's intake at 1453 with 360 ml fluids; the evening shift documented her intake at 1454 with 360 ml; and the night shift documented her intake at 1802 with 240 ml. In Point of Care there wasn't a daily tally that totaled her intake for the day. As with Resident #14, the DON reported she relied on her CNAs to accurately document supplemental intake. She further relied on the RD to monitor Resident #14's supplemental intake. A review of Resident #31's care plan on the afternoon of 11/7/17 at 2:30 P.M. revealed a problem titled, Resident at risk for fluid-nutritional imbalance related to End Stage [MEDICAL CONDITION] on [MEDICAL TREATMENT], Diabetes Mellitus, and [MEDICAL CONDITIONS]. Interventions included, Provide and serve supplement(s) as ordered: [MEDICATION NAME] Renal 120 ml twice a day with morning snack and dinner meal. On the morning of 11/8/17 a review of the RD's notes for Resident #31 found one dated 10/3/17 which stated, (MONTH) labs for HD reviewed: mild low [MEDICATION NAME] despite good meal intake and drinking high protein supplement, potassium within normal limits, phosphorus within normal limits. The CNAs documented intake in two separate locations - intake binder and Point of Care program. The RD reviewed Resident #31's intake via the intake binder, which had differing values/information from the Point of Care system. The DON was unable to access the Point of Care program and instead relied on the CNAs to accurately enter data. The DON further relied on the RD to ensure Resident #31's nutritional supplements were meeting her daily nutritional needs. The facility failed to maintain an accurate system to monitor, assess, and evaluate the efficacy for the use of nutritional supplements for Resident #31. 4) Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #92 had physician's orders [REDACTED]. The facility failed to accurately document, monitor, and evaluate the use of nutritional supplements for Resident #92. On the morning of 11/8/17 at 8:15 [NAME]M. a review of Resident #92's Medication Administration Record [REDACTED]. On the MAR for the month of (MONTH) (YEAR), the assigned Licensed Nurses only signed off three times (11/4/17 day shift; 11/7/17 day shift; and 11/7/17 evening shift) to indicate the supplement was given. On the MAR for the month of (MONTH) (YEAR), the assigned Licensed Nurses did not sign off for the entire month. The entire month of (MONTH) (YEAR) was blank for Boost VHC 60 ml 3 times daily. An interview of Staff #6 on the morning of 11/8/17 at 8:30 [NAME]M. revealed that the licensed nurses were not required to sign off for Boost VHC since the CNAs document all of it in the intake binder. When asked why Resident #92's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of the RD's noted for Resident #92 found the latest quarterly assessment dated [DATE] which indicated, Resident continues with poor meal intake, however, drinks Boost Plus very well. The previous assessments were: an annual dated 8/15/17; a quarterly dated 5/23/17; and another quarterly dated 3/7/17, all of which noted, Resident continues with poor meal intake, however drinks Boost Plus very well at meals. On the morning of 11/8/17 at 11:00 [NAME]M. a review of Resident #92's care plan found one titled, Risk for fluid-nutritional imbalance related to poor intake, dysphagia, and [MEDICAL CONDITION]. 1/19/16 weight loss/underweight. 4/19/16 weight loss. Care plan interventions included, Provide and serve supplement(s) as ordered: Boost Plus 120 ml three times daily with meals, Boost VHC 60 ml three times a day as med pass. The facility failed to accurately document, monitor and evaluate the use of nutritional supplements for Resident #92 despite being identified as nutritionally at risk. Facility policies were reviewed on the morning of 11/8/17 at 10:30 [NAME]M. and found one titled, Therapeutic Diets with revision date of (MONTH) (YEAR). The policy noted, 7. The Clinical Dietitian and nursing staff will document significant information relating to the resident's response to his/her therapeutic diet in the resident's medical record. Another policy titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol with revision date of (MONTH) 2012 noted under Monitoring: 1. The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: a. (1) Evaluating the resident's response to interventions should be based on defined criteria for improvement/worsening of nutritional status; for example, stabilization of weight, laboratory values, or food/fluid intake.",2020-09-01
315,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2017-11-09,327,D,0,1,3IW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and resident and staff interview the facility failed to offer sufficient fluids to maintain hydration for 1 (Resident #312) of 2 residents sampled for hydration of 28 residents in the Stage 2 sample. Findings include: On 11/06/2017 at 11:06 AM while observing Resident (Res) #312 in her bed it was noted that resident had dry lips and when asked if she was thirsty Res #312 complained of dry mouth. While looking around resident's room for fluids, that might have been left for her, it was noted that there were 3 new empty cups on resident's bedside table. Review of resident's care plan (CP) found that resident is Risk for fluid-nutritional imbalance/deficit r/t variable intake, chew/swallow deficit, [MEDICAL CONDITION], diuretic use, CKD, UTI, and wt below IBW. Goal for this problem was Resident will not have s/sx aspiration, dehydration or fluid overload. Some interventions listed to meet this goal were Encourage, cue, assist or feed as needed to complete at least 50% of meals and at least 300 cc fluids with meals and 120 cc fluids between meals. Monitor for s/sx of dehydration. ex: poor skin tugor, decreased or dark urine output, wt loss, dry mucous membranes, reduced BP, etc. Provide and serve diet as ordered: Regular moist minced solids, nectar thick liquids. Review of resident's documented fluids from 10/21/2017 - 11/05/2017 showed that resident did not have a daily intake of 1,260 cc of fluids as recommended on the resident's CP. Res #312 had the following documented fluid intake: 620 cc on 10/21/2017 640 cc on 10/22/2017 240 cc on 10/23/2017 240 cc on 10/24/2017 240 cc on 10/25/2017 870 cc on 10/26/2017 720 cc on 10/27/2017 600 cc on 10/28/2017 360 cc on 10/29/2017 720 cc on 10/30/2017 840 cc on 10/31/2017 600 cc on 11/01/2017 720 cc on 11/02/2017 240 cc on 11/03/2017 540 cc on 11/04/2017 480 cc on 11/05/2017 On 11/08/2017 at 2:55 PM interviewed staff #156 who explained that fluids are given to residents during: meals, with snacks, per resident request, during rounds (nurses and CNAs will assess if residents need anything and at that time will offer fluids), and during medication administration the nurses offer fluids unless the resident is on fluid restrictions. Staff #156 and #266 both agreed that Res #312 was not on fluid restrictions. These staff did state that resident has order for thickened liquids (nectar thickened liquids) and this type of liquid cannot be left with resident for her own safety to prevent her from choking. Staff #156 was able to state what CNAs should be looking for and reporting to the nurse if the resident is dehydrated, such as dry mouth, dry lips, and dry mucous. On 11/08/2017 at 3:06 PM interviewed staff #15 who was able to state signs and symptoms of dehydration resident would say they are thirsty and look for dry skin, skin is pale, texture is dry, dry lips. The facility failed to offer sufficient fluids to maintain hydration for 1 (Resident #312) of 2 residents in the Stage 2 sample who are at risk of dehydration due to variable intake, swallow deficit, [MEDICAL CONDITION], diuretic use, CKD, and UTI.",2020-09-01
316,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2017-11-09,329,D,0,1,3IW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 2 (Residents #313 and #307) of 5 residents sampled drug regimen was free from unnecessary drugs. Findings include: 1) Resident #313 was admitted to the facility on [DATE] with the following admission Diagnoses: [REDACTED]. A record review was done on 11/6/17 at 11:00 [NAME]M. found physician's orders [REDACTED]. one tab by mouth once daily for a [DIAGNOSES REDACTED]., 0.5 tab (12.5 mg.) by mouth twice daily, no diagnosis; [MEDICATION NAME] 25 mg. one tab by mouth at bedtime, no diagnosis; [MEDICATION NAME] 4 mg. one tab by mouth once daily for [MEDICAL CONDITION]; and [MEDICATION NAME] 5 mg. tabs, 2 tabs (10 mg.) by mouth at bedtime for [DIAGNOSES REDACTED]. Also noted there is no documentation of [DIAGNOSES REDACTED]. The behavior monitoring for the use of the [MEDICATION NAME] and [MEDICATION NAME] included monitoring the resident for change of mood. Further review found an admission summary from the acute hospital with principle [DIAGNOSES REDACTED]. A review of the resident's admission history and physical notes the resident was seen at the emergency department for confusion and abdominal pain but was discharged home. Further review noted at home the resident complained of abdominal pain and also presented with confusion, agitation, hallucinations and delusions and almost hit his daughter. The admission orders [REDACTED]. one tab daily, [MEDICATION NAME] 25 mg (1/2 tab) twice a day, [MEDICATION NAME] 25 mg. at bedtime for Alzheimer's dementia and [MEDICATION NAME] for [MEDICAL CONDITION]. On 11/8/17 at 10:26 [NAME]M. the facility provided a copy of Resident #313's care plan. On 11/8/17 at 11:20 [NAME]M. an interview and concurrent record review was conducted with Staff Member #87. The staff member confirmed a care plan was not developed for the use of the antipsychotic ([MEDICATION NAME]); [MEDICATION NAME] (antidepressant); and an anticoagulant. The staff member acknowledged a care plan is indicated to address side effects of these medications nor were non-pharmacological interventions developed to address the resident's behavior. Staff Member #87 also reported once the resident's care plan is developed, this information is placed in the instructions (kardex) for the direct care staff. On 11/8/17 at 1:20 P.M. an interview was conducted with direct care Staff Member #106. Inquired what would the staff member report to the nurse regarding the resident, the staff member responded if the resident became combative and restless, this would be reported to the licensed nurse. Further queried whether the staff member was aware Resident #313 is taking an anticoagulant. The staff member did not respond, further queried when residents are on an anticoagulant what would be reported to the nurse, the staff member replied bleeding or skin tears. A request was made to the staff member to view the resident's chart for instructions to the direct care staff. The review with the staff member found no instructions to the direct care staff related to behaviors or use of an anticoagulant. On 11/9/17 at 8:57 [NAME]M. queried Staff Member #87 regarding the indications for the use of [MEDICATION NAME]. A concurrent review of the physician's orders [REDACTED]. The staff member also noted the resident was admitted to the facility with the [MEDICATION NAME]. Further queried why is an antidepressant and antipsychotic being used to address Alzheimer's and the resident receives [MEDICATION NAME] and [MEDICATION NAME] at HS (bedtime). The staff member responded the [MEDICATION NAME] will not necessarily make the resident sleepy but will calm him down. Following the interview with Staff Member #87, an interview was conducted with the Director of Nursing (DON). The DON reported the pharmacist reviewed the medication for this resident and did not want to do a gradual dose reduction as the resident was a new admission. The plan is to monitor the resident then consider a gradual dose reduction. The DON recalled Resident #313 has sundowning as evidenced by aggressive behavior. The DON also noted there is no documentation of depression related to the use of an antidepressant and usually an antidepressant is not used for behavior. The facility failed to ensure there is documentation for the indications of use for the antipsychotic and antidepressants with behavioral monitoring. Although the resident was admitted from an acute hospital with documented behaviors including confusion, agitation, hallucinations and delusions and almost hit his daughter, the facility did not monitor the resident for these behaviors. The facility also failed to ensure a care plan was developed to address the use of the following medications: [REDACTED]. 2) Cross Reference to F279. On 11/08/2017 at 4:57 PM review of Res #307 EMR showed that this resident was ordered and receiving [MEDICATION NAME] 10,000 unit/mL inject 0.5 mL (5,000 units) SQ every 12 hours until patient ambulates for Dx: [MEDICAL CONDITION] since the resident's admission on 10/23/2017. Further review of Res #307 EMR and her CP found that there was no care plan for the use of [MEDICATION NAME]. On 11/09/2017 at 10:34 AM interviewed staff #17 who was taking care of Res #307 and this staff was able to state that she would monitor resident for signs and symptoms of side effects from [MEDICATION NAME] such as bruising and bleeding and stated that this information is documented in the nurse's progress note. Interviewed staff #201 right after and he confirmed that there was no CP for [MEDICATION NAME] use for [MEDICAL CONDITION] for Res #307. Further review of resident's hard copy chart found that there were no labs done with this resident since admission to the facility and no orders for labs to be done to monitor resident's platelets. On 11/09/2017 at 11:39 AM continued review of Res #307's medical record found a nutritional assessment completed by RD #1 on 10/27/2017 at 13:27. RD #1 listed pertient medications: [REDACTED]. RD #1 did not document that the resident was getting [MEDICATION NAME] injections twice a day. [MEDICATION NAME] is an anticoagulant and is considered a high risk medication and there was no diet restriction related to this in this nutritional assessment. On 11/09/2017 at 11:50 AM spoke with staff #263 and when inquired about labs for Res #307 such as a Partial [MEDICAL CONDITION] Time (PTT) he ordered a Complete Blood Count (CBC) with differential and Complete Metabolic Profile (CMP) to be done the next day. On 11/09/2017 at 12:16 PM met and interviewed RD #2, to discuss Res #307's Nutritional Assessment that was completed by RD #1. When asked if this resident had any food restrictions RD #2 stated that the facility's menu is to provide a menu consistant to supply an amount of vitamin K in our menu to support/ balance with medical anticoagulation. Res #307 did not have any food restrictions in place even though she was receiving [MEDICATION NAME] injections twice a day to prevent [MEDICAL CONDITION]. On 11/09/2017 at 1:49 PM spoke with the facility's contract pharmacist, regarding lab monitoring for [MEDICATION NAME] that Res #307 is receiving subcutaneous. Pharmacist stated that this resident does not require PTT lab monitoring for bleeding time, only requires close watch of CBC and H and H. The facility failed to provide adequate monitoring of an anticoagulant ([MEDICATION NAME]), a high risk medication, such as side effects, diet restictions, lab monitoring as there was no comprehensive care plan developed for the use of [MEDICATION NAME] to prevent [MEDICAL CONDITION] for this resident.",2020-09-01
317,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2017-11-09,353,E,0,1,3IW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with staff members, the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, psychosocial well-being of each resident. Findings include: 1) Cross Reference to F314. The facility failed to provide treatment for [REDACTED]. 2) Cross Reference to F325. The facility failed to ensure the nursing staff accurately documented, monitored and evaluate the use of nutritional supplements for residents who were identified as nutritionally at risk (Residents #14, #31, #92 and #74). 3) Cross Reference to F327. The nursing staff failed to ensure Resident #312 received adequate hydration. The resident's fluid goal was 1260 cc of fluids per day. A review of the intake records from [DATE] through [DATE] documents the resident did not meet this goal, the range was from 240 cc to 870 cc a day. The resident also reported to have been thirsty and observed to have dry lips. 3) Cross Reference to F329. The facility failed to ensure the nursing services were provided for Resident #313 for the use of antipsychotic, antidepressant and anticoagulant medications. The staff did not acquire a physician's orders [REDACTED]. The nursing staff also failed to assess the resident's behaviors associated with the use of these medications to ensure monitoring of the efficacy of the medications. Also, the nursing staff did not develop a care plan for the use of the antidepressant, antipsychotic and anticoagulant. The nursing staff also failed to provide adequate monitoring for the use of [MEDICATION NAME] was done for Resident #307. Also, a care plan was not developed for the use of [MEDICATION NAME]. 4) Cross Reference to F431. The nursing staff failed to ensure refrigerated medications were stored at the proper temperatures as evidenced by missing documentation of the refrigerator temperature log. The nursing staff also failed to ensure attestation was done for dispensing and reconciling of narcotics. The nursing staff also failed to dispose of two expired vials of vaccines. 5) Cross Reference to F279. The nursing staff failed to ensure a care plan was developed to treat/heal a pressure ulcer for Resident #284 who was admitted with a pressure ulcer. The nursing staff also failed to develop a care plan for Resident #307 for the usage of [MEDICATION NAME].",2020-09-01
318,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2017-11-09,371,E,0,1,3IW611,"Based on observation and interview the facility failed to ensure food was stored under sanitary conditions. Findings include: During the initial tour on (MONTH) 6, (YEAR), it was observed in one of the refrigerators there were several items that had no labeling on them to indicate expiry dates or dates when they were prepared. These items were Papaya, cut and individually wrapped, cups of apple juice and other juice drinks and fruit cups. In another refrigerator there were 8 juice containers that had no labeling on them to indicate date prepared and no expiry dates. Staff #18 was present when the initial tour was conducted and validated these items were not labeled. Lack of labeling of these items has the potential for the items to be used beyond their expiry date posing the risk of food borne pathogens being passed on to residents.",2020-09-01
319,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2017-11-09,431,F,0,1,3IW611,"Based on observation, record review and staff interview the facility failed to monitor and document the temperatures of their medication refrigerators, failed to discard outdated refrigerated vaccines, and failed to document narcotic reconciliation every shift with the on-coming and out going nurses. Findings include: 1) On 11/08/2017 at 10:29 AM was shown the unit 2 medication room by staff #201. Upon entrance to the medication room it was noticed that there were 2 refrigerators. Staff #201 explained that the smaller of the 2 refrigerators was a new refrigerator on his unit from about a month ago and is only used for vaccines and when checked it was noted that there were only flu and pneumococcal vaccines inside. Staff #201 also explained that there was no temperature log for this medication refrigerator. Reviewed medication refrigerator temperature logs, for the other medication refrigerator, and noticed that there were columns for the following *freezer refrig., food refrig. and med refrig. on the Refrigerator Checklist form. There is a column for RCU only spec refrig. and nothing was documented in that column. There is an action/discrepancy reported to column as well. Staff #201 explained that the nurses are responsible for documenting the medication refrigerator temperatures on the Refrigerator Checklist Form for their shift. It was noted that there are 3 times listed on the form when the medication refrigerator's temperature is checked 800, 1600 and 2400 along with a space for the nurse to sign. Reviewed the temperature logs with staff #201 and he confirmed that there were missing temperatures and staff signatures from the log. Upon further review it was noted that there were a couple of weeks in (MONTH) and (MONTH) (YEAR) (09/04/2017 - 10/19/2017) that did not have any recorded temperatures and signatures on the log, minus 10/06/2017 and 10/09/2017 both 800 times have documented temperatures and nurse's signatures. Staff # 201 confirmed that this information was missing from the form and apologized for this. Staff #201 was asked and provided the facility's policy on refrigerated medications and how the facility ensures that medications that are refrigerated are kept at proper temperatures. The facility policy Medication Storage in the Facility policy states 10. Medications requiring refrigeration or temperatures between 2 degrees C (36 degrees F) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. 11. Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. (Other foods such as employee lunches, activity department refreshments are not stored in this refrigerator). 2) On 11/08/2017 at 10:49 AM interviewed staff #262 and looked through medications stored in medication cart on unit 2. No expired medications were found in cart, narcotic count was correct, however the Controlled Item Checklist form for narcotic reconciliation, used at the end of each shift, were missing signatures. Staff #262 explained the process for the narcotic count reconciliation with licensed staff. She stated that the on-coming and out going nurse count the narcotics together to make sure the count is accurate and then sign off on the Controlled Item Checklist form'. Interviewed staff #201 at that time to see if he was aware that some of the licensed staff were not signing off on the Controlled Item Checklist form and he confirmed that some signatures were missing and apologized. Staff #201 was asked and provided the facility policy on Controlled Substances. The facility policy states 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. Requested, received and reviewed from staff #201 copies of the Controlled Item Checklist for Unit 2. It was found that in (MONTH) (YEAR), a 31 day span, there were 34 signatures missing out of 186 signatures from licensed staff signing off on the narcotic count at the end of each shift for one of the medication carts on Unit 2. Review of (MONTH) (YEAR) Controlled Item Checklist for Unit 2 found 48 signatures missing from the 180 signatures that were required for this 30 day span for one of the mediation carts on Unit 2. 3) On 11/08/2017 at 12:58 PM interviewed DON regarding findings on Unit 2 refrigerator checklist and controlled checklist forms. DON explained that she is doing QA on these items, had identified the problems in (MONTH) this year, and did training in (MONTH) and (MONTH) (YEAR) (09/20/2017 - 10/20/2017) and she believes the controlled checklist forms have improved. DON was shown the temperature logs and that even after the training that was provided the staff did not change the Refrigerator Checklist form to show that there were 2 medication refrigerators being monitored on unit 2. From (MONTH) 25, (YEAR) - (MONTH) 4, (YEAR) someone had put an X on the *Freezer Refrig, Food Refrig, and Med Refrig columns on the Refrigerator Checklist form and nothing was written above the X's to identify which refrigerator was being monitored. Looking at this form I could not tell which documented temperatures go with the refrigerators on Unit 2. 4) On 11/08/2017 at 2:30 PM DON gave a copy of the Summary of in-services provided 09/20/2017 - 10/20/2017, which covered the following topics: Formulary Medication Interchange, Expired Medications, Refrigerator Log, Narcotic Log and Expired Medications. The following items were covered for this training Narcotic Log 7. All LN must sign the narcotic sheet log post counting with the on-coming shift LN. Refrigerator Log 8. Must document temperature log each shift for all the refrigerator in each unit. and Expired medications 9. No expired medications in medication carts. Follow manufacturer's recommendations and destroy medication dated started on the medication label provided by the pharmacy. See expiration date medication guidelines. 5) On 11/09/2017 in the AM, went to Unit 3 to check the medication refrigerators and their temperature logs. Staff #156 showed me the refrigerator and logs and upon inspection of the medication refrigerator found 2 expired pneumococcal vaccines. Expired vaccines were shown to staff #156 who confirmed that they were expired in (MONTH) (YEAR). Review of Unit 3's Refrigerator Checklist for (MONTH) (YEAR) found 12 out of 93 signatures and temperatures missing from these forms. It was noted that there were also 15 times that a nurse signed the form but did not document the temperatures on the log and this appears to be one staff member who works in the evening shift. Overall there were 27 times out of 93 that there were no temperatures documented for the medication refrigerator in (MONTH) (YEAR) for the Unit 3 medication refrigerator. Review of the Medication Storage in the Facility policy states 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. Requested, received and reviewed, from staff #156, copies of the Controlled Item Checklist form for Unit 3, as far back as (MONTH) 15, (YEAR) - (MONTH) 16, (YEAR), a 30 day span. Found that there were 63 signatures missing, out of a possible 180 signatures for this time spam, from licensed staff signing off on the narcotic count at the end of the shift for one of the medication carts on Unit 3. 6) On 11/09/2017 in the AM, requested, received and reviewed from staff #145 copies of the Controlled Item Checklist for the Ventilator Care Unit (VCU). Review of the VCU Controlled Item Checklist forms found that (MONTH) (YEAR) had 10 signatures missing out of a possible 186 signatures required for that time span. Review of the VCU Controlled Item Checklist forms from (MONTH) (YEAR) found that there were 6 signatures missing out of 186 signatures required from that time span. This information was from one of the back medication cart on the VCU. The facility failed to properly identify, monitor and document the temperatures of their medication refrigerators, failed to discard outdated refrigerated vaccines, and failed to document narcotic reconciliation every shift with the on-coming and out going nurses, per facility policy, which may have resulted in a resident receiving mediations that were no longer effective, received an expired vaccine, or the unit may have had an incorrect narcotic count.",2020-09-01
320,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2017-11-09,441,D,0,1,3IW611,"Based on a random observation and interview with staff member, the facility failed to ensure hand hygiene practices to reduce the spread of infections and prevent cross-contamination was implemented. Findings include: On 11/8/17 at 11:07 [NAME]M. observed Resident #66's wife approach the medication cart which was parked in front of the nurses' station, the wife grabbed one of four cartons of thickened water, unscrewed the cap and poured the thickened water in a plastic cup. The cap was replaced on the carton and the wife put the carton back with the other cartons. At this time the Director of Nursing (DON) was approaching the cart and was asked whether the resident's wife is allowed to get water from the medication cart. The DON responded the wife has been trained by the speech therapist; however, the wife needs to inform the nurse. Further queried whether the resident's wife was also instructed on hand washing before pouring the thickened water from the carton. The DON instructed another licensed nurse to talk to Resident #66's wife. On 11/8/17 at 11:18 [NAME]M. an interview was conducted with Resident #66's wife. The resident's wife reported when she arrived she knew her husband was thirsty and she will usually ask one of the ladies but nobody was around so she went to get the water herself. Inquired whether she has been provided any instructions regarding getting water for her husband from the nurses' cart. She responded she is not supposed to get water from the cart but could not get assistance and her husband was asking for water. On 11/8/17 at 1:55 P.M. the Staff Member #6 confirmed the cartons of thickened liquid on the nurses' med carts are used for residents that required thickened or nectar consistency liquids during medication pass. The facility failed to ensure hand hygiene practices are performed by visitors or refrain visitors from touching items on the medication cart which is utilized by staff members to dispense medications to residents of the facility.",2020-09-01
321,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2017-11-09,514,E,0,1,3IW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure medical records were kept in accordance with professional standards and practices to assure records are accurate, complete and organized. Findings include: 1) Cross Reference to F325 for four residents (Residents #92, #14, #74 and #31). The investigation of residents that were prescribed nutritional supplements found the facility's documentation did not provide evidence that the resident's care plans and physicians' orders were being implemented. The intake documentation stored in binders on the unit found inconsistency for the documentation of the consumption of nutritional supplements. Further investigation found the documents in the unit binders and the electronic medical record found evidence of missing documentation and the two programs combined did not present the actual care the residents received. The facility failed to have a system in place to ensure accurate documentation of nutritional supplements which placed residents at high risk for nutritional deficits. 2) Cross Reference to F329. The medical record for Resident #313 did not document the resident's [DIAGNOSES REDACTED].",2020-09-01
322,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2019-12-19,550,J,1,0,S0P811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure a vulnerable Resident (R1) was free from criminal sexual assault by a Certified Nurse Aide (CNA)1 while providing personal care early in the morning. The deficient practice violated the residents right to be free from sexual abuse, the right to a dignified existence, and finally the right to an acceptable quality of life which failed when R1 was left traumatized, afraid, and unable to sleep or participate in her skilled services program. The facility also failed to provide R1 with emotional support and trauma informed care after the assault. The facility did not promote and protect R1's quality of life. (refer F600). Findings include: The facility reported that R1 and her sister (FM)1 asked to speak with Social Services (SS) on 12/10/19 at approximately 12:45 PM. The alleged incident was discussed with the facility Administrator (FA) at 01:15 PM. The alleged perpetrator (CNA1) contacted by cell phone and message left to contact F[NAME] At 01:45 PM the Honolulu Police Department (HPD) was notified and officers arrived at 02:30 PM to interview resident and staff, and discuss resident going to the emergency department (ER) for an evaluation. The unit staff were advised of the situation and orders given for all care for R1 to be done with two staff present in the room, going forward. R1 was transferred to the ER at 04:15 PM. CNA1 was contacted via telephone call and placed on Administrative leave of absence at 08:30 PM. Upon return of the resident to the facility at 05:00 AM on 12/10/19 to 12/17/19 there was no psycho-social support services put in place and the next follow up appointment to the Sex Abuse Treatment Center (SATC) was not until 12/26/19. During an interview with R1 on 12/18/19 at 10:00 AM, who appeared in bed. Pale complexion, awake, alert, eyes open wide, and sitting up in bed. The Resident spoke slowly and quietly requiring the listener to lean in close to hear her speak. The resident stated Its difficult, so many people I have to talk to you can talk to my sister . R1 stated yes nodding her head up and down when asked if she was afraid. During a telephone interview with R1's sister (FM)1 on 12/18/19 at 08:33 AM FM1 recounted the incident R1 had described to her. It was about 11:30 AM. After R1 gave the description of CNA1, SS staff looked to see who was on duty and said there was a staff who had those letters in his name and matched the description that worked that previous night shift. I met her later at the ER and was present during the evaluation which was very difficult for my sister, especially after the hip surgery. She had to wait until 11:30 PM to start the assessment and didn't complete it until 2 or 3 AM. I thought she shouldn't go back there. Now R1 is afraid, and not sleeping well even though CNA1 is gone. When I went to see her the next morning she told me she heard scratching on her window. I don't know if they could find her a place, at least they could find her another room. I think she thinks he'll come back. It seems pretty clear that he's not coming back. Every time I go see her I just feel so badly for her. When I see R1 she is concerned and worried, looking at her face. I've been spending a lot of time there. R1 is very dependent on me. I feel that I know her very well, I almost feel as if it happened to me. The SATC offered to provide therapy. R1 said she wanted it when she got back to the facility, she was so tired, she was up all night during the evaluation. I'm really concerned because she hasn't been participating in her therapy and not making the progress she needs to so she can come home. She needs to walk at home. I'm afraid it has something to do with what happened, she's got to learn to walk so she can go home. During an interview with the SS Assistant (SS2) on 12/17/19 at 11:23 AM stated, I was mostly the one to talk to R1. According to R1, the incident occurred early that morning. When she was describing it, she started shaking a little more, became teary eyed, very anxious, panicky, I told her to take her time with this. She did get choked up. Her sister was upset as well. I think she really believed it happened. Two days later I went to see her, the sister said she has trouble sleeping. She did say she was sore down there, it hurt from the pounding. she stated that she didn't want to have sex with anyone after her husband passed away. R1 laid in there in bed subdued. She didn't mention the incident again. It was upsetting for her to have to give more details about the incident to the other investigators. During an interview with the Assistant Director of Nursing (ADON) on 12/17/19 at 1:06 PM stated R1 seems fairly cognitively intact, she takes time to respond to you. She is able to respond if you give her time. She has [MEDICAL CONDITION], and has a [DIAGNOSES REDACTED]. She has a flat affect. During an interview with the Director of Nursing (DON) on 12/18/19 at 11:11 AM I talked to R1 to see if she was ok coming back to us. I didn't think they were coming back. I learned yesterday that the family want to transfer to another facility. The SS Director came into my office and said the Adult Protective Services (APS) investigator came in on Monday and said the sex assault ink test was positive. I asked her to contact the FA and let him know this information. She stated we updated R1's care plan which states which states that two staff were to provide R1's care at all times. If male staff were assigned they needed to work with a female staff. During an interview with Registered Nurse (RN)2 on 12/18/19 at 02:25 PM I was working on the unit on the night of the incident but working on the back side. There are no other male CNA's working on the unit, only an RN but he wasn't working that night. I never worked with the resident before, she usually sleeps at night. Two nights now she has been complaining that she can't sleep. I think they referred her to a psychiatrist. Electronic Medical Record (EMR) reviewed. Skilled nursing (SN) notes dated 12/11/19 04:05 PM reviewed, one person total assist; no transfer activity on this shift, no ambulation made. SN notes dated 12/12/19 02:41 PM reviewed. No transfer activity this shift. No ambulation made. One person total assist. SN notes dated 12/15/19 02:27 PM reviewed. Alert and oriented x 1-2, with episode of confusion. One person total assist no transfer activity on this shift. No ambulation made. SS notes dated 12/16/10 04:13 PM reviewed. SW met with APS worker regarding open APS case. Investigator reported that R1 is requesting for lateral transfer to another facility. SN notes dated 12/16/19 05:35 PM. R1 complained of inability to sleep well at night. Refused to take any as needed (PRN) sleeping pill and requested to increase her [MEDICATION NAME] (antipsychotic medication) from 15 milligram (mg) to 20 mg at bedtime. Resident assisted to wheelchair at lunch with two person extensive assist. SN notes dated 12/17/19 03:37 AM reviewed. Received resident in bed, watching television (TV).",2020-09-01
323,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2019-12-19,600,J,1,0,S0P811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure a vulnerable Resident (R1) was free from alleged criminal sexual assault by a Certified Nurse Aide (CNA)1 while providing personal care early in the morning. CNA1 allegedly entered her room, placed an object in her mouth which left her unable to call for help, held her down on her bed and aggressively sexually assaulted her. The deficient practice left the resident traumatized and afraid which was demonstrated by the inability of the resident to sleep and feel safe in the facility. In addition to the emotional trauma suffered by the resident, R1 experienced pain and injury (lacerations) to her vagina and buttocks. The facility also failed to provide emotional support and trauma informed care after the assault, leaving the resident to feel helpless and afraid while residing in the facility. Findings include: On 12/10/19 at 01:50 PM the Office of Healthcare Assurance (OHCA) received a telephone call from the facility Administrator (FA) who stated that a Resident reported sexual assault by a staff member. The FA stated that the police had been called and an investigation was being conducted. Initial facility Event report dated 12/10/19 and received on 12/11/19 at 10:13 AM via email from the F[NAME] The initial report stated that R1 and her sister (FM)1 asked to speak with Social Services (SS) on 12/10/19 at approximately 12:45 PM. The alleged incident was discussed with FA at 01:15 PM. The alleged perpetrator (CNA1) contacted by cell phone and message left to contact F[NAME] At 01:45 PM the Honolulu Police Department (HPD) was notified and officers arrived at 02:30 PM to interview resident and staff, and discuss resident going to the emergency department (ER) for an evaluation. The unit staff were advised of the situation and orders given for all care for R1 to be done with two staff present in the room, going forward. R1 was transferred to the ER at 04:15 PM. CNA1 was contacted via telephone call and placed on Administrative leave of absence at 08:30 PM. Adult protective services (APS) report dated 12/11/19 at 03:00 PM received via fax and reviewed. Presenting problem states: Allegations of sexual abuse of an [AGE] year old female by a male certified nurse aide (CNA) at the Facility, name NOT provided by the facility to APS. R1 reported that on 12/10/19 at about 08:00 AM the alleged perpetrator (AP) came into alleged victim's (AV)'s room at the facility to check her diaper and returned at about 9:00 AM stating that AV had diarrhea/ peed herself, and that AP would return to change AV. AV stated she did not have a good feeling about AP at this point. At 9:15 AM. AP returned with supplies, entered AV's room, put a handkerchief in AV's mouth, thus AV could not speak and could barely breathe they were alone, no known witness. AP held AV down by the bend of AV's elbows, got on top of AV, and penetrated AV's vagina with AP's penis. AV stated she felt pain. AV repeatedly stated I didn't want that. At about 11:30 AM when AV's sister arrived at the facility, AV informed sister of the incident, who reported it to the social worker staff, who called the police. The Sex Abuse Treatment Center (SATC) Forensic exam showed findings of assault including lacerations from the vagina to the anus, and also in the anus. AV's Diagnosis: [REDACTED]. Alert/ oriented, has decisional capacity, but no known formal assessment. Currently has mobility issues due to recent hip surgery, but reportedly needed assistance with her care prior as AV indicated her sister has been AV's primary caregiver. Assessment/ Disposition: The AV meets the definition of a vulnerable adult as statutorily defined. Protective services are warranted for sexual abuse, per HRS 346-222 (3). Disposition: Accepted for investigation. Facility event report completed by the Administrator dated 12/13/19 received via email by the State Agency and reviewed. On 12/11/19 at 05:15 AM R1 returned to the facility from the ER. Administrator's summary states: Based on my interviews, and the information I have available to me, I do not believe this assault occurred here at the facility. This resident came to us from an acute care facility a short while after hip surgery and general anesthesia. The time line of work activities of the staff, as well as the absence of any physical injury evident leads me to this decision. Please refer to the attached documents for further evidence of my conclusion. Attachments include the following: 1. Handwritten statement by two CNA's. 2. Handwritten timeline of shift activities by CNA1 and his partner (CNA2). CNA1 and his partner worked together in caring for R1 from 11:05 PM till 06:15 AM when the partner ended her shift. Noted CNA1 was working alone with R1 from 03:00 AM till 04:00 AM while partner was on her break and again from 06:15 AM till 08:00 AM till his shift ended. He stated R1 called to be changed at 6:55 AM when he changed her alone. 3. Time card report from CNA1. 5. Interview with CNA1. When asked do you have an idea why this resident would accuse you of this? he answered, no I don't have any idea why she would have this story, she is going to change her story anytime now. I think she is confused. Why would I do anything to her like that? I don't know her, I don't know how she knows my name since we are wearing gown's when we go in to clean her. When she have wet diaper my partner did by herself and I did one time at the end of the shift by myself. Like I put on the paper. I think it was just before I talked to you in the hall outside that room. FA stated we did talk about 06:45 AM I believe. I started my rounds about 06:35 AM and saw you charting about 10 minutes later. CNA1 stated I will do whatever I need to swab or blood or test, even lie detector test anytime you want. I never did this. Why would I do something like this? You know you can call me and I will come to do anything you want for tests or what I need to do. I never did this. I am innocent. Why would I do anything to her like that. Sex with her??? I never did. 6. Interview with CNA2 (CNA1's partner). Stated we changed R1 together only a couple of times. We worked together all night until I went home at 06:15 AM. We are in gown and masks because she is on isolation. How she knows his name then if we are covered in gowns every time we are in there? 7. Professional summary by the F[NAME] Several calls were made to the detective at the Criminal Investigation Division (CID). I was unable to speak with the Officer, therefore I am writing my professional summary of the investigation I conducted, as follows: Summary of the alleged events. R1 states that during the alleged assault, It hurt from him pounding into me During independent and separate interviews, both CNA staff state the resident was calm and unemotional, and talking normally with them during the personal care they provided to her approximately 08:00 AM. Neither of the CNA staff noted any type of abnormal findings or injury/ blood in the resident's perineal area, buttocks, or abdominal area during the personal care. Neither of the CNA staff identified any abnormal fluid in the brief when it was changed. I made a call to the ER and was informed I could not have any information because there is no account of the physician's assessment in the record. This information concludes what I have for my investigation. Neither R1 or FM1 have expressed any interest in leaving this facility. R1 is cooperative and involved with rehab services. Based on review of the documentation in the FA completed report, noted the FA made his conclusion based on interviews with four CNA staff, the SS interview with R1 and without obtaining further information from the ER assessment or HPD. During an interview with the FA during the entrance conference on 12/17/19 at 9:15 AM, stated that the employee (CNA1) is currently on administrative leave. The Administrator gave a verbal account of the events from the initial report by R1 until the investigation was completed. The Director of Nursing was out with illness so I met with the Assistant Director of Nursing (ADON) to inquire what are our procedures for reporting and conducting the investigation. I have never had a situation like this occur before in any of the facilities I have worked in. I made several attempts to call the investigating officer at the police department Criminal Investigative Division (CID) and have not been able to make contact with the detective. I called the ER and asked for a copy of the assessment and was told I was not able to receive a copy. When asked about the facility reporting requirements and who was notified of the alleged sexual assault stated, we called HPD and the office of healthcare assurance (OHCA), I did not call adult protective services (APS). The FA added that CNA1 was employed here at the facility last (MONTH) 2019, and certified as a CNA in (MONTH) 2019. Requested and received CNA1's personal file that included the background investigation conducted at the time of hire. Discharge summary report dated 12/09/19 reviewed. R1 is an [AGE] year old female admitted to an acute care facility on 11/30/19 after a fall at home. Primary [DIAGNOSES REDACTED]. Secondary Diagnosis: [REDACTED]. She was diagnosed with [REDACTED]. Her hemoglobin was noted to be 8.5 (Low). discharged to long term care for rehabilitative services on 12/09/19. Progress notes reviewed. Admission note dated 12/09/19 11:17 PM. Able to speak but with some words unclear. Able to move in bed with extensive assistance one person assist. Incontinent to bowel and bladder on shift. Percare provided by staff. Skilled Progress Note dated 12/10/19 06:13 AM. On contact isolation for positive [MEDICAL CONDITION] resistant staff aureus(MRSA) to nares and positive ESBL to urine, a bacterial infection requiring the resident to be on isolation precautions,. Staff are required to wear personal protective equipment (PPE). Resident was able to communicate needs. Incontinent to bowel and bladder kept clean, dry and comfortable. 4. SS note dated 12/10/19 at 12:15 PM stated Pt. reported that at some point this morning, she was raped by someone name who she describes as Five feet three or four inches, with a broad face, broad around the middle, and has a chin with whiskers on it. She stated that this morning she had diarrhea, and he stated he needed to get some supplies to clean her up, came back in 20 minutes . note continues to state details of the assault. 12/10/19 11:44 General Note. At 04:30 PM EMS came to pick up resident going to ER for sexual abuse assessment. During a telephone interview with Social worker (SW) at the SATC where R1 completed the sexual assault assessment. R1 has a follow up appointment on 12/26/19. Requested a copy of the exam results for R1. During an interview with the SS Director on 12/17/19 at 10:26 AM stated on the 10th FM1 was seen in the hall and asked for help and to talk with the Social Worker. FM1 gave a brief account of the incident that R1 reported had happened earlier in the morning. My assistant and I went into the room to interview R1. R1 said she couldn't remember the time the incident occurred but said the sun was up. We told R1 that we were talking this very seriously and I wanted to be sure of our protocol here, only been here for three months. I found the ADON and asked her what is the protocol to follow in this facility. She responded saying she took it to the F[NAME] When asked if APS was notified, she stated I don't know if the Administrator reported the incident to APS. When asked if any psychosocial support had been provided to R1 she stated No. The following day the APS investigator called to ask for the medication list and for the identity of the AP, I told them I need to check with our Human resources offices. My associate SS2 did most of the interviewing, she said she saw R1 tear up during the interview. When asked if the care plan was updated after the incident the SS Director responded that we updated the care plan to state no male care giver alone with R1. If with male care giver, needs to have 1 female care giver at all times. During a telephone interview with the APS investigator on 12/17/19 at 11:00 AM, stated that she came to the facility the previous day on 12/16/19 and requested the name and contact information for the AP from the Human resources office. She conducted an interview with R1 and FM1. After speaking with R1 the investigator notified the SS Director that the results of the sexual assault assessment were conclusive. She also requested the facility begin to locate another facility for R1 to be transferred to considering the severity of the trauma that she suffered. The investigator provided the name and contact information for the detective at CID, who planned to conduct a formal interview with R1. During an interview with the SS Assistant (SS2) on 12/17/19 at 11:23 AM stated I was mostly the one to talk to her. According to R1 the incident occurred early that morning. She could only recall five letters in CNA1 name, although she stated that there were more letters in the name but she couldn't remember them all. He had come in to clean her up and said he had to go get supplies, then returned in about 20 minutes. When he came back he put a handkerchief like tissue in her mouth so she wouldn't scream. He took off her clothes and she tried to grab his thing .he said she was in a state of shock and didn't really remember what happened after that. She wanted to contact the police but she didn't know how so she told us. I just started here at the facility and the day of the incident was my first day here, I wasn't really sure about the state regulations. When asked if she knew if APS was notified by the facility stated that she didn't know and that the FA said he had calls to make. When she was describing it, she started shaking a little more, became teary eyed, very anxious, panicky, I told her to take her time with this. She did get choked up. Her sister was upset as well. I think she really believed it happened. Two days later I went to see her, the sister said she has trouble sleeping. She did say she was sore down there, it hurt from the pounding. she stated that she didn't want to have sex with anyone after her husband passed away. R1 laid in there in bed subdued. She didn't mention the incident again. It was upsetting for her to have to give more details about the incident to the other investigators. During an interview with CNA1 on 12/17/19 at 12:40 PM in the facility conference room, who presented as a dark completed male, medium height, stocky stature with short groomed haircut and beard that appeared as thick gray short whiskers. He had a calm affect, was cooperative, smiling. He stated this is my first job as a CN[NAME] I have worked here at the facility for about eight months. When asked to describe what sexual abuse means stated touching a patient in a non appropriate way, touching a breast or fondling them, and can actually be intercourse. When asked to describe in his own words what happened that day stated. It was a regular day for me, R1 was alert, but she wasn't talking that much, that's kind a normal for a new patient. She seemed ok, I took her vitals, took other peoples vitals than we started patient care. Me and my partner did diaper changes. The one time I was alone with her was when my partner left. We changed her a lot since she had the urine infection maybe seven or eight times. My partner left at least an hour early, around 6:15 AM. R1 called around 6:50 AM to be changed. The whole time while we were cleaning her we wore, gown, gloves and mask. The last time I went in I only wore the gloves and mask, not a gown. I was by myself. She only requires one CN[NAME] She told me she needed to be changed, that time she had a bowel movement, the whole night it was just urine. I cleaned her and left the room. I stayed in the room less than 5 minutes. After that I washed my hands, fixed her sheets and then went out to the nurses station. It was light then, all of the people were starting to come in at that time. I reported off to the new CNA's coming in,, about her being on isolation for urine, about her legs. When asked how long he knew the resident stated I didn't know her for more than one day. They said that she just arrived on her shift. I was really surprised to learn about the incident that she claimed I had consensual sex with her. In training we learned about some patient's having mental issues. CNA1 stated he introduced his self to R1 and had his name tag on. When asked why he didn't wear a PPE gown only on that one visit with R1, stated we only wear the gowns for extra protection. The type of isolation she was on didn't require me to wear a gown. She had diarrhea at that point. She was on isolation for urine. During the interview with CNA1 noted that his description of the event conflicted with the interview he had with the FA which placed him in R1's room without a PPE gown on. In the interview with the FA he questioned how R1 could know his name when he was wearing a gown and mask. He also stated that he introduced his self to R1 and was wearing his badge. The description R1 gave about his identity was accurate, being wide and with whiskers. The letters stated in his name were also an accurate account of CNA's name (or part of his name). CNA1 employee personnel record reviewed. Received CNA certification on 03/18/19. Prior employment as Barber and security guard. Date of hire 04/09/19 by facility. Background investigation summary noted on 10/13/98 was charged with a misdemeanor for a violation of an order for [REDACTED]. Honolulu family court. All other information in the file was negative. Noted the file did not contain documentation from the facility about the allegation of assault. Reviewed in-service training record signed and dated 05/15/19. Resident rights; resident abuse/ dominant language, posttest includes misappropriation of resident property, physical abuse, sexual abuse. Problems and needs of the elderly: dementia, restraints, elopement, fall precautions. Sexual harassment. Staff meeting minutes dated (MONTH) 2019 with inservice training staff sign off roster reviewed. In service training provided: Dignity/ abuse/ dining. 89 staff signatures completed out of 180 staff. CNA1 did not sign the sign in roster that he completed the training. During an interview with the ADON on 12/17/19 at 1:06 PM. The DON was out with illness so I was covering for her. I collaborated with the FA to follow up with procedures we needed to follow. We went to interview R1. ADON recounted the report of the incident. R1 seems fairly cognitively intact, she takes time to respond to you. She is able to respond if you give her time. She has [MEDICAL CONDITION] and has a [DIAGNOSES REDACTED]. She has a flat affect. The Administrator made the phone calls to OHCA and HPD, I don't know if there was any report to APS. Not to my knowledge was there any complaints or incidents involving CNA1. When staff are onboarded here they receive abuse prevention training during orientation then annually. Last facility wide training that included abuse and neglect was given in (MONTH) 2019. Most but not all of the staff signed off on the attendance form. During a telephone interview with FM1 on 12/18/19 at 08:33 AM stated that when I went in to see her that morning, she told me about it. R1 doesn't have a great deal of confidence, she was very self contained and very clear when she was telling me about it, she held herself together very well although she was very upset and wanted to take care of this. She wants to press charges. FM1 recounted the incident R1 had described to her. It was about 11:30 AM. After R1 gave the description of CNA1 SS looked to see who was on duty and said there was a staff who had those letters in his name that worked that previous night shift. I met her later at the ER and was present during the assessment. I thought she shouldn't go back there when we were at the ER. R1 is afraid and not sleeping well even though CNA1 is gone. When I went to see her the next morning she told me she heard scratching on her window. I don't know if they could find her another place, at least they could find her another room. I think she thinks he'll come back. It seems pretty clear that he's not coming back. Every time I go see her I just feel so badly for her. When I see R1 she is concerned and worried, looking at her face. I've been spending a lot of time there. R1 is very dependent on me. I feel that I know her very well, I almost feel as if it happened to me. The SATC offered to provide therapy. R1 said she wanted it when she got back to the facility. During an interview with the Registered Nurse (RN) unit manager on 12/18/19 at 10:30 AM stated that R1 is able to tell you what she needs she speaks softly. I made several rounds during the night and in the morning. We had a care plan meeting, the care plan was updated. The sister came to the meeting. She mentioned about being transferred. The SS responded that they made referral's to two other facilities to transfer R1, but no definite answer yet. During an interview with the DON on 12/18/19 at 11:11 AM stated she was out sick three days and returned to work on Thursday and feeling very overwhelmed. I talked to R1 to see if she was ok coming back to us. I didn't think they were coming back. I learned yesterday that the family want to transfer. The SS Director came into my office and said APS came in on Monday and said the sex assault ink test was positive. I asked her to contact the FA and let him know this information. When asked were there any updates to the care plan? Was psycho-social support being offered? stated the staff are only providing care for R1 with no male alone and two people at all times. I don't know if SS provided any psycho-social support to R1. She stated that she really doesn't know CNA1. During an interview with CNA3 on 12/18/19 at 11:40 AM stated she was working on the same unit as CNA1 although in the back of the unit so she didn't see him. During an interview with the RN Supervisor on 12/18/19 at 01:17 PM stated that she was working with CNA1 and CNA2 the night/ morning of the incident. I just saw the two CNAs charting and talking while doing rounds. I gave the medication at 12:00 AM and 6:00 AM. She was smiling at 06:00 AM. There was a period of time when I wanted to ask the CNA's about the new patient and they weren't around, maybe before 5. I can't remember the time exactly. At around 04:00 AM I noticed CNA1 was around me a lot, always standing right next to me, and he was just looking at me, it made me feel really uncomfortable. He asked if he needed to do the the six AM vital signs. His partner left at 06:15 AM. During an interview with CNA4 on 12/18/19 at 01:00 PM stated We saw each other when we were doing our rounds. I saw him in the hallway. We saw each other in the hall. During an interview with CNA 5 on 12/18/19 at 01:47 PM stated CNA1 reported off to my partner that he change a lot of the BM and changed her by himself. That was before 7:00 AM. I was putting my things in the back. CNA1 reported off to CNA3 at the end of the shift. I think they were done by the time I got back between 7:00 and 7:30 AM. During an interview with RN2 on on 12/18/19 at 02:25 PM I was working on the unit on the night of the incident but working on the back side. There are no other male CNAs working on the unit, only an RN but he wasn't working that night. I never worked with the resident before, she usually sleeps at night. Two nights now she has been complaining that she can't sleep. I think they referred her to a psychiatrist. Recently only. During an interview with CNA6 on 12/18/19 at 02:46 PM stated when asked if he knew CNA1 and how is his demeanor with the residents, stated he's ok. So far, he's here as a part time on call. He works as a hair dresser and a security guard. We only see him at night time, he stays by himself. Sometimes the residents say they don't want him to provide their care. He is a good worker. He floats. Some floors don't get used to him. They are hesitant to let him take care of them. Some residents have said they don't want him, I don't know why, he's quiet, maybe they don't like the way he looks.",2020-09-01
324,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2019-12-19,607,E,1,0,S0P811,"> Based on interview, record review and policy review, the facility failed to implement its policy and procedures on abuse prevention, investigation, reporting and response after a Resident (R)1 was allegedly sexually assaulted by a Certified Nurse Aide (CNA)1 employed in the facility. In addition, the facility failed to conduct a thorough investigation into the allegation of sexual abuse and did not provide oversight and monitoring to ensure all of its staff were trained on the abuse prevention policy. This deficient practice was demonstrated by staff interviews and in-service training records that were not completed by all of its staff. The deficient practice left vulnerable Residents residing in the facility at a high risk of sexual abuse by its facility staff. (Ref F600). Findings include: Facility Abuse Prevention Program Policy revised date (MONTH) (YEAR) reviewed. As part of the resident abuse prevention, the administration will: 4. Require staff training/ orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Facility Abuse Investigation and Reporting Policy revised (MONTH) (YEAR) reviewed. All reports of resident abuse, neglect, exploitation .shall be promptly reported . and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Roll of the investigator. The individual conducting the investigation will, as a minimum. i. Interview other residents to whom the accused employee provides care or services . 3. The investigator will notify the ombudsman .Reporting. 1. All alleged violations involving abuse . will be reported by the facility Administrator, or his/ her designee . to the following persons or agencies: b. The local/ State Ombudsman. 4. Notices will include, as appropriate: e. The name (s) of all persons involved in the alleged incident; and .Any allegations of abuse will be filed in the accused employee's personnel record along with any statement by the employee . On 12/10/19 at approximately 01:50 PM the Office of Healthcare Assurance (OHCA) received a telephone call from the facility Administrator stated that a Resident reported had been sexually assaulted by a staff member. The Facility Administrator (FA) stated that the police had been called and an investigation was being conducted by the F[NAME] Initial facility Event report dated 12/10/19 and received on 12/11/19 at 10:13 AM via email from the F[NAME] The initial report stated that R1 and her sister (FM)1 asked to speak with Social Services (SS) on 12/10/19 at approximately 12:45 PM. The alleged incident was discussed with FA at 01:15 PM. The alleged perpetrator (CNA1) contacted by cell phone and message left to contact F[NAME] At 01:45 PM the Honolulu Police Department (HPD) was notified and officers arrived at 02:30 PM to interview resident and staff, and discuss resident going to the emergency department (ER) for an evaluation. The unit staff were advised of the situation and orders given for all care for R1 to be done with two staff present in the room, going forward. R1 was transferred to the ER at 04:15 PM. CNA1 was contacted via telephone call and placed on Administrative leave of absence at 08:30 PM. Completed facility event report dated 12/13/19 received via email by the State Agency and reviewed. On 12/11/19 at 05:15 AM R1 returned to the facility from the ER. Summary states: Based on my interviews, and the information I have available to me, I do not believe this assault occurred here at the facility. This resident came to us from an acute care facility a short while after hip surgery and general anesthesia. The time line of work activities of the staff, as well as the absence of any physical injury evident leads me to this decision. Please refer to the attached documents for further evidence of my conclusion. Attachments include the following: 1. Handwritten statement by two CNA's who cared for R1 after the alleged incident. 2. Handwritten timeline of shift activities by CNA1 and his partner (CNA2). CNA1 and his partner worked together in caring for R1 from 11:05 PM till 06:15 AM when the partner ended her shift. 3. Time card report from CNA1. 5. FA Interview with CNA1. 6. Interview with CNA2 (CNA1's partner) who partnered with CNA1 until 06:15 AM when CNA2 went home. 7. Professional summary by the F[NAME] Several calls were made to the detective at the Criminal Investigation Division (CID). I was unable to speak with the Officer, therefore I am writing my professional summary of the investigation I conducted, as follows: Summary of the alleged events. R1 states that during the alleged assault, It hurt from him pounding into me During independent and separate interviews, both CNA staff state the resident was calm and unemotional, and talking normally with them during the personal care they provided to her approximately 08:00 hour. Neither of the CNA staff noted any type of abnormal findings or injury/ blood in the resident's perineal area, buttocks, or abdominal area during the personal care. Neither of the CNA staff identified any abnormal fluid in the brief when it was changed. I made a call to the ER and was informed I could not have any information because there is no account of physician's assessment in the record. This information concludes what I have for my investigation. Neither R1 or FM1 have expressed any interest in leaving this facility. R1 is cooperative and involved with rehab services. Based on review of the documentation in the FA completed report, noted the FA made his conclusion based on interviews with four CNA staff, the SS interview with R1 and without obtaining further information from the ER assessment or HPD. The FA did not report the alleged sexual assault to Adult Protective services (APS) or the Long Term Care Ombudsmen (LTC Ombudsmen). During an interview with the FA during the entrance conference on 12/17/19 at 9:15 AM, stated that the employee (CNA1) is currently on administrative leave. The FA gave a verbal account of the events from the initial report by R1 until the investigation was completed. The Director of Nursing was out with illness, so I met with the Assistant Director of Nursing (ADON) to inquire what are our procedures for reporting and conducting the investigation. I have never had a situation like this occur before in any of the facilities I have worked in. I made several attempts to call the investigating officer at the police department Criminal Investigative Division (CID) and have not been able to contact the detective. I called the ER and asked for a copy of the assessment and was told I was not able to receive a copy. When asked about the facility reporting requirements and who was notified of the alleged sexual assault stated, we called HPD and the office of healthcare assurance (OHCA), I did not call APS or the LTC Ombudsmen . During an interview with the FA on 12/19/19 at 12:10 PM stated the investigation was completed, what we received in his completed report was the extent of the investigation, there has been no further investigation. The FA added that CNA1 was employed here at the facility last (MONTH) 2019, and certified as a CNA in (MONTH) 2019. I am not aware of the type of training he received although it was provided before I came to be employed here as the Facility administrator. When I came here in (MONTH) of 2019, we provided annual training to all of the staff to help prepare them for the upcoming survey. The training included abuse policy and prevention and dining. Staff meeting minutes dated August/ 2019 with Inservice training titled Abuse and Neglect? How to Report it? staff sign off roster reviewed. Out of the 180 staff names listed on the roster, only 89 staff signatures were documented that training was completed. It was noted that CNA1 did not sign the roster to indicate that he completed the training. Of the Fifteen staff (including Administration) interviewed on 12/17/19 to 12/19/19 only six completed the abuse training that was conducted in (MONTH) 2019. When questioned why the facility did not report the allegation to APS and if the facility staff know they are mandated reporters, the FA stated the facility staff were provided training that included a power point presentation that covers mandated reporting requirements and who are mandated reporters in (MONTH) of 2019. The training was given by the previous SW. The facility staff should know they are mandated reporters. CNA1 employee personnel and in-service training record reviewed. The employee personnel record did not contain any documentation of the alleged abuse that occurred on 12/10/19 by CNA-1. The in-service training record was signed and dated 05/15/19 reviewed. The Inservice training was provided during new employee orientation. Training content included the following: Resident rights; resident abuse/ dominant language, posttest includes the following: misappropriation of resident property, physical abuse, sexual abuse. Problems and needs of the elderly: dementia, restraints, elopement, fall precautions. Sexual harassment. During an interview with CNA1 on 2/17/19 at 12:40 PM confirmed that he received the training upon hire in (MONTH) 2019 and did not attend or complete the inservice training that was held at the staff meeting in (MONTH) 2019. In-service training content reviewed. Titled What is abuse and neglect? How to Report it? Reporting: All reports of resident abuse .shall be promptly reported to local, State and Federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Results: 3. Any allegations of abuse will be filed in the accused employees personnel record along with any statement by the employee disputing the allegation, if the employee chooses to make one .",2020-09-01
325,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2019-12-19,609,D,1,0,S0P811,"> Based on interview, record review, and policy review, the facility failed to implement its policy and procedures on reporting the alleged sexual abuse to mandated state agencies. The facility did not report the alleged sexual assault to Adult protective services, (APS) after a Resident (R)1 was allegedly sexually assaulted by a Certified Nurse Aide (CNA)1 employed in the facility. In addition, the facility Administrator and Social Services Director did not cooperate with the Adult intake unit (AIU) investigator by delaying to provide the identity and contact information of the alleged perpetrator (AP) by several days into the investigation. The deficient practice delayed the criminal investigation by APS which ensures the oversight of criminal investigation into allegations of staff abuse and timely and appropriate action for the Resident to receive an assessment and follow up psycho-social support services. (Ref F600). Findings include: On 12/10/19 at approximately 01:50 PM the Office of Healthcare Assurance (OHCA) received a telephone call from (TCF) the facility Administrator (FA) who stated that a Resident reported had been sexually assaulted by a staff member. The FA stated that the police had been called and an investigation was being conducted by the Facility. Initial facility Event report dated 12/10/19 and received on 12/11/19 at 10:13 AM via email from the F[NAME] The initial report stated that R1 and her sister (FM)1 asked to speak with Social Services (SS) on 12/10/19 at approximately 12:45 PM. The alleged incident was discussed with FA at 01:15 PM. The alleged perpetrator (CNA1) contacted by cell phone and message left to contact F[NAME] At 01:45 PM the Honolulu Police Department (HPD) was notified and officers arrived at 02:30 PM to interview resident and staff, and discuss resident going to the emergency department (ER) for an evaluation. The unit staff were advised of the situation. Careplan updated. No male caregiver alone, if with male caregiver, needs to have one female caregiver at all times. R1 was transferred to the ER at 04:15 PM. CNA1 was contacted via telephone call and placed on Administrative leave of absence at 08:30 PM. Completed facility event report from the FA dated 12/13/19 received via email and reviewed. On 12/11/19 at 05:15 AM R1 returned to the facility from the ER. FA Summary states: Based on my interviews, and the information I have available to me, I do not believe this assault occurred here at the facility. This resident came to us from an acute care facility a short while after hip surgery and general anesthesia. The time line of work activities of the staff, as well as the absence of any physical injury evident leads me to this decision. This information concludes what I have for my investigation. Neither R1 or FM1 have expressed any interest in leaving this facility. R1 is cooperative and involved with rehab services. Review of the documentation in the FA completed report, noted the FA made his conclusion based on interviews with four CNA staff, the SS interview with R1, and without obtaining further information from the ER assessment or HPD. The FA or other facility staff who are mandated reporters, did not make a report to APS. The report to APS was made by the SATC after R1 forensic evaluation was completed. Adult abuse and neglect case report dated dated 12/11/19 02:49 PM reviewed. Alleged perpetrator: Unknown, Male Relationship to victim. Staff of care facility. Resident unknown. The alleged victim (AV) is currently at the facility. in a private room for short term rehab after having hip surgery at an acute care facility on or about 12/02/19. AV was admitted to the rehab facility on 12/09/19 for IV antibiotics, physical therapy, and occupational therapy. Prior to surgery, AV was residing with her sister/ primary caregiver. Discharge plan is for AV to return home to her sister, however discharge date is unknown. NOTE: The facility knows the alleged perpetrator's (AP) Identity (Name/ Information), however at the time of this intake disposition, the facility Social Services Director (SSD) stated being in the process of obtaining AP's information from Human resources and will provide it to intake worker, who will do clearances/ update case. Sex abuse treatment center (SATC) forensic exam showed findings of assault including lacerations from the vagina to the anus, and also in the anus. Harm: per summary of written report and collateral contact: After the police arrived/ took the report, AV was transported to the emergency department then to the SATC for the forensic exam. Report to HPD was made. Collateral contacts: 12/11/19 03:25 PM telephone call to (TCT) complainant: AV stated she doesn't have the name/ contact information for the AP, but stated that the facility has AP's information since the facility placed AP on Administrative leave pending investigation. 12/11/19 03:40 PM/ 03:50 PM TCT/TCF SSD stated SSD will get AP's name/ information to Adult intake unit (AIU) intake worker, confirmed that AP has been placed on administrative leave pending investigation. 12/12/19 08:05 AM/11:00 AM TCT/TCF SSD stated that her Adminsitrator wants to know what APS is going to do with the information AIU intake worker asked for (AP's name, address, phone, DOB if possible, and CNA certification number) if the allegations do not pan out. Explained that if a report is accepted for APS investigation, APS would confirm or not confirm the allegations after completing their investigation. The SSD asked if they can be told who made the report. AIU intake worker said no, explained that the complainant's identity is confidential. SSD discussed that the administrator had these questions before they decide to release information to APS. AIU intake worker reminded the facility SSD that all staff at the facility are mandated reporters and are required by law to report to APS if they have any information of abuse/ neglect of a vulnerable adult, and if APS had not received the initial report from the complainant, it would be expected that the facility would have made the AP report which would include AP's name and information. SSD apologized, stated she is aware, but that these questions are from the administrator, but she will let the administrator know. AIU intake worker said if the administrator has any questions about APS statue/ process, to have him call AIU intake worker or he can speak to the AIU supervisor. SSD stated she has to get AP's information from Human Resources (HR) and will get the information to AIU intake worker. AIU intake worker went over the importance of getting the information as soon as possible to commence an APS investigation. SSD stated she will get it to AIU intake worker before the end of the day. The SSD stated that she will get the information to the AIU intake worker. 12/12/19 14:49 fax received from the facility with AV's list of medications received from the facility, however as of this time, the facility has still not provided AP's name/ information. During an interview with the FA on 12/17/19 at 9:30 AM stated when we learned of the incident I first talked to the SSD, and the Assistant Director of Nursing (ADON). We discussed what happened. The FA called the non 911 number at the HPD who recommend I call 911. An hour later the officer came. I have not received any records from the ER. I have no contact with them. APS called me on Wednesday and Thursday and asked for the identity and contact information of the alleged perpetrator. We provided that information to APS. During a telephone interview with the AIU investigator later that day on 12/17/19 at 11:00 AM, stated that she came to the facility the previous day on Monday 12/16/19 and requested the name and contact information for the AP from the Human resources (HR) office. She obtained the identity of the AP and contact information five days after she was told by the SSD that she would provide the information to the AIU later that day (on 12/12/19) after checking with HR. The AIU conducted an interview with R1 and her sister (FM1). After speaking with R1 the investigator notified the SSD that the results of the sexual assault assessment were conclusive. She also requested the facility begin to locate another facility for R1 to be transferred to considering the severity of the trauma that she suffered. The AIU also recommended the facility conduct an internal investigation. The investigator provided the name and contact information for the detective at HPD criminal investigative division (CID), who planned to conduct a formal interview with R1. AIU is currently assisting the SSD to transfer R1 out to another facility based on the trauma suffered and feeling afraid in the facility. During an interview with FA on 12/19/19 at 12:10 PM. When asked if the facility staff are aware they are mandated reporters to Adult protective services the FA stated yes, the facility staff were provided training that included a power point presentation that covers mandated reporting requirements and who are mandated reporters in (MONTH) of 2019. The training was given by the previous SW.",2020-09-01
326,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2019-12-19,610,H,1,0,S0P811,"> Based on observation, interview and record review, the facility failed to conduct a thorough investigation of an allegation of sexual assault of a vulnerable Resident (R)1 by a facility certified nurse aide (CNA)1. The facility did not immediately assess the resident for psycho-social trauma and take steps to alleviate R1's fear by moving her to another room or transfer to another facility. The facility did not conduct interviews with other Residents who may have been assaulted by CNA1. The facility did not conduct interview's with personnel from outside agencies at Honolulu Police Department (HPD), Adult protective services (APS), or obtain medical records from the emergency department (ER) to include in its investigation. The deficient practice left Vulnerable resident's who reside in the facility at an increased risk for abuse, and left one Resident (R1) traumatized from the abuse and without immediate psycho-social support from the facility. (Ref F600). Findings include: On 12/10/19 at approximately 01:50 PM the Office of Healthcare Assurance (OHCA) received a telephone call from (TCF) the facility Administrator (FA) who stated that a Resident reported had been sexually assaulted by a staff member. The FA stated that the police had been called and an investigation was being conducted by the Facility. Completed facility event report from the FA dated 12/13/19 received via email and reviewed. On 12/11/19 at 05:15 AM R1 returned to the facility from the forensic evaluation at Sex abuse treatment center (SATC). FA Summary states: Based on my interviews, and the information I have available to me, I do not believe this assault occurred here at the facility. This resident came to us from an acute care facility a short while after hip surgery and general anesthesia. The time line of work activities of the staff, as well as the absence of any physical injury evident leads me to this decision. This information concludes what I have for my investigation. Neither R1 or her caregiver have expressed any interest in leaving this facility. R1 is cooperative and involved with rehab services. Review of the documentation in the FA completed report, noted the FA made his conclusion based on interviews with four CNA staff, the Social services (SS) interview with R1 and without obtaining further information from the ER assessment or HPD. The FA or other facility staff who are mandated reporters to APS did not make a report. Therefore, there was no follow up collaboration done to include in the investigation findings. During an interview with the FA on 12/17/19 at 9:15 AM, stated that the employee (CNA1) is currently on administrative leave. The FA gave a verbal account of the events from the initial report by R1 until the investigation was completed. The Director of Nursing was out with illness, so I met with the Assistant Director of Nursing (ADON) to inquire what are our procedures for reporting and conducting the investigation. I have never had a situation like this occur before in any of the facilities I have worked in. I made several attempts to call the investigating officer at the police department Criminal Investigative Division (CID) and have not been able to contact the detective. I called the ER and asked for a copy of the assessment and was told I was not able to receive a copy. When asked about the facility reporting requirements and who was notified of the alleged sexual assault stated, we called HPD and the office of healthcare assurance (OHCA), I did not call adult protective services (APS) or the State Long Term Care Ombudsmen. There were no interviews with other residents who were potentially abused by CNA1. There was nothing in CNA1's record to indicate he had any previous incidents of alleged abuse. There were no complaints made against CNA1. During an interview with CNA6 (who worked with CNA1) on 12/18/19 at 02:46 PM stated when asked if he knew CNA1 and how is his demeanor with the residents, stated he's here as a part time on call. He also works as a hair dresser and a security guard. We only see him at night time, he floats, and stays by himself. Sometimes the residents say they don't want him to provide their care and we change the assignment for them. Some floors don't get used to him because he is part time and floats to different units. They are hesitant to let him take care of them. Some residents have said they don't want him, I don't know why, he's quiet, maybe they don't like the way he looks. During an interview with the FA on 12/19/19 at 12:10 PM stated the investigation was completed, what OHCA already received in his completed report was the extent of the investigation and there has been no further investigation. During an interview with the SS Director on 12/17/19 at 10:26 AM stated my associate SS2 did most of the interviewing with R1, she said she saw R1 tear up during the interview. When asked if any psychosocial support had been provided to R1 she stated No. During an interview with the SS Assistant (SS2) on 12/17/19 at 11:23 AM stated I was mostly the one to talk to her. According to R1 the incident occurred early that morning. She could only recall five letters in CNA1 name, although she stated that there were more letters in the name but she couldn't remember them all. He had come in to clean her up and said he had to go get supplies, then returned in about 20 minutes. When he came back he put a handkerchief like tissue in her mouth so she wouldn't scream. He took off her clothes and she tried to grab his thing .he said she was in a state of shock and didn't really remember what happened after that. She wanted to contact the police but she didn't know how so she told us. I just started here at the facility and the day of the incident was my first day here, I wasn't really sure about the state regulations. When asked if she knew if APS was notified by the facility stated that she didn't know and that the FA said he had calls to make. When she was describing it, she started shaking a little more, became teary eyed, very anxious, panicky, I told her to take her time with this. She did get choked up. Her sister was upset as well. I think she really believed it happened. Two days later I went to see her, the sister said she has trouble sleeping. She did say she was sore down there, it hurt from the pounding. she stated that she didn't want to have sex with anyone after her husband passed away. R1 laid in there in bed subdued. She didn't mention the incident again. It was upsetting for her to have to give more details about the incident to the other investigators. When asked if R1 received a psycho-social assessment and were support services offered responded, not that I'm aware of, although the SSD has been out sick off and on since the incident occurred. I think we expected the SATC to follow up with the psycho-social support.",2020-09-01
327,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2019-12-19,656,D,1,0,S0P811,"> Based on observation, interview and record review the facility failed to develop a Resident (R)1's comprehensive care plan to provide emotional support services after the resident suffered an alleged sexual assault. The deficient practice left the resident without the timely care/ services so that the resident can attain her highest practicable physical, mental and psychosocial well-being. After the alleged sexual assault R1's interdisciplinary team did not develop a comprehensive care plan that would meet the medical, nursing, mental and psychosocial needs for R1. (CR F600) Findings include: During an Interview with the SS Director (SSD) on 12/17/19 at 10:26 AM stated after R1 returned to the facility from the sex abuse treatment center (SATC) early in the morning on 12/11/19, there was no follow up counseling services or psychosocial support provided for R1. My assistant went to check on her a couple of time. She was to have a follow up appointment with the SATC. We thought they would provide the counseling services. SS2 notes dated 12/11/19 at 0:624 AM reviewed. Residents care plan updated, no male caregiver alone. If with male care giver needs to have 1 female care giver at all times. Staff made aware. Care plan dated 12/11/19 reviewed. R1's base line care plan includes one intervention under the problem for Poly pharmacy and states: 2 staff assist. No male caregiver alone, should have 1 female caregiver at all times. No update to the care plan that included Psycho-social support for the resident. Only that 2 staff members will work and provide personal care when the CNA is a male. The intervention is inappropriate for the problem and the resident.",2020-09-01
328,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2019-12-19,675,G,1,0,S0P811,"> Based on observation, interview and record review, the facility failed to provide one Resident (R)1 with care and services necessary to maintain a quality of life after she suffered an alleged sexual assault from a certified Nurse Aide (CNA)1, In addition, the facility did not consider moving the resident to a location in another room or in another facity to provide a feeling of safety and security. In addition, the facility did not develop the comprehensive care plan to ensure services were provided to R1 to meet her psycho-social needs. (CR F600). Findings include: On 12/10/19 at approximately 01:50 PM the Office of Healthcare Assurance (OHCA) received a telephone call from the facility Administrator stated that a Resident reported she had been sexually assaulted by a staff member. The Facility Administrator (FA) stated that the police had been called and an investigation was being conducted by the F[NAME] Initial facility Event report dated 12/10/19 and received on 12/11/19 at 10:13 AM via email from the F[NAME] The initial report stated that R1 and her sister (FM)1 asked to speak with Social Services (SS) on 12/10/19 at approximately 12:45 PM. The alleged incident was discussed with FA at 01:15 PM. The alleged perpetrator (CNA1) contacted by cell phone and message left to contact F[NAME] At 01:45 PM the Honolulu Police Department (HPD) was notified and officers arrived at 02:30 PM to interview resident and staff, and discuss resident going to the emergency department (ER) for an evaluation. The unit staff were advised of the situation and orders given for all care for R1 to be done with two staff present in the room, no male caregiver alone, at least one female present going forward. R1 was transferred to the ER at 04:15 PM. During an Interview with the SS Director (SSD) on 12/17/19 at 10:26 AM stated after R1 returned to the facility from the Sex Abuse Treatment Center (SATC) early in the morning on 12/11/19, there was no follow up counseling services or psychosocial support provided for R1. My assistant went to check on her a couple of time. She was to have a follow up appointment at the SATC on 12/26/19. We thought they would provide the counseling services. During an interview with R1 on 12/18/19 at 10:00 AM, who appeared in bed. Pale complexion, awake, alert, eyes open wide, and sitting up in bed. The Resident spoke slowly and quietly requiring the listener to lean in close to hear her speak. The resident stated Its difficult, so many people I have to talk to you can talk to my sister . R1 stated yes nodding her head up and down when asked if she was afraid. During a telephone interview with R1's sister (FM)1 on 12/18/19 at 08:33 AM FM1 recounted the incident R1 had described to her. It was about 11:30 AM. After R1 gave the description of CNA1 SS staff looked to see who was on duty and said there was a staff who had those letters in his name that worked that previous night shift. I met her later at the ER and was present during the evaluation which was very difficult for my sister, especially after the hip surgery. She had to wait until 11:30 PM to start the assessment and didn't complete it until 2 or 3 AM. I thought she shouldn't go back there. Now R1 is afraid and not sleeping well even though CNA1 is gone. When I went to see her the next morning she told me she heard scratching on her window. I don't know if they could find her a place, at least they could find her another room. I think she thinks he'll come back. It seems pretty clear that he's not coming back. Every time I go see her I just feel so badly for her. When I see R1 she is concerned and worried, looking at her face. I've been spending a lot of time there. R1 is very dependent on me. I feel that I know her very well, I almost feel as if it happened to me. The SATC offered to provide therapy. R1 said she wanted it when she got back to the facility, she was so tired, she was up all night during the evaluation. I'm really concerned because she hasn't been participating in her therapy and not making the progress she needs to so she can come home. She needs to walk at home. I'm afraid it has something to do with what happened, she's got to learn to walk so she can go home. During an interview with the SS Assistant (SS2) on 12/17/19 at 11:23 AM stated I was mostly the one to talk to her. According to R1 the incident occurred early that morning. When she was describing it, she started shaking a little more, became teary eyed, very anxious, panicky, I told her to take her time with this. She did get choked up. Her sister was upset as well. I think she really believed it happened. Two days later I went to see her, the sister said she has trouble sleeping. She did say she was sore down there, it hurt from the pounding. she stated that she didn't want to have sex with anyone after her husband passed away. R1 laid in there in bed subdued. She didn't mention the incident again. It was upsetting for her to have to give more details about the incident to the other investigators. Care plan dated 12/11/19 reviewed. R1's base line care plan includes one intervention under the problem for Poly pharmacy and states: two staff assist. No male caregiver alone, should have 1 female caregiver at all times. No update to the care plan that included Psycho-social support for the resident. Only that 2 staff members will work and provide personal care when the CNA is a male. The intervention is inappropriate for the problem and the resident.",2020-09-01
329,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2019-12-19,745,G,1,0,S0P811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to provide psyco-social support to a Resident (R)1 after an alleged sexual assault by a certified Nurse Aide (CNA)1. The deficient practice left R1 who expressed symptoms of [MEDICAL CONDITIONS] evidenced by crying, the inability to sleep and verbal expressions of not feeling safe and feeling afraid without psycho-social support. The facility Social services failed to assess the residents mental and physical status, move the resident to a different location in the facility or transfer R1 out to another facility and failed to develop the comprehensive care plan which would ensure the provision of services. (CR F600). Findings include: During an Interview with the SS Director (SSD) on 12/17/19 at 10:26 AM stated after R1 returned to the facility from the sex abuse treatment center (SATC) early in the morning on 12/11/19, there was no follow up counseling services or psychosocial support provided for R1. My assistant went to check on her a couple of time. She was to have a follow up appointment at the SATC on 12/26/19. We thought they would provide the counseling services. During an interview with R1 on 12/18/19 at 10:00 AM, who appeared in bed. Pale complexion, awake, alert, eyes open wide, and sitting up in bed. The Resident spoke slowly and quietly requiring the listener to lean in close to hear her speak. The resident stated Its difficult, so many people I have to talk to you can talk to my sister . R1 stated yes nodding her head up and down when asked if she was afraid. During a telephone interview with R1's sister (FM)1 on 12/18/19 at 08:33 AM FM1 recounted the incident R1 had described to her. It was about 11:30 AM. After R1 gave the description of CNA1 SS staff looked to see who was on duty and said there was a staff who had those letters in his name that worked that previous night shift. I met her later at the ER and was present during the evaluation which was very difficult for my sister, especially after the hip surgery. She had to wait until 11:30 PM to start the assessment and didn't complete it until 2 or 3 AM. I thought she shouldn't go back there. Now R1 is afraid and not sleeping well even though CNA1 is gone. When I went to see her the next morning she told me she heard scratching on her window. I don't know if they could find her a place, at least they could find her another room. I think she thinks he'll come back. It seems pretty clear that he's not coming back. Every time I go see her I just feel so badly for her. When I see R1 she is concerned and worried, looking at her face. I've been spending a lot of time there. R1 is very dependent on me. I feel that I know her very well, I almost feel as if it happened to me. The SATC offered to provide therapy. R1 said she wanted it when she got back to the facility, she was so tired, she was up all night during the evaluation. I'm really concerned because she hasn't been participating in her therapy and not making the progress she needs to so she can come home. She needs to walk at home. I'm afraid it has something to do with what happened, she's got to learn to walk so she can go home. During an interview with the SS Assistant (SS2) on 12/17/19 at 11:23 AM stated I was mostly the one to talk to her. According to R1 the incident occurred early that morning. When she was describing it, she started shaking a little more, became teary eyed, very anxious, panicky, I told her to take her time with this. She did get choked up. Her sister was upset as well. I think she really believed it happened. Two days later I went to see her, the sister said she has trouble sleeping. She did say she was sore down there, it hurt from the pounding. she stated that she didn't want to have sex with anyone after her husband passed away. R1 laid in there in bed subdued. She didn't mention the incident again. It was upsetting for her to have to give more details about the incident to the other investigators. During a phone conversation with the State Long Term Care Ombudsmen on 12/19/19 at 12:00 PM, who questioned if there was counseling offered by the facility or at the very minimum, if there was a room change. He offered to visit the resident if she is okay to speak to him. Requested if surveyor can give his contact information to the sister. During an interview with the Administrator on 12/19/19 at 12:10 PM who stated, usually the Social Workers are the drivers of care following an incident like this one. Our SSD has been out sick off and on since the incident occurred. Her assistant SS2 is new so she cant be expected to know all of the necessary steps. Care plan dated 12/11/19 reviewed. R1's base line care plan includes one intervention under the problem for Poly pharmacy and states: 2 staff assist. No male caregiver alone, should have 1 female caregiver at all times. No comprehensive care plan developed after the incident that included Psycho-social support for the resident. One updated intervention stated that two staff members will work and provide personal care when the CNA is a male.",2020-09-01
330,THE CARE CENTER OF HONOLULU,125019,1900 BACHELOT STREET,HONOLULU,HI,96817,2019-12-19,835,G,1,0,S0P811,"> Based on observation, interview and record review the Facility failed to collaborate with its social services Department to coordinate the thorough reporting of an alleged sexual assault, thoroughly investigate the allegation, and file the allegation of abuse in the accused employee's (CNA)1 personnel record along with a statement by the employee disputing the allegation. The facility Administrator (FA) failed to ensure steps were completed to provide one Resident (R)1 with the highest practicable mental, physical and psycho-social well being. The Administration knew the proper steps which is described in in its abuse investigation and reporting policy which is referenced to Regulatory reference number483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment. (CR F600, F609, F610) Findings include: Completed facility event report from the FA dated 12/13/19 received via email and reviewed. On 12/11/19 at 0515 AM R1 returned to the facility from the Emergency Department (ER). FA Summary states: Based on my interviews, and the information I have available to me, I do not believe this assault occurred here at the facility. This resident came to us from an acute care facility a short while after hip surgery and general anesthesia. The time line of work activities of the staff, as well as the absence of any physical injury evident leads me to this decision. This information concludes what I have for my investigation. Review of the documentation in the FA completed report, noted the Facility Administrator (FA) made his conclusion based on interviews with four CNA staff, the SS interview with R1 and without obtaining further information from the ER assessment or HPD. During no time the FA or other facility staff who are mandated reporters, made a report to APS. The report to APS was made by the SATC after R1 forensic evaluation was completed. During an interview with the FA on 12/17/19 at 9:15 AM, stated the Director of Nursing was out with illness, so I met with the Assistant Director of Nursing (ADON) to inquire what are our procedures for reporting and conducting the investigation. I have never had a situation like this occur before in any of the facilities I have worked in. I made several attempts to call the investigating officer at the police department Criminal Investigative Division (CID) and have not been able to contact the detective. I called the ER and asked for a copy of the assessment and was told I was not able to receive a copy. When asked about the facility reporting requirements and who was notified of the alleged sexual assault stated, we called HPD and the office of healthcare assurance (OHCA), I did not call adult protective services (APS). There were no interviews with other residents who were potentially abused by CNA1. There was nothing in CNA1's record to indicate he had any previous incidents of alleged abuse. There were no complaints made against CNA1. Facility Abuse Investigation and Reporting Policy revised (MONTH) (YEAR) reviewed. All reports of resident abuse, neglect, exploitation .shall be promptly reported . and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The individual conducting the investigation will, as a minimum. i. Interview other residents to whom the accused employee provides care or services . 3. The investigator will notify the ombudsman .Reporting. 1. All alleged violations involving abuse . will be reported by the facility Administrator, or his/ her designee . to the following persons or agencies: b. The local/ State Ombudsman. 4. Notices will include, as appropriate: e. The name (s) of all persons involved in the alleged incident; and .Any allegations of abuse will be filed in the accused employee's personnel record along with any statement by the employee . CNA1 employee file reviewed. No documentation of the allegation of abuse or the written statement of the allegation found in CNA1's file. During an interview with the Director of Nursing (DON) on 12/18/19 at 11:11 AM stated that documentation of the allegation of abuse is usually placed in the employees file. She wasn't aware that the accused employee's file did not have any documentation of the alleged abuse. During an interview with the Administrator on 12/19/19 at 12:10 PM, stated he wasn't aware that the employee's file did not contain documentation of the allegation of abuse.",2020-09-01
331,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2019-08-12,550,E,0,1,JSYQ11,"Based on resident interviews, the facility failed to treat each resident with respect and dignity and provide care to residents in an environment that promotes maintenance of enhancement of his or her quality of life. Findings include: 1) On 08/06/19 at 10:48 AM a confidential resident interview was conducted. The resident reported that staff members are speaking in a non-dominant language of the facility in the resident's room. The resident stated he/she is not sure whether staff members are talking about him/her or making faces at him/her. On 08/07/19 an interview was done with resident council representatives. The representatives were asked whether staff members are speaking in the non-dominant language of the facility. The representatives confirmed staff members are heard speaking to one another in another language and this occurs especially when there are two staff members present. One representative reported this occurs on a daily. 2) On 08/17/19 at 08:06 AM a confidential resident interview was conducted. The resident reported during lunch, she/he has had to wait for assistance to change personal brief. The resident recalled the longest amount of time she/he had to wait was one hour. The resident also reported the facility does not have enough staff members to provide care, especially during meal times and overall states the staff members here are overworked and underpaid. 3) On 08/07/19 an interview was done with the resident council representatives. On resident reported pressing the call light and having to wait a long time for assistance. Eventually the resident will use her/his cellular phone to call the facility to get assistance. Other representatives reported the call light is activated and the staff members respond to inquire what kind of assistance is required, then the staff member will tell the resident that they will come back as they are involved with another resident. 4) On 08/06/19 at 9:00 AM a confidential resident interview was conducted. The resident reported waiting approximately a half hour at night before the staff member provides care. The resident clarified the call light is being pressed to request medication.",2020-09-01
332,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2019-08-12,578,E,0,1,JSYQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with staff members and a review of the facility's policy and procedure, the facility failed to ensure residents were provided with the right to formulate an advance directive (including whether the residents requested assistance in formulating an advance directive) and the facility failed to ensure residents were periodically offered the opportunity to formulate an advance directive for 4 (Residents 148, 41, 3 and 96) of 24 residents reviewed. Findings include: 1) On the morning of 08/07/19 a record review for Resident (R)148 found the resident was admitted to the facility on [DATE]. Further review of the electronic medical record (EMR) could not find documentation of an advance directive or Physician order [REDACTED]. On 08/07/19 at 09:07 AM, the SW provided a progress note dated 08/07/19 to document R148's family was contacted and confirmed R148 does not have an advance directive. SW1 scheduled a meeting with the family for 08/08/19. Subsequently, at 09:55 AM, the SW provided a copy of the POLST which was signed on 08/07/19 by the physician. 2) On the morning of 08/07/19 a record review was done for R41. R41 was admitted to the facility on [DATE], there was no documentation of an advance directive. An interview was done with the SW, the SW was agreeable to review the resident's chart. On 08/07/19 at 09:07 AM, the SW provided a progress note dated 09/07/18 documenting the resident and the responsible party was notified of the right to formulate an advance directive and given a copy of the policy. The documentation did not indicate whether the resident and/or the responsible party requested aid to formulate an advance directive. The SW was asked whether the facility periodically reviews advance directive information for those residents without a directive. Further queried whether the facility has documentation whether the resident or the responsible party declined or requested assistance to formulate an advance directive. The SW reported the facility will review advance directives quarterly and annually. A request was made for documentation of the facility's periodic discussion with the resident or responsible party regarding advance directives. The facility was unable to provide documentation of whether the resident and/or the responsible party declined the option to formulate an advance directive. Also, there was no subsequent documentation of periodic review regarding the right to formulate an advance directive. 3) On the morning of 08/07/19 a record review was done for R3. This resident was admitted on [DATE]. The review found there was no documentation of an advance directive. An interview was conducted with the SW. The SW was agreeable to review R3's records for an advance directive. On 08/07/19 at 09:07 AM, the SW provided documentation which was dated 09/07/18 that notes the resident and the responsible party were notified of the right to an advance directive and provided a copy of the facility's policy. There was no documentation of whether the resident or the responsible party declined the assistance to formulate a directive. The SW confirmed the documentation does not include whether the resident or the responsible party was interested in formulating a directive. A request was made to review documentation of periodic discussion regarding formulation of an advance directive. On 08/08/19 at 2:01 PM, SW1 provided a copy of the IDT Care Plan Conference dated 02/06/19 documenting advance directive was reviewed and discussed with resident's spouse. The documentation notes the SW discussed advance directives and POLST, as well as, offered assistance in creating a POLST or advance health care directive. There was no documentation whether the spouse wanted assistance with either. Following the discovery of the deficient practice, R3 had an IDT care plan conference on 08/08/19 at 10:09 AM which documents R3's current POLST is on file and the resident's spouse was offered assistance in updating/creating POLST and advance health care directive. The spouse refused assistance at this time. 4) On the morning of 08/07/19 a record review was done for R96. R96 was admitted on [DATE]. The review of the EMR found no documentation of an advance directive. An interview was done with SW1, the SW was agreeable to follow up. At 09:07 AM the SW provided a copy of the IDT Care Plan Conference/Welcome Meeting form (dated 08/07/19). The team documented on the form, the POLST and advance directive education was given at this time. The SW confirmed there is no acknowledgement of whether the resident requested assistance in formulating an advance directive. On 08/07/19 at 09:07 AM, SW1 provided the facility's policy and procedures for advance directive. The guidelines include the following: 1. Upon admission, staff will verify the formulating of an advance directive or the resident's wishes with regards to formulating an advance directive. Resident's wishes may be communicated through the resident representative; and 3. Upon admission, if the resident has not formulated an advance directive, the facility will determine if the resident wishes to formulate an advance directive. As indicated, the facility will inform the resident of his or her right to establish advance directives and will aid the resident in the development of advance directives in accordance with state law. The resident can accept or decline the help. Documentation in the medical record will reflect the discussion of advance directive occurred, and that assistance has been offered to the resident, and the resident's acceptance or declination of assistance.",2020-09-01
333,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2019-08-12,585,D,0,1,JSYQ11,"Based on an anonymous resident interview, the facility failed to ensure a resident has the right to voice grievances to the facility or other agency or entity without discrimination or reprisal and without fear of discrimination or reprisal. Findings include: On 08/17/19 at 08:06 AM an anonymous interview was conducted by request of the resident. The resident reportedly had many concerns regarding the facility; however, recognizes the walls get ears so has not voiced concerns. The resident reported being concerned that staff members may retaliate by being slow to respond to the call light. The resident reported a hair in her/his food then later the kitchen would send hot water without the tea bag and on another occasion sent a tea bag but no hot water.",2020-09-01
334,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2019-08-12,689,E,0,1,JSYQ11,"Based on observations, and staff interview, the facility failed to identify potential electrical accident hazards in four resident rooms out of eight resident rooms reviewed. As a result of this deficient practice, the facility put the safety and well-being of all the residents as well as the public at risk for electrical accident hazards, such as a fire. Findings Include: 1. During an observation of Resident (R) 93's room on 08/06/19 at 09:00 AM, an extension cord was noted to be plugged in to the electrical outlet. Connected to that extension cord was a power strip with the following three medical devices plugged in: two medical beds and a machine used for oxygen treatment. A second observation of R93's room on 08/07/19 at 10:00 AM, revealed the same findings as previously described on 08/06/19 at 09:00 AM. 2, During an observation of Resident (R) 46's room on 08/06/19 at 09:10 AM, an electrical power strip was noted to be plugged in to the electrical outlet. Connected to that power strip was the following two medical devices: two medical beds. A second observation of R46's room on 08/07/19 at 10:05 AM, revealed the same findings as previously described on 08/06/19 at 09:10 AM. 3. During an observation of Resident (R) 57's room on 08/06/19 at 09:15 AM, an extension cord was noted to be plugged in to the electrical outlet. Connected to that extension cord was a power strip with the following four devices plugged in: one medical bed, a machine used for oxygen treatment, TV, and fan. A second observation of R57's room on 08/07/19 at 10:10 AM, revealed the same findings as previously described on 08/06/19 at 09:15 AM. 4. During an observation of Resident (R) 9's room on 08/06/19 at 09:20 AM, an extension cord was noted to be plugged in to the electrical outlet. Connected to that extension cord was a power strip with the following four devices plugged in: one medical bed, a suction machine, TV, and fan. A second observation of R9's room on 08/07/19 at 10:15 AM, revealed the same findings as previously described on 08/06/19 at 09:20 AM. On 08/09/19 at 09:10, the Maintenance Director (Maint Dir) was queried about the above findings. Maint Dir acknowledged the above findings were a hazard and further stated that the building was old with only a few electrical outlets.",2020-09-01
335,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2019-08-12,758,D,0,1,JSYQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with staff member, and a review of the facility's policy and procedures, the facility failed to ensure PRN orders for [MEDICAL CONDITION] medications are limited to 14 days, unless the attending physician/prescribing practitioner documents a rationale to extend the medication for 1 (Resident 96) of 5 residents reviewed for unnecessary medication. Findings include: Resident (R)96 was admitted to the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. On 08/06/19 during the initial tour, R96 was observed in bed eating breakfast. Subsequent observation at mid-morning found R96 eating a snack in her room. R96 also ate her lunch in the room. During the observations on 08/06/19, attempts were made to interview R96; however, she expressed a desire not to talk while she was eating. Observations between meals and snack found R96 asleep. On 08/08/19 at 03:21 PM a record review was done. A review of the physician's orders [REDACTED]. The start date was 08/01/19, last ordered was 08/05/19 and the end date was indefinite. R96 was also prescribed routine [MEDICATION NAME], 30 mg (three capsules) once a day for anxiety and [MEDICATION NAME], 350 mg. at bedtime for anxiety/[MEDICAL CONDITION]. A review of the Minimum Data Set with assessment reference date of 07/30/19 notes R96 yielded a score of 12 (moderately impaired) when the Brief Interview of Mental Status was administered. The review of Section N. Medications, R96 received antipsychotic and antianxiety on six of the last seven days. R96 also noted to have received antidepressant on five of the last seven days. Further review found a [MEDICAL CONDITION] Medication Quarterly Review dated 08/05/19 which documents R96 is stable with no new symptoms, behavior or adverse reaction to the use of [MEDICATION NAME] and [MEDICATION NAME]. On 08/12/19, the facility provided documentation of progress notes from 07/26/19 through 08/09/19. A review of the nursing note dated 07/26/19 documents the system has identified a possible drug interaction lists an order [MEDICATION NAME] 0.5 tablet, give one tablet by mouth STAT for anxiety and [MEDICATION NAME] 0.5 mg, every 8 hours as needed for anxiety (max 2 dose per day). The progress notes document PRN orders for use of [MEDICATION NAME] starting 07/26/19. Subsequent orders note an increase from 0.5 mg to 1 mg (08/01/19) of [MEDICATION NAME]. On 08/09/19 at 11:17 AM an interview was conducted with the facility's physician. The physician reviewed the medication orders and recalled reviewing R96's medications in the [MEDICAL CONDITION] medication meeting. The physician reported [MEDICAL CONDITION] medications are usually ordered for 14 days at a time and the pharmacist will review and ask the resident's attending physician to renew the order. On 08/09/19 at 11:20 AM an interview was conducted with the Unit Manager (UM). The UM reported a [MEDICAL CONDITION] medication review was done for R96 and the recommendation was for a psychological consult before contacting the resident's attending physician. The UM confirmed the order did not have an end date. On 08/12/19 the facility provided a policy and procedure entitled, Pharmacy Services: [MEDICAL CONDITION]. The guideline includes: 4. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days; without exception, the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.",2020-09-01
336,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2019-08-12,812,E,0,1,JSYQ11,"Based on observation and interview with staff member, the facility failed to prepare food and clean dishes under sanitary conditions. Findings include: On 08/08/19 at 08:50 AM a follow up to the kitchen was done to observe food preparation. The Nutrition Services Director (NSD) was present during the observation. The concurrent observation found a colander filled with raw chicken placed in the sink. The Nutrition Services Cook (NSC)1 was observed to prepare an herb mixture for the chicken. The cook donned gloves and removed three pieces of chicken and placed it on a small metal bowl and placed on a rolling cart. The cook explained these pieces will be used for the no added salt diets. The rest of the raw chicken was placed on baking trays. The cook removed gloves, washed his/her hands, tied the apron, donned gloves, then proceeded to sprinkle the herb mixture onto the chicken. After placing all the chicken on the baking tray, NSC1 removed the colander from the sink and carried it across the kitchen to the three-compartment sink to be washed. While traveling across the kitchen, the cook placed one hand under the colander to catch the drips; however, some of the pink-tinged liquid dripped to the floor. The NSD was asked about the liquid that dripped to the floor, the NSD then asked a staff member to mop up the drippings. At 09:05 AM, upon return to the cooking area, the three pieces of raw chicken in the metal bowl remained on the cart which was placed in front of the steamer. NSC1 was observed to rinse the sink with water, removed the drain strainer and empty the contents into the rubbish can next to the sink. NSC1 was observed to get a pitcher and fill it with water at the sink. The NSD was asked whether the sink requires sanitation or is rinsing the sink with water enough to clean the sink after the colander of raw chicken was being strained in the sink. The NSD acknowledged the sink needed to be sanitized and directed the staff member to sanitize the sink with quat solution. At 09:20 AM, approximately a half hour later, the three pieces of raw chicken were still stored in the metal bowl on the cart. The NSD was asked about the chicken, the NSD responded the cook probably forgot about it but it should be okay as there is still ice from the chicken. The cook began to apply plastic wrap to cover the raw chicken. A request was made to check the temperature of the raw chicken. The temperature was 46 degrees Fahrenheit. Further inquired whether this was the appropriate holding temperature for raw chicken and okay to prepare for lunch. The NSD responded the holding temperature of raw chicken should be below 40 degrees Fahrenheit. The NSD instructed the cook to throw the raw chicken. On 08/08/19 at 11:30 AM observation was made of the dish wash machine. The plastic dish crates which house the dirty dishes (plates, cups) as it goes through the washing process was observed to have white and brown substance on the exterior and in the crevices of the slots. The NSD reported the white substance is hard water build up and proceeded to scrape the brown substance off the surface of the crates with his/her fingernail. Inquired when was the last time the dish crates were cleaned, the NSD responded the crates are cleaned once a week. There were over 34 crates that were covered with brown and white substance. One crate had a greenish/blackish material hanging from the side of the crate (possibly dried up vegetable).",2020-09-01
337,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2019-08-12,842,E,0,1,JSYQ11,"Based on record review, staff interview, and review of the Accepted Abbreviations List (provided by the facility), the facility failed to use approved abbreviations when charting in the progress notes, for four out of the eight residents reviewed. With this deficient practice, there was a risk of misinterpreting the un-approved abbreviations and thus causing adverse outcomes for any, or all the residents. Findings Include: 1. During review of the progress notes for Resident (R) 47, the following abbreviations were used, in various places, in the progress notes: RP, TAR. According to the Accepted Abbreviations List (provided by the facility), these abbreviations were not approved to be used for charting. 2. During review of the progress notes for Resident (R) 14, the following abbreviation was used, in various places, in the progress notes: RP. According to the Accepted Abbreviations List (provided by the facility), this abbreviation was not approved to be used for charting. 3. During review of the progress notes for Resident (R) 9, the following abbreviation was used, in various places, in the progress notes: LS. According to the Accepted Abbreviations List (provided by the facility), this abbreviation was not approved to be used for charting. 4. During review of the progress notes for Resident (R) 84, the following abbreviation was used, in various places, in the progress notes: RP. According to the Accepted Abbreviations List (provided by the facility), this abbreviation was not approved to be used for charting. On 08/09/19 at 09:25 PM, inquiry with the Director of Nursing (DON) was done. DON acknowledged that the abbreviations, previously mentioned, were not approved to be used for charting.",2020-09-01
338,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2018-09-07,578,E,0,1,Z0D111,"Based on medical record (MR) review and interview, the facility failed to document advance directive (AD) information was offered and given to residents (R) 15, R20, R33, R46, R52, and R76 and keep a copy of the AD in the MR for these residents. Findings include: 1) On 09/06/18 at 12:01 PM MR review showed no AD on file and no documentation that AD information was offered or given to R76 or his representative. On 09/06/18 at 2:40 PM interview with Social Worker Director (SWD) who stated R76 does not have an AD in the MR and no documentation in MR regarding AD information was offered and given to R76 or his representative. 2) Review of R20, R33, R46, and R52's MR were reviewed for presence of AD or documentation that residents were informed of their rights to formulate an AD. There was no AD or documentation that residents were informed of their rights to formulate an AD. Interview with SWD on 09/06/18 at 07:24 AM who validated that R20, R33, R46, and R52 only had POLST forms, and no AD or documentation that these residents were informed of their rights to formulate an AD. 3 ) On 09/05/18 at 8:40 AM, review of R15's MR revealed her general durable power of attorney did not authorize the listed agent to make health care decisions for R15. On 09/06/18 at 8:18 AM, the facility's SWD verified with the State agency (SA) that R15's AD was only financial and R15 did not have a one for health care decisions.",2020-09-01
339,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2018-09-07,726,D,0,1,Z0D111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, meidacl record (MR) review, and policy review, the facility failed to provide competent care for one of four residents (R) 68 whose water flushes given via a gastrostomy tube ([DEVICE]) after each medication did not follow the physician's orders [REDACTED]. This deficient practice had the potential to affect the other three residents identified by the facility to have [DEVICE]s. Findings Include: On 09/05/18 at 9:54 AM, licensed nurse (LN) 39 was observed administering R68's [DEVICE] medications. LN39 administered R68's [MEDICATION NAME], potassium chloride, and senna by separately administering each medication followed by a water flush. However, the water flushes after each medication administration was in excess of the physician's orders [REDACTED]. R68's (MONTH) (YEAR) Physician order [REDACTED]. On 09/05/18 at 10:20 AM, LN90 confirmed for R68, the amount of water flush was per the physician's orders [REDACTED]. LN90 said the amount of water flush to be given between each medication, is 10-15 (mls), and the 70 mls is for before and after the medications. At 10:26 AM, LN39 said she gave the 70 mls water flushes between the medications because it was how she understood the order to read. LN39 said she has been employed at the facility for about five months. On 09/07/18 at 8:43 AM, an interview with the Assistant Director of Nursing (ADON) was done. The ADON said he is the facility's staff development and training coordinator. He verified LN39 completed her nursing skills competency in (MONTH) of (YEAR) which included the administration of enteral medications. The ADON said with the 09/05/18 incident, he identified the water flushes given between medications should follow the facility's protocol of 15 mls. The ADON acknowledged that it also was how the order was written with the, 70 mls before and after medications. The facility's policy, Administering Medications through an Enteral Tube (Revised (MONTH) (YEAR)), stated, 26. If administering more than one medication, flush with 15 mL (or prescribed amount) warm sterile or purified water between medications. 27. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of warm sterile or purified water (or prescribed amount). The ADON said LN39 had this protocol, but believed it was her misinterpretation of the orders. He also acknowledged the facility used tap water for flushes and not warm sterile or purified water as specified in their policy. The ADON verified he did not clarify what the licensed staff should be using, as LN39 did not know either. The ADON stated re-education with all licensed staff with a review of the written orders was being done. In addition, the ADON verified LN39's Medication Administration Record [REDACTED]. There was a failure by the facility to ensure their protocol/ standard of nursing care was followed by licensed staff.",2020-09-01
340,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2017-09-08,241,D,0,1,ZF0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and medical record reviews (MRR) the facility failed to ensure that 2 of 29 residents (R#225 and R#226), on the Stage 2 Sample Resident List, were provided services that respected their dignity. Findings include: 1) On 09/05/2017 at 09:26 during the initial tour on Hoopono Unit 1, Resident #226 was observed in a Hoyer lift in her room completely nude and exposed to the open doorway. Two Staff, (staff #2 and staff #64) were transferring Resident #226 from a geri-chair to the bed using a Hoyer lift. Staff #2 looked up, made eye contact with the surveyor and quickly pulled the privacy curtain shut. At 10:15 AM Staff #62 concurred that Resident #226 was exposed after returning from a shower and being transferred from the geri-chair to the bed using a Hoyer lift. It is usually the practice of the staff to close the door to the room and/or the privacy curtain to ensure privacy for the Resident. The facility did not provide the Resident with privacy, by insufficiently covering the resident after a shower. 2) On 09/05/2017 at 09:41 AM went to interview R#225 during Stage 1 of the survey. The resident was sitting in a chair next to his/her bed and stated that, waiting for wound care from 6:30 AM, and turned to show that back of shirt was soaked through with blood and serosanguinous exudates. On 09/06/2017 at 11:35 AM review of R#225's EMR found that the resident had an abscess to the left (L) upper back identified on 09/02/2017. The physician orders [REDACTED]. The resident's care plans (CP) included: Resident has abscess to Left upper back, with goal that he resident will be free of signs/symptoms (s/s) of infection through the next review date. Interventions included: Licensed staff to provide treatment and administer antibiotic as ordered; Please refer to wound rounds for detailed information; Staff to keep area clean and dry to prevent infection; Staff to monitor any s/s of infection such as increased pain, swelling, redness or warmth around the affected area and to update MD/NP as needed. On 09/06/2017 at 2:25 PM observed the Staff#111 do dressing change on R#225. Staff#111 stated that the nurse practitioner was contacted and that the dressing change now included the use of an abdominal pad as more absorbent of drainage, instead of the bordered foam, and packing the wound with calcium alginate. There was a small amount of bloody serosanguinous soiling to the back of the resident's shirt, as Staff#111 changed R#225's dressing before the resident went out for a doctor's appointment. On 09/07/2017 at 10:15 AM observed R#225 come out into the hallway from his/her room upset that dressing change not done yet and stated to Staff#88, who was at the medication cart, You want me to walk around with my bloody shirt? Staff#111 was near nursing unit and stated that R#225 had wound debrided yesterday and not bloody anymore. Staff#111 started prepping to do the resident's dressing change as Staff#88 was busy passing meds. Interviewed R#225 and he/she stated that, had been waiting since early this morning for dressing change to the abscess on his/her back. The resident stated that the doctor debrided the wound yesterday and observed that his/her shirt was soaked with serosanguinous exudates from the back wound. The facility practice of having R#225 wait for approximately four hours to do dressing change while his/her shirt is soaked with bloody serosanguinous exudates was demeaning to the resident.",2020-09-01
341,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2017-09-08,323,E,0,1,ZF0911,"Based on observations and staff interviews the facility failed to monitor and implement interventions to reduce hazard and risks for hot water temperatures. Findings include: On 09/05/2017 at 09:40 AM felt the hot water in R#225's bathroom basin as the resident was able to perform his/her own activities of daily living (ADLs) for hygiene and oral care. The hot water felt too hot to hold your hand under for a few seconds and requested that maintenance check hot water temperatures. On 09/06/2017 at 1:12:02 PM accompanied Staff#40 as he checked the hot water temperatures in rooms: 107 (hot water temp at 125 degrees Fahrenheit (F); 111 (122 degrees F); 212 (118 degrees F). Staff #40 stated that hot water temperatures should be at 110 degrees F for resident safety, but often the facility staff complain that the water is too cold when bathing residents, as all residents are assisted in the shower. Staff#40 provided the facility's Daily Water Temperature log sheet for (MONTH) (YEAR), and the hot water temperatures ranged from 114-122 degrees F. On 09/07/2017 at 6:01 AM interviewed Staff#113 and she stated that the facility closed down 2 shower rooms because hot water temperatures were higher than 120 degrees F. There were 2 other shower rooms for the residents to be showered until the temperatures could be fixed. Previously, the facility's regional project manager looked at the mixing valve and will return today to troubleshoot. On 09/07/2017 at 1:24 PM, Staff#113 came to inform surveyor that a plumber was consulted and will need to call in engineer to trouble shoot for hot water temps. She also called another contracting company to address the issue. According to Staff#113, the facility policy is that hot water temperatures should be between 105-115 degrees F and to alert the administrator for temperatures exceeding that range. Staff#113 stated that she was made aware of high temperatures on 09/06/2017. Staff#133 was also present, and she stated that a skin assessment was done on 09/06/2017, for all residents that used the shower rooms that had high hot water temperatures. Staff#133 stated that those resident skin assessments were all negative for skin redness, discoloration or s/s of burns. The facility failed to commit to a monitoring system of hot water temperatures that exceeded a safe range for the prevention of accidental burns to residents.",2020-09-01
342,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2017-09-08,371,F,0,1,ZF0911,"Based on observation, staff interview, and review of maintenance records, the facility failed to properly sanitize dishes and utensils during two separate staff observations Findings include: On 09/07/2017 at 7:58 AM, Staff #126 was observed to run the dishwasher for 1 wash/rinse cycle and remove the dishes from the washer. The final rinse temperature on the dishwasher read 140 degrees Fahrenheit (F). The Food Services Manager (FSM)requested staff #126 to put the rack of dishes back into the wash unit and repeat the wash until 180 degrees F was obtained. The temperature log for the dishwasher was reviewed. The final rinse temperature recorded on 9/07/17 at 5:45 AM was 180 degrees F. The FSM stated when running the dishwasher in the morning for the first time, the dishwasher may take up to 5 cycles to reach the required final rinse temperature of 180 degrees F. At 1:40 PM staff #126 was observed to run a rack of dishes in the dish washer. The temperature gauge during the final rinse cycle read 170 degrees F. The cycle ended and staff #126 removed the dishes from the unit. Staff #52 told staff #126 that when washing dishes he needs to stand right in front of the dishwasher while it is running to ensure the final rinse temperature reaches 180 degrees F. Staff #52 concurred the final rinse temperature was 170 degrees F. Upon review of the maintenance logs for the dishwasher, all temperatures recorded from 8/01/17 to 9/07/17 read 180 degrees F for the dishwasher final rinse temperature. Per the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code the following temperatures are recommended for safely sanitizing dishes and utensils: Dishwasher heat sanitization: Wash 150-165 degrees F and final Rinse 180 degrees F. The facility failed to properly sanitize dishes and utensils to ensure sanitary conditions and safe food handling.",2020-09-01
343,"AVALON CARE CENTER - HONOLULU, LLC",125020,1930 KAMEHAMEHA IV RD,HONOLULU,HI,96819,2017-09-08,441,D,0,1,ZF0911,"Based on observation and staff interview, the facility failed to put practices into place to prevent the spread of infection including proper hand washing techniques. The facility is expected to utilize proper personal hygiene practices including proper hand washing to prevent cross contamination. Findings include: On 09/07/2017 at 5:31 AM during med pass and accuchecks of five different residents, the nurse did not demonstrate hand sanitization before and after direct contact with residents. Hand sanitization was not done consistently before touching the resident and after touching the resident and the resident surroundings, including accucheck machine. The facility's policy and procedure states: Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents; c. Before preparing or handling medications; l.After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . In summary, the facility must prevent and control outbreaks and cross-contamination using transmission - based precautions in addition to standard precautions.",2020-09-01
344,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2017-01-27,279,D,0,1,3BP711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to develop comprehensive care plans for 3 (Residents #22, #12 and #3) of 7 reviewed care plans of 16 residents in the Stage 2 sample related to use of anticoagulant and insulin. Findings include: 1) Cross Reference to F329. Resident #22 (Res#22) was admitted to the Skilled Nursing Facility on 9/9/16 for an extended course of physical therapy (PT). Res#22 has a history of End Stage [MEDICAL CONDITIONS] on [MEDICAL TREATMENT] three times per week. He also has a history of [MEDICAL CONDITION] Fibrillation (AF),[MEDICAL CONDITION] pain to left knee and right leg. Lab work: Hemoglobin (HGB) and international normalized ratio (INR) was 10.2 and 1.29, respectively. The reference range for HGB on report dated 9/8/16 is 13.4-17.2 g/dL. and the INR therapeutic Range on lab report dated 9/8/16 is 2.0-3.0. According to lab reference range and therapeutic range, HGB of 10.2 and INR of 1.29 were within the normal parameters at the time of admission. Interview on 1/26/17 at 10:30 [NAME]M. with the Nurse Manager (NM) and concurrent record review was done. NM produced admission orders [REDACTED] Monday - 5 mg Tuesday - 2.5 mg Wednesday - 5 mg Thursday - 5 mg Friday - 5 mg Saturday - 2.5 mg Sunday - 5 mg Admissions orders were dated 9/9/16. Clarification orders dated 9/9/16 at 1500 did not specify any lab orders to be drawn to monitor [MEDICATION NAME]. NM was not able to produce a care plan for Res#22 for the 21 days of of the resident's stay at the facility, starting on 9/9/16. In summary, Res#22 was placed on [MEDICATION NAME] in the facility. Although the facility was aware that Res#22 was on alternating doses of [MEDICATION NAME], dialyzes three times a week, and yet, there was no care plan developed to monitor the side effects of [MEDICATION NAME]; the hemoglobin and INR levels were not tracked. 2) Cross Reference to F329. Resident #12 has a [DIAGNOSES REDACTED]. Further review found the care plan was not specific to identify the parameters for blood sugar levels. Interview with the Nurse Manager (NM) on the morning of 1/26/17 confirmed the care plan did not document the specific parameters for Resident #12's blood sugar levels. The NM further clarified, although it is not documented, the facility is aware of the physician's parameters. 3) Cross Reference to F329. Resident #3 has a [DIAGNOSES REDACTED]. Further review found the care plan was not specific to identify the parameters for blood sugar levels. On the morning of 1/26/17 an interview with the NM confirmed the care plan did not document the specific parameters for blood sugar levels for Resident #3.",2020-09-01
345,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2017-01-27,309,D,0,1,3BP711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record reviews, the facility failed to ensure that Res#22 received services consistent with professional standards of practice. Findings include: Record review on 1/25/17 at 2:30 P.M. revealed that Resident #22 (Res#22) was admitted to the Skilled Nursing Facility on 9/9/16 for an extended course of physical therapy (PT). Res#22 has a history of End Stage [MEDICAL CONDITIONS] with [MEDICAL TREATMENT] three times per week. He also has a history of [MEDICAL CONDITION] Fibrillation (AF) for which [MEDICATION NAME] was prescribed. Lab work done 9/8/16 showed: Hemoglobin (HGB) and international normalized ratio (INR) was 10.2 and 1.29, respectively which were within the normal parameters. Reference range for HGB on lab report dated 9/8/16 is 13.4-17.2 g/dL. The INR therapeutic range on lab reported dated 9/8/16 was 2.0-3.0. Lab report dated 9/30/16 states CBC Comment: Critical value called: HH low report to (Staff Name) at 1300 hours. On 9/30/16 an INR value of 4.21 with the following comment: Critical value called, Readback done and verified as correct at 1310. On 9/30/16, Res#22 was at the [MEDICAL TREATMENT] center. His HGB was drawn and reported to be 5.0. Res#22 was sent to the Emergency Department by the doctor at the [MEDICAL TREATMENT] center and was admitted to the hospital with [REDACTED]. A query with the NM and LN#1 on 1/26/17 at 1300 was done. LN#1 and the NM contacted the [MEDICAL TREATMENT] center for the Facility to Facility Communication Form (FFCF see below). The NM and LN#1 stated that the [MEDICAL TREATMENT] facility had drawn labs on 9/28/16 and the [MEDICAL TREATMENT] MD was aware of a HGB at 5.9. The NM further stated that she was not made aware of this low HGB by telephone or by the FFCF. The FFCF form did document that Res#22 voided dark urine. NM stated that it was not until Res#22 was admitted to theER on [DATE] that she was informed of Res#22's critical HGB and INR levels. On 1/27/17, the NM provided the contract between the [MEDICAL TREATMENT] center and the facility. The Scope of Services outlined for [NAME] Responsibilities of Skilled Nursing Facility stated on line 2: Communicate changes to the [MEDICAL TREATMENT] facility regarding the resident's status, medications, including but not limited to vital signs, weight, medications, diet and psychosocial needs, by initiation of the Facility to Facility form to be sent with the resident for completion and return. B. Responsibilities of [MEDICAL TREATMENT]: 2. Monitor the resident's response to [MEDICAL TREATMENT] and also develop and implement care plans and communicate such interventions necessary for continuity of care. Such communication of changes will be the Facility to Facility form. The Facility to Facility form will accompany the resident back to the nursing unit for final record keeping in the medical record chart. Res#22 was admitted to the acute hospital on [DATE] from the [MEDICAL TREATMENT] center. Res#22 received 4 units of blood transfusion. [MEDICATION NAME] was stopped and Res#22 did not receive any [MEDICATION NAME] during the hospital course. In summary, Res#22 was placed on [MEDICATION NAME] in the facility. The resident went to the [MEDICAL TREATMENT] facility Mondays, Wednesdays and Fridays. Although the facility was aware that R#22 was on alternating doses of [MEDICATION NAME], there was no care plan developed to monitor the side effects of [MEDICATION NAME]. The HGB and INR levels were not tracked between the nursing facility and the [MEDICAL TREATMENT] unit, until R#22 had a low critical value of HGB 5.0 and was admitted to the Emergency Department in which he required blood [MEDICAL CONDITION]. The facility failed to ensure that Res#22 received [MEDICAL TREATMENT] services consistent with professional standards of practice.",2020-09-01
346,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2017-01-27,329,G,0,1,3BP711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 3 (Residents#22, #3 and #12) of 5 residents selected for medication review received monitoring for anticoagulant and insulin. Findings include: 1) Medical record review on 1/25/17 at 2:30 P.M. Resident #22 (Res#22) was admitted to the Skilled Nursing Facility on 9/9/16 for an extended course of physical therapy (PT). Res#22 has a history of End Stage [MEDICAL CONDITIONS] with [MEDICAL TREATMENT] three times per week. He also has a history of [MEDICAL CONDITION] Fibrillation (AF) for which [MEDICATION NAME] was prescribed. Lab work done on 9/8/16: Hemoglobin (HGB) and international normalized ratio (INR) was 10.2 and 1.29 respectively. The reference range for HGB on lab report dated 9/8/16 is 13.4-17.2 g/dL. and the INR therapeutic range on lab report dated 9/8/16 was 2.0-3.0. According to lab report HGB of 10.2 and INR of 1.29 were within the normal parameters. Medical record review on 1/27/17 at 10:00 [NAME]M. revealed that on 9/30/16, Res#22 was at the [MEDICAL TREATMENT] center. Res#22's HGB was drawn and reported to be 5.0. Res#22 was sent to the Emergency Department by the doctor at the [MEDICAL TREATMENT] center. He was hospitalized for [REDACTED]. Lab report dated 9/30/16 states CBC Comment: Critical value called: HH low report to (Staff Name) at 1300 hours. On 9/30/16 INR value of 4.21 with the following comment: Critical value called, readback done and verified as correct at 1310. Interview on 1/26/17 at 10:30 [NAME]M. with the Nurse Manager (NM) and concurrent record review was done. The NM produced admission orders [REDACTED] Monday - 5 mg Tuesday - 2.5 mg Wednesday - 5 mg Thursday - 5 mg Friday - 5 mg Saturday - 2.5 mg Sunday - 5 mg Record review done on 1/26/17 at 10:30 [NAME]M. with NM revealed admission orders [REDACTED]. Clarification orders dated 9/9/16 at 1500 did not specify any lab orders to be drawn to monitor [MEDICATION NAME]. NM was not able to produce a care plan for Res#22 for the 21 days at the facility, starting 9/9/16. NM was not able to show any lab work to track Res#22's INR levels. NM was not able to show any interventions or teaching to monitor for side effects of [MEDICATION NAME]. A query with the NM and LN#1 on 1/26/17 at 13:00 was done. LN#1 and the NM contacted the [MEDICAL TREATMENT] center for the Facility to Facility Communication Form (FFCF see below). The NM and LN#1 stated that the [MEDICAL TREATMENT] facility had drawn labs on 9/28/16 and the [MEDICAL TREATMENT] MD was aware of a HGB at 5.9. The NM further stated that she was not made aware of this low HGB by telephone or by the FFCF. The FFCF form did document that Res#22 voided dark urine. NM stated that it was not until Res#22 was admitted to theER on [DATE] that she was aware of Res#22's critical HGB and INR. Interview on 1/26/17 at 4:30 P.M. with NM, LN#1, CNE and QO was done (facility representatives). The facility representatives were advised and queried for any documentation showing that the facility had designed a care plan for Res#22 to monitor adverse effects, any lab work to track INR levels or HGB levels. On 1/27/17 at 7:30 [NAME]M., interview with facility representatives stated that they had not developed a care plan or interventions to monitor for adverse effects or lab work to track INR levels. It was not done. The facility stated that the [MEDICAL TREATMENT] center was aware of the drop in HGB on 9/28/16; however, this was not communicated to them on 9/28/16 on the communication form or by telephone. On 1/27/17, the facility representatives provided the contract between the [MEDICAL TREATMENT] center and the facility. The Scope of Services outlined for [NAME] Responsibilities of Skilled Nursing Facility stated on line 2: Communicate changes to the [MEDICAL TREATMENT] facility regarding the resident's status, medications, including but not limited to vital signs, weight, medications, diet and psychosocial needs, by initiation of the Facility to Facility form to be sent with the resident for completion and return. B. Responsibilities of [MEDICAL TREATMENT]: 2. Monitor the resident's response to [MEDICAL TREATMENT] and also develop and implement care plans and communicate such interventions necessary for continuity of care. Such communication of changes will be the Facility to Facility form. The Facility to Facility form will accompany the resident back to the nursing unit for final record keeping in the medical record chart. In summary, the facility was aware that Res#22 was on alternating doses of [MEDICATION NAME], dialyzes three times a week, and yet, there was no care plan developed to monitor the side effects of [MEDICATION NAME]; the hemoglobin and INR levels were not tracked between the nursing facility and the [MEDICAL TREATMENT] unit until Res#22 had a low critical value of HGB of 5.0 and was admitted to the hospital to receive blood [MEDICAL CONDITION]. 2) Cross Reference to F279. Resident #12 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 1/25/17 a record review was done. A review of the physician's orders [REDACTED]. twice a day; [MEDICATION NAME] 100 unit/ml subcutaneously, inject five units in the morning and at bedtime; and [MEDICATION NAME] (sliding scale). Further review found lab results dated 12/29/16 documenting an A1C result of 7.3 (high). A review of the resident's care plan provided by the facility on 1/26/17 at 12:52 P.M. notes an expected outcome for blood sugars will be managed within MD parameters. The plan of care included instructions to administer medications as ordered diabetic medications as ordered ([MEDICATION NAME] and [MEDICATION NAME]); monitor for effectiveness and side effects of report to Charge Nurse (side effects of mentoring - metallic taste to mouth, mild anorexia, nausea, abdominal discomfort and diarrhea); and monitor for effectiveness and side effects of insulin - pallor, palpitation, [MEDICAL CONDITION] headache, and confusion. Upon further review, there was no documentation that the physician reviewed the lab results, including the high result of the A1C. An interview and concurrent record review with Licensed Nurse #1 (LN #1) was done on 1/26/17 at 10:21 [NAME]M. The licensed nurse confirmed there is no documentation that the physician reviewed the resident's lab results. The LN #1 also confirmed based on the lab results, there is no documentation whether a change to the current orders were needed or to continue with the current order. 3) Cross Reference to F279. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. The results noted glucose of 192 (high) and A1C of 8.5 (high). A review of Resident #3's care plan documents an expected outcome for blood sugars will be managed within MD parameters. The instructions included: monitor blood sugars as indicated per protocol, per order; and administer medication as ordered by physician, [MEDICATION NAME] to prevent [MEDICAL CONDITION]. There was no documentation of the resident's physician reviewing the lab results or indication whether a change in order is warranted or no changes to the order. On 1/26/17 at 9:23 [NAME]M. LN #1 confirmed there is no documentation of the physician reviewing the resident's lab results. The Nurse Manager (NM) provided a copy of the facility's policy and procedure for Acute Care Patient Assessment/Documentation on 1/26/17 at 1:00 P.M. The procedure for Lab Work notes the date and time the physician is notified of the results is documented. The NM also confirmed there is no documentation the residents' physicians were notified of the lab results. The facility failed to demonstrate residents (Residents #12 and #3) with orders for insulin received monitoring for efficacy of the present insulin dosage and failed to establish a monitoring process, identifying who is to communicate with the prescriber and when to ask the prescriber to evaluate and consider modifying the medication regimen to ensure residents achieved their highest practicable level of functioning. The facility also failed to identify blood sugar parameters for Residents #12 and #3. The care plan is not specific for each resident.",2020-09-01
347,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2017-01-27,428,D,0,1,3BP711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 2 (Residents #12 and #3) of 5 residents selected for medication review received pharmacy services including a review of laboratory results. Findings include: Cross Reference to F505. 1) Resident #12 is diagnosed with [REDACTED]. twice a day; lantus 100 unit/ml subcutaneously, inject five units in the morning and at bedtime; and novolog (sliding scale). Further review found laboratory results dated [DATE] with an A1C of 7.3 (high). 2) Resident #3 is diagnosed with [REDACTED]. Further review found laboratory results dates 11/1/16 which documents a glucose of 192 (high) and A1C 8.5 (high). On 1/26/17 at 9:53 [NAME]M. a concurrent record review and interview was done with the Licensed Nurse #1 (LN #1). The licensed nurse confirmed there is no documentation that the pharmacist reviewed Residents #12 and #3 laboratory results. On 1/26/17 at 11:00 [NAME]M. an interview was conducted via telephone with the Pharmacist. The Pharmacist reported the residents' lab results are usually reviewed by the physician. The Pharmacist further reported following a review of the lab results, if necessary the results will be discussed with the Nurse Manager (NM). The Pharmacist could not recall whether Residents #12 and #3 lab results were reviewed and discussed with the NM. The Pharmacist was provided with the results of the resident's labs for glucose and A1C, the Pharmacist reported the lab results were not terribly out of range and did not recall whether these results fell within the parameters specified by the physician. However, the Pharmacist reported if the physician has not made orders for laboratory studies then this will be brought to the physicians' attention.",2020-09-01
348,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2017-01-27,493,D,0,1,3BP711,"Based on interview with staff member, the facility failed to ensure the facility has a licensed administrator. Finding includes: On 1/25/17 at 8:32 [NAME]M. the Chief Nurse Executive (CNE) reported the facility's Nursing Home Administrator (NHA) has retired and presently the facility does not have a licensed NH[NAME] The CNE reported the facility has submitted a request for a waiver to the State Agency.",2020-09-01
349,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2017-01-27,505,D,0,1,3BP711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 2 (Residents #3 and #12) of 5 residents selected for medication review had laboratory provided to their physician in a timely manner. Findings include: 1) Resident #3 is diagnosed with [REDACTED]. On 1/26/17 at 9:53 [NAME]M. concurrent record review and interview was done with Licensed Nurse #1 (LN #1). The licensed nurse could not find documentation that the physician reviewed the resident's laboratory results. 2) Resident #12 is diagnosed with [REDACTED]. On 1/26/17 at 9:53 [NAME]M. concurrent record review and interview was done with LN #1. There is no documentation that the physician reviewed the resident's laboratory results. On 1/26/17 at 12:20 P.M. the facility provided a copy of the policy and procedure for Nursing - Acute Care Patient Assessment/Documentation. The procedure for lab work includes: date and time specimens obtained and date and time physician notified of results. On 1/26/17 at 1:00 P.M. the Nurse Manager confirmed there is no documentation that the notification of laboratory results were provided for Residents #3 and #12 and reviewed by the ordering physician. The facility failed to ensure a system was in place to document that lab results were reviewed promptly by the physician.",2020-09-01
350,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2019-05-22,574,E,0,1,JXQC11,"Based on observation, interview and record review, the facility failed to verbally inform eight of 20 residents how to make a formal complaint to the state survey agency concerning suspected violation of state or federal nursing facility regulations. Findings include: During a meeting with eight Resident Council participants (Resident (R)1, R2, R10, R16, R17, R18, R119, and R120) on 05/20/19 at 11:15 AM when asked if they were given information how to file a formal complaint to the state survey agency they all answered no. Resident council meeting minutes dated (MONTH) 31, (YEAR) to (MONTH) 27, 2019 reviewed. No documentation found to indicate that residents were given written or verbal information on how to file a formal complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations. Facility admission packet reviewed: Patient rights & responsibilities brochure states under concerns and complaints how the resident or their representative can file a formal grievance or complaint. During an interview with the Social Worker (SW) on 05/21/19 at 02:17 PM regarding how the information is shared with the resident and resident's family how to file a formal complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations. The SW stated that at various intervals including the quarterly resident care conference review meetings the residents are informed which staff they can talk to about their complaints. It depends on what their complaint is who we refer the resident or their representative to.",2020-09-01
351,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2019-05-22,638,D,0,1,JXQC11,"Based on record review and interview, the facility failed to submit timely quarterly assessments for one of four residents in the sample. The deficient practice resulted in Resident (R) 71 not having an accurate and timely quarterly assessment which guides a resident's plan of care. Findings include: The facility's electronic medical record (EMR) for R71 reflected there was a draft version of the quarterly assessment that was created on 04/05/19 and not finalized/submitted by the due date of 04/12/19. The previous quarterly assessment was submitted on 01/10/19. During an interview with Staff (S) 15 (Unit manager and acting as MDS coordinator) on 05/21/19 at 11:57 AM, said that R71 did not have a significant change and validated that the quarterly assessment should have been submitted by 04/12/19. S15 further explained that she did not submit the quarterly assessment on time because she was overwhelmed with her duties as unit manager that included, MDS coordinator and recent intensive training for facility's new electronic medical record system.",2020-09-01
352,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2019-05-22,758,D,0,1,JXQC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, Resident (R) 18 was prescribed an as needed (PRN) antipsychotic medication that was not prescribed to treat a specific condition or [DIAGNOSES REDACTED]. The deficient practice had the potential to affect one of 12 sampled residents who may have received an unnecessary antipsychotic (a mood stabilizing medication). R18 received the antipsychotic medication on five occasions without a documented condition or [DIAGNOSES REDACTED]. Findings include: During a record review (RR) for R18 it was noted R18 had a [DIAGNOSES REDACTED]. Resident's medication regimen review (MRR) was monitored by pharmacy services from the time of admission to the current date. Review of the physician (MD) orders noted that on 04/07/19 the resident was prescribed [MEDICATION NAME] (an antipsychotic medication) 5 milligram's (mg), 1/2 tab (2.5 mg) every 4 hours PRN for agitation. Upon further review, there was no documented condition or [DIAGNOSES REDACTED]. Furthermore, the PRN order was active from 04/07/19 to 05/21/19 beyond the 14 day limit for PRN antipsychotic medication. The medication must be reordered after 14 days with documented rationale by the prescribing provider. During an interview with Staff (S) 15 on 05/21/19 at 11:42 AM, queried when R18 received PRN doses of the antipsychotic medication. S15 reviewed the record and reported that resident received the antipsychotic five times, one dose daily 04/07/19, 04/08/19, 04/09/19, 04/10/19 and 04/12/19. S15 was asked if she was aware that a PRN antipsychotic medication can only be prescribed for a 14 day period and only if there is a documented clinical rationale for extending the order. S15 stated that she was of the PRN antipsychotic requirement although she did not inform the prescribing physician.",2020-09-01
353,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2019-05-22,880,D,0,1,JXQC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to maintain bedside equipment in accordance with infection prevention and control standards to prevent the transmission of communicable diseases and infections and to incorporate routine cleaning and care of bedside equipment into their policy & procedures. Findings include: During an observation in room [ROOM NUMBER] on 05/20/19 at 12:51 P.M., a [MEDICATION NAME] Suction Catheter with attached tubing contained thick yellow residue. The suction canister was soiled. There was no label found to identify when the suction equipment was placed. During an interview with Staff (S) 13 on 05/20/19 at 12:55 P.M., was queried as to what is the protocol when using suction equipment. S13 replied I never use it. During an Interview with S15 on 05/20/19 at 01:00 P.M. when asked about the soiled equipment and how long it had been in place, stated that the nurse on duty said she suctioned the resident last night. It's good for one week. During an Interview with S30 on 05/21/19 at 01:31 P.M. stated 24 hours is the standard from the time of use and also if the tubing is dirty, nurses should use their judgement and change. Standard and Transmission Based Precautions Policy and Procedure dated (MONTH) 13, (YEAR) was reviewed. Environmental control, a. Ensure that facility-approved procedures for the routine care, cleaning and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other high touch surfaces are being followed.",2020-09-01
354,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2019-05-22,881,D,0,1,JXQC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, Resident (R) 1 was prescribed antibiotics symptomatically, in contravention of the antibiotic stewardship protocol for suspected pneumonia. The deficient practice had the potential to affect one of 12 sampled residents, and the deficient practice had the potential that the resident was not prescribed the most appropriate antibiotic medication. The facility provided matrix was reviewed and reflected that R1 was prescribed antibiotics. The Infection Surveillance note dated 05/16/19 was reviewed and revealed that R1 was prescribed [MEDICATION NAME] 250 milligrams (mg) (an antibiotic) by mouth, daily for 10 days for pneumonia. Infection surveillance note format also indicated that a chest x-ray would have to be conducted to confirm a [DIAGNOSES REDACTED]. During an interview with Staff (S)15, on 05/21/19 at 11:28 AM she was queried about how and why R1 was prescribed the antibiotics. S15 replied that R1's physician was notified of the symptoms consistent with a respiratory infection. S15 was asked if a chest x-ray was done for R1 to confirm pneumonia and replied that a chest x-ray was not done nor was a culture and sensitivity (C&S) of sputum obtained. S15 was asked if she was aware of the antibiotic stewardship program and the criteria for prescription of antibiotics. S15 said she was aware but R1's physician wanted to start an antibiotic as soon as possible and justified the choice of ordered antibiotic as evidenced by R1's improved symptoms.",2020-09-01
355,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2018-06-29,578,D,0,1,BC7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical record (EMR) and medical record review, and staff interview the facility failed to ensure that 1 of 17 residents, (R2) on the survey sample list, had an advance directive in the medical record and/or there were policies and procedures for implementing advance directives. Findings: Reviewed R2's EMR and the physician orders [REDACTED].** No code - comfort care, no hospitalization **. On 06/26/18 at 01:58 PM reviewed R2's hard-copy medical record and the form for No code DNR, comfort care was signed by the physician on 10/24/17. The resident's physician order [REDACTED]. Requested for the facility's policies and procedures for implementing advance directives and none was provided by the end of the survey.",2020-09-01
356,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2018-06-29,689,G,0,1,BC7G11,"Based on observations, staff interviews, and record review, one of three Facility Reported Incidents (FRI) was substantiated. The facility failed to provide adequate supervision and assistance to prevent an avoidable fall. As a result of this deficient practice, (Resident (R) 6) sustained a fall with injury. Findings Include: 1. During staff interview on 06/27/18 at 11:00 AM, Staff Member (SM) 15 recalled the incident and remembered that R6 fell while posing for a picture. SM15 said that two staff members were standing alongside R6 but that did not prevent the fall from happening. 2. During observation on 06/28/18 at 07:45 AM, it was observed that outside staff (referred to as Regional Staff) came for part of the scheduled day to work with the Kauai Veterans Memorial Hospital (KVMH) residents. This regional staff would spend the remaining part of the scheduled day to work with other residents from[NAME]Mahelona Memorial Hospital. During an interview with regional staff on 06/28/18 at 07:50 AM, SM14 acknowledged that they did work with residents from two different facilities and that they were not in-serviced or familiar with any of the KVMH resident's recommended activity orders. 3. During an interview with the Physical Therapist (PT) on 06/28/18 at 01:42 PM, SM4 stated when there are new or updated PT activity recommendations, that not only gets typed in the chart for everyone to view, it is subsequently communicated directly to KVMH staff by either a short in-service or through verbal communication. However, SM4 acknowledged that these recommendations may not always get communicated to every staff member, including regional staff, as they should. In relation to the investigated FRI, record review showed that R6 had an updated activity recommendation by Physical Therapy almost four months prior to the incident. This activity recommendation included that the resident be provided Min Assist or Minimal Assistance. According to SM4, Min Assist included a waist belt be applied to the resident, and a hand on the resident was to be provided at all times for support. This was not done. Based on observations and staff interview, the facility failed to secure the Emergency Cart (Code Cart), which is shared between the Long-Term Care unit and the Obstetric (OB) unit. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards. Findings Include: 1. On 06/27/18 at 09:31 AM, during an observation of a Code Cart (located on the OB unit), it was noted that all the drawers were locked except the top drawer. The top drawer contained various venipuncture supplies such as needles, syringes, tubing, tape, and laboratory tubes for blood draw. Also, there was no one in the immediate vicinity to prevent the residents or general public from getting ahold of the various venipuncture supplies. During staff interview on 06/27/18 at 09:40 AM, Staff Member (SM) 5 acknowledged that the drawer should have been locked and the contents secured.",2020-09-01
357,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2018-06-29,711,D,0,1,BC7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical record (EMR) and staff interviews, the facility failed to ensure that the primary care physician (PCP) or alternate physician reviewed the total program of care for 1 of 17 residents (R2), on the survey sample list. Findings include: Review of R2's EMR found that R2 had glycemic monitoring done every 90 days with the hemoglobin (Hgb) A1c test, which measures the average level of blood glucose for the past 3 months, (Hgb A1c of 6.5% or higher indicates diabetes). The nutritionist evaluation for R2 done on 04/24/18 noted R2's quarterly HgbA1c results were: 11.2% (4/23/18); 10.8% (1/12/18); and, 11.4% (10/12/17). The physician's orders [REDACTED]. On 04/23/18 R2's HgbA1c of 11.2% was faxed to her primary care physician (PCP). Documentation in progress notes on 4/25/18 showed, Still awaiting reply. On 04/26/18 facility staff called the PCP's office and left message with the nurse. On 04/27/18 it was documented, MD made aware regarding the Hgb A1c result and no new order, still awaiting reply at this time; continue with current med. On 06/28/18 at 01:28 PM queried S2, regarding change of insulin dose one month after PCP aware of increased HgbA1c results, S2 replied PCP feels that too much insulin not good also. On 06/28/18 01:39 PM during telephone interview with the PCP, inquired why R2's insulin was increased one month after HgbA1c result was reported to him. The PCP simply stated he was waiting for the recertification visit on 05/23/2018, which was a month after he was informed of the HgbA1c results. On 06/29/18 10:18 AM review of R2's EMR, and on 05/23/18 the PCP's recertification statement under interim history noted, The patient has steadily declined over the months, but there has been no significant change from her last visit. Chronic problems are reviewed, they are unchanged. There was no documentation that the PCP reviewed R2's current problem for maintaining and/or improving her [DIAGNOSES REDACTED]. Documentation did not reflect how the PCP decided on the appropriateness of R2's medical regimen.",2020-09-01
358,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2018-06-29,757,D,0,1,BC7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to adequately monitor the drug regimen for unnecessary medication for two of 5 residents reviewed for unnecessary medications, (Resident (R) 1 and 9). 1) Record Review (RR) on 06/28/18 reveals R1 who is on [MEDICATION NAME] 25 mg po daily at 1800 to be given one hour after meals for [MEDICAL CONDITION] and agitation. Order written on 11/01/18 for [MEDICATION NAME] for [MEDICAL CONDITION] with agitation and and restlessness. Physician order [REDACTED]. Further record review reveals care plan did not plan for monitoring of side effects for headache, fatigue, [MEDICAL CONDITION], blurred vision, illogical thinking, dizziness, constipation, diarrhea and xerostomia. Interview on 06/29/18 at 08:25 [NAME]M. interview with Staff (S) 2 who stated Initially R1 came to us and would not sleep at night. Resident would dust things at wee hours of the night and when staff tried to orient R1, R 1 would get very agitated with redirection. We had to assign a staff to R1 until she goes to bed. We tried to get her sleeping patterns switched around but it took a while. She is much better now. We attempted to reduce her [MEDICATION NAME] in (MONTH) but reduction of dose was contraindicated. S2 acknowledged the deficiency and presented a copy of an updated careplan. 2) Record review revealed R9 is on [MEDICATION NAME] (blood thinner) 75 mg by mouth every night with dinner. Plan of care report did not show documentation for adequate monitoring of blood thinner. Some of the side effects from [MEDICATION NAME] are serious and sometimes fatal bleeding, bruising, bleeding more easily, nosebleeds and it will take longer than usual for bleeding to stop or blood in urine or stool. Interview with S2 who was able to show me a care plan for skin integrity but was not able to show this surveyor a plan of care for bleeding which is a severe side effect from this medication.",2020-09-01
359,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2018-06-29,880,D,0,1,BC7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policies, the facility failed to ensure that a Gastrostomy Tube ([DEVICE]) flush bag was capped and protected from the open air. This deficient practice put the resident at risk for the development and transmission of communicable diseases and infections. Findings Include: 1. On 06/27/18 at 09:47 AM, during an observation of a [DEVICE] feeding for (Resident (R) 3), it was noted that the flush bag, for the feeding, was not capped and not protected from the open air. On 06/27/18 at 09:50 AM, during staff interview with Staff Member (SM) 9 and review of facility policy, the [DEVICE] flush bag should have been capped as per manufacturer instructions. SM 9 also acknowledged that the flush bag should have been capped and protected from the open air.",2020-09-01
360,KAUAI VETERANS MEMORIAL HOSPITAL,125021,4643 WAIMEA CANYON DRIVE,WAIMEA,HI,96796,2018-06-29,926,D,0,1,BC7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to establish policies, in accordance with applicable Federal, State and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents. Findings include: Interview with Staff Nurse (SN)9 on 06/27/18 at 0800 [NAME]M. who stated that R9's smoking schedule is 0800 a.m., 1000 a.m., 1200 p.m., 0300 p.m., and 0530 p.m. Observation was made on 06/27/18 at 09:33 [NAME]M. when resident (R) 9's daughter came to take him to smoke. R9's daughter states that she comes every day to take him to smoke. R9 is able to stand and place himself in the wheelchair. R9's daughter wheeled him across the street to smoke and states it's a different view and he enjoys it. When R9 was done smoking, he put out his cigarette and put the butt in a butt pack. R9's daughter states that if there is any other butts outside, he will want to pick them up. Record review reveals a physician order [REDACTED]. Care plan dated 08/04/16 states Allow resident to go outside to smoke in a designated area as desires or out on pass with family and friends as desired. Pending response from administration regarding staff assisting resident to/from. Policy provided and dated (MONTH) 27, (YEAR) with subject and titled Tobacco free Campus. The purpose of this policy is to repeal all existing corporate and regional smoking policies effective immediately and to inform employees, volunteers, contractors, and visitors that on (MONTH) 26, (YEAR) following the passage of Act 25, (YEAR) Session Laws of Hawaii (Act 25), smoking is prohibited on the premises of all HHSC facilities throughout the State of Hawaii. Interview with Staff (S)2 who states that the new policy is under nursing union grievance. The policy is in conflict with the careplan and doctor's orders and the facility states that according to the corporate office, the policy is under grievance.",2020-09-01
361,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2017-02-10,279,D,0,1,OT9B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 6 (Residents #6 and #8) residents in the Stage 2 sample. Findings include: 1) On 02/10/2017 at 8:10 AM medical record review was conducted. It was found that on 06/23/16 Res #6 has a written physician's orders [REDACTED]. The care plan was reviewed. There was no care plan for the use of [MEDICATION NAME]. Staff member #1 (SM#1) was interviewed and asked if there was a care plan for [MEDICATION NAME] and its use in Res #6's medical record and she stated it is not in the care plan. SM#8 was interviewed and stated [MEDICATION NAME] is used to treat Res #6's palsy disorder and not for depression. 2) On 02/10/2017 at 8:27 AM during a medical record review it was noted that Res #8 was receiving [MEDICATION NAME] 20 po mg Q daily. The care plan was updated on 11/30/15 at 23:47 to include [MEDICATION NAME] 20 mg Q daily for history of [MEDICAL CONDITION] [MEDICAL CONDITION] (CKD) and [DIAGNOSES REDACTED]. On 02/23/16 at 11:32 there were added interventions to the care plan to include Plan-Assess/Monitor Lab Values check A1C every 6 months, check hemogram and CMP yearly, will monitor electrolytes more frequently since on [MEDICATION NAME]. Further review of the electronic and hard copy medical records revealed that there was only one electrolyte check done. It was done on 02/23/16, in which the electrolytes were within normal range. SM#1 was interviewed and asked if she could pull up any copies of electrolyte test results from the resident's electronic medical record or if she could find any other results in Res #8's hard copy medical record. The only results that she could show the surveyor was from 02/23/16. Therefore the intervention written in the care plan was not implemented. In summary, the facility failed to develop and implement a comprehensive person-centered care plan for residents #6 and #8.",2020-09-01
362,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2017-02-10,280,D,0,1,OT9B11,"Based on interview and record review, the facility did not revise and implement a care plan for 1 of 6 (Resident #5) residents reviewed in Stage 1. Findings include: During an interview on 2/9/17 at 9:02 [NAME]M. with family member #3 (FM#3) who stated as far as her physical therapy, I wondered if she would get more physical therapy. I also inquired about a pap smear and mammogram during the IDT and they did not get back to me. 02/09/2017 at 1:51 P.M. inquiry with SM#1 and concurrent record review regarding Resident #5 (Res#5). Notes reviewed for Interdisciplinary team (IDT) quarterly meeting. A note was entered by the RAI coordinator dated 7/1/16 about the follow-up of a colonoscopy and a mammogram as requested by her daughter in which SM#13 agreed with. On 02/10/2017 at 9:34 [NAME]M. SM#1 stated that they did not implement follow-up for the mammogram and colonoscopy as had been discussed in their IDT quarterly meeting. SM#1 would follow-up with SM#13. SM#1 further stated that SM#14 stated to her that because they could not do the mammogram or colonoscopy on facility, she did not follow-up with this. In summary, the facility failed to revise and implement a careplan for 1 of 6 residents reviewed in Stage I of the survey.",2020-09-01
363,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2017-02-10,425,D,0,1,OT9B11,"Based on record review and staff interview the facility failed to accurately discontinue a physician's order for 1 of 6 (Resident #4) residents in the Stage 2 sample list. Findings include: On the afternoon of 02/09/2017 Resident #4's (Res #4) medical record was reviewed. During medical record review, there was a physician's order written on 1/21/17 to DC Bactrim DS. The Medication Administration Record [REDACTED]. However, the (MONTH) (YEAR) MAR indicated [REDACTED]. SM#3 was interviewed and shown the (MONTH) and (MONTH) (YEAR) MARs and doctor's orders and he stated That's an error. Then he phoned the doctor and received an order, To restart Bactrim DS 1 po daily on 02/09/17 at 1349. In summary, the facility failed to follow doctor's written order to discontinue Bactrim DS for Res #4.",2020-09-01
364,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2017-02-10,456,D,0,1,OT9B11,"Based on interview and observation, the facility failed to maintain equipment in safe operating condition. 1) On 2/10/17 during kitchen tour, it was noted that the main basin that dishes are washed had rust along the perimeter of sink and leaks. Interview with SM#4 stated that a request was submitted to have the sink recaulked on 2/4/17. SM#4 verbalized that their was also concern that when filling sink with water that the sink may collapse because of the rust. It was also observed that the handwashing sink was leaking under sink seal areas. On further interview, SM#4 stated that storage area maintained with a manual fan for correct temperature because it will get too hot for food storage. SM#4 stated the concern that the fan is not working correctly and if it breaks, termperature will become too hot for food storage. On 2/10/17 at 10:00, discussed these observations with SM#1 who stated that she would look into these concerns. 2) On 2/9/17 during an interview with Resident #4 (Res #4) surveyor noticed the shower chair in resident's shower stall that had rust on it. All four metal legs had rust up to the area that meets the seat. On the morning of 2/10/17 SM #3 was interviewed and asked if the shower chair in Res #4's room is currently being used for the resident and he acknowledged that is was. SM #3 stated that new shower chairs had been purchased and needed to be switched out. Staff member #1 was interviewed about replacement shower chairs and she acknowledged that new shower chairs had been purchased. In summary, the facility failed to maintain equipments for resident care in a safe operating condition.",2020-09-01
365,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2017-02-10,465,D,0,1,OT9B11,"Based on interview and observation, the facility failed to provide a sanitary environment for residents, staff and public. On 2/08/17 at 0900 [NAME]M. during an initial kitchen tour, it was noted that two fans above the dishwashing sinks were prominent with dust and needed to be cleaned. SM#4 stated that they have not been cleaned on a regular basis and did not have a service log. On 2/10/17 at 0830 [NAME]M. during a follow-up kitchen tour, it was noted that the two fans above the dishwashing sinks were still covered with dust. SM#4 stated that a request was sent for the fans to be cleaned. On 2/10/17 at 10:00, discussed these observations with SM#1 who stated that she would look into these concerns and that housekeeping takes care of this. In summary, the facility failed to provide a clean and sanitary environment for their staff and residents.",2020-09-01
366,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2019-09-26,641,E,0,1,60GQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to ensure staff members accurately completed 2 (Residents 7 and 4) of 9 residents' assessments for activities of daily living. The facility identified system failure and provided staff education/training. Findings include: 1) Resident (R)7 was admitted to the facility on [DATE]. R7's [DIAGNOSES REDACTED]. A record review was done on 09/23/19 at 03:30 PM. A comparison of R7's quarterly Minimum Data Set (MDS) found a decline in activities of daily living (bed mobility and transfer). The quarterly MDS with an assessment reference date (ARD) of 06/20/19 was assessed to require extensive assist with two-person physical assist for bed mobility and extensive assist with one-person physical assist for transfer. Previous quarterly assessment with an ARD of 03/21/19 notes R7 required extensive assist with one-person physical assist for bed mobility and supervision with one-person physical assist for transfer. The quarterly assessment with an ARD of 12/22/18 notes R7 required limited assistance with one-person physical assist for both bed mobility and transfers. R7 was found to have a decline in bed mobility (limited assist with one-person physical assist to requiring extensive assist with two-person physical assist). R7 was also noted to have a decline in transfer (supervision with one-person physical assist to extensive assist with one-person physical assist). On 09/24/19 at 11:52 AM an interview and record review was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC explained R7 did not have a decline in bed mobility and transfer, there was an error in coding. The facility identified the aides were not accurately coding for the residents' self-performance in activities of daily living; therefore, the registered nurses completing the assessments were utilizing this data resulting in an inaccurate assessment. The MDSC reported training was done in (MONTH) 2019 with the aides to ensure accuracy of the coding for the residents' self-performance abilities. 2) Resident (R)4 was admitted to the facility on [DATE]. R4's [DIAGNOSES REDACTED]. On 09/23/19 at 03:14 PM a record review was done for R4. A comparison of R4's MDS, annual assessment (ARD of 04/25/19) and quarterly assessment (ARD of 07/25/19) found R4 had a decline in bed mobility, transfer, dressing, eating and personal hygiene. R4 annual assessment for activities of daily living found the resident was coded with requiring limited assistance with one-person physical assist for bed mobility, transfer, dressing, eating and personal hygiene. The subsequent quarterly assessment noted decline in the level of support R4 required in the aforementioned areas, the resident now required extensive assistance in these areas. On 09/24/19 at 11:52 AM an interview was conducted with the MDSC regarding R7. The MDSC explained the facility identified inaccurate coding by the aides; therefore, resulting in inaccurate assessment. The MDSC confirmed that the same situation would apply for R4's inaccurate assessment. The MDSC also reported the nurses completing the assessment attended and training and are currently certified.",2020-09-01
367,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2019-09-26,757,D,0,1,60GQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with facility staff, the facility failed to ensure 1 (Resident 4) of 5 residents reviewed for unnecessary medication was monitored for the use of an anticoagulant. Findings include: Resident (R)4 was admitted to the facility on [DATE]. R4's [DIAGNOSES REDACTED]. A record review on 09/24/19 at 10:30 AM found physician's orders [REDACTED]. A review of the lab reports found missing lab result for PT/INR for the months of March, (MONTH) and (MONTH) 2019. On 09/24/19 at 12:07 PM a concurrent review of the Electronic Health Record (EHR) and interview was conducted with the Director of Nursing (DON). The DON found the results for (MONTH) and (MONTH) 2019; however, could not locate the lab results for (MONTH) 2019. The DON was agreeable to follow up. A review of the pharmacy medication regimen review found reviews were done on 06/07/19, 07/08/19, 08/05/19 and 09/09/19. The review for (MONTH) referenced an INR result of 2.8 from 05/06/19. However, there is no further documentation of subsequent lab results that were reviewed by the pharmacist. On 09/24/19 at 12:48 PM, the DON confirmed that the PT/INR was not done for the month of (MONTH) 2019. The DON reported a chart audit done in (MONTH) 2019 also confirms the lab for the resident's PT/INR was not done in June.",2020-09-01
368,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2019-09-26,761,E,0,1,60GQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with staff member, and review of the facility's policy and procedures, the facility failed to ensure opened drugs were labeled. Findings include: On 09/25/19 at 08:45 AM concurrent observation of the medication cart was done with Charge Nurse (CN)1. The polyethylene [MEDICATION NAME] ([MEDICATION NAME]) powder for Resident (R)9 found the bottle was not labeled with an open date. CN1 reported the powder should be labeled to ensure it is discarded after 30 days. Further observation found a bottle of [MEDICATION NAME] for R1 which was not labeled with an open date. CN1 confirmed there was no label with an open date. CN1 stated that the [MEDICATION NAME] will be thrown out. On 09/25/19 at 09:00 AM concurrent observation and interview was done with the Director of Nursing (DON). Approximately 15 minutes later, the [MEDICATION NAME] powder was still on the medication cart, the DON confirmed the bottle was not labeled. The DON stated liquids require labeling with open dates. The DON was agreeable to provide a copy of the facility policy and procedures regarding medication storage and labeling. On 09/25/19 at 09:01 AM, the DON provided the policy and procedure entitled Storage of Medications and Solutions in Patient Care Areas. Noted under procedure, place open and discard dates on solution bottles.",2020-09-01
369,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2019-09-26,812,D,0,1,60GQ11,"Based on observations and staff interview the facility failed to ensure that staff followed hygienic practices during food preparation. Findings include: On 09/24/19 at 11:14 AM observed Cook (C)1 preparing lunch trays for residents. C1 had disposable gloves on and observed that she used the microwave, opened the oven door several times, used different thermometers to take food temperatures, and grabbed different serving ladles by the scooper part and not by the handle without changing gloves. Inquired of C1 if only one pair of gloves were used throughout the food preparation for lunch trays, and she was not sure when she should have changed gloves. The observation was shared of her touching different kitchen equipment and surfaces, grabbing ladles by the scoop, and then scooping food onto the different dishes. The facility staff did not follow proper sanitation practices to minimize the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, and/or utensils.",2020-09-01
370,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2019-09-26,880,D,0,1,60GQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that staff followed proper infection control practices while performing point of care testing for one of eight sampled residents (R)5. Findings include: On 09/25/19 at 07:22 AM observed charge nurse (CN)1 use the facility's glucometer to test R5's blood sugar, before administering insulin. CN1 gathered the necessary supplies and equipment, went to R5's bedside and placed the items onto the resident's blanket atop her stomach area. R5 is diagnosed with [REDACTED]. Inquired of CN1 if placing the bandage and gauze packages, with a plastic cup that held the lancet and glucometer strip onto R5's blanket was the usual practice. CN1 did not have an answer.",2020-09-01
371,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,578,D,0,1,8I7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to ensure 1 (Resident 9) of 9 residents reviewed for advance directive was provided the right to formulate an advance directive. Finding includes: On 09/18/18 at 1:26 PM a record review was done for Resident 9 (R9). The record did not contain an advance directive. On 09/20/18 at 8:45 AM the Charge Nurse (CN) was asked whether R9 has an advance directive or is there documentation the resident was provided with information to formulate an advance directive. The CN was able to produce the resident's POLST (Physician order [REDACTED]. The CN was agreeable to review the resident's record. On 09/20/18 at 9:22 AM the CN confirmed the resident does not have an advance directive and there is no documentation the resident was informed of the right to formulate an advance directive.",2020-09-01
372,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,584,D,0,1,8I7411,"Based on an interview with resident, the facility did not ensure 1 (Resident 9) of 9 residents in the sample was provided with a comfortable home environment. Findings include: On 09/20/18 at 12:32 PM an interview was conducted with Resident (R9). R9 reported the facility is too hot and would like to have a fan. R9 further reported the heat interferes with the ability to sleep at night.",2020-09-01
373,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,656,E,0,1,8I7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to develop a comprehensive care plan for 3 of 8 residents in the sample. The facility failed to develop a care plan for a smoking resident (Resident 9). The facility also failed to develop a care plan for residents using [MEDICAL CONDITION] medication (Residents 6, 8 and 9). Findings include: 1) Cross Reference to F689. Resident 9 (R9) was readmitted to the facility on [DATE]. R9 is a resident that smokes. The facility failed to develop a care plan based on an individualized assessment to provide the necessary safeguards while R9 is smoking. 2) Cross Reference to F758. Resident 8 is prescribed with antipsychotic and [MEDICAL CONDITION] medications. The facility failed to develop a care plan to address how the resident will be monitored for side effects related to the use of these medications. 3) Cross Reference to F758. Resident 9 is prescribed with [MEDICAL CONDITION] medications. The facility failed to develop a care plan to address how the resident will be monitored for side effects related to the use of these medications. 4) Cross reference to F757. R6 had a history of [REDACTED]. A record review for R6's care plans on the afternoon of 09/19/18 did not find a plan for the use of anticoagulants. An interview of the Charge Nurse on 09/19/18 at 2:00 PM noted they did not create a care plan for the use of anticoagulants for R6.",2020-09-01
374,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,657,D,0,1,8I7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the care plans for two residents (R1 and R7). Findings include: Cross reference F692. 1) R7 experienced unplanned significant weight loss after a [DEVICE] placement on 08/13/18. After her [DEVICE] placement, the Registered Dietician (RD) recommended weekly weight monitoring. Despite the recommendation, the facility did not update her care plan to indicate R7 required weekly weights. An interview of the Charge Nurse on the afternoon of 09/19/18 at 2:30 PM found they did not update the care plan to reflect the RD's recommendation for weekly weights. 2) R1 was on a physician prescribed weight loss program. A concurrent record review and staff interview on the afternoon of 09/19/18 at 2:30 PM found R1's care plan was not updated to indicate the weight loss plan. An interview of the Charge Nurse revealed the facility did not update his care plan to reflect the physician prescribed weight loss plan.",2020-09-01
375,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,689,J,0,1,8I7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview with resident and staff members, the facility failed to ensure a resident, Resident 9 was assessed to determine the resident's capacity to safely smoke unsupervised. R9 has a [DIAGNOSES REDACTED]. Findings include: Resident 9 (R9) was admitted to the facility on [DATE] following an acute hospitalization . The [DIAGNOSES REDACTED]. On 09/18/18 at 12:00 PM, R9 was observed exiting the unit via a motorized scooter. The surveyor accompanied R9 out through the facility's Emergency Department (ED) door. R9 parked at the back of the facility. There were staff members sitting at a table and greeted R9. An interview was conducted with the resident. R9 reported four cigarettes are allowed per day and the time for smoking is in the morning, after lunch, after dinner and at night. R9 further reported she holds her own cigarettes and showed the surveyor the ashtray in the basket of her scooter. As the ED door is secured, R9 will press the buzzer for the ED staff/lab staff to let her back into the facility. The resident did not smoke at this time. Subsequent observation at 2:44 PM found the resident going by the nursing station, stating she was going out for a smoke. The resident was unaccompanied by staff and exited the double doors of her unit. R9 was observed to go out of the facility unaccompanied and was not wearing a smoking apron. R9 shared that she continues to have delusions and will go to her room, close the door and rest until it stops. A record review was done on the afternoon of 09/19/18. The quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 08/01/18 found the resident yielded a score of 14 (cognitively intact) on the Brief Interview for Mental Status. The resident was also coded to have delusions and feeling down, depressed, or hopeless. R9 noted with functional range of motion to one side of the upper and lower extremities. In section [NAME] Health Conditions, the resident was coded to have had a fall with injury. A review of the physician orders [REDACTED]., three tablets (7.5 mg) daily to stabilize mood; and okay to give [MEDICATION NAME] and [MEDICATION NAME] the same time. On 07/29/18 R9 was seen by the psychiatrist for hallucinating and requesting more medication. The resident's [DIAGNOSES REDACTED]. At this time R9 complained of poor sleep and appetite with pain related to arthritis. Further review found no documentation of an assessment regarding R9's capabilities and/or deficits to determine whether R9 required supervision while smoking outside of the facility. There was no documentation of a care plan related to the resident's smoking (i.e. approved times for smoking, the designated smoking area, the need for supervision). On 09/20/18 at 8:45 AM an interview was done with the Charge Nurse (CN). The CN was asked whether the facility assessed R9 for safe smoking without supervision and/or developed a care plan. The CN reported the resident's cigarettes and lighter are held at the nurses' station and R9 is allowed to smoke four times a day. The CN further reported R9 is safe as the hospital staff members will check on R9 and the resident can be seen from the back door (the ED door). The CN stated the facility did not assess R9 for smoking and based on the assessment developed a care plan. On 09/20/18 at 9:33 AM, the Director of Nursing, CN and Accreditation Regulatory and License (ARL) staff member were notified of immediate jeopardy. R9 was observed to exit the unit unsupervised to smoke. The smoking area is located at the back of the facility to the side of the ED entrance/exit which requires a code to re-enter the facility. R9 was not assessed to determine whether she has the capability of smoking unsupervised or what precautions are required to be in place to ensure the resident smokes safely. The facility was aware the resident was smoking unsupervised; however, failed to assess the resident for safety and develop a care plan. The failure to assess and care plan resulted in potential for harm without immediate correction. On 09/20/18 at 2:51 PM a correction/abatement plan was provided to the State Agency. The facility provided the following documents: Plan of Correction; Smoking Rules; and Acknowledgement of Smoking Risks. The facility completed a Smoking Assessment which determined R9 is not safe to smoke unsupervised due to the side effects of [MEDICAL CONDITION] medications. A care plan was developed to include intervention for supervised smoking, donning of smoking vest and smoking items to remain in locked location. Observation with the CN found the resident's cigarettes and lighter were stored in a locked cabinet. On 09/20/18 at approximately 3:00 PM R9 was observed requesting cigarettes, the staff member offered the resident the smoking apron. R9 was heard saying the apron was absurd, refusing to wear the apron. R9 was not allowed to go out to smoke. On 09/20/18 at 3:21 PM, the State Agency validated that the immediate jeopardy abated.",2020-09-01
376,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,692,G,0,1,8I7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and staff interviews, the facility failed to maintain the necessary nutritional requirements for two residents (R7 and R1) who experienced weight loss Findings include: 1) Resident 7 (R7)was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Due to the disease process of PSP, R7 experienced anticipated declines in her ability to swallow. R7 was unable to swallow independently which lead to unplanned weight loss in (MONTH) (YEAR). Over a six month period from 03/1/18 to 08/1/18, R7 experienced a severe weight loss (greater than 10%) - 11% of her body weight. R7 was sent to a hospital on [DATE] for gastric tube ([DEVICE]) placement to provide formula nutrition. Upon return to the facility the same day, 08/13/18, R7 was started on tube feedings: Fibersource HN 160 ml/hour at 5:00 AM, 10:00 AM, 3:00 PM and 8:00 PM. Observation of R7 on the morning of 09/18/18 found her laying in bed awake. She was not connected to her [DEVICE] feeding at the time. The Formula bag did not have a label to include resident's name, name of the formula and amount to be infused and date/time the formula was hung. Observation of R7 on the morning of 09/19/18 found the formula bag with the resident's name, formula name and infusion amount and frequency. R7 was awake and non responsive to questions. Observation of R7 on the afternoon of 09/19/18 found her seated in a recliner chair in the activities room. She was seated facing the TV where a movie was playing. On the morning of 09/19/18 a concurrent medical record review and staff interviews found R7 returned to the facility on [DATE] with a [DEVICE]. She was 106 pounds on 08/01/18 and lost 3% over the next three weeks, weighing 103 pounds on 08/21/18. R7 was weighed again on 09/01/18 when she weighed 101 pounds or 5% over the past month. The next weight on 09/13/18 found R7 at 98 pounds (decrease of 14% over 6 months) or 3% in 12 days. The final weight noted in R7's medical record found she remained at 98 pounds on 09/19/18. From 02/01/18 to 08/01/18, R7 experienced a decrease of 12% of body weight. An interview of the Registered Dietician (RD) on 09/19/18 at 9:26 AM revealed R7's [DIAGNOSES REDACTED]. In addition to R7's difficulty swallowing, she would refuse to eat (prior to tube placement). R7's spouse would come for every lunch meal to assist with feeding her. The RD had the Speech Language Pathologist (SLP) do a swallow evaluation which found her difficulty with swallowing which also contributed to her not wanting to eat. The RD stated the staff should have been weighing R7 at least weekly since her [DEVICE] was placed on 08/13/18. A review of the RD's note dated 08/10/18 noted her recommendation to weigh R7 weekly for four weeks after [DEVICE] placement. The RD noted that if weekly weights had been obtained, she was likely to have intervened earlier to avoid additional weight loss. An interview of the Charge Nurse revealed the staff weighed R7 every 2 weeks after her [DEVICE] placement despite the RD's recommendation for weekly weights. On the morning of 09/19/18 a review of R7's Minimum Data Set ((MDS) dated [DATE] found he was totally dependent with one person assistance for bed mobility and eating. The MDS further noted she was totally dependent with toileting requiring two person assistance. On the morning 09/19/18 at 10:00 AM an interview of the Charge Nurse noted R7 was experiencing constipation with possible bowel obstruction over the past few weeks. The Charge Nurse noted the physician ordered [MEDICATION NAME] 15 ml per day on 09/2/18 to aide with constipation. On 09/13/18 an additional dose of [MEDICATION NAME] was added for bowel obstruction found on x-ray taken 09/13/18. On 09/19/18 a suppository was added due to R7 having diarrhea. On 09/18/18 R7's bowel obstruction was cleared. On the morning of 09/19/18 at 11:00 AM found R7's orders for enteral feeding were changed as follows: 08/26/18 80 cc/hr four times daily; 09/05/18 160 cc/2 hours four times daily; 09/11/18 200 cc/one hour 45 minutes four times daily. On the morning of 09/19/18 a review of R7's care plan found one for Enteral Nutrition with a start date of 08/16/18 noting one goal as, Stable weight for next 2 months with gradual gain. Interventions included, Dietician will review weight and feeding orders monthly and as needed. Weight monitored monthly with review by nurse and dietician. The care plan did not reflect the RD's note dated 08/10/18 which recommended weekly weights after [DEVICE] placement (08/13/18). The facility did not implement necessary interventions as recommended by the RD to weigh R7 weekly. R7 experienced an unplanned severe weight loss despite being on a controlled, consistent diet of enteral nutrition. 2) Resident 1 (R1) was a long time (several years) resident of the facility. The resident experienced complications after a J-tube placement was attempted in June/July (YEAR). R1 was sent to the hospital to resume his former tube style - J[DEVICE]. R1 was readmitted to the facility on [DATE] after J[DEVICE] (re)placement. R1 was on comfort care. On the afternoon of 09/19/18 at 3:37 PM, a concurrent medical record review and RD interview found R1 recently experienced a slight weight loss. R1's weight changed from 181.3 pounds on 06/01/18 to 176.1 pounds on 09/01/18 (3% loss). The RD's note dated 06/05/18 noted she received reports from the Nursing staff relating R1 was unable to meet his tube feeding goal rate. The nursing staff further noted R1 does not have residual gastric contents but nursing staff were unable to give medications due to formula coming out. R1 also with large liquid bowel movements daily. The RD made a recommendation for R1 to have a gradual weight loss and optimize tube feeding tolerance. The RD recommended slow weight loss to his usual weight of 170 pounds. The RD specified her recommended weight loss plan as 4% by 07/05/18 to 174 pounds and 2% by 12/05/18 or 170 pounds. On the afternoon of 09/19/18 at 3:12 PM, a concurrent medical record review and Charge Nurse interview found R1's weight loss was planned and done in collaboration with the RD and physician. However, the Charge Nurse was unable to find the physician's orders [REDACTED]. Additionally, R1's care plan did not reflect the facility's plan for physician prescribed weight loss. The Charge Nurse stated since R1 experienced complications with the J-tube, she didn't want to risk R1 experiencing more weight loss than they could handle. Therefore, R1's physician prescribed weight loss program was discontinued to avoid additional problems. The RD was present during this interview and noted she was unaware of the discontinued weight loss program. A review of R1's annual MDS dated [DATE] found he required extensive assistance with bed mobility with one person assist. He was noted to be dependent with two person staff assistance for transfer and toileting. The facility failed to ensure appropriate orders, goals and interventions to obtain a safe, consistent approach to R1's weight loss plan.",2020-09-01
377,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,693,D,0,1,8I7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and facility policy review, the facility failed to properly label one of two resident's (R7) enteral feeding bag. Findings include: Observation of R7 on the afternoon of [DATE] at 12:57 PM found her [DEVICE] formula bag without a label. Observation of R7 on the morning of [DATE] at 10:22 AM found her formula bag labeled with her name and physician's orders [REDACTED]. An interview of Licensed Nurse (LN1) revealed her uncertainty of the bag's expiration. She stated she thought the formula bag expired in 24 hours but was unsure and would check on it. An interview of the Charge Nurse on the afternoon of [DATE] at 4:00 PM revealed her expectation of staff is to label the formula bag with the date, time and staff's initial. The Charge Nurse noted staff weren't expected to write the resident's name on the bag. The Charge Nurse further noted the formula can remain hanging in the bag for 48 hours since it's a closed system. The Charge Nurse stated she would discard a formula bag if it had not been labeled with a date and time. On the morning of [DATE] at 7:50 AM the Charge Nurse noted they didn't have a policy for labeling and storing enteral feedings.",2020-09-01
378,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,712,F,0,1,8I7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to ensure 3 (Residents 1, 8, and 9) of 3 residents were seen by a physician at least once every 30 days for the first 90 days following an admission. Findings include: 1) On 10/05/18 at 12:20 PM a record review for Resident 8 (R8) was done with the assistance of the Director of Nursing (DON). The DON reported R8 was initially admitted to the facility late (YEAR) and re-admitted on [DATE]. The DON reported the facility is unable to access closed records and would need to request the specific documents. The DON reported there is documentation of 60-day visits for R8, dated 05/17/18, 07/10/18 and 09/27/18. The DON confirmed the physician did not visit R8 every 30 days for the first 90 days upon the admission of 04/24/18. 2) On 10/05/18 at 12:20 PM a record review was done for Resident 1 (R1) with the assistance of the DON. R1 was re-admitted to the facility on [DATE]. The DON reported there is a physician progress notes [REDACTED]. The DON was unable to produce documentation of the physician visit once every 30 days for the month of August. 3) On 10/05/18 at 12:20 PM with the assistance of the DON a record review was done for Resident 9 (R9). R9's initial admission was 01/23/18 with a re-admission on 05/15/18. The DON reported the record for the first admission could not be accessed from the facility's electronic medical record (EMR) and would have to request for the record. The current admission of 05/15/18 was reviewed. The DON found a history and physical completed on 05/16/18. The next physician visit was dated 07/07/18 and subsequent 60-day interval was dated 09/19/18. The DON was unable to provide documentation of physician visits at least once every 30 days for the first 90 days after admission for the first and second admission.",2020-09-01
379,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,757,D,0,1,8I7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to monitor/evaluate the use of an anticoagulant for one resident (R6) of one resident reviewed for anticoagulant use. Findings include: Resident 6 (R6) was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation of R6 on the morning of 09/18/18 found her celebrating her birthday with her family and the other residents in the dining room for lunch. On the morning of 09/19/18, R6 was in her room putting makeup on. She is nonverbal but clearly understands when spoken to as she nods her head in agreement or shakes her head in disagreement appropriately. A medical record review on the afternoon of 09/19/18 found R6 had a physician's orders [REDACTED]. A review of R6's care plan did not find one for the use of an anticoagulant. R6's [MEDICATION NAME] Time (PT) and international normalized ratio (INR) were monitored monthly, as is indicated when using anticoagulants. PT and INR are tests to monitor bleeding or clotting disorders. On 01/16/18, R6 experienced a fall and fell on her head. She was sent to a hospital on Oahu to get an MRI to determine if there were any head injuries. The resident was noted to be at high risk for falls, placing her at greater risk for bleeding in addition to taking anticoagulant medications. An interview of the Charge Nurse on the afternoon of 09/19/18 at 2:38 PM revealed R6 did not have a care plan for the use of a blood thinner. The Charge Nurse noted the things the Certified Nurses Aides (CNAs) should watch for is a change in R6's neuro status. When asked if the CNAs knew what neuro status meant, the Charge Nurse said she thought they did. The Charge Nurse further noted the CNAs would come find me when they're unsure. The facility did not have a system for monitoring anticoagulant use for R6, leaving staff members without the guidance/outline on managing a resident who is at high risk for bleeding/complications. The Charge Nurse noted it would be best practice to have a care plan which would ensure staff knew how to manage R6's care.",2020-09-01
380,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,758,F,0,1,8I7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 4 (Residents 1, 3, 8, and 9) of 4 residents reviewed for the use of [MEDICAL CONDITION] medication had a rationale for an extension of prn (as needed) [MEDICAL CONDITION] medications beyond 14 days; residents were monitored for side effects related to the use of [MEDICAL CONDITION] medication; and established a system to monitor residents for efficacy of medication as evidenced by identifying targeted behavioral symptoms. Findings include: 1) Resident 8 (R8) was admitted to the facility on [DATE]. R8's [DIAGNOSES REDACTED]. On 09/19/18 at 10:30 AM a record review found physician's orders [REDACTED]. The prn of [MEDICATION NAME] has an initial order date of 08/07/18 with renewal on 08/24/18 and last renewal on 09/15/18. Further review of the physician's orders [REDACTED]. The order for 09/06/18 notes renew [MEDICATION NAME] prn for anxiety, 14 days. The last order for prn of [MEDICATION NAME] notes continuation of prn order. The physician did not document the rationale for the continued prn use of [MEDICATION NAME]. On 07/09/18, R8 was assessed by the psychiatrist. The psychiatrist identified [DIAGNOSES REDACTED]. The staff reports R8 is not sleeping at night. The psychiatrist recommended adding [MEDICATION NAME] nightly for sleep and decrease [MEDICATION NAME] to 3 mg. nightly. The quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 09/04/18 documents R8 received antipsychotic, anti-anxiety and an antidepressant daily during the ARD period. The team reviewed R8's antipsychotic medication and there was no recommendation for gradual dose reduction. A review of the care plan found no intervention for monitoring of side effects related to the [MEDICAL CONDITION] medication A review of R8's Behavior/Intervention Monthly Flow Record for the months of July, (MONTH) and (MONTH) (YEAR) found the resident is being monitored for the following behaviors: wandering; [MEDICAL CONDITION], hiding utensils, clock watching, meds/water/juice schedule; and impulsive behavior, touching, cursing, aggression and repetitive speech. The medications listed included [MEDICATION NAME] (antipsychotic); [MEDICATION NAME] (anti-anxiety) and [MEDICATION NAME] (for sleep). The flow record is divided by shifts and the facility added a code 12. too many to count for the number of behavior episodes. There is no parameters for too many to count. The flow record also includes areas for documentation of intervention/outcome and side effects. Overall, the review of the flow records found missing documentation for side effects of medication. The flow record did not define the targeted behaviors for which the various [MEDICAL CONDITION] medications were being administered. For example, although the [MEDICATION NAME] was administered to aide in R8's sleep; the resident's sleep pattern was not monitored to demonstrate the efficacy of this medication (dosage). 2) Resident 9 (R9) was admitted to the facility on [DATE] following an acute hospitalization . The [DIAGNOSES REDACTED]. On 09/19/18 at 12:45 PM a record review found a physician's orders [REDACTED]. A review of the Minimum Data Set (MDS) with assessment reference date (ARD) of 08/01/18 notes the resident received the following medication during the ARD: antipsychotic, anti-anxiety, and antidepressant. The medication review was done on 06/07/18 and there is documentation of an attempt at gradual dose reduction. A review of the care plan found no intervention to monitor for side effects related to use of antipsychotic and [MEDICAL CONDITION] medication. R9 was evaluated by the psychiatrist on 07/29/18. The [DIAGNOSES REDACTED]. Also noted R9 reports poor sleep and appetite. A review of the Behavior Intervention Monthly Flow Record found the following behaviors were being monitored: yelling at staff; cursing at staff or other residents; clock watching for medication; delusions; and crying. The listed medications associated with the behaviors included duloxetine HCL; [MEDICATION NAME]; [MEDICATION NAME]; and MS contin, [MEDICATION NAME] (pain medication). The targeted behaviors are not associated with the use of the medications. The flow records for (MONTH) and (MONTH) (YEAR) were missing documentation for episodes of behavior and there was no documentation for monitoring of side effects. On 09/19/18 at 2:16 PM, an interview and concurrent review for R8 and R9 was done with the Director of Nursing (DON). The Behavior/Intervention Monthly Flow Record and care plans for R8 and R9 were reviewed. The DON acknowledged the coding for too many to count was not specific to define how many times is too many. The DON was queried regarding how the facility determines the targeted behavior related to the use of medication. The DON responded the medications address all the behaviors listed for the residents. However, the DON recognized the facility did not include targeted behaviors for which medications used to address pain and sleep. The DON confirmed that there are missing entries for the flow record. The DON also confirmed the residents' care plans did not include monitoring for side effects and the flow record to document the monitoring of side effects was not being done by staff. 3) Resident 1 (R1) had [DIAGNOSES REDACTED]. He was a long term resident of the facility. R1 had experienced some declines over the past year resulting in increased dependence on staff for Activities of Daily Living (ADLs). R1 had a history of [REDACTED]. On the afternoon of 09/19/18 at 3:12 PM, a concurrent medical record review and interview with the Charge Nurse found a discrepancy with the physician's rationale for use of prn medications and behavior monitoring for R1. A physician's orders [REDACTED]. R1 also received routine [MEDICAL CONDITION] medications: [REDACTED]. A review of the physician's orders [REDACTED]. The next entry dated 09/06/18 noted, Renew [MEDICATION NAME] ([MEDICATION NAME]) 1 mg orally every 4 hours prn anxiety. The physician did not document a rationale for continued use of prn [MEDICATION NAME] and did not indicate a specific duration. Additionally, the order noted the administration route as oral. R1 did not take medications or food orally. On 09/19/18 a review of R1's annual MDS dated [DATE] found he displayed verbal behaviors towards others one to three days during that assessment period. The annual MDS further noted he did not display rejection of care. On the morning of 09/19/18, a review of R1's Medication Administration Record [REDACTED]. A review of R1's Behavior Intervention Monthly Flow Record dated (MONTH) (YEAR) noted two behaviors: Anxiety, yelling during ADL care; and Yelling at staff or other residents. On the behavior flow record, two medications were noted: [MEDICATION NAME] and [MEDICATION NAME]. An interview of the Charge Nurse on the afternoon of 09/19/18 at 1:50 PM found the facility utilized one flow record for all [MEDICAL CONDITION] medications and all behaviors. The Charge Nurse noted they don't distinguish between [MEDICAL CONDITION] medications as they relate to specific behaviors. The Charge verified it would be difficult to extract information from the behavior flow record when evaluating the effectiveness of the [MEDICAL CONDITION] medication. Additionally, the Charge Nurse noted the physician did not provide a rationale for R1 to continue with the prn [MEDICAL CONDITION] medication ([MEDICATION NAME]). 4) Resident 3 (R3) was a long term resident of the facility having lived there for many years. His [DIAGNOSES REDACTED]. On the afternoon of 09/19/18 a concurrent medical record review and an interview with the Charge Nurse found a discrepancy with the physician's orders [REDACTED]. A review of R3's physician's orders [REDACTED]. On 08/24/18, R3's physician's orders [REDACTED]. On 09/6/18, R3's physician's orders [REDACTED]. On 9/19/18, R3's physician's orders [REDACTED]. The physician did not document a rationale for continued use of prn [MEDICATION NAME] and did not indicate a specific duration. On 09/19/18 a review of R3's annual MDS dated [DATE] found he displayed verbal behaviors towards others one to three days during that assessment period. The annual MDS further noted he rejected care daily. On the morning of 09/19/18, a review of R3's Medication Administration Record [REDACTED]. A review of R3's Behavior Intervention Monthly Flow Record dated (MONTH) (YEAR) noted several behaviors: Elopement - walking or by wheelchair; Hitting staff or other residents; Disruptive, cursing, singing out loudly, laughing at or making fun of people; Wandering/roaming in wheelchair, self propelled; Cursing at staff or other residents; Pacing hallway and standing. On the behavior flow record, three medications were listed for all of the above behaviors: [MEDICATION NAME]; [MEDICATION NAME]; and [MEDICATION NAME]. An interview of the Charge Nurse on the afternoon of 09/19/18 at 2:00 PM found the facility utilized one flow record for all [MEDICAL CONDITION] medications and all behaviors. The Charge Nurse noted they don't distinguish between [MEDICAL CONDITION] medications as they relate to specific behaviors. The Charge verified it would be difficult to extract information from the behavior flow record when evaluating the effectiveness of the [MEDICAL CONDITION] medications. Additionally, the Charge Nurse noted the physician did not provide a rationale for R3 to continue with the prn [MEDICAL CONDITION] medication ([MEDICATION NAME]). An interview of the Director of Nursing and Charge Nurse on the afternoon of 09/19/18 at 1:50 PM found they did not have physicians' rationale for all prn [MEDICAL CONDITION] medications being provided to all residents. The Charge Nurse noted it would be beneficial to monitor each behavior for which the medication was targeted for.",2020-09-01
381,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,838,D,0,1,8I7411,"Based on a review of the facility's assessment and interview with staff member, the facility failed to include an assessment to ensure resources were available to provide care to residents who smoke. Findings include: On the morning of 10/05/18 a request was made to review the facility assessment. The Director of Nursing (DON) provided a copy of the facility assessment. Further review found smoking residents were not included in the facility's resident profile and facility resources/equipment (i.e. smoking assessment tool, staff training, smoking vests, etc.) was not identified to support smoking residents. On 10/05/18 at 11:35 AM a telephone interview was conducted with the Administrator. Queried the Administrator whether the facility included smoking residents in their facility assessment. The Administrator responded this was a misstep and acknowledged the facility assessment did not include smoking residents. The Administrator also reported following the identification of immediate jeopardy, the facility developed a policy and procedure for smoking residents and acquired a smoking vest.",2020-09-01
382,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,842,E,0,1,8I7411,"Based on record review and interview with staff member, the facility failed to ensure residents' medical records are readily accessible. Findings include: Cross Reference to F712. On 10/05/18 at 12:20 PM, the Director of Nursing (DON) provided assistance with electronic medical record review for three residents (Residents 1, 8, and 9). The DON was unable to access the discharge record from the facility's electronic medical record system. The DON explained the documents that were being requested by the surveyor would have to be requested and sent to the facility demonstrating the residents' electronic medical records are not readily accessible.",2020-09-01
383,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,943,F,0,1,8I7411,"Based on interview with staff, the facility did not provide education to staff related to abuse, neglect and exploitation. Findings include: On the morning of 10/05/18 a request was made to the Director of Nursing (DON) for documentation of the in-service provided to staff members for abuse, neglect and exploitation. On 10/05/18 at 12:20 PM, the DON was asked whether the staff members complete in-service online or attend an in-service training. The DON reported the facility is not able to provide documentation that training was provided for staff members regarding abuse, neglect and exploitation.",2020-09-01
384,LANAI COMMUNITY HOSPITAL,125023,628 7TH STREET,LANAI CITY,HI,96763,2018-10-05,947,F,0,1,8I7411,"Based on interview with staff member, the facility failed to ensure 12 of 12 nurse aides received the required in-service training for nurse aides of no less than 12 hours per year. Findings include: On the morning of 10/05/18 a request was made to the Director of Nursing (DON) to review the in-service training for the nurse aides in the facility. On 10/05/18 at noon, the DON reported the facility is in the process of developing training and curriculum for their staff members. The DON confirmed the 12 (twelve) nurse aides are not up to date with the required minimum of 12 hours of annual training.",2020-09-01
385,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2017-03-24,164,D,0,1,CL5011,"Based on observation and staff interview the facility failed to ensure privacy while providing personal care for 1 of 22 residents (Resident # 50) in the Stage 2 resident sample. Findings include: On 03/24/2017 at 9:21 AM observed Staff # 12 blow drying Resident # 50's hair in front of the hallway TV just outside the resident's room. Queried Staff # 12 if the facility had a beauty shop area, and they stated I wish. Inquired why the resident wasn't being groomed in their room and Staff # 12 stated that the resident didn't want to bother the other residents that shared the room. Inquired whether the practice of blow-drying residents hair in the hallway didn't disturb the acitivities of other residents sitting in the hallway. The Staff # 12 then stated that they would bring Resident # 50 to their room to finish blow-drying the resident's hair. The facility failed to provide personal privacy for R#50 during activities of personal hygiene and grooming.",2020-09-01
386,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2017-03-24,221,D,0,1,CL5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure the residents have the right to be free from any physical restraint not required to treat the resident's medical symptoms, and/or failed to use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for 2 of 24 stage 2 residents (Resident # 32 and Resident #45). Findings include: 1. On 3/22/2017 at 1:14 PM, Resident # 32 was observed laying in bed watching a Japanese television station. The resident had both bilateral 3/4 metal side rails up. The resident had a care plan for risk for falls which noted the resident has a visual deficit, cognitive impairment, impaired functional limitation and her last fall occurred on 11/18/16. One of the interventions included having the bilateral 3/4 side rails up. A 10/31/16, a Physical Device Evaluation form noted the use of the two 3/4 metal side rails was started 5/25/16, and that the resident had cognitive deficit/dementia and a history of falls. The functional capacity for use of the side rail was that it facilitated turning from side to side and prevented the resident from rolling out of bed (history of falls from rolling out of bed). Of note, the (MONTH) (YEAR) quarterly MDS assessment was not done and thus, Section P for Physical Restraint use had not been assessed since (MONTH) (YEAR). Cross-reference to findings at F276 and F323. Further, there was no documentation that a thorough assessment was done to rule out the potential risk for entrapment with the use of the long 3/4 length metal side rails for this cognitively impaired resident. On 3/23/2017 at 9:30 AM, Staff # 2 said the use of the resident's 3/4 metal side rails is for positioning and safety. The staff said the resident can hold onto rails especially when she watch TV. No, they cannot get out of bed, but one time they could. They gets restless too. Staff # 2 then said, I don't think we have, when queried whether there was a risk assessment done for potential entrapment with the use of these types of metal rails. On 3/23/2017 at 9:35 AM, Staff # 1 confirmed for Resident # 32, who is cognitively impaired, they did not do a risk assessment for the potential for entrapment. Staff # 1 said, Yeah, the space between the side rails are large. On 3/23/2017 at 12:14 PM, Staff # 3 said Resident # 32 could get out of bed with the side rails up, especially if the resident wants to go the bathroom. Record review also found for the resident's last fall on 11/8/16, the nursing entry stated the resident was found in sitting position on right foot part of the bed .The resident probably slid herself toward the foot part of the bed and got down on the area with no sidereal. Body assessment was done and no signs of injury . The last 11/2/16 IDT Care Conference Summary and the Resident Status Update noted for safety needs/interventions: 2 - 3/4 rails up for the resident. However, there was no risk assessment found regarding the potential for entrapment although the documented fall entry stated that, the resident probably slid toward the foot part of the bed and got down on the area with no siderail. 3) On 03/21/2017 at 10:21 AM observed that Resident # 45's bed had metal bilateral side rails with a body pillow lying against the left side rail. On 03/22/2017 at 2:12 PM, Resident # 45's medical record review (MRR) found that the resident had a care plan #2 At risk for Falls r/t [MEDICAL CONDITION]; Pain; Poor safety awareness caused by cognitive impairment; Taking [MEDICAL CONDITION] med's; Hx falls; dated 11/6/16. The interventions included, 2 (3/4) up rail for bed mobility & positioning. Also, the facility's, Resident Admission Physician order [REDACTED]. The Physical Device Evaluation form documented, Devices: 3/4 side rails L/R Date: 11/02/16. On 03/23/2017 at 9:31 AM interviewed Staff # 14, and when asked why Resident # 45's side rails were kept up, and she stated, To keep Resident # 45 from getting out of bed. According to Staff # 14 during the resident's previous admission, the resident would get out of bed and not use the call-light, so staff were instructed by Staff # 1 to keep the side rails up. Staff # 14 further commented that since Resident # 45 returned to the facility, the resident no longer exhibits those behaviors. On 03/23/2017 at 9:34 AM interviewed Staff # 1 regarding side rails for Resident # 45. According to Staff # 1, when the resident was readmitted to the facility in 11/2016, the resident no longer tried to get out of bed. When queried Staff # 1 if side rails are primarily used as a restraint, Staff #1 stated that Resident # 45 requested to have side rails up so that they didn't fall. Asked Staff # 1 for documentation on Resident # 45's request for side rails but Staff # 1 could not provide any and just smiled. Discussed with Staff # 1 that the staff did not want Resident # 45 to get out of bed without using the call-light, so side rails would be considered a restraint. The Staff # 1 did not comment. On 03/23/2017 at 10:57 AM interviewed Resident # 45 and when asked if they used the side rails, the resident stated that they didn't use them. Staff # 13 was present preparing the resident for lunch in bed and asked Staff # 13 why side rails were being used. Staff # 13 stated that Resident # 45 used to get out of bed, but no longer tries to get out of bed now. I think they're currently evaluating the side rails because the resident had been asking to lower the right side rail as the resident was unable to reach the urinal through the side rail metal bars. On 03/23/2017 at 1:12 PM observed that Resident # 45's right side rail was lowered. According to Staff # 13, they had lowered the right side rail because Resident # 45 got mad when they ' d spilled cup of water on themselves after reaching for it on the right side table. The resident used the call-light and complained to Staff # 13 when it happened. Staff # 13 lowered the right side rail and was making frequent checks on Resident # 45, and made Staff # 1 aware that Resident # 45 wanted their right side rail down. The right side rail was lowered but not all the way down. On 03/23/2017 at 1:37 PM, Staff # 1 informed surveyor that they were starting a side rail reduction plan today. Informed the staff member that side rails are being used as restraints and Staff # 1 stated that is why they will try the side rail reduction plan. The facility failed to thoroughly evaluate the potential for side rail entrapment for cognitively impaired residents, and failed to consider restraint reduction techniques as an alternative to the use of the metal side rails.",2020-09-01
387,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2017-03-24,272,D,0,1,CL5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure a comprehensive assessment was conducted for 2 (Residents #77 and #45) of 17 sampled residents of the 21 residents included in the Stage 2 review. Findings include: 1) Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review done on 3/23/17 at 8:30 AM found no documentation of a comprehensive admission Resident Assessment Instrument (RAI) within 14 calendar days of admission. An interview was done with Staff # 4 and # 5 on 3/23/17 at 9:00 AM. The staff members confirmed an admission RAI was not done. It was further reported the facility is behind on completing resident assessments. 2) On 03/22/2017 at 2:12 PM the medical record review for Resident # 45 revealed that the MDS 3.0 dated 11/15/2016 for significant change did not have bed restraint checked in Section P. Restraints. The physician orders [REDACTED]. The 11/06/16 care plan, #2 At risk for Falls r/t [MEDICAL CONDITION]; Pain; Poor safety awareness caused by cognitive impairment; Taking [MEDICAL CONDITION] med's ; Hx falls; .; interventions included 2 (3/4) up rail for bed mobility & positioning. The facility's Resident Admission Physician order [REDACTED]. The Physical Device Evaluation form documented, Devices: 3/4 side rails L/R Date: 11/02/16. On 03/23/2017 at 9:34 AM, interviewed Staff f# 1 regarding side rails for Resident # 45. According to Staff # 1, when the resident was readmitted to the facility in 11/2016, the resident no longer tried to get out of bed. When queried Staff # 1 if side rails are primarily used as a restraint, Staff # 1 that Resident # 45 requested to have side rails up so that they didn't fall. Asked Staff # 1 for documentation on Resident # 45's request for side rails but Staff # 1 could not provide any and just smiled. Discussed with Staff # 1 that the staff did not want Resident # 45 to get out of bed without using the call-light, so side rails would be considered a restraint. Staff f# 1 had no comment and smiled. On 03/23/2017 at 1:37 PM, Staff # 1 informed the surveyor that they were starting a side rail reduction plan on this date. Informed Staff # 1 that side rails were being used as restraints, and Staff # 1 stated that is why they will try the side rail reduction plan. The facility failed to do a comprehensive assessment for the intended use of the bed side rails as a restraint when Resident #45 was readmitted to the facility.",2020-09-01
388,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2017-03-24,273,D,0,1,CL5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure a comprehensive assessment was done within 14 calendar days after admission for 1 (Resident #77) of 17 sampled residents of the 21 residents in the Stage 2 review. Findings include: Cross Reference to F272. The record review found Resident #77 was admitted to the facility on [DATE] for hospice care. On the morning of 3/23/17, the record review found an admission comprehensive assessment was not done for this resident within 14 calendar days after admission. On 3/23/17 at 9:00 AM. An interview with staff members confirmed the admission assessment was not done.",2020-09-01
389,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2017-03-24,276,E,0,1,CL5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure quarterly assessments , not less frequently than once every three months were completed for 9 (Residents #3, #8, #26, #30, #32, #44, #45, #48 and #50) of 17 sampled residents of the 21 residents in Stage 2. Findings include: 1) Resident #3 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) was completed on 10/21/16 (assessment reference date). Record review on the afternoon of 3/23/17 found no documentation of a subsequent quarterly assessment. On 3/23/17 at 3:25 P.M. an interview was conducted with Staff Members # 4 and # 5. The staff members confirmed the quarterly review was due on 1/29/17; however, it was not done. 2) During a review of Resident # 32's clinical record, it was found the resident's quarterly MDS assessment for (MONTH) (YEAR) had not been completed. Staff # 1 confirmed this on 3/23/17 and said, it should have been done, but there is none. During an interview with a facility consultant and Staff # 6 on 3/23/17 at 10:15 AM, they verified at least 16 assessments have been done, but were also doing catch up with unfinished MDS assessments, such as Resident # 32's. The facility consultant stated she was recently hired the first week in (MONTH) (YEAR) to assist the facility in meeting this requirement to have their MDS assessments completed and submitted. 3) On 03/24/2017 at 7:44 AM, the medical record review on Residnet # 8 found that MDS 3.0 quarterly review was last done on 10/06/2016. The resident had a significant change on 07/08/2016 due to graduation from hospice according to Staff # 6. On 03/24/2017 at 8:17 AM, the medical record review for Resident # 48 found that the MDS 3.0 annual assessment was done on 10/22/2016 and no quarterly review thereafter. On 03/24/2017 7:49 AM, the medical record review for Resident # 45 found that the last MDS 3.0 data entry was on 11/15/2016 for significant change in status assessment after re-entry from acute hospital on [DATE]. According to Staff # 6, she was advised to do a significant change instead of readmission to the facility because Resident # 45 was due for an annual assessment in 9/2016 when he was discharged to the acute hospital. The MDS Coordinator from another facility provided instructions to Staff # 6. No MDS 3.0 quarterly review was done since. The medical record review for Resdient # 50 also found that the last MDS 3.0 quarterly review was done on 10/05/2016 with the last readmitted on 01/08/2016. The medical record review for Residnet # 26 found that the last MDS 3.0 quarterly review was done on 10/26/2016, and the resident's last readmitted was on 09/28/16. The facility failed to update resident assessments on a quarterly basis. 4) 2) During a review of Resident # 30 and Resident # 44's clinical records, it was found the resident's quarterly MDS assessment had d not been completed. During an interview with a facility consultant and Staff # 6 on 3/23/17 at 10:15 AM, they verified at least 16 assessments have been done, but were also doing catch up with unfinished MDS assessments, such as Resident # 30 and Resident #44s. The facility consultant stated they were recently hired the first week in (MONTH) (YEAR) to assist the facility in meeting this requirement to have their MDS assessments completed and submitted.",2020-09-01
390,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2017-03-24,279,E,0,1,CL5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs was developed for 6 of 24 residents (Res #48, 26, 45, 44, 36 and 38) in the Stage 2 sample. Findings include: 1) Resident # 36 triggered for a review of unnecessary medications in Stage 2. Resident has been routinely taking [MEDICATION NAME] 75 mg 1 tab by mouth daily for a [DIAGNOSES REDACTED]. However, a review of the resident's care plan for the use of this medication was not found. On 3/23/2017 at 9:09 AM, Staff # 1 stated they did not include the resident's use of [MEDICATION NAME] in a care plan. Staff # 1 said, I missed this one. Staff # 1 acknowledged there should be one since residents taking aspirin have a care plan for the risk of potential for bleeding. Staff # 1 said they were going to develop Resident #36's care plan for [MEDICATION NAME] right then. 2) Resident # 38 also triggered for a review of unnecessary medications in Stage 2. On 3/14/17, Resident # 38 was prescribed the diuretic medication [MEDICATION NAME] 20 mg to be taken by mouth daily for 7 days and Potassium Chloride 10 milliequivalents by mouth daily for 7 days due to [MEDICAL CONDITION]. During an interview with Staff # 1 on 3/23/2017 at 9:25 AM, they confirmed the resident did start the medications on 3/14/17 and finished the [MEDICATION NAME] on 3/21/17. Staff # 1 confirmed they had failed to develop a care plan for the use of the [MEDICATION NAME] as well. 3) On 03/22/2017 at 2:12 PM, Resident # 45's medical record review included a 11/06/16 care plan #2 At Risk for Falls r/t [MEDICAL CONDITION]; Pain; Poor safety awareness caused by cognitive impairment; taking [MEDICAL CONDITION] drugs; hx falls; .; with interventions that included 2 (3/4) up rail for bed mobility & positioning . The facility's Resident Admission Physician order [REDACTED]. SIDE RAIL (Full, half rail, one side) 2 (3/4) up side rail for mobility & transfer. The Physical Device Evaluation Devices form documented, 3/4 side rails L/R Date: 11/02/16. On 03/23/2017 at 9:31 AM interviewed Staff # 14 and queried them why the 3/4 side rails are kept up. Staff # 14 stated, To keep the resident from getting out of bed, because on the previous admission, the resident used to just get out of bed and not use the call-light, as instructed by Staff # 1 to keep side rails up. Staff # 14 further stated that since Resident # 45 returned to the facility, the resident no longer had those behaviors. On 03/23/2017 at 9:34 AM interviewed Staff # 1 regarding side rails for Resident # 45. According to Staff # 1, when the resident was readmitted to the facility in 11/2016, they no longer tried to get out of bed. When queried Staff # 1 if side rails are primarily used as a restraint, they responded, stating Resident # 45 requested to have side rails up so that the resident didn't fall. Asked Staff # 1 for documentation on Resident # 45's request for side rails but Staff # 1 could not provide any. Discussed with Staff # 1 that if side rails are used so Resident # 45 cannot get out of bed without using the call-light, side rails are considered a restraint. The Staff # 1 had no comment and smiled. On 03/23/2017 at 10:57 AM interviewed Resident # 45 and when asked if they used the side rails, the resident stated that they didn't use them. Staff # 13 was present preparing the resident for lunch in bed and asked Staff # 13 why side rails were being used. Staff # 13 stated that Resident # 45 used to get out of bed but no longer tries to get out of bed. I think they're currently evaluating the side rails because the resident had been asking to lower the right side rail as the resident was unable to reach the urinal through the side rail metal bars. On 03/23/2017 at 1:12 PM the surveyor observed that Resident # 45's right side rail was lowered. According to Staff # 13, they lowered the right side rail because Resident # 45 got mad when the resident spilled a cup of water on themselves after reaching for it on the right side table. The resident used the call-light and complained to Staff # 13 when it happened. Staff # 13 lowered the right side rail and was making frequent checks on Resident # 45, and made Staff # 1 aware that Resident # 45 wanted their right side rail down. The right side rail was lowered but not all the way down. On 03/23/2017 at 1:37 PM, Staff # 1 informed the surveyor that they were starting a side rail reduction plan on this date. Informed Staff # 1 that side rails are actually used as bed restraint and Staff # 1 stated that is why they will try the side rail reduction plan. The facility did not develop and implement a comprehensive care plan for use of side rails as a bed restraint. 4) On 03/23/2017 at 1:44 PM the medical record review for Resident # 26 was done for the use of potentially unnecessary medications. The physician order [REDACTED].#26 included: [MEDICATION NAME] 20 mg tab ([MEDICATION NAME]); 3/7/2017 Increase [MEDICATION NAME] 20 mg PO QD; and, 3/21/2017 Increase [MEDICATION NAME] to 25 mg PO BID per psych recommendation. A Psychiatry Consult dated 3/20/17, documented that Resident # 26 had depressive symptoms, chronic pain issues and now with behavior problems in the context of dementia .[MEDICATION NAME] started for behavioral control, now increased to 20 mg. The plan/recommendations was to: 1) Continue with [MEDICATION NAME] 20 mg PO Q daily. 2) Increase [MEDICATION NAME] to 25 mg PO BID. Target up to 100 mg. Some evidence that [MEDICATION NAME] may be more effective but for now should continue with [MEDICATION NAME] trial. The care plan # 1 dated 8/23/16, Episodes of Confusion & Agitation, with Goals: Staff will redirect or reorient resident during episodes of confusion or restlessness 8/16-11/16. Approaches were, Staff will reorient, redirect resident during episodes of confusion; staff will speak to resident in a calm tone during episodes of agitation; Out of bed in a wheelchair for small & large group activities; assist & tell resident activities featuring music, wheelchair exercise; assist in outings to the mall; encourage family visits. On 03/23/2017 at 2:23 PM queried Staff # 2 if there was a care plan for use of [MEDICAL CONDITION]'s. Staff # 2 called Staff # 6 downstairs who replied that they were working on Resident # 26's care plan # 1 because [MEDICATION NAME] and other [MEDICAL CONDITION] was just increased. On 03/23/2017 at 2:31 PM interviewed Staff # 1 regarding care plan for Resident #26's use of [MEDICAL CONDITION]'s and behaviors. Staff # 1 stated I will do it,because they thought they had done it. The facility did not develop and implement a comprehensive care plan that integrated the use of [MEDICAL CONDITION]'s with alternative interventions to address Resident #26's problems of agitation and confusion. 5) Cross Referenced with F514. On 03/22/2017, Resident # 44 was observed to have gauze dressing with tape over it on the right side of her neck. During the medical record review of Resident # 44, no documentation could be found in record to state why the resident had gauze dressing on the side of their neck. There was no care plan as to how to care for what was under the gauze dressing. Interview with Staff #1 on (MONTH) 23 rd (YEAR), confirmed there was no documentation or care plan in place for care of the wound under the gauze dressing on Resident # 44. Staff # 1 was able to state that it was an access site used by QMC ER department to place a temporary pacemaker, and that the dressing remained intake as the resident's skin was fragile and they did not want to tear Resident #44's skin by removing tape. Staff #1 looked through the medical record of Resident #44 and was unable to find any documentation or care plan for the care of this issue for Resident # 44. The facility failed to develop Resident # 44's care plan with aftercare following an acute episode that required Resident # 44 to be sent to QMC ER department.",2020-09-01
391,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2017-03-24,280,D,0,1,CL5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to revise care plans for 3 (Residents #47, #3 and R#48) of 17 sampled residents of the 21 residents included in the Stage 2 review. Findings include: 1) Resident #47 was admitted to the facility on [DATE] with diagnoses of acute hypoxic [MEDICAL CONDITION], generalized weakness, pneumonia, metastic [MEDICAL CONDITIONS] and urinary tract infection. Record review done on 3/23/17 at 10:00 AM found the Body Audit Form which documents on 1/14/17 Resident # 47 was found to have an open area to the right buttock. An interview and review of the audit form was done with Staff Member # 7. The staff member reported they were the staff member that documented the open area. The staff member further reported when there is a concern, the staff member will bring it to the attention of the licensed nurse. Further review found a physician's orders [REDACTED]. Apply skin sealant to skin. Apply [MEDICATION NAME] to wound TID till healed. The [DIAGNOSES REDACTED]. The care plan was not revised to include the treatment and further prevention of the excoriation to the right buttock. The progress note dated 1/14/17 at 2.40 PM documents the excoriation to the right buttock, 0.3 x 0.4 cm, the physician was notified and an order was made. An interview was conducted with Staff Member # 1 on 3/27/17 at 12:38 PM. The staff member confirmed a care plan was not developed to address Resident # 47's excoriation. The staff member reported the treatment for [REDACTED]. Resident # 47's care plan was not revised to address treatment and further prevention of skin breakdown related to the excoriation to the right buttock. 2) Resident # 3 was admitted to the facility on [DATE] with diagnoses [MEDICAL CONDITION] secondary to left foot gangrene; diabetes mellitus, type II; [MEDICAL CONDITION]; CAD with prior CABG in 2012; left foot wound open; and diabetic [MEDICAL CONDITION]. Record review on 3/21/17 at 12:15 PM found a physician's orders [REDACTED]., take one tab by mouth at bedtime with a [DIAGNOSES REDACTED]. On the afternoon of 3/23/17 an interview and concurrent record review was done with Staff Member # 1. The staff member confirmed the facility did not develop a care plan for the use of [MEDICATION NAME] as an appetite stimulant. The staff member acknowledged a care plan is indicated for the use of [MEDICATION NAME] and stated a care plan will be developed. Resident # 3's care plan was not revised to include the use of [MEDICATION NAME] as an appetite stimulant. 3) On 03/22/2017 at 1:03:13 PM, medical record review for Resident # 48 documented in the social services notes dated 01/10/2017. that the resident's daughter was upset that Resident # 48 had told them that they had been burnt by hot water when showered by staff on 01/05/2017 (Thurs) when the daughter visited the resident on Sunday. The daughter felt that nursing failed to inform the daughter of the resident burnt, and that nothing had been done for several days. Apparently, therapy staff reported blisters to nursing on 01/06/17 (Fri) and the daughter was upset that this had not reported to her. The physician progress notes [REDACTED].# 48 documented, New chest rash, and the review of systems noted, small water blisters.The physician assessment and plan included, [MEDICAL CONDITION]. Ordered steroids . On 01/10/2017 (Monday), Staff # 11 assessed Resident # 48's blisters and noted that the blisters were spreading over the resident's left shoulder. The blisters appeared similar to shingles, although no [DIAGNOSES REDACTED].# 11 stated that the resident may have thought that they were burnt when showering, as when the water touched the blister it must of stung. The physician was alerted and the physician progress notes [REDACTED]. The review of systems included, Central chest with more vesicles. The assessment and plan noted, shingles. Ordered [MEDICATION NAME]. [MEDICAL CONDITION]. [MEDICATION NAME] . The physician progress notes [REDACTED]. On 03/22/2017 at 1:35 PM interviewed Staff # 1 and they stated that Resident # 48 never complains of pain. Queried Staff # 1 about partially lifted scab on resident's chest that could potentially be pulled off by bed sheet or clothing. According to Staff # 1 the scab area is where shingles started and went up towards the resident's neck area. There were no special treatment provided to the scab area as the shingles have resolved and only that area with dry scab left. The resident's care plan #3 At risk for alteration in skin breakdown .risk for friction and shear w/contributory [DIAGNOSES REDACTED]. The care plan interventions included. Provide good skin care, inspect daily during care, CNA to report if any concerns, showers every other day, use lotion to moisturize skin. On 03/22/2017 at 2:09 PM Staff # 1 approached surveyor and stated that they went to cover Resident # 48's scab with a band-aid so that it doesn't get caught in residents clothing or bed sheets. The resident's care plan #3 At Risk for Alteration in Skin Breakdown, was not revised to include nursing care for shingles and the resident and/or representative was not kept informed of the results.",2020-09-01
392,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2017-03-24,309,D,0,1,CL5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview with staff members and a review of the facility's policy and procedures, the facility failed to ensure based on a comprehensive assessment of a resident, the facility ensures that residents receive treatment and care in accordance with professional standards of practice for 1 (Resident # 77) of 1 residents selected for hospice review. Findings include: Cross Reference to F272 and F273. The facility failed to complete a comprehensive assessment within 14 calendar days of admission to develop a plan a care based on Resident # 77's choices, needs and treatment. Record review done on [DATE] at 8:30 AM documents Resident # 77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. pylori [MEDICAL CONDITION]; gastritis with GI bleed; and anorexia. A review of the physician's orders [REDACTED].) PO/SL every hour as needed for moderate pain or shortness of breath if [MEDICATION NAME] ineffective; [MEDICATION NAME] sulfate 100 mg/5 ml solution, take 1 ml (20 mg) PO/SL every hours as needed for severe pain or shortness of breath if [MEDICATION NAME] ineffective; and [MEDICATION NAME] 5 mg. table, take one tab by mouth every six hours as needed for moderate to severe pain. Further review found a comprehensive assessment was not done for this resident and there was no documentation of a coordinated plan of care between the facility, hospice entity and the resident/family. On the morning of [DATE], Resident # 77 was observed lying in bed asleep and breathing appeared labored. The resident's roommate was heard yelling, repeatedly saying help me .help me. There was no response by a staff member until a staff member was alerted by the surveyor. Subsequently an interview was done with Staff Member # 8. The staff member reported at this time they were trying to make the resident comfortable through repositioning and providing oxygen. The staff member reported the resident is now flaccid and does not talk or respond. Inquired whether the staff member provided Resident # 77 with any PRN medication ([MEDICATION NAME]), the staff member reported that [MEDICATION NAME] was not provided as there is concern regarding aspiration and the resident has difficulty swallowing. Queried Staff Member # 8 regarding the services the hospice is entity is providing for Resident # 77. The staff member replied that she/he has not seen any hospice staff come to visit the resident as she/he works on the night shift. The staff member was not aware of what services the hospice entity provides. A review of the hospice entity record was done. The hospice entity has a separate binder upstairs with the residents' information. The review found documentation by the hospice aide, dated [DATE]. The aide noted the following, patient is transitioning; slow breathing; no movement at all. A subsequent clinical note by the hospice nurse notes Resident # 77 lying in bed actively dying. The hospice nurse recommended providing the resident with Tylenol suppository. There was no documentation of the time the hospice staff came to visit Resident # 77. On [DATE] at 9:30 AM an interview was conducted with Staff Member # 9. The staff member confirmed the facility did not collaborate with the hospice entity to develop a plan of care to address the resident's needs for comfort/end of life care. On [DATE] at approximately 11:45 AM, an interview was done with Staff Member # 10. The staff member reported Staff Member # 8 provided [MEDICATION NAME] at 11:25 AM. Staff Member # 10 reported the hospice nurse called to find out how Resident # 77 was doing. Inquired whether she would have called the hospice nurse or provided the resident with [MEDICATION NAME]. The staff member replied Staff Member # 8 could not get a blood pressure and the resident was gasping for air; therefore, a PRN of [MEDICATION NAME] was indicated. The staff member reported the [MEDICATION NAME] is given sublingually, so it would be placed under the tongue and dissolve so there is no concern regarding aspiration. On the morning of [DATE] a review of the resident's record found an entry dated [DATE] at 10 PM notes Resident # 77 was experiencing shortness of breath at 5:45 PM, 0.25 mg of [MEDICATION NAME] was given sublingually. Also noted the resident's pulse was weak and unable to get vital signs. The staff member contacted the hospice nurse and was advised to provide another dosage of [MEDICATION NAME]. There is no progress note for [DATE]. A review of the Medication Administration Record [REDACTED]. An entry for [DATE] at 6:04 AM by Staff Member # 8 notes the resident is not following commands or verbalizing anything. Also notes the staff member was unable to get oxygen saturation, respirations are at 8, heart rate at 128, unable to get blood pressure and hands are cold. Subsequent progress note for [DATE] at 11:37 AM by Staff Member # 8 notates an attempt was made to give the resident PRN of [MEDICATION NAME] but the resident was unable to swallow and the pill came out through the side of the mouth. The staff member also notes that there is no information on this chart regarding (hospice entity's name). Observation throughout the survey found Resident # 77 is located on the first floor; however, the resident's medical record is located on the second floor. Also, the resident's medical record related to the hospice services/documents are kept in a separate binder on the second floor. On the morning of [DATE], Staff Member # 8 was asked about transferring Resident # 77 to a private room during her transition as the resident in room [ROOM NUMBER] was discharged on [DATE] and the room was vacant during this time. The staff member responded that they would be able to transfer the resident if the family requests for a private room. An interview with Staff Member # 1 was done on the morning of [DATE]. The staff member confirmed there was no identification on the resident's medical chart to identify the hospice entity and telephone number. The observations made on the morning of [DATE] and the interview with Staff Member # 8 were shared with Staff Member # 1 who commented the Staff Member # 8 should have come to her for help and let her know what was happening with Resident # 77. A review of the facility's policy and procedures provided by Staff Member # 11 on [DATE] at 12:49 PM was done. The policy entitled Hospice Program includes the following: 3. When a resident chooses to participate in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status .and 6. The facility will be responsible to assure that the MDS is complete and submitted to the State in accordance with Nursing Home requirement . The facility failed to assess and develop a plan of care for Resident # 77 to address comfort care/end of life care. The facility failed to collaborate with the hospice entity to identify which provider is responsible for various aspects of the resident's care and to identify resident-directed care, treatment, interventions and support consistent with the resident's choice. The facility failed to notify the hospice entity of the significant change (decline) in the resident's physical status (unable to obtain vital signs, flaccid, unresponsive) because the staff member was unable to locate a phone number for the hospice entity. Resident # 77 expired on the morning of [DATE].",2020-09-01
393,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2017-03-24,323,D,0,1,CL5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure the resident environment remains as free from accidents hazards as is possible and if bed rails are used, must also assess the resident for risk of entrapment from the rails prior to installation and use for 2 of 24 residents (Resident # 32 and Resident # 45) in the Stage 2 sample. Findings include: 1. Cross-reference to findings at F221. For Resident # 32, there was no initial nor on-going assessment for the risk of entrapment of the long 3/4 metal side rails used bilaterally while the resident was in bed. Even after the resident's fall in (MONTH) (YEAR), this assessment was not done although the nursing entry stated, She probably slid herself toward the foot part of the bed and got down on the area with no siderail. This was verified by an interview on 3/23/2017 at 9:35 AM with Staff # 1. She confirmed for Resident # 32, who is cognitively impaired, they did not do a risk assessment for the potential of entrapment related to the use of her bilateral 3/4 side rails. 2) Cross reference to findings at F221. On 03/21/2017 at 10:21 AM observed that Resident # 45's bed had full metal bilateral side rails with a body pillow lying against the left left side rail. The facility's Resident Admission Physician order [REDACTED]. SIDE RAIL (Full, half rail, one side) 2 (3/4) up siderail for mobility & transfer.The Physical Device Evaluation form documented, Devices: 3/4 side rails L/R Date: 11/02/16. On 03/23/2017 at 10:57 AM surveyor interviewed Resident # 45 and when asked if they used the side rails, the resident stated that they didn't. Staff # 13 was present preparing the resident for lunch in bed and asked the resident her why the side rails were being used. Staff # 13 stated that Resident # 45 used to get out of bed but no longer tries to get out of bed now. I think they're currently evaluating the side rails because the resident had been asking to lower the right side rail as the resident was unable to reach the urinal through the side rail metal bars. The facility did not evaluate the safety for use of the bilateral metal side rails that were used to prevent Resident # 45 from exiting the bed without using the call-light. The side rails were made of 3 parallel metal bars placed bilateral 3/4 length of the bed with a high- risk for limb, head and neck entrapment.",2020-09-01
394,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2017-03-24,329,D,0,1,CL5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 1 (Resident # 3) of 5 sampled residents reviewed for medication received an antidepressant with adequate monitoring. Findings include: Cross Reference to F276. The facility failed to ensure a quarterly assessment was done for this resident. The admission assessment was done on 10/21/16. The physician ordered the use of [MEDICATION NAME] as an appetite stimulant on 11/11/16, the current order reflects the continued use of [MEDICATION NAME]. A quarterly assessment was not done in 1/29/17 which would document the use of an antidepressant. Cross Reference to F280. The facility failed to revise Resident # 3's care plan to include the use of [MEDICATION NAME] which was started on 11/11/16. Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 3/21/17 at 12:15 P.M. found a physician's orders [REDACTED]., take one tab by mouth at bedtime with a [DIAGNOSES REDACTED]. Further record review was done on 3/22/17 and 3/23/17 which found an admission Minimum Data Set (MDS) with assessment reference date of 10/21/16 which notes Resident # 3 scored a 4 (severe impairment) upon administration of the Brief Intellectual Mental Status interview. In Section D. Mood, the resident was noted to exhibit the following: little interest or pleasure in doing things; feeling or appearing down, depressed or hopeless; trouble falling or staying asleep or sleeping too much; feeling tired or having little energy; poor appetite or overeating; and trouble concentrating on things such as reading the newspaper or watching television. A review of the nutrition assessments found documentation dated 12/7/16 that Resident #3 had an unplanned weight loss of 5.7 pounds over three weeks. Of note was the resident's poor intake and use of antibiotics for wound infection. The Dietitian notes the onset of [MEDICATION NAME] 11/11/16 for anorexia. The resident was also noted to not drink the supplement (glucerna) as prescribed. Subsequent assessment of 1/25/17 notes an improvement in eating with a liberalized diet and the resident's weight was up 6.2 pounds since the last review and now within the ideal body weight. A review of the progress notes dated 3/2/17 at 4:00 AM notes while the aide was making rounds a clang was heard in the resident's room and the resident was found in supine position alongside the bed. There was no fall related injury. On 3/23/17 at 2:40 PM an interview was conducted with Staff Member # 10. The staff member was queried regarding the use of [MEDICATION NAME]. The staff member reported the [MEDICATION NAME] is being used for an appetite stimulant as the resident doesn't eat and is sleepy, sometime. Inquired what are the side effects for the use of [MEDICATION NAME], the staff member replied there is usually a behavior monitoring sheet that lists the side effects of the medication; however, as the medication is not being used as an antidepressant a sheet was not developed. The staff member reported Resident # 3 also receives supplements for weight. The staff member acknowledged they were not familiar with the side effects related to the use of [MEDICATION NAME]. On the afternoon of 3/23/17 an interview and concurrent record review was done with Staff Member # 1. The staff member confirmed the facility did not develop a care plan for the use of [MEDICATION NAME] as an appetite stimulant. The staff member acknowledged a care plan is indicated for the use of [MEDICATION NAME] and stated a care plan will be developed. The facility failed to ensure adequate monitoring for side effects related to the use of [MEDICATION NAME] was being done for Resident #3 who had a fall on 3/2/17 and was also noted to be sleepy at times.",2020-09-01
395,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2017-03-24,514,D,0,1,CL5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain complete and accurate clinical documentation for 2 of 24 residents (Resident # 44 and Resident #36) in the Stage 2 sample. Findings include: 2) On 3/22/2017 at 12:45 PM, Staff # 12 stated she was going to change Resident # 36's briefs. Observation noted the resident had a dressing on the resident's mid-coccyx area, which Staff # 3 said the nurse was going to change later. The staff said it was only on for protection and the resident no longer had an open area to there resident's buttocks. On 3/23/2017 at 8:45 AM, Staff # 2 said she just changed the foam dressing yesterday. She said, it's for protection only and would be changing it later. At 8:48 AM, during a concurrent record review with Staff # 1, they reviewed the physician orders [REDACTED].#36's coccyx region. A review of the Body Audit form for 3/1/17 showed old scab and another note dated 3/4/17 stated reddened. Yet, on 3/23/17 of the audit form, the comment by a licensed staff said, None for the 11-7 shift. However, at 8:57 AM, surveyor and Staff # 1 saw the resident's dressing was still intact and staff said it was a bordered foam dressing. The dressing had 3/22 protection only handwritten on it. Staff # 1 was asked if the night shift nurse assessed and saw this because the documentation was None on the body audit form for that shift. When Staff # 1 was further queried, Staff # 1 nodded and agreed that it appeared the night shift nurse did not assess the resident and thus, the clinical documentation was inaccurate. There also was no order for the protection only dressing the staff used for the resident's coccyx area, which Staff # 1 confirmed was not obtained. 2) Cross Referenced with F279. On 03/22/17, Resident # 44 was observed to have gauze dressing with tape over it on the right side of her neck. During the medical record review of Resident # 44, no documentation could be found in record to state why resident had gauze dressing on the side of her neck. There was no care plan as to how to care for what was under the gauze dressing. Interview with Staff # 1 on 03/23/17, confirmed there was no documentation or care plan in place for care of the wound under the gauze dressing on Resident # 44. Staff # 1 was able to state that it was an access site used by QMC ER department to place a temporary pacemaker, and that the dressing remained intake as the resident's skin was fragile and they did not want to tear Resident # 44's skin by removing tape. Staff # 1 looked through the medical record of Resident # 44 and was unable to find any documentation or care plan for the care of this issue for Resident # 44. The facility failed to maintain a complete and accurate clinical record for Resident # 44 following an acute episode that required Resident # 44 to be sent to QMC ER department.",2020-09-01
396,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,550,D,0,1,GY1211,"Based on observations and interviews, the facility failed to promote dignity for two of 24 residents (R48, R222) included in the initial pool. Findings Include: 1) On 08/26/19 at 11:16 AM observed R48 being fed lunch outside of her room in the hallway. Initially, RN12 placed a spoonful of pureed food with rice into R48's mouth, but the resident did not continue to open her mouth. The RN12 then used a syringe to feed R48 and coaxed R48 to open her mouth. Using the tip of the syringe, RN12 attempted to insert food into R48's mouth on the left side. There were three other residents having lunch in the hallway, with a family member for one of those residents eating. Feeding R48 a pureed diet with a syringe in the hallway did not promote dignity while dining. 2) On 08/26/19 at 08:29 AM upon entering R222's room, observed R222 sitting on a bedside commode with R222's personal brief around the knees. The bedside commode was located between R222 and R3's bed. The privacy curtain separating the beds was open. Furthermore, R3 was in the room while R222 was utilizing the bedside commode. In addition, the window curtain and louvers were open, and the adjacent building was visible through the window. On 08/30/19 at 08:34 AM, a second observation found that R222 was within view of visitors to the adjacent building from the room window. A record review of the Minimum Data Set with Assessment Reference Date of 08/15/19 documented that R222 requires extensive assistance with one person physical assist for toilet use. Additionally, R222 is not steady and requires staff assistance while moving on and off the toilet.",2020-09-01
397,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,585,D,0,1,GY1211,"Based on a confidential resident interview and record review, the facility failed to ensure residents have the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Findings include: During an confidential interview with a confidential resident on 08/27/19 at 08:11 AM, the resident was informed that surveyors would follow up on some concerns relayed in the interview. The resident responded not wanting to do anything about the concerns, stating I'm gonna get it. Resident was asked what do you mean by that, resident replied I'm not gonna get the help I need and commented The walls have ears. The resident was alert and oriented. The Minimum Data Set notes resident is cognitively intact.",2020-09-01
398,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,604,D,0,1,GY1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, staff interview, the facility failed to provide one (Resident (R) 55) out of three residents reviewed, the right to be free from physical restraint; where R55's wheelchair was restrained to a wall railing, for the purpose of convenience, and not for the treatment of [REDACTED]. Findings Include: During resident interview with another resident (R) 35 on 08/29/19 at 01:55 PM, R35 stated a couple weeks ago, witnessed R55 sitting in a wheelchair which was tied to a railing in the hallway near the nursing station. R35 stated that it prevented R55 from being able to role their wheelchair around. R35 stated the concern was brought up to the Social Worker (SW) 1 several days later. During staff interview with SW1 on 08/29/19 at 02:50 PM, SW1 was able to recall the following witnessed events discussed from R35: On 08/15/19, R55's wheelchair was tied to a railing. On 08/19/19, the concern was brought up to SW1. SW1 then reported the incident (in stand-up meeting) to facility administration. During an interview with the Administrator (Admin) on 08/29/19 at 03:30 PM, Admin was able to recall the incident and stated that the facility had done and completed their investigation on 08/21/19. Record review revealed R55 was admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of the most recent quarterly assessment with an Assessment Reference Date (ARD) of 07/19/19 showed a Brief Interview for Mental Status (BIMS) score of 01 which indicated severe cognitive impairment. A review of R55's progress notes showed the following: 08/05/19 Propels self along the hallway, transferred self back to bed, 08/02/19 pleasantly confused, combative, non-compliant, 08/01/19 can't stay sitting on her w/c for long period of time. Review of the care plan for R55 revealed the following: Problem, Falls, at risk for falls d/t medical condition with [DIAGNOSES REDACTED]. Resident is not aware of . safety and does not call for assistant. Approach, make sure everything . is within reach at all times, frequent visual check, offer toileting q2hrs or as needed and when see res. heading to . bedroom, follow resident and ask . needs. A review of the event report/investigation revealed R55 had no physical injury, no signs of mental abuse, and no change in demeanor or behavior. R55 was taken to the toilet, but continued to wheel self around. R55's wheelchair was tied to the railing, for about five minutes, to allow finishing breakfast, then was released to watch TV.",2020-09-01
399,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,609,D,0,1,GY1211,"Based on record review, staff interview, and review of policy, the facility failed to report an allegation of abuse and/or the results of the abuse investigation to other officials (including the State Survey Agency) in accordance with State law through established procedures. Findings Include: Cross Reference F604, F610 During resident interview with another resident (R) 35 on 08/29/19 at 01:55 PM, R35 stated a couple weeks ago, witnessed R55 sitting in a wheelchair which was tied to a railing in the hallway near the nursing station. R35 stated that it prevented R55 from being able to role their wheelchair around. R35 stated the concern was brought up to the Social Worker (SW) 1 several days later. During staff interview with SW1 on 08/29/19 at 02:50 PM, SW1 was able to recall the following witnessed events discussed from R35: On 08/15/19, R55's wheelchair was tied to a railing. On 08/19/19, the concern was brought up to SW1. SW1 then reported the incident (in stand-up meeting) to facility administration. A review of the investigation report revealed the following: the possibility of abuse incident was identified, there was no reports of injury and/or changes to R55's demeanor, behavior, and cognition was discussed. During an interview with the Administrator (Admin) on 08/29/19 at 03:30 PM, Admin was able to recall the incident and stated that the facility had done and completed an investigation on 08/21/19. Admin acknowledged that the possibility of an abuse incident was identified. Admin also acknowledged that the facility had an in-depth discussion on the determination of actual or potential for harm. Thus, the facility determined that there was no actual harm, so an event report was not submitted to other officials (including the State Survey Agency). During a second interview with the Admin on 08/30/19 at 12:30 PM, Admin acknowledged that a potential for harm existed; thus, an allegation of abuse and/or results of an abuse investigation should have been reported to other officials (including the State Survey Agency). A review of facility policy titled Resident's Rights, Freedom from Abuse, Neglect, and Exploitation stated the following: Policy; Nuuanu Hale shall assure that all residents are fully aware of and able to exercise their rights during their stay at this facility and are treated by staff members, family members, friends, visitors and other residents in accordance with the rights to which they are entitled under applicable Federal and State regulations. Procedure for Investigation of allegations of abuse, neglect, exploitation or mistreatment; An investigation is immediately conducted when there are allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property and shall be immediately reported. 1. Allegations that involve abuse or result in serious bodily injury shall be reported immediately, but not later than 2 hours after the allegation is made. 2. Allegations that do not involve abuse and do not result in serious bodily injury shall be reported no later than 24 hours. 3. The Administrator or designee shall be notified immediately, who will immediately initiate the reporting to the Office of Health Care Assurance, Adult Protective Services and/or the Department of Human Services via the required reporting forms for each respective agency and as per above time frames. 4. An initial report will be initiated with a final report submitted within 5 days. If the investigation is not able to be completed, an interim report shall be submitted providing the agencies with a revised time frame for submittal of final investigative report.",2020-09-01
400,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,610,D,0,1,GY1211,"Based on record review, staff interview, and review of policy, the facility failed to thoroughly investigate an allegation of abuse and/or report the results of the abuse investigation to other officials in accordance with State law, including the State Survey Agency, within 5 working days of the incident. Findings Include: Cross Reference F604, F609 During resident interview with another resident (R) 35 on 08/29/19 at 01:55 PM, R35 stated a couple weeks ago, witnessed R55 sitting in a wheelchair which was tied to a railing in the hallway near the nursing station. R35 stated that it prevented R55 from being able to role their wheelchair around. R35 stated the concern was brought up to the Social Worker (SW) 1 several days later. During staff interview with SW1 on 08/29/19 at 02:50 PM, SW1 was able to recall the following witnessed events discussed from R35: On 08/15/19, R55's wheelchair was tied to a railing. On 08/19/19, the concern was brought up to SW1. SW1 then reported the incident (in stand-up meeting) to facility administration. A review of the investigation report revealed the following: the possibility of abuse incident was identified, there was no reports of injury and/or changes to R55's demeanor, behavior, and cognition was discussed. During an interview with the Administrator (Admin) on 08/29/19 at 03:30 PM, Admin was able to recall the incident and stated that the facility had discussed the issue, but determined that there was no actual harm, and thus, no further investigation was done. During a second interview with the Admin on 08/30/19 at 12:30 PM, Admin acknowledged that a potential for harm existed; thus, a thorough abuse investigation should have been initiated and reported to other officials (including the State Survey Agency). A review of facility policy titled Resident's Rights, Freedom from Abuse, Neglect, and Exploitation stated the following: Policy; Nuuanu Hale shall assure that all residents are fully aware of and able to exercise their rights during their stay at this facility and are treated by staff members, family members, friends, visitors and other residents in accordance with the rights to which they are entitled under applicable Federal and State regulations. Procedure for Investigation of allegations of abuse, neglect, exploitation or mistreatment; An investigation is immediately conducted when there are allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property and shall be immediately reported. 1. Allegations that involve abuse or result in serious bodily injury shall be reported immediately, but not later than 2 hours after the allegation is made. 2. Allegations that do not involve abuse and do not result in serious bodily injury shall be reported no later than 24 hours. 3. The Administrator or designee shall be notified immediately, who will immediately initiate the reporting to the Office of Health Care Assurance, Adult Protective Services and/or the Department of Human Services via the required reporting forms for each respective agency and as per above time frames. 4. An initial report will be initiated with a final report submitted within 5 days. If the investigation is not able to be completed, an interim report shall be submitted providing the agencies with a revised time frame for submittal of final investigative report.",2020-09-01
401,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,640,D,0,1,GY1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to transmit a discharge assessment within 14 days after completion. Findings include: A record review on the afternoon of 08/28/19 found Resident (R)1 was admitted to the facility on [DATE] and discharged home on[DATE]. A review of the Minimum Data Set (MDS) found the facility's software was populated with red Xs for finish, submit and accept of the discharge MDS. On 08/29/19 at 12:49 PM concurrent record review and interview was conducted with Director of Nursing (DON)1. The review confirmed the software documented red X for finish, submit and accept. DON1 reported the red Xs indicate the MDS was not done; however, the assessment was completed on 05/14/19 as indicated by the signature of the MDS Coordinator. DON1 was agreeable to follow up. On 08/29/19 at 01:08 PM, DON1 reported the review of the MDS submission and confirmation report found no confirmation R1's assessment was done. The DON reported that there may have been an error and the assessment was rejected. The facility will attempt to resubmit this assessment.",2020-09-01
402,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,656,D,0,1,GY1211,"Based on observations, record reviews and interviews with staff member, the facility failed to develop a comprehensive person-center care plan for 2 (Residents 48 and 224) of 17 care plans reviewed. Findings Include: 1. Cross Reference to F689. R48 receives feeding via syringe to prevent aspiration as recommended by the Speech Therapist and ordered by the physician. The record review found no documentation of a plan of care with interventions regarding how to feed R48 (how many cc's of food/liquid to expel at one time, is there a trial of spoon-feeding before using the syringe, signs and symptoms of aspiration) to ensure prevention of aspiration. 2. Cross Reference to F697. Based on an individualized assessment of R224, the facility failed to develop a care plan to ensure management of pain. The facillity did not develop non-pharmacological and pharmacological interventions for pain management.",2020-09-01
403,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,657,D,0,1,GY1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview, record reviews, and review of the facility's policy and procedure, the facility failed to revise Resident (R)7's care plan following an unwitnessed fall and reassess the effectiveness of current interventions. Findings include: 1) During an interview with R7 on morning of 08/27/19, R7 informed the surveyors of a recent fall. A progress note written on 07/27/19 at 22:39 by Registered Nurse (RN)7 documented R7 had an unwitnessed fall with no evidence of injury. Additionally, a progress note written on 07/26/19 at 10:41 AM by Minimum Data Set Coordinator (MDSC)4, reported that R7 has been showing some possible signs of worsening dementia with increased forgetfulness/confusion. A review of R7's Care Plan documented that the care plan Goal was implemented on 03/21/18 and remained unchanged. The Approach or interventions to achieve the Care Plan Goal was implemented/edited on 3/21/18; 3/22/18; and 11/22/18. There was no evidence to suggest that the facility evaluated any of the Approaches implemented or effectiveness after R7 fell on [DATE]. In an interview with Director of Nursing (DON)1 on 08/29/19 at 02:04 PM, inquired about how the facility evaluated R7's care plan to address R7's recent fall and worsening dementia. DON1 reviewed R7's Electronic Medical Record (EMR) with surveyors and confirmed that none of the interventions were updated or edited since the fall and stated that the goals and interventions should have been reviewed. A review of the facility's policy and procedure for Nursing Services states, the plan of care will be reviewed, monitored, evaluated and revised as necessary by all disciplines involved in the care of the resident during the care planning meeting or more frequently as required.",2020-09-01
404,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,679,D,0,1,GY1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with staff member, the facility failed to implement the activity care plan for 1(Resident 56) of 1 sampled residents. Findings include: Resident (R)56 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Observation on 08/27/19 at 10:19 AM found R56 asleep in bed and he opened his eyes when surveyor spoke to him. The television was not on and there was no music playing. Second observation on 08/28/19 at 01:21 PM found R56 was on contact isolation (requiring personal clothing protector and gloves when entering the resident's room), R56 was asleep, snoring with no television/radio on. Observations on 08/29/19 at 08:23 AM R56's eyes were open and at 11:32 AM R56 was receiving nutrition via [DEVICE]. There was no television or radio on during these observations. On 08/30/19, R56 was observed laying in bed. A review of the annual Minimum Data Set with assessment reference date of 02/08/19 found in Section F. Preferences for Customary Routine and Activities, staff assessment was conducted. R56's preferences include receiving shower, receiving bath, family or significant other in involvement of care decision. There was no item checked for activity preference. On 09/03/19, the facility provided a copy of R56's care plan. The care plan identified the problem for the resident being at risk for social isolation and sensory deprivation (onset of care plan 11/08/18 with editing done on 08/28/19). The goal is for activity staff to encourage resident and work with nursing staff to participate on one group activity a week and activity staff to provide sensory stimulation room visits two times a week. Also included in the care plan were interventions to address R56's psychosocial well-being. The interventions included: 1:1 room visit by activity aides; continue family visits; continue to engage him in simple conversations during visits and care; continue to monitor for signs/symptoms of depression; provide gentle approach at all times; and refer to psychiatrist if indicated. On 09/03/19 at 09:06 AM, the facility provided a copy of R56's annual activity assessment (signed by the Activities Coordinator on 02/08/19). The activity preferences identified included: contact with others, room visits, 1 on 1, small group, and noted R56 has strong family support with Father visiting every morning. Also noted, activity supply needed or relevant to activity involvement included TV/radio in room. The coordinator notes that sensory stimulation is most effective for resident. A review of the Activity participation documentation found R56's care plan interventions for small group activity and sensory stimulation during room visits (two times a week) was not being implemented. There was no documentation of activity participation for the following weeks: 07/14/19 to 07/20/19; 07/21/19 to 07/27/19; 08/04/19 to 08/10/19; and 08/18/19 to 08/24/19. R56 received activity once a week for the following weeks between 06/30/19 to 08/31/19: 06/30/19 to 07/06/19; 07/07/19 to 07/13/19; 07/28/19 to 08/03/19; and 08/25/19 to 08/31/19. An interview was conducted with the Director of Nursing (DON)1 on the morning of 09/03/19. DON1 reported the Activities Coordinator is working part-time or on-call. A review of the documentation of R56's activity participation was done with the DON. The DON acknowledged activities were not being provided in accordance with the resident's care plan; however, reported the activity staff meet daily to discuss all the residents. Inquired whether activities were not provided due to R56's contact isolation status? DON1 was unable to provide documentation of the reason for not meeting R56's activity goal.",2020-09-01
405,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,689,D,0,1,GY1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews with staff members, the facility failed to ensure 1 (Resident 48) of 5 residents in the sample was free of accident hazards (aspiration) while feeding a resident with a [DIAGNOSES REDACTED]. Findings Include: Cross Reference to F656. Resident (R)48 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 08/26/19 at 11:16 AM, R48 was observed during lunch meal with assistance from Registered Nurse (RN)12. RN12 was observed to scoop a spoonful of rice with pureed meat and placed the food in R48's mouth. R48 did not swallow the food, RN12 left R48 and entered room [ROOM NUMBER]. While in room [ROOM NUMBER], R48 was observed to cough as she was trying to swallow the food. RN12 returned and scooped a spoonful of mashed potatoes onto the spoon. RN12 then used a syringe to continue feeding R48, RN12 attempted to coax R48 to open her mouth, but R48 did not open her mouth. RN12 then used the tip of the syringe to pry open R48's mouth and expel food into her mouth (left side). On 08/29/19 at 11:25 AM, R48 was observed in the hall with Certified Nurse Aide (CNA)11 assisting with the meal. R48's food was pureed and liquid thickened. CNA11 already filled the syringe with food. CNA11 alerted the resident by calling her name and rubbing her arm, R48 opened her mouth and CNA11 expelled food into the resident's mouth. CNA11 repeated this process, R48 was not choking or coughing. On 08/29/19 at 02:42 PM an interview was conducted with CNA11. CNA11 reported she expels 2 to 5 cc's of food at a time so R48 does not cough. CNA11 also reported trying to spoon-feed R48 but if she bites down on the spoon, the syringe is used. CNA11 states it takes approximately 20 minutes to feed R48 by syringe. Further queried whether the facility provided training on syringe feeding, CNA11 responded training was not provided. A review of R48's quarterly Minimum Data Set with assessment reference date of 07/01/19 documents R48 is severely impaired for cognitive skills for daily decision making. Also noted R48 is totally dependent on staff with one person physical assist for eating. On 08/29/19 at 01:43 PM, the facility provided a copy of R48's plan of care. A review of R48's care plan found no documentation that a care plan was developed for feeding R48. Further record review found a physician's orders [REDACTED]. A review of the initial Speech Therapist (ST) evaluation dated (10/05/18) notes R48 demonstrates oral stage dysphagia characterized by the inability to open her mouth. The resident also noted to bite on the spoon creating anterior spillage and delayed oral transit. The recommendation was to feed R48 with a syringe as the inability to open her mouth is the result of motor coordination and not behavioral refusal of PO intake. The ST discharge summary for date of service 10/05/18 to 10/22/18 documents R48 is fed via syringe with no overt signs and symptoms of aspiration. Delayed pharyngeal state noted. On 08/29/19 at 02:14 PM concurrent record review and interview was done with Director of Nursing (DON)1. DON1 confirmed there is no care plan for R48's feeding. DON1 reported the syringe may be used for meals and med pass. Inquired how are staff supposed to use the syringe (how much food to expel), is a trial of spoon feeding done first, who can feed the resident and is training required for feeding R48 via the syringe. DON1 reported the RN should feed the resident and maybe give the resident 25 cc of food at one time. The DON was not sure if training was required for syringe feeding.",2020-09-01
406,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,693,D,0,1,GY1211,"Based on observation, review of the facility's policy and procedures, and interviews with staff, the facility failed to adhere to facility protocol regarding tube feeding for 1 Resident (R)224 of 2 residents. Findings include: 1) On 08/26/19 at 12:53 PM, observed R224's gravity feeding bag was written as 08/21/19. Inquired with the Registered Nurse (RN)7 about the date on the label written as 08/21/19, RN 7 stated that it was written as 08/26/19 and RN7 had bad handwriting, the date was supposed to read as 08/26/19 and proceeded to write over the 21st to change it to the 26th. RN7 stated the 11:00 PM- 07:00 AM shift usually replaces and labels the gravity feeding bag daily, but due to R224 resuming tube feeding RN7 wrote the label. A second observation on 08/27/19 at 07:51 AM, the label on the gravity feeding bag in use was not dated. A review on the facility's policy and procedure on 09/03/19 at 11:18 AM, indicated that the gravity feeding bag label should contain the date. Inquired with the Director of Nursing (DON)1 on 09/03/19 at 10:10 AM regarding the policy on the labeling of the Gravity feeding bag. DON1 was not sure whether the resident's name, date, and time was on the label, but did endorse that the gravity feeding bag is usually changed by the 11:00 PM- 07:00 AM shift daily.",2020-09-01
407,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,697,D,0,1,GY1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview with staff member and resident representative, the facility failed to ensure pain management was provided to 1(Resident 224) of 3 residents in the sample. The facility failed to define parameters for use of medications and consistently manage pain. Findings Include: Cross Reference to F697. Resident (R)224 was admitted to the facility on [DATE]. On 07/27/19, R224 was transferred to the hospital with [MEDICAL CONDITION] with [MEDICAL CONDITION] and returned to the facility on [DATE] at 03:32 PM. R224 [DIAGNOSES REDACTED]. Observed R224 in bed moaning and waving his right hand in the air on 08/26/19 at 12:34 PM. R224 placed his hand on his abdomen and mumbled sore. Inquired if R224 needed help, R224 nodded head yes. A resident representative interview was done on 08/26/19 at 01:00 PM with R224's wife and son, R224's wife reported that R224 has pain. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date of 08/06/2019 assessed R224's cognitive skills for daily decision making as modified independence (some difficulty in new situations only). A review of R224's activities of daily living found R224 is totally dependent with 2 person assist for transfer and bathing; totally dependant with 1 person physical assist for toileting; requires extensive assistance with 1 person physical assist for personal hygiene; and R224 is limited assist with 2 person physical assist for bed mobility and dressing. R224 has bilateral upper and lower extremity limitation. In the Health Condition section of the MDS, J0100 notes no scheduled pain medication regime, received as needed (PRN) pain medication and no non-medication intervention with in the last 5 days. The staff assessment for pain was conducted, indicators of pain include non-verbal sounds, vocal complaints, and facial expressions. In the last 5 days, R224 exhibited indicators of pain or possible pain observed for 3 to 4 days. Review of the Care Area Assessment Summary documented R224 has complaints of generalized pain per staff, he moans occasionally and sometimes can tell staff that he is in pain. He is on PRN Tylenol and [MEDICATION NAME]. He mostly stays in bed; per staff he moans even when he is not doing any activities and there has been occasion where sleep has been affected. Staff to continue to give him his pain medication as ordered and update the medical doctor for increasing pain or discomfort. Put him in the position of comfort. Will proceed with care plan with the goal that his pain will be controlled while in the facility with the current regimen. Further review showed no documentation of pain management in the Care Plan. Review of the physician's orders [REDACTED]. The orders do not provide parameters for the distinguishing between the use of [MEDICATION NAME] or [MEDICATION NAME]. Which medication is used to treat mild pain versus severe. Also, are staff able to combine both PRN pain medication for relief of pain. In addition, the scale used by staff to rate and relay R224's level of pain is inconsistent. A progress note written on 07/25/19 by Licensed Practical Nurse (LPN)6 rated R224's pain level on a 1-10 pain scale, then documented the effectiveness of the PRN as slight relief. Furthermore, a review of the Medication Administration Record (MAR) R224 received [MEDICATION NAME] Oral 650 mg 3 doses on 07/25/19 and 1 dose on 07/26/19. The (MONTH) 2019 MAR documented R224 received 13 doses of [MEDICATION NAME] and no doses of [MEDICATION NAME], there was no documentation of the time the medication was provided. Further review found staff members endorsed by initial that R224 was assessed for pain; however, there is limited record of the results of the assessment. Additionally, a progress note written on 08/20/19 documents a physician's orders [REDACTED]. Further review of the all documented progress notes provided by the facility found inconsistency of the evaluation of R224's pain levels, numeric pain level or other indicators (facial grimacing/moaning) were utilized. In an interview and concurrent review of the resident's record was done on 09/03/19 at 08:40 AM. DON1 confirmed the facility did not develop a plan of care to address the management of R224's pain. Inquired with DON1, regarding the administration times of the pain medication on MAR, DON1 reviewed the MAR and reported the MAR does not have documentation of the time the medication was administered. The DON also reported nursing staff should document in the progress notes if the pain subsided and if not they are to call the physician. Inquired whether the facility's system for monitoring R224's pain was effective. DON1 did not confirm effective management of the resident's pain.",2020-09-01
408,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,725,E,0,1,GY1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of policy, the facility failed to ensure there was sufficient nursing staff to assist four Resident's (R48, R47, and R7) in maintaining their highest practicable level of physical, mental, functional and psycho-social well-being. Findings Include: 1. On 08/26/19 at 11:27 AM observed dining on the Pali unit hallway. A lunch tray was set-up for R48 on an overbed table, and registered nurse (RN) 12 proceeded to feed R48 a spoonful of rice mixed with pureed food. Before R48 finished swallowing the spoonful of food, RN12 walked into room [ROOM NUMBER], and assisted R26 into the hallway to set-up that resident with a lunch tray. While RN12 was assisting R26, R48 began to cough while trying to swallow the spoonful of rice and pureed food mixture. Within a few minutes RN12 returned to R48 with a syringe, and filled it with pureed food and mashed potatoes. While attempting to feed R48 by syringe filled with pureed food, RN12 also provided cues to another resident eating in the hallway. Then a staff member called for assistance from room [ROOM NUMBER], and RN12 put down the syringe and went to provide assistance. The R48 was left unsupervised again, as R12 helped and provided assistance to other residents on the unit. 2. On 08/29/19 at 12:02 PM during an interview with the Resident Council, three residents (R47, R7, Anonymous) stated that sometimes it takes between 30-45 minutes for staff to respond when pressing the call bell. They also stated that it usually happens when there is a shortage of staff. A review of facility policy titled Nursing Services revealed the following: Procedures, General Care, 1. Provides total nursing care including restorative nursing measures to the resident and coordiante nursing service with other resident care services directed toward assisting the resident to achieve and maintain his optimum level of self-care and independence. 3) A confidential resident interview was conducted on 08/27/19 at 07:45 AM. The resident was asked whether he/she is continent of bowel and bladder. The resident responded having awareness to urinate or defecate, pressing the call light and experiencing incontinence as care is not received in a timely manner. The resident commented that shi-shi (urine) and dodo (feces) does not wait and also stated who would want to to wipe you, so everybody disappears. A brief record review of the Minimum Data Set found this resident is cognitively intact and requires extensive assistance with one person physical assist for toilet use. This resident did not have a trial of a toileting program and coded as frequently incontinent of bladder and bowel.",2020-09-01
409,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,812,F,0,1,GY1211,"Based on surveyor observations,interviews with the dietary staff and a review of the facility's policy and procedures the kitchen failed to follow proper sanitation to prevent the outbreak of food borne illness. Findings Include: 1. Observation on 08/29/2019 after food preparation, there was a rack full of drinking cups with approximately 9 cups right side up and filled with fluid from the dishwasher. Staff D7 confirmed that the cups should have been placed upside down in the sanitary rack to allow thorough sanitization. 2. Observation on 08/29/2019 at 10:00 AM, found towels in a bucket filled with a clear solution. D5 stated that the solution was chlorine bleach and water, the mix is 3 teaspoons of chlorine bleach and water. D7 stated the solution should be 100 parts per million (ppm). Inquired whether the chlorine solution was tested , D5 stated no. D5 tested the solution with Hydrion test strips, when D5 compared the strip with the color indicator and reported it was 100ppm. However, D7 confirmed the test strip indicated the solution was 10 ppm not 100 ppm. D7 stated chlorine solution needs to be 100ppm. 3. Observation of food preparation on 08/28/2019, D6 scooped powder from a container which was labeled powdered mashed potato with vitamin C and placed the scooper back into the container. On 08/30/2019 at 11:38 AM, D6 and D7 were asked to open the container and both D6 and D7 observed the scooper in the container. When inquired about the facility's practice regarding the scooper in the mash potato container, D7 and D6 responded the scooper should not have been in the container. 4. Observation on 08/29/2019, D5 picked an oven mitt off the floor, placed the oven mitt on the plating counter. D6 was plating lunch with disposable gloves on, D6 then put on the oven mitt that had fallen on the ground and used the oven mitt to open and remove food from the oven. After using the oven mitt, D6 placed the fallen oven mitt partially on the tray of soup bowls. D6 did not change disposable gloves and continued plating lunch wearing the same disposable gloves that were placed inside of the oven mitt. Review of the facility's policy and procedure on Hand washing and Food Safety states, Wearing gloves is not a substitute for appropriate, effective, thorough and frequent hand washing. Hands should be washed before and after application and removal. Gloves must be intact and in good condition and changed appropriately to help reduce the spread of microorganism.",2020-09-01
410,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,880,D,0,1,GY1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with staff members, the facility failed to ensure transmission-based precautions were followed to prevent the spread of infections during cleaning of room which was occupied by a resident on contact isolation precautions. The facility also failed to utilize hand hygiene procedures between residents. Findings Include: 1) Observation on 08/28/19 found Resident (R)56 was on contact precaution/isolation. The Certified Nurse Aide (CNA)34 instructed surveyor to wear a personal clothing protector and gloves when entering the resident's room. A record review on 08/29/19 at 07:35 AM found an infection control report which notes R56 has an infection to his [DEVICE] site which was acquired in the facility. The symptoms included skin (swelling, redness-localized, drainage) with yellow purulent draining and light brown and greenish drainage. The culture (07/03/19) found pseudomonas, staphylococcus, and proteus mirabilis. Antibiotics (cipro, Bactrim, [MEDICATION NAME] and [MEDICATION NAME]) were provided. Also of note was the [DEVICE] site was noted with four organisms: serratia marcescens (4+) which is sensitive to [MEDICATION NAME] sulfa; pseudomonas aeruginosa (1+) which is sensitive [MEDICATION NAME] levo; staph [MEDICAL CONDITION] (4+) and proteus mirabilis (1+) which is sensitive to sulfa and [MEDICATION NAME]. A review of the physician's orders [REDACTED]. three times a day for seven days due to GT site infections. On 08/29/19 at 09:39 AM, Registered Nurse (RN)5 reported R56 is no longer on contact precaution. Observation on 08/29/19 at 09:45 AM found Housekeeper (HSKP)7 cleaning room [ROOM NUMBER]. R56 was on contact isolation [MEDICAL CONDITION]. The housekeeper was wearing blue gloves, removed the lid of the sanitizing cloth container (gold top) which was placed on a stand outside of the resident's room. The housekeeper entered the room and began to wipe down the outside of the two black trash bins at the entrance to the room. HSKP7 did not remove gloves and removed more wipes from the container. The housekeeper proceeded to wipe the inside of the trash bins, under the bins and the lid pedal. HSKP7 did not remove gloves, exited the room and covered the sanitizing cloth container. HSKP7 removed the gloves and used hand sanitizer. The housekeeper was then observed to roll out a bedside tray and place a roll of trash liners and tape dispenser atop the bedside tray. HSKP7 donned gloves and removed a trash liner and placed one of the trash bins into the liner. The liner was taped to the top. The second trash bin was placed in a liner and taped at the top. The housekeeper exited the room and used a sanitizing cloth to wipe the signage then proceeded to wipe the top, side and inside the cart. While holding the used sanitizing cloths in his/her hand, closed the top of the dispenser. The used sanitizing cloth was thrown in the rubbish can in room [ROOM NUMBER]. The sanitizing cloth dispenser, roll of trash liners and tape dispenser were placed in the nurse station. HSKP7 removed the gloves and threw the used gloves into room [ROOM NUMBER]. HSKP7 donned gloves, returned to the room and carried the two trash bins outside and placed the bins in front of a closed door. HSKP7 reported maintenance will be called to get the bins for cleaning. On 08/29/19 at 10:00 AM an interview was conducted with Director of Nursing (DON)2. The observation of the cleaning of the trash bins was shared with DON2. The DON acknowledged infection control breeches when the housekeeper wiped down the trash bins, did not removed gloves and covered the sanitizing cloth container. DON2 reported the used gloves and sanitizing cloths should not be thrown into another resident's room. DON2 also reported the HSKP7 should have wiped down the roll of trash liners and tape dispenser before returning it to the nursing station. DON2 was agreeable agreed to follow-up whether HSKP7 needed to wear a personal clothing protector while cleaning the trash bins. On 08/29/19 at 02:09 PM an interview was conducted with DON1. Inquired whether the housekeeper is required to wear a clothing protector while cleaning the trash bin. DON1 replied if HSKP7's clothing doesn't touch or is in contact with the trash bin, a clothing protector is not required. DON1 acknowledged the whole role of trash liners should not have been taken into the room, the housekeeper should have taken only the amount of liners required. 2. Observation on 08/26/2019 at 10:40 AM in the 1st floor dining room, Activities Staff (AS)5 was wearing blue disposable gloves and handing out individual cleaning wipes to residents. AS5 approached Resident (R)22, opened the individual cleaning wipe, removed the wipe, and proceeded assist R22 with wiping of hands. AS5 assisted R22 by utilizing hand-over-hand method. AS5 did not remove or change disposable glove or perform hand sanitization/hand washing and proceeded assist R34. AS5 assisted R34 with opening the cleaning wipe packet then proceeded to assist R34 with hand-over-hand method of cleaning. At 10:45 AM, AS5 was interviewed and stated that disposable gloves should be changed between assisting residents with hand hygiene.",2020-09-01
411,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2019-09-03,921,D,0,1,GY1211,"Based on observations and staff interview, the facility failed to secure the Biohazard room located on the Ewa nursing unit. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards. Findings Include: During an observation of the Biohazard room (located on the Ewa nursing unit) on 08/28/19 at 10:40 AM, it was noted that the door to enter the room was not secured and anyone could have entered the room freely. There was also no staff in the immediate vicinity to prevent anyone from entering the room. The room contained two trash containers with Biohazard waste material, and two plastic containers labeled Rx Destroyer, Pharmaceutical Disposal. Any of these items could have put the safety of the residents and the public at risk for accident hazards. During the above observation, Housekeeper (HSKP) 10 was queried about the room not being secured. HSKP 10 acknowledged that the door should have been locked and the room secured. HSKP 10 also acknowledged that when closing the door, you would have to close it forcefully in order for the lock to latch on.",2020-09-01
412,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2018-09-27,656,D,0,1,53Y711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medical Record Reviews and Interviews, the facility failed to ensure that a care plan was in place for 1 resident receiving a [MEDICAL CONDITION] medication and another resident for their incontinence of bowel an bladder. Findings: 1. A medical record review was conducted on 09/26/2018 for R 25. The Minimum Data Set (MDS) assessment review dated 07/06/2018 had marked in Section H (Bowel and Bladder), that R 25 was always incontinent for bladder and bowel. There was no care plan in place in R 25's medical record for being incontinent of bowel and bladder. This was verified by MDS Coordinator on 09/26/2018. 2. A medical record review was conducted on 9/26/2018 for R 53. There was a physician's orders [REDACTED]. No care plan for the use of [MEDICATION NAME] was found in R 53's medical record. Interview with RN 1 and MDS Coordinator verified that there was no care plan in place for the use of [MEDICATION NAME] for R 53.",2020-09-01
413,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2018-09-27,677,D,0,1,53Y711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, and review of the facility's policy/procedures, the facility failed to provide assistance with activities of daily living (ADLs), oral hygiene, for 2 sampled residents (Resident R4 and Resident R49) who required staff assistance. Findings: 1. Review of R49's Face Sheet revealed she was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of R49's quarterly Minimum Data Set (MDS- an assessment tool completed by the facility to identify resident care problems and assist with care planning) with an Assessment Reference Date (ARD- the end point of the evaluation period) of 08/10/16, indicated, Section C: Cognitive Patterns, the resident had a Brief Interview for Mental Status (BIMS-a cognitive evaluation) score of 14 out of 15, which indicated an intact cognitive response. Section G-Functional Status, indicated the resident was coded as being totally dependent of one staff for brushing teeth. Section K-Nutritional Status, indicated she was coded as having a feeding tube. Section-L Dental Status, indicated the resident was identified as having obvious or likely cavity or broken natural teeth. Review of the resident's plan of care, dated 02/12/18, identified the problem of natural teeth with possible cavity and at risk for oral pain and infection. The pertinent care plan approaches were, assist with dental hygiene at least two times a day, monitor for oral/dental pain/infections, and a dental consult as needed. Review of the Dental Progress Notes indicated the resident had been seen by the facility's dentist on 03/14/16 and 03/13/17 with no cavity concerns. Interview the Registered Nurse (RN) 1 on 09/25/18 at 2:48 PM confirmed the resident had not been seen by the facility's dentist since (YEAR). On 09/24/18 at 2:28 PM, R49 was observed with an enteral feeding due to dysphagia. The resident had gray plaque and dark brown areas noted on her teeth and gum line. The resident stated she was unable to brush her own teeth and the nursing staff does not brush them. She also stated she did not have oral/dental pain. On 09/25/18 at 11:42 AM, R49 was observed in bed. The resident's teeth were covered with gray plaque with brown areas at the gum line. She stated her teeth had not been cleaned for a long time. Interview with Certified Nurse Aide (CNA)3 on 09/25/18 at 11:50 AM indicated she cleaned the resident's teeth with an oral care sponge swag and mouth wash daily. Interview with CNA2 on 09/25/18 at 11:55 AM stated she used a tooth brush and tooth paste to cleanse the resident's teeth. She showed the surveyor the residents' personal hygiene basket. The resident had a toothbrush but there was no tooth paste in her hygiene basket. The CNA further stated she cleans her teeth daily. Review of the Nurse Aides' Plan of Care, documentation for oral care revealed the resident had received oral care 10 times from 09/17/18 to 09/25/18. Interview with RN1 on 09/25/18 at 12:48 PM indicated R49's oral care documentation did not reveal the resident had received oral care two times a day per her plan of care. On 09/25/18 at 2:46 PM, RN1 accompanied the surveyor to R49's room and inspected the resident's mouth. She confirmed there was gray plague with brownish/black areas on the resident's teeth and gun line. Review of facility's policy and procedure titled, Nursing Services, revised date 01/05/18, revealed residents who require assistance are to receive oral hygiene/grooming general daily care. The grooming consisted of brushing teeth. 2. During observations on the morning of 09/24/2018, R 25 was found lying in bed with visible fecal matter on both the top and bottom sheets of the bed. R 25's left hand was visibly covered in fecal matter and was waving it around. The odor from the fecal matter a strong unpleasant smell that could be smelt throughout the whole room and surrounding hallway of the Diamond wing of the facility. After 30 minutes, observations were reconducted on R 25 who was found in the same state as initially observed and no one had attended to his ADL's and cleaned R 25. On 09/26/2018, R 25's medical record was reviewed and there was a care plan in place for R 25's ADL's, stating that R 25 required full assistance with all areas of care.",2020-09-01
414,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2018-09-27,812,E,0,1,53Y711,"Based on observation, interview, and record review, the facility failed to ensure safe and sanitary processes were maintained for food preparation for one of one observed meal services. Specifically, the thermometer used to check food temperatures was not sanitized before checking food temperatures. Additionally, the temperature of rice and items heated in the microwave were not checked before being served to residents. Findings include: Findings included: Observation on 09/26/18 at 10:45 AM of the lunch meal service revealed Cook 1 had not sanitized the thermometer used to check the temperatures of the soup, sandwiches, and pureed items served at that meal. No sanitizing wipes to clean that thermometer were observed in the immediate area where food was being plated. Dietary Aide (DA) 1 had plated multiple trays of food prior to checking to ensure temperatures of the pureed food and chopped turkey sandwiches were within safe limits (41 degrees Fahrenheit or under). Bowls of ramen noodles (saimin) were not checked for proper temperatures (at least 135 degrees Fahrenheit) prior to serving them to residents. [NAME] rice was taken out of a rice cooker, plated, and served without checking for proper temperature. Interview with Cook 1 at that time of observation revealed temperatures were to be taken prior to serving food. Review of the Food Temperatures log revealed there were no other temperatures documented for the foods listed above that had been observed being served. Interview on 09/27/18 at 09:33 AM with the Dietary Manager (DM) revealed there was no policy for how to properly take food temperatures. Training was done by word of mouth. There was no policy for sanitizing the thermometers before taking food temperatures. The DM stated staff had been nervous and should have sanitized the thermometer and taken all temperatures before serving food. She also stated they had sanitizing wipes were available for the thermometer. No policies regarding taking food temperatures had been available on 09/27/18 when requested during the survey.",2020-09-01
415,NUUANU HALE,125024,2900 PALI HIGHWAY,HONOLULU,HI,96817,2018-09-27,880,D,0,1,53Y711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure contact precautions were maintained for one of one sampled resident (Resident (R) 54) with an infection requiring contact precautions. Findings include: 1. Observation of R54's room on 09/26/18 at 07:17 AM, revealed a station with Personal Protective Equipment (PPE) including gowns, gloves, and masks outside her door. A sign stating to stop and see a nurse before entering was posted on the wall. Further observation at that time revealed Certified Nurse Aide (CNA) 1 entered R54's room without donning PPE. She then exited the room, put on a gown and gloves, and re-entered the room. She proceeded to assist R54 with her breakfast meal. CNA1 then removed the gown and gloves and exited the room. At 07:45 AM, CNA1 re-entered that room without donning PPE. Review of R54's Face Sheet revealed was admitted [DATE]. She had [DIAGNOSES REDACTED]. Review of R54's Physician order [REDACTED]. Review of R54's 09/24/18 Resident Progress Notes revealed a note stating her wound culture lab results had come back positive [MEDICAL CONDITION] infection and contact precautions initiated. Notes dated, 09/25/18, revealed she had been transferred to a private room due to [MEDICAL CONDITION] infection. Observation on 09/26/18 at 01:00 PM of R54's room revealed staff from Pharmacare had arrived to perform a medical procedure for R54. Two randomly observed staff from that company stopped in front of the door, mentioned the contact precautions, then proceeded to enter R54's room without donning PPE. They then exited the room, put on gowns and gloves and re-entered the room. Interview on 09/26/18 at 08:00 AM with CNA1 revealed staff should gown and glove every time they enter a resident's room that is on contact precautions. Interview on 09/26/18 at 01:24 PM with Registered Nurse (RN) 1 revealed staff should gown and glove every time they work with a resident that is on contact precautions. A mask should also be worn if working in close contact with a resident. Review of the facility's (YEAR) Infection Control Transmission-Based Precautions policy revealed Healthcare personnel caring for residents on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning PPE before room entry and discarding before exiting the resident room is done to contain pathogens . Interview on 09/27/18 at 10:30 AM, the Director of Nursing (DON) stated that training was given to the facility staff on 9/18/18, 09/19/18, 09/20/18 and 09/21/18 regarding contact precautions. The DON stated it was the facility's expectation that the staff were to wash their hands, obtain the gown, mask and gloves and secure all ties before entering a room. When care was completed staff were to place all materials in the bin in the resident's room, wash hands, and leave the area. Staff were to use those transmission-based precautions before going into a resident's room that was on contact precautions.",2020-09-01
416,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,170,E,0,1,H76111,"Based on resident and staff interviews, the facility failed to ensure the residents' mail was delivered unopened and on Saturdays for all residents in the facility. Finding includes: During a Stage 2 interview with Resident #39 (Res #39), she verified that she never received mail on Saturdays. She said she did not think the receptionist worked on Saturdays and therefore the mail was not delivered to the residents residing in the facility on Saturdays. On 05/0417 at 1:26 PM, during an interview with Staff #131, she said she is the person who delivers the mail to the residents on the fourth floor. Staff #131 stated on Saturdays however, the mail office is closed and the residents won't get mail on the Saturdays. She said she unless it was the Friday mail that's delivered, then I can go down to pick up and deliver the Friday mail on Saturday. She said every unit clerk went down to check the mail for their unit. On 05/05/17 at 3:00 PM, during an interview of Staff #33, she said, No one gets mail on Saturdays because the information area is closed. They (residents) get it on Monday, the Saturday mail. She is the unit clerk for the third floor and affirmed this is how the mail is handled. The Director of Nursing (DON) produced the facility's Information Sheet which stated, Mail Residents are able to receive personal mail. Mail is delivered directly to the resident or via the Care Management/ Medical Social Work Department. There was no information that residents have the right to receive mail unopened and on Saturdays. The facility failed to allow residents prompt access to mail but not having it delivered to them on Saturdays.",2020-09-01
417,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,176,J,0,1,H76111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of the facility's policy and procedure, the facility failed to ensure the resident was comprehensively assessed to safely self-administer medications if the interdisciplinary team, as defined by 483.21(b)(2)(ii), has determined that this practice is clinically appropriate for 1 of 37 residents (Resident #39) in the Stage 2 sample. Finding includes: Cross reference to findings at F280, F333, F353, F514. On 05/04/17 at 12:52 PM, an interview was conducted with Resident #39 (Res #39). During the interview, the resident stated, Sometimes I wait an hour before the nurse can come to help me, like my 8 o'clock medication, yeah, the morning one. I don't get it until 10:30 or 11:00 am. Today I had it earlier because you guys are here (her other routine medications). That's why I have to hang onto my sprays, I have to give myself, my [MEDICATION NAME], because I can't wait on them. I need it for my breathing. I told them I need to be responsible for my own health. Res #39 said one of the nurses had given her the inhalers to keep at her bedside but did not recall who it was. Res #39 said it has been around a month or so that she's been self-administering her own inhalers. The resident was observed to have both her [MEDICATION NAME] disc and ProAir inhaler at the foot of her bed. She said she kept it there so I can grab it and use it. She denied ever being taught by licensed staff how to use her inhalers. She denied that staff watched her when she used her inhalers on her own and said, I know how to do it. They're always late, that's why I have to keep it here. On 05/04/2017 at 1:36 PM, the resident went out on an appointment and was not in her room. A concurrent observation was made with Staff #99 on 05/04/17 at 1:39 PM of Res #39's room. It was observed that both the [MEDICATION NAME] and ProAir inhalation medications were left unsecured, on the top of her bed mixed in with baby powder, sugar packets in a tub, books, a small Kleenex box, etc. Staff #99 said, We never ask doctor if may keep medication at bedside. It is our fault. We never ask doctor. Staff #99 was queried whether she observed the resident doing her own self administration of medications and whether the resident was using them properly and dosing correctly for both the inhalers. Staff #99 also said, She's alert and I observed her inhaling, but to be honest, but I haven't seen her use it at lunch time. Staff #99 said the resident's ProAir order was to use four times a day and the [MEDICATION NAME] was twice daily. Staff #99 said she would ask Res #39, I ask have you done your cough? and based on what the resident said was how she documented it on the Medication Administration Record [REDACTED]. On 05/04/17 at 1:44 PM, during an interview with Staff #57, she acknowledged documenting on the MAR indicated [REDACTED]. Staff #57 said only last month for the [MEDICATION NAME] and admitted not administering the medication nor watching/observing whether Res #39 did her inhalations. Yet, Staff #57 documented that those medications were administered to the resident by her when in fact, she did not. Staff #121, the unit's patient care coordinator (PCC) was also present and said she was not aware that Res #39 was self administering her medications. Staff #121 said it was not acceptable what the licensed staff were doing. She acknowledged the lack of monitoring and risk for overdose by the resident. Staff #121 also said, We are not following what's in the policy and patient safety. She acknowledged it was a concern that licensed staff were signing off on the MAR indicated [REDACTED]. It was later reported to the State Agency (SA) that two other residents were found to have medications at the bedside which should not have been left there. On 05/04/17 at 3:20 PM, during a re-interview with Res #39, she stated, The nurses came in and took away my medication and said they also have to teach her how to correctly self-administer the inhalers. She shook her head and said, I told them it's because you don't give it to me on time. For my 8 o'clock medication, they give it to me at 10:30 or 10:45. I need it. They don't watch, no, no. I do it myself, I know I can and I know how much I have left (doses), but they don't look. Before this, they never watch. She said she had a stroke in 2008, has [MEDICAL CONDITIONS], a [MEDICATION NAME] asthma condition and had to be on continuous oxygen all the time via nasal cannula. The resident had an H tank at her bedside and portable oxygen. On 05/04/17 at approximately 2:00 PM, the State Agency (SA) team identified an immediate jeopardy (IJ) situation at the facility. The IJ was for the facility's failure to protect the resident from the potential harm from adverse effects of self administering medications, as evidenced by a lack of assessment, a lack of a physician's orders [REDACTED]., although they were aware, of providing the resident her prescribed medications timely, and yet, documenting on the MAR indicated [REDACTED] The policy on Medication Administration Self-Administration by Resident (10/07, Section 7.3) was provided by the facility on 5/4/17 at 1:20 PM. It stated, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe .1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 2. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process .5. The resident is instructed in the proper cleaning of inhalers where applicable, proper storage and the necessity of reporting each medication dose used to the nursing staff. The completion of this instruction is documented in the resident's medical record. The nursing staff, as deemed necessary, undertakes periodic review of these instructions with the resident .7. If the interdisciplinary team determines that bedside or in-room storage of medications would be a potential safety risk to other residents, the medications of residents permitted to self-administer are stored in the central medication cart or medication room. The medication nurse will provide the medication to the resident in the unopened package, when appropriate, for the resident to self-administer. The nurse then records such self-administration on the MAR indicated [REDACTED] On 5/4/17 at 3:35 PM, the DON and the Vice President/CAO were notified of the IJ situation. The facility provided an initial acceptable abatement plan by 5:11 PM. The facility's abatement plan included notifying Res #39's attending physician, an inspection of all residents' bedrooms with implementation of a bedside tracking log, in-service of licensed staff, a house wide investigation, monitoring of actual times medications were being administered compared to the scheduled times, and the implementation of a daily nursing management rounding sheet.",2020-09-01
418,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,272,D,0,1,H76111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete a comprehensive assessment as part of an ongoing process to identify mood and behavioral symptoms and psychosocial well-being, and as a result an individualized care plan for depression with specific and individualized interventions/goals was not developed for 1 of the 37 residents included in the Stage 2 sample. Findings include: On 05/04/2017 at approximately 2:15 PM during a record review of Resident #43 (Res #43) medical record it was noted that resident was originally admitted on [DATE]. Res #43 was discharged to a hospital for treatment and returned to facility on 03/08/2017. The most recent Minimum Data Set (MDS) Resident Assessment and Care Screening Nursing Home and Swing Bed Tracking (NT/ST) Item Set was dated 03/10/2017 with only sections A and Z completed. Staff #131 checked with Medical Records for MDS that were completed from 03/08/2017 for Res #43 and none were found. Staff #131 explained that the staff who was responsible to fill out the MDS had quit her job and left the facility in (MONTH) (YEAR). On 05/04/2017 at 2:35 PM interview with staff #121 confirmed that Res #43 only had the MDS dated [DATE] in their medical record. During this time Res #43's Care Plan was reviewed and there was no care plan for depression and the administration for [MEDICATION NAME] 10 mg po daily for depression as ordered by Res #43's physician. Staff #121 confirmed that Res #43's care plan did not include depression and goals along with individualized interventions. The facility failed to complete a comprehensive assessment of a resident likely resulting in the development of a care plan that did not include care for depression.",2020-09-01
419,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,279,E,0,1,H76111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medical Record review and Interview, the facility failed to develop comprehensive plans of care based on the results of assessment for 4 out of 37 stage 2 residents. Findings include: 1) Review of Resident # 93's medical record reflected that a bed rail assessment had been completed on 13 December, (YEAR) with a recommendation made to develop care plan to include bed rail use. No care plan for the use of bed rails was found in the medical record. Interview with Staff # 121 confirmed there was no care plan developed for the use of bedrails for Resident # 93. 2) Review of Resident # 90's medical record had documented in the care areas triggered section of the MDS assessment completed on the 29 March, (YEAR), for the area of falls to have a care plan developed for. There care plan for the area of falls was found in the medical record. 3) (MONTH) 4, (YEAR) at 7:43 AM, interview with Resident #313. Resident #313 is awake and more alert today. Eating breakfast. Resident #313 states I have [MEDICAL TREATMENT] today but not sure what time [MEDICAL TREATMENT] is. Resident #313 underwent right arm declotting of Arterial venous fistula (AVF) on (MONTH) 2, (YEAR). Observation reveals right upper arm bruising and Resident #313 states that is was sore yesterday and they did not use it. Resident #313 initially entered through the emergency room for fever and chills and states that she had pneumonia. She further stated that her right groin catheter was infected. May 5, (YEAR) at 7:25 AM, Resident #313 chart review - [AGE] year old with End-Stage-[MEDICAL CONDITIONS] on [MEDICAL TREATMENT] 3 x/week. Resident #313 was admitted to Skilled Nursing Facility (SNF) Kuakini Geriatric Center (KGC) today. Upon discharge from Kuakini Medical Center (KMC) where she was admitted for complaint of fever and chills and diagnosed and treated for [REDACTED].#313 has a permacath and is being treated with [MEDICATION NAME]. At KMC, Resident #313's blood culture from the permacath grew [MEDICATION NAME] cloacae. Record Review revealed careplan is specific to monitor for sign and symptoms of infection to right groin area permacath site dated on (MONTH) 4, (YEAR). Right forearm catheter was declotted on (MONTH) 2, (YEAR); however, there was no careplan to monitor right forearm catheter especially after declotting or to check for bleeding, positive bruit and thrill. Resident #313 stated sore on (MONTH) 2, (YEAR) to right arm to this surveyor. On exam, resident has extensive bruising superior to right forearm AVF catheter. May 5, (YEAR) at 8:37 AM, Resident #313 record review and concomitant interview with Staff #5. Staff #5 was asked What do they do for monitoring of the groin catheter and right forearm catheter? They write it on the progress notes. Resident #313 returned back on (MONTH) 2, (YEAR) from declotting of right forearm. Progress notes on (MONTH) 2, (YEAR) stated back from [MEDICATION NAME] Radiology procedure - stable condition. Right AVF ok to use on 5/2/17. 5/2/17 - right thigh and right AVF kept intact and clean. There was no documentation of detecting a bruit or thrill. Staff #5 agreed that there should be monitoring of bleeding, bruit and thrill, especially after declotting. Staff #5 stated We don't have a monitoring sheet or documentation. Staff #5 stated We do not have a careplan for this. May 5, (YEAR) at 9:01 [NAME]M. Interview with Staff #13. This surveyor asked Staff #13, Did you listen to Resident #313 AVF? Staff #13 stated - you mean her right groin. Staff #13 Oh, she has an AVF? Surveyor - She has a right forearm AVF that was declotted and I'm wondering if you have assessed her? Staff #13 stated I'm still going around. 4) On (MONTH) 4, (YEAR) at 2:35 PM interview with staff #121 confirmed that Resident #43 Care Plan was reviewed and there was no care plan for depression along with the intervention to administer [MEDICATION NAME] 10 mg PO daily for depression as ordered by Resident #43's physician. Staff #121 confirmed that Resident #43's care plan did not include depression and goal(s) along with individualized interventions.",2020-09-01
420,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,280,D,0,1,H76111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to revise and develop a comprehensive care plan prior although there was knowledge by licensed staff allowing a resident to self-administer medications, for ___ of 37 residents (Res #39 and ___ ([NAME]'s resident) in the Stage 2 sample. Finding includes: Cross-reference to findings at F176. Resident #39 (Res #39) was admitted to the facility with [DIAGNOSES REDACTED]. Res #39 was interviewable and had a BIMS score of 15 on her annual 1/2/17 MDS assessment. The resident's comprehensive 2/6/16 care plan for [MEDICAL CONDITION] included an approach to Administer inhaler as ordered, ensure she had continuous oxygen via a nasal cannula and to administer updraft treatments as needed for wheezing. The resident's current quarterly interdisciplinary team (IDT) care conference at the end of (MONTH) (YEAR) noted 1 of the resident's 5 goals included adequate oxygen exchange. Yet, there was no updated documentation to show the resident was self-administering her inhalers. Staff #57, who admitted to having knowledge of this, attended the 3/24/17 care conference, and thus should have been aware this resident was using her inhalers and should have updated the resident's care plan, but did not. There was a failure by the IDT and all licensed staff who were aware and observed/allowed the resident to self-administer her medications to not have revised her care plan. Based on record review and staff interview the facility failed to include the resident and their family in the person-centered plan of care review and revision of Care Plan for 1 of 37 residents of the Stage 2 sample. Findings include: On (MONTH) 4, (YEAR) at 2:35 PM while reviewing Resident #43's Medical Record it was noted that there was no careplan for depression and medication given for depression as ordered by the resident's physician. On (MONTH) 8, (YEAR) at 10:26 AM staff #121 was interviewed to question about the careplan missing. Staff #121 confirmed that the careplan was incomplete, comprehensive assessment was not performed when Resident #43 was readmitted on (MONTH) 8, (YEAR) and careplan review that was performed on (MONTH) 20, (YEAR) with interdisciplinary staff at facility and hospice nurse did not include resident or their family member. There was no documentation that resident or family member was invited to this careplan review and refused to attend the careplan review. Based on record review and staff interview the facility failed to involve the resident and their family in their careplan review and revision.",2020-09-01
421,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,281,D,0,1,H76111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and review of the facility's policy and procedure, the facility failed to ensure it accurately label enteral nutrition bags for residents who require enteral nutrition (EN) for 4 of 37 residents (Res #318, Res #84, Res #303 and Res #63 in the Stage 1 sample. Finding includes: On 05/02/17 at 8:21 AM, Res #318's enteral nutrition (EN) bag was not labeled but was infusing on an IV pole with a pump. The resident was with the speech therapist in the TV room fronting the unit's nurse's station. Staff #5, the PCC for the 6th floor unit, observed and concurred with the surveyor's observations and said, It's supposed to be labeled, so we're aware of what it is, the type of infusion, how much he's supposed to be getting, start time and orders. Staff #5 toured the unit with surveyor and it was found for three other residents (Res #84, #303 and #4), their EN bags also were not labeled. Res #84's EN bag had a white label on it, but it was left blank with no name, date, infusion order and start time/date. The facility's policy and procedure for EN practices did not address the labeling of EN products when administered to a resident. The State Agency (SA) references the Journal of [MEDICATION NAME] and Enteral Nutrition, ASPEN, Enteral Nutritional Practice Recommendations, Bankhead, R., et al., [DATE], pp 129-130: D. Labeling of Enteral Nutrition .Practice Recommendations .3. All EN labels in any healthcare environment shall express clearly and accurately what the patient is receiving at any time .4. The EN label should be compared with the EN order for accuracy and hang time or beyond-use date before administration. The facility failed to ensure licensed staff followed clinical standards of practice for the labeling of EN bags.",2020-09-01
422,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,323,E,0,1,H76111,"Based on observation and interview the facility failed to ensure the resident environment remained as free as possible from accident hazards. 1) Direct observation of resident beds showed that 11 (Residents #150, #293, #39, #121, #90, #148, #5, #43, #2, #144 and #313) out of 37 stage 2 residents had metal bed rails attached to their beds. These metal bed rails have gaps large enough inbetween the bars for residents to have their limbs entrapped in and some cases large enough for the resident's head to be entrapped in. The metal bed rails are fitted to the beds leaving large gaps between the rails and the mattresses where residents would be able to entrap limbs and some instances their heads. The use of these metal bed rails pose as an accident hazard for these residents. 2) On (MONTH) 2, (YEAR) while introducing self to residents in Stage 1 survey sample and doing observations it was noted that the water in the resident's rooms and bathrooms was too hot to the touch. On (MONTH) 2, (YEAR) at 11:13 AM, while rounding with maintenance staff #111 on the 5th floor in room 518, the sink water temperature was recorded at 122.3 degrees Fahrenheit while using a digital thermometer. Staff #111 was asked for a log of water temperatures from the last 6 months. Staff #111 stated that he had (MONTH) (YEAR) - (MONTH) (YEAR) temperature logs available. Staff #111 stated that he was working on the (MONTH) temperature logs. Review of these temperature logs documented faucet and showerhead with temperature ranges from 100-110 degrees Fahrenheit. On 05/02/2017 at approximately 1:30 PM after resident interview with Resident #102 sink in resident's room hot water was tested for comfort. Hot water was hot but tolerable. Facility failed to maintain safe water temperatures, putting residents at high risk for burns.",2020-09-01
423,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,329,D,0,1,H76111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview 1 resident of the 37 residents from the Stage 2 sample was ordered and given two antidepressants without having a completed comprehensive assessment, Care Plan (CP) and adequate monitoring of medications. Findings include On 05/04/2017 at approximately 2:15 PM during a record review of Resident #43 (Res #43) medical record it was noted that resident was originally admitted on [DATE]. Res #43 was discharged to a hospital for treatment and returned to facility on 03/08/2017. The most recent Minimum Data Set (MDS) Resident Assessment and Care Screening Nursing Home and Swing Bed Tracking (NT/ST) Item Set was dated 03/10/2017 with only sections A and Z completed. Staff #131 checked with Medical Records for MDS that were completed from 03/08/2017 for Res #43 and none were found. On 05/04/2017 at 2:35 PM interview with staff #121 confirmed that Res #43 did not have a CP for depression along with the intervention to administer [MEDICATION NAME] ([MEDICATION NAME]) 10 mg po daily for depression as ordered by Res #43's physician. Staff #121 confirmed that Res #43's care plan did not include depression and goal(s) along with non-pharmaceutical individualized interventions. CP did have [MEDICATION NAME] ([MEDICATION NAME]) and lorapepam (sp) under Nutrition/hydration as an intervention. While reviewing the Behavior/Intervention Monthly flow record with staff #121, for (MONTH) (YEAR) and (MONTH) (YEAR), for Res #43, it was noted that medications listed were [MEDICATION NAME] 10 mg daily and [MEDICATION NAME] 7.5 mg daily with hitting, kicking as the behavior that is being monitored and side effects listed were [NAME] Nausea/vomiting and B. Headache. Nursing staff, who filled out the monitoring form only put 0 for the # of behavior episodes and nothing was written for intervention/outcome and side effects. On 05/05/2017 9:31 AM spoke with PharMerica pharmacist, Stephanie[NAME]to discuss why resident is on 2 antidepressants ([MEDICATION NAME] and [MEDICATION NAME]) she stated a substitute pharmacist was covering for her but she would look at this when she returns to the facility. 05/05/2017 9:42 AM Staff #149 was interviewed and explained why the resident is receiving 2 antidepressants. Staff #149 explained that she has had this resident over one year and resident #43 has been on both medications prior to admission for depression and continues to take both for situational depression. Resident is now in hospice and per doctor's practice with hospice residents 2 antidepressants works more effectively. Staff #149 did state she would stop by facility that day to document in resident's chart the use of 2 antidepressants. The facility failed to make sure that a resident 's drug regimen was free from unnecessary drugs based on a comprehensive assessment and by providing adequate monitoring and adequate indication for its use.",2020-09-01
424,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,333,D,0,1,H76111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of the facility's policy and procedure, the facility failed to ensure that residents' medications were administered as ordered and documented accurately by licensed staff'; and failed to ensure two nursing unit's medication refrigeration temperatures were monitored. Findings include: 1) Cross reference to findings at F176, F353 and F431. Res #39 was the resident for whom the IJ was identified. This resident reported her routine medications, including her inhalers, were not being administered to her on a timely manner and the licensed staff would usually give her 8:00 AM morning medications at 10:45 or 11:00 AM. The resident stated she needed her inhalers to be given on time because she worried about her own health maintenance given her respiratory status. She affirmed the nurses were almost always late on their morning medication administration, and around a month ago, she was given her two inhalers ([MEDICATION NAME] and ProAir) to self-administer on her own. Yet, there was no physician order and no documentation that Res #39 was assessed as capable of self-administering her medications. In addition, licensed staff on her unit admitted they were aware the resident kept her inhalation medications at her bedside, but were documenting in the electronic MAR (eMAR) that they had administered it to her. This was revealed in the eMAR print outs for (MONTH) and (MONTH) (YEAR), which showed at the 0800 and 2000 hours, licensed staff were initialing as having given the resident her [MEDICATION NAME] 250-50 Diskus medication, shown by the code 0 (administered by licensed staff). The same code 0 was also documented by licensed staff for the ProAir HFA 90 mcg inhaler at the 0800, 1200, 1600 and 2000 administration times. During an interview with Staff #62 on 05/05/17 at 7:40 AM, she said if a resident self administers their own medication, the correct code is 7 for self administered and not 0. Again, none of the eMAR entries for Res #39's inhalers were being documented as a 7 for the two inhalers, and, all entries were being signed off as being given by the licensed staff. The State Agency (SA) references the facility's failure of licensed staff to follow their Medication Administration policy on Oral Inhalations at Section 7.7. The facility's licensed staff who cared for Res #39 were aware of the inhalers left at the resident's bedside. Yet, licensed staff also were not ensuring by leaving the inhalers unsecured, if the resident was dosing based on the specific manufacturer's recommendations for use, such as priming the HFA inhaler, cleaning it prior to use, checking the counter reading, ensuring it was not dropped, etc. On 05/05/17, further record review of a print-out showing the actual medication administration times found Res #39's morning medications are administered late per the DON. For example, for Res #39's medication Eliquis 2.5 mg, one tab to be taken twice daily, there were approximately 11 entries which the 0800 medication was given late in (MONTH) (YEAR) (beyond the hour window to administer). One dose was given at 12:33 PM and other administration times were at 11:36 AM, 10:29 AM, 11:44 AM, etc. During the concurrent review of this print out with the DON, she said, it shows the lateness of the morning meds. She said it was something they were working on to correct with the Medical Director's involvement as well. 2) During the morning medication pass with Staff #62 on 05/04/17 at 7:48 AM, she was observed administering 5 units of [MEDICATION NAME] to Res #125. However, prior to the injection, Res #125, who is alert and oriented, stated, I ate already. The resident's breakfast tray was in front of her and she had eaten her food. During an interview with Staff #62 thereafter, she verified the insulin is ordered to be given before breakfast. Staff #62 stated this has been a concern as the night shift nurse often leaves by 4:30 AM, and the night supervisor does not assist in giving the morning insulins and it is left up to the day shift to figure out if it had been given or not. Staff #135 also affirmed this. She also said although the night shift nurse is responsible to give the morning insulins, they often do not assist with it. Staff #135 stated for one of her residents who also receives a morning insulin, she said I gave it late, since the night shift supervisor was unable to give it. Both staff stated this happens frequently, at least 2-3 times a week, when the night nurse leaves at 4:30 AM and the supervisor who patches in is unable to give the insulins timely, as observed for Res #62. Review of the facility's policy on Medication Administration General Guidelines at Section 7.1 found: 14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center . 3) During an observation of Staff #120 on 5/4/17 at 10:18 AM, she was found to be passing her residents' 8:00 AM medications. She stated she should have been done by 9:00 AM, but there were too many interruptions. On 05/05/17 at 9:23 AM, Staff #120 was again observed passing her 8:00 AM morning medications. She stated, I even started at 7:30 but I had updraft treatment to give and (a physician) calling about the doppler results, so I'm telling the truth, we are running trying to keep up. She verified this is almost a daily occurrence and especially on the weekends, they are often only staffed with 3 CNAs, but there's lots of people who need assistance and not enough help. On 05/05/17 at 2:11 PM, per Staff #120, she stated her last morning medication she passed today was at 10:45 AM, given to a resident (third floor) and one of her medications was an anti-[MEDICAL CONDITION] medication. She said this resident is supposed to be getting [MEDICATION NAME] 500 mg, one tablet orally at 8:00 AM and a second at 4:00 PM, but has become more like a noon medication by then. She stated, too busy with too many interruptions. 4) On 05/05/17 at 12:52 PM, during an interview with the DON, she verified and said, A lot of the 8:00 morning meds are averaging around 10:00 AM. We are in the process of trying to get it more directed for the patient care coordinators (PCCs) to review instead of just wandering the floor with the new management observation sheet. And these sheets will be brought to the weekly meeting for review with reference to the staffing concerns and late medication administration found during survey. 5) On 05/05/17 at 8:00 AM, the DON stated after her review of the 6th floor nursing unit's refrigeration checklist, the reason or importance that the refrigerator temperature is be monitored and accurately recorded was because, Otherwise you wouldn't know if the meds are still good. She produced the temperature logs for the other 3 nursing floors as well. Cross-reference to findings at F431. 6) On 05/08/17 at 2:02 PM during an interview with the Medical Director, she acknowledged there was an issue with medications on the ICF (Intermediate Care Facility) level residents' medications being passed late. She stated the phyisicians are looking at the daily medications and what time they should be given. She stated they can look at the medical orders and see whether or not it will be necessary to have these orders continued. She said it could be a matter of the organization of the work and workloads on the units (reasons for the delay in medication administration). There was a failure by the facility to ensure the administration of drugs were in accordance with physician's orders, manufacturer's specifications regarding the storage, preparation and administration of the drug and the accepted professional and clinical standards/principles of practice",2020-09-01
425,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,353,K,0,1,H76111,"Based on observations and interview the facility failed to ensure there was sufficient nursing staff to provide services according to the residents assessments and comprehensive care plans and physician orders. Findings include: 1) Residents were observed having 8 AM medications administered at 10.30 AM -11 AM daily for the duration of the survey. Interview with Staff #109 and Staff #148 confirmed their core nursing staff was currently down in required numbers due to a large number of nursing staff resigning from mid (MONTH) through to (MONTH) (YEAR). This left gaps in required number of nursing staff required on a daily basis as reflected on the daily staffing sheets from 1 April, (YEAR)- 3 May, (YEAR). 2) On 05/05/17 at 12:52 PM, during an interview with the DON, she stated, A lot of the 8:00 morning meds are averaging around 10:00 AM. We are in the process of trying to get it more directed for the patient care coordinators (PCCs) to review instead of just wandering the floor with the new management observation sheet. And these sheets will be brought to the weekly meeting for review with reference to the staffing concerns and late medication administration found during survey. Cross-reference to findings cited at F176, F333, F431 and F514. On the afternoon of 05/08/17, during the interview of the Medical Director, she stated their physicians are looking into the medication administration times for long term care residents and a plan to adjust some of the routine medication administration times. Although she stated the medical care is excellent, it is the SA's cumulative findings with the IJ, that the overall failure of the facility to identify these substantive issues has affected the residents' care and well-being, and was corroborated by resident, family and staff interviews, including the lack of sufficient staffing as a contributory factor. 3) On 05/02/17 at 11:47 AM, observation was started for the lunch meal service with the delivery of the food carts on the 5th floor. At 12:03 PM, Res #103 had not received a meal tray yet, as well as several other residents. Staff #58 informed surveyor that those residents who needed to be fed, we leave them (trays) in the cart. She said these residents were always fed last. At 12:36 PM, Staff #58 was feeding Res #527 beef stew and rice, but she had no green tea to drink as listed on her menu. Staff #58 did not realize the resident was missing this from her tray and was only spoon feeding her the entree. Surveyor queried whether the resident can have liquids in between, and that's when Staff #58 said, I will go get yeah fast kine and left to get the tea. Another staff, Staff #60 said, because we have plenty who need assist! and that was why they felt rushed even though they had 4 CNAs passing the trays and feeding residents. One CNA was dedicated to the Solarium to observe those residents. At 12:42 PM, Staff #50 said was finishing up with another resident and said once Staff #60 was finished in the Solarium, she was going to feed Res #103. However, by 12:45 PM, Res #103 still had not been fed, which was approximately an hour later by then. On 05/03/17 at 8:02 AM, Staff #67 was feeding one resident in the TV room. She had four other residents with her, one who could eat by himself, and one she was assisting. Staff #67 admitted that she still had two more residents to feed, even though the food cart arrived at 7:30 AM. She said before they had 6 CNAs, but now 5 CNAs. Yet, another resident, Res #216 did not know she had eaten and said, I ate already. Res #216's meal tray however was left untouched and Staff #67 said the resident does not remember. Staff #67 was not able to assist Res #216 since she was feeding someone else, but yet stated she would have to in addition to two other residents she still had to feed. At 9:16 AM, Staff #67 said it took her until 9:10 AM to finish feeding the three residents their breakfast, which was about an hour and 45 minutes after the meal cart was brought up. On 05/04/17 at 8:01 AM, Staff #62 and Staff #135 said they used to have six CNAs for 50 residents with three licensed staff. They said now there is only two licensed staff with three to four CNAs. They said sometimes, they have one CNA for 16 residents and only one licensed staff on the weekend. They both said, It's really bad and Staff #62 felt we're running and the families always say that to us too. Staff #135 confirmed they had 20 residents who are dependent in feeding, four with tube feeding and for the remaining residents, she said, although they can eat they still require supervision. Almost all need assistance. When she was asked why are the residents who required feeding assistance were fed last, she said, Because they have to go one at a time with them .But the food usually cold by then and so staff have to reheat it. On 05/04/17 at 8:28 AM, a family member of a resident who requested not to be identified, stated the reason why he/she came to help feed the resident was because if he/she did not, (resident) won't get fed timely. The family member said he/she feels sorry for the CNAs because they're always running and they're always short staffed. Even sometimes the patients are crying out loud too, like where's my food, where's my food. The family member said lately too, the meal carts were being delivered half an hour later, and the meals trays are mixed up. The family member shook his/her head acknowledging this. On 05/04/17 at 8:33 AM, an interview of Staff #121 was done. She was asked what quality measures were identified and what improvement measures were being implemented on her nursing unit. She stated there was a decrease in the number of falls due to the changes she made to the break hours for the night shift, as I was reviewing the trends, it was much improved, instead of 2 (staff) at a time, only 1 goes on break at a time. When asked about her observations of the residents' dining service on her unit, the PCC stated, We do get them up for lunch and dinner and how to feed residents and to be on the eye level. When further queried about the meal service itself, such as the delivery of the meal trays and if residents were fed timely, she stated, So far it's been good. Staff #121 was then asked again if she observed the meal trays coming up to the unit and the delivery of the trays to the residents to ensure timely meal service and consumption. She replied, No, not really. She was unable to identify the number of residents who were dependent on feeding assistance by the staff, but then said it was around 10. She acknowledged their ICF census had not changed that much. Staff #121 was also asked why the residents who required feeding assistance, such as Res #103 was always fed last. She was queried if it was because the cognitively impaired residents were less likely to complain if their meal was served to them an hour later and colder. Staff #121 had no comment and then acknowledged because she has not really observed the dining experience for her unit, she did not know. On 05/04/17 at 8:59 AM, Staff #36 stated she often has to help the CNAs with assisting the residents. She said, it's pretty bad and even though we attend the staff meetings, nothing has changed. Even family members will complain, but the families say, 'Oh no sense we say anything because nothing is going to change.'",2020-09-01
426,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,371,D,0,1,H76111,"Based on record review and staff interview the facility failed to monitor the before and after trayline temperatures for 1 breakfast, 2 lunch and 1 dinner in (MONTH) (YEAR). Findings include: On 05/08/17 at 8:37 AM Food Temperature Checklist Before and After Trayline forms were reviewed with staff # 147 and 148. It was noted that there were 8 different columns on the forms that had been left blank. 2 columns were blank on (MONTH) 30, (YEAR) during the breakfast trayline resulting in no temperatures documented for before and after trayline for the following foods cooked: breakfast meat, cooked cereal, egg, low cholesterol egg, pureed egg, miso and okai. On (MONTH) 2, (YEAR) and (MONTH) 22, (YEAR) there are a total of 4 blank columns for the lunch trayline resulting in no temperatures documented for the before and after trayline for the following foods cooked on those days: Okai, Miso, house soup, soft soup, SF soup, strained soup and thick soup. On (MONTH) 24, (YEAR) there are 2 blank columns for the dinner trayline resulting in no temperatures documented for the before and after trayline for the following foods cooked: Okai, Miso, broth, house entree, soft entree, chop entree, PD entree/meal, house veg., soft veg., chop veg., Pd veg., rice, mashed potato, and gravy. Staff #147 explained the disciplinary process for staff working in the kitchen who do not follow the departments policy regarding preparation and holding temperatures of foods on the trayline. Staff #148 was able to provide a copy of the Dietary Department Infection Control Policy which does state Foods will be held at proper holding temperatures / records will be maintained. The facility failed to monitor the before and after trayline temperatures in accordance with professional standards for food service safety.",2020-09-01
427,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,431,E,0,1,H76111,"Based on observation, record review, staff interviews and review of the facility's policy and procedure, the facility failed to obtain the services of a licensed pharmacist to ensure that the storage of all drugs and biologicals were kept under proper temperature controls, and also failed to ensure that licensed staff monitored the medication refrigeration temperatures on the nursing units. Finding includes: On 05/05/17 at 7:40 AM, during a tour of the medication refrigerator on the 6th floor nursing unit, the temperature was found to be within range at 36 degrees. However, during a review of the temperature log with Staff #91, it was found the recordation of the refrigeration temperatures were not being done. Staff #91 said it was to be done every shift. She said, If not being done, there's no way to know that we're maintaining medication potency and efficacy. She thought the pharmacist came to check on this too, but said she worked the night shift so she was uncertain how often the pharmacist came to check it. On 05/05/2017 at 8:00 AM, the DON stated after her review of the 6th floor nursing unit's medication refrigeration log, the reason or importance of monitoring the refrigerator temperatures and accurately recording them was because otherwise you wouldn't know if the meds are still good. She also produced the temperature logs for the other 3 nursing units. It was revealed for the 6th floor nursing unit, from 1/1/17 to 5/4/17, each week (Sun-Sat) for those prior months had undocumented temperature recordings on the Controlled Drugs - Refrigeration Checklist. In fact, most notably from 3/12/17-4/3/17 and 4/17/17-5/4/17, the temperature recordings were either all missing or documented by only a single shift. On the 5th floor refrigeration checklist, it was found there were some entries by various shifts of staff who were not documenting the temperatures and/or missed signing it on the 4/1/17-5/4/17 logs. On the 4th floor unit, there were entries where the licensed staff failed to sign their name as well. Review of the facility's policy, Medication Storage, Storage of Medication, 9/10, Section 4.1, it states under Procedures, 11. Medications requiring refrigeration or temperatures between 2 degrees C (36 degrees Fahrenheit) and 8 degrees C (46 degrees Fahrenheit) are kept in a refrigerator with a thermometer to allow temperature monitoring .16. Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken. On 05/08/17, during a morning telephone interview with the facility's consultant pharmacist, she stated her role included doing the resident chart review, reconciliation with the eMAR, etc., but stated she did not monitor the medication refrigerator temperatures. She could not recall the 6th floor had a medication refrigeration unit in the Solarium. She said if she knew the temperatures were missing for a number of days, she would report it and the facility would follow their protocol. The facility, albeit licensed staff having knowledge of the missing temperature recordings for months, had not followed up with the manufacturers even during survey to follow up on whether any of the refrigerated medications had the potential to be affected. In addition, although some licensed staff were recording the temperatures, it was not brought to anyone's attention when there was a clear failure that it was not done. Thus the pharmacist, nor the licensed staff did not ensure the refrigerated medications for use by their residents were maintained at safe temperature levels. There was no monitoring of the various nursing unit's medication refrigerators and temperature logs on a regular basis as a random QA check as evidenced by the lack of documentation found on the logs from (MONTH) (YEAR) to present.",2020-09-01
428,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,441,E,0,1,H76111,"Based on interviews and record review, the facility failed to establish a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services following national standards. Findings include: 1) 05/02/2017 at 0930 [NAME]M. Observation: Resident #317 (R#317) was observed to be in isolation status with Personal Protective Equipment (PPE) at entrance of doorway. It was observed that R#317 spouse entered room without gowning up with PPE and then came to the nursing station and handed a portable phone that came from the room to staff at nurse's station. According to the Kuakini Health System Policy IC 3200 (4) on Visitor Use of Personal Protective Equipment, section (b) states For Contact Precautions, gloves and gown shall be worn by anyone entering the patient room that may have patient contact or contact with potentially contaminated area in the patient's environment. 05/08/17 at 12:12 Interview with Staff #109. Staff #109 stated I knew about this. Stated that R#317 was discharged and that they had talked with the resident and also resident's spouse about this before and they have been noncompliant. 2) 05/04/2017 at 4:34 P.M. Observation: Staff #122 was conducting an Accucheck with the Assure meter. The meter was taken into an isolation room. Staff #68 was asked how long is your contact time for cleaning. Staff #122 stated just clean with alcohol wipes and to air dry. Staff #68 stated for clean and air dry for 5 minutes. Staff #122 was asked to read sani wipe bottles which clearly stated that should contact time is 2 minutes. 05/08/2017 at 12:12 Interview with Staff #109 stated We use the purple tops to clean any equipment and the contact time is two minutes. Staff #109 was made aware of the inconsistency among staff as to how to clean equipment and contact time for Purple top Sani Wipes. Staff #109 acknowledged and planned inservices in the future. 3) 3) On 05/02/2017 at 11:44 AM staff #112 was seen in Res #43 room delivering the lunch tray. Res #43 is on contact isolation for MRSA of the nares. The PPEs were noted on a table outside of the room. Staff #112 did not have on any PPEs while delivering the lunch tray to Res #43 in the room. Staff #112 was interviewed at that time. Staff #112 was asked if she knew why Res #43 was on contact isolation and why she did not use any PPEs she stated I don't know and I'm a float. Staff #112 was asked if she has been trained on how to use PPEs and she stated yes. On 05/08/2017 at 9:53 AM met and interviewed staff #121 who confirmed that if a resident is on contact precautions that staff must use PPEs even when delivering a lunch tray. The facility failed to maintain an infection control program to stop the spread of infection.",2020-09-01
429,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2017-05-08,514,E,0,1,H76111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and interview the facility failed to maintain complete clinical records according to professional standards and practice for residents and monitoring logs. Findings include: 1) Review of Resident #90's medical record had documentation in progress notes for the 9 (MONTH) that was illegible about orders from the MD, after the MD was notified about the resident's swollen right ankle that was warm to touch. There was no documentation as to how the staff found the resident's swollen ankle, or assessment of the resident including pain at the time that was legible. X-Ray Report dated 9 February, (YEAR) stated Severe osteopenia, non displaced spiral [MEDICAL CONDITION] tiabial metadiaphysis. Probable subtle non displaced distal fibula fracture. Diffuse [MEDICAL CONDITION] arterial calcification. Progress notes in medical record further to this occasion were illegible as well as being insufficient information documented to inform others. On 3 May, (YEAR) there was an entry in the progress notes that was partially legible about Resident #90's having a blackish ischimic wound on their right big toe. The rest of the entry was illegible leaving the progress notes incomplete and insufficient. 2) On 05/04/17 at approximately 2:00 PM, the State Agency (SA) team identified an immediate jeopardy (IJ) situation at the facility. The IJ was for the facility's failure to protect from the potential harm from adverse effects of a resident self administering medications, as evidenced by a lack of assessment, lack of a physician's orders [REDACTED]. In addition, licensed staff were falsifying their documentation of Res #39's self-administration of medication on the MAR. Cross-reference to findings at F176, F280, F333 and F353. 3) There was missing documentation of the various nursing unit's medication refrigerator temperature logs from (MONTH) (YEAR) to present. Cross-reference to findings at F431. 4) During a review of Res #104's physician order [REDACTED]. However, the resident's attending physician signed both the (MONTH) and (MONTH) POS on 4/17/17. On 5/8/17, during an interview with the Medical Director, she stated this needed to be clarified as to why the attending physician failed to sign the (MONTH) POS and signed the (MONTH) POS on 4/17/17. She stated the monthly POS should be signed by physicians monthly. 5) On 05/05/2017 at approximately 9:35 AM while doing a record review of Res #43 medical chart it was noted that 3 physician notes was not in the chart. The notes were from 03/08/2017, 03/30/2017 and 04/10/2017. These 3 progress notes were not readily available. Staff #149, who had written the missing notes, was paged and returned my phone call and was able to answer questions regarding the residents medications. Staff #131 was able to contact staff #149 office and they faxed over the notes that were missing from the chart.",2020-09-01
430,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,561,D,0,1,Y2I511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were given the opportunity to choose to have continued use of their bed side rails to aid in their activities of daily living (ADL) function to prevent decline, for two of seven residents (Residents (R) 55 and 73) selected for review. The facility failed to involve R55 and R73 in their decision and right to make a choice about the continued use of their side rails. The resident's self determination through support of resident choice was not ensured. The deficient practice had the potential to affect two residents functional ability and right to make choices in the planning and care received at the facility. Findings Include: 1. R55 was found to be alert and oriented and stated he has lived in the nursing home for [AGE] years. His last (MONTH) (YEAR) annual minimum data set (MDS) review to his last quarterly review in (MONTH) 2019, showed R55's brief interview for mental status (BIMS) scores were consistently at 15, 15 and 14. During the resident's interview, it was found his responses were reflective of his high BIMS scores and was well aware of his care and environment. On 07/24/19 at 09:24 AM, during an interview with R55, he stated he wished to have his bed side rails (side rails) placed back on. He said last week Thursday, facility staff came in and removed both of his bilateral upper half rails, but without his knowledge or permission. When he was asked if he wanted the side rails placed back, he said, Oh yes, absolutely. R55's family member (FM) was also present during the interview. The FM stated the side rails helped R55 with his bed mobility, especially the right side when the staff have to put him back to bed, he can help with his transfers. The FM further stated he could grab the bar to help himself, and makes him feel more normal too that he can do it, and it's better for him to be able to, right? On 07/24/19 at 02:58 PM, during a re-interview with R55, he said the staff took off side rails last week Thursday. He thought it was maintenance who removed his side rails. R55 said they did not give him a reason for the removal except it was a board of health decision. He said, Oh yeah, I was surprised. R55 said he has told others that he wanted his side rails replaced. R55 said the side rails gave him a sense of protection, and I feel more comfortable with it, going in and out of bed, and, to turn to side in bed when they change me. R55 said they removed both top side rails. He said his legs were weak, but he could hold onto the side rails to help turn. On 07/24/19 at 03:17 PM, an interview with RN135 was done. She said in her role, she was to review the residents' charts, do interviews and come up with care plans with the resident and/or family members. She said she has been working on assessing residents for possible side rail use and the discontinuation of the side rails on this unit was the beginning of July, 2019. RN135 denied knowing about R55's request for the replacement of his side rails. When RN135 was asked how the information was conveyed to the residents prior to the discontinuation of the use of side rails, she remained silent and then said, I'm not sure if there was something in writing, I'm sure something was said to the residents when it was being removed. When I came into the picture, it was 'please assess the resident if he really needs the side rail back.' During an interview with RN181 on 07/24/19 at 03:47 PM, she said, there was a family forum and a letter was given to the families about the side rails. And one day maintenance came and start removing and we said what's happening and we were told to come and take them all out. So when families are asking, we have to refer them to management. RN181 said for R55, his side rails were removed but now they were having to re-assess him and other affected residents. It was not based on assessing each resident first, nor was it based on the residents' existing side rail assessment forms. R55 had a assessment form which stated it was not considered to be a restraint, and with the abrupt removal, the resident was not given a choice about the removal. For R55, RN181 said the FM also asked about the removal of the side rails. On 07/25/19 at 04:05 PM, during an interview with the unit's nurse care coordinator, RN157, she was asked whether they looked at R55's most recent 05/07/19 bed rail/other device assessment record before removing his side rails. She replied, No. R55 was an alert and oriented resident who could make his needs known with a high BIMS score. The (MONTH) side rail assessment for R55 found it was not a restraint for him as he could ask to lower or raise the rail, had a medical condition of an old stroke with left sided [MEDICAL CONDITION]/weakness for which he could demonstrate the use of the side rail to assist himself for bed mobility, postural support or transfers during ADL care and a specific care plan had been developed that included how the side rail was used for this purposes. 2. During an interview with R73 on 07/23/19 at 01:04 PM, she said her side rails were removed, very recently. It's been a problem here, the beds are narrow. I'm a medium to heavy build, and when I turn, I have to grab on the side of mattress now. Feels like I'm going to fall off without it. R73 stated the reason for removing her side rail was, It's a board of health reason, but I want it for safety. I want it put back on. A FM also present stated it helped R73 with her bed mobility. On 07/25/19 at 08:32 PM, during a re-interview with R73, she stated staff came to re-assess her about her side rail use. R73 said, I told them I want it back up because it helps keep me secure, and I like it for my exercise. R73's side rail assessment record was similar to that of R55, but lacked a medical condition for its use. R73's (MONTH) annual MDS and (MONTH) quarterly MDS assessment showed repeat BIMS of 15.",2020-09-01
431,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,568,E,0,1,Y2I511,"Based on interviews and policy review, the facility did not provide residents with a financial record or quarterly statements of their personal funds. As a result of this deficient practice, the resident does not know the status of their account. Findings include: On 07/25/19 at 10:55 AM, attended a Resident Council meeting. When asked the residents if they had any money they kept at the facility, and if they received quarterly statements of their accounts, one resident (R)103 replied, Yes, I need a new one (statement) now. On 07/26/19 at 08:42 AM during an interview with the financial representative (FR) in charge of the resident trust funds, she described the process to establish a financial account when admitted to the facility. When an account is set up, we ask the Resident or representative if they want a monthly statement. If they do, we make labels and I have a system to mail the monthly statements to the designated durable power of attorney (DPOA) .or I hand deliver them to the residents. A lot of them don't want them (financial statements). When asked if a quarterly statement was routinely provided, the FR replied, No, but they can ask for one any time. Inquired if there was any documentation that a discussion occurred about the financial statements with the residents/DPOA's, and the FR replied, No, we currently do not document that anywhere. Review of policy #96-06 titled Kuakini skilled nursing facility (KSNF) Kuakini intermediate care center (KICF). Resident trust fund accounts with effective date (MONTH) 2010, revealed the following statement, If the resident is the authorizer for the account, the social work assistants (SWA) will inform the resident directly of account balances on a monthly basis. If the resident is incapable of handling his/her finances, the SWA will inform the DPOA of the account balances. On 07/26/19 at 09:41 AM during an interview, the Manager of Care Management (Care Mgr.), said they have about 30 trust accounts. Reviewed the facility policy and requirement to provide quarterly statements, and the Care Mgr. said she was unaware of the requirement and would be revising the policy.",2020-09-01
432,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,578,D,0,1,Y2I511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews (RR) the facility failed to produce documentation that a discussion took place to review and update the advance directive (AD) and clarify the wishes for medical treatment for one resident (R) 345 of five residents sampled. The deficient practice could potentially affect all residents by not honoring wishes for healthcare decisions at the end of life. Findings include: R345 is a [AGE] year old male admitted to the facility on [DATE] for rehabilitation and management of: chronic [MEDICAL CONDITION], weakness, chronic [MEDICAL CONDITION] disease, chronic [MEDICAL CONDITION], and [MEDICAL CONDITION]. R345 has had multiple admissions to the hospital. His past medical history included [MEDICAL CONDITION]. R345 was alert, oriented and capable of understanding and expressing his wishes regarding medical treatment. 1. Progress note encounter dated 07/09/19 by Physician (MD)1 revealed the following: Full Code (all resuscitative efforts), and Advance care planning comment: Living will, 11/07/17, doesn't want life prolonged . 2. RR on 07/24/19 10:26 AM, revealed an AD signed by R345 dated 11/17/17. On the AD, R345 marked the box that states, I want to stop or withhold medical treatment that would prolong my life. The AD also indicated R345 did not want any artificial nutrition or hydration. The admission order for R345 was Full Code, and there was no Provider orders for life-sustaining treatment (POLST). 3. During an interview with Medical Social Worker (MSW)50 on 07/25/19 at 01:20 PM , reviewed R345's AD that stated not to prolong life, the code status, and order of full code. Asked what the facility process was to address AD's. MSW50 said on admission they ask if the resident has an AD, and it is put in the chart. The MD reviews the AD with the resident, and writes the order. MSW50 said R345 still wanted to be transferred to the hospital for treatment. 4. On 07/26/19 at 09:50 AM reviewed R345's AD with MSW179. Asked if there was any documentation in the record that MD1 had discussed the AD with R345, and she replied No. MSW179 agreed there should be documentation of the discussion with R345 that clarified current wishes and the full code order.",2020-09-01
433,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,584,D,0,1,Y2I511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide an environment with comfortable sound levels on third floor Intermediate care facility (ICF). The deficient practice has the potential to affect the well being of other residents who reside on the floor. Findings include: During an interview with Resident (R)96 Family member (FM)1 on 07/23/19 at 12:21 PM, stated that the roommate plays his music really loud and its very noisy. I noticed that some of the rooms have the volume on the television turned up really loud. During an observation in front of room [ROOM NUMBER] on 07/23/19 at 02:30 PM loud yelling could be heard coming from R111 in room [ROOM NUMBER], which is on the other side of the unit. During an observation on 07/24/19 at 9:00 AM, a loud television could be heard while standing in front of room [ROOM NUMBER]. The loud television was coming from room [ROOM NUMBER], also on the other side of the unit. During an observation on 07/24/19 at 10:42 AM while sitting at the nurses station a loud moaning was heard from R78 in room [ROOM NUMBER]A near the nurses station. During an observation on 07/24/19 at approximately 03:45 PM while sitting at the nurses station loud yelling was heard coming from R11 in room [ROOM NUMBER]. During an observation on 07/25/19 at 08:59 AM next to the elevator, the television in room [ROOM NUMBER] was very loud. During an observation on 07/25/19 at 03:08 PM loud yelling was heard from Resident # 111 while staff were completing change of shift. Care plan for R78 reviewed. One of the behavioral interventions written on the care plan states provide the resident with a quiet environment . During an interview with Registered Nurse (RN)63 on 07/26/19 at 08:49 AM regarding the noise level on the unit, stated that R111 has her call light but doesn't know how to use it so yells out frequently and staff go to check on her. The roommate and family of the resident in 329 who keeps the television loud was asked if they want to move to another room due to the noise and they declined. Many of the residents are hard of hearing so they like the television louder. RN63 agreed that the loud noise on the floor can affect the well being of some of the other residents on the floor.",2020-09-01
434,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,623,F,1,1,Y2I511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview and policy review, the facility failed to ensure the Hawaii State Long Term Care (LTC) Ombudsman was notified at the time of a transfers or discharges for six of seven residents (Resident (R)129, 296, 86, 297, 348, and 59 selected for review. The deficient practice had the potential to affect all residentswho are transferred or discharged . Findings Include: 1. Resident (R) 129 was interviewed on 07/23/19 at 03:10 PM and stated she recently returned from the hospital. She thought she had pneumonia and was beginning to slowly feel better. She was found to be alert, oriented and conversant. Record review found that R129 was coded on the Minimum Data Set (MDS) with a discharge with return anticipated. On 07/26/19 at 09:13 AM, during an interview with RN157, she confirmed the resident was recently discharged from the hospital, and returned to the facility on [DATE]. RN157 showed the transfer form they used to transfer the resident to the hospital. Upon inquiry as to what was sent to notify the State's LTC ombudsman of the transfer, she stated, No, because this is something new I'm hearing. RN157 confirmed they have not been sending any notice of transfers/discharges to the State LTC ombudsman. 2. A closed record review for R296 was done as part of a complaint investigation. One allegation was that the resident's family was not notified of the resident's remaining skilled rehabilitation days with this admission. As a result, the family was told R296 had to be discharged because her insurance for skilled rehabilitation services had been exhausted. Record review found R296 was admitted to the facility on [DATE] after a hospital stay. Upon admission to the facility, R296 received skilled rehabilitation services due to physical deconditioning, amongst other diagnoses. R296 received physical and occupational therapy services during her stay, but by 03/21/19, there was a physician's orders [REDACTED]. R296 was then discharged to home on 03/24/19, but there was no Notice of Medicare Non-Coverage (Notice) found in R296's record. This Notice outlined when the effective date of coverage for R296's then skilled nursing services was to end, and was to have been provided to the resident and/or appropriate resident representative with signature/date attestation. RN157 verified the Notice was not provided. Furthermore, on 07/29/19 at 08:45 AM, RN157, re-verified they have not been notifying the ombudsman for any transfers or discharges. RN157 stated, going forward they will be sending it to the State LTC ombudsman. RN157 also confirmed there was no policy on this. A review of policy, Discharge Management Program, (illegible policy number, but supersedes: 02/99), was done and it was found that there was no procedure in place to notify the State LTC ombudsman as part of the facility's discharge planning process. 3. Discharge/ Transfer summary dated 05/08/19 reviewed for R86. R86 was admitted to an acute care hospital on [DATE] to 04/15/19 [MEDICAL CONDITION] due to healthcare associated pneumonia (HCAP). No documentation found in the record to indicate that the States Long Term Care (LTC) Ombudsmen was notified of the transfer of R86 to acute care. During an interview with RN63 on 07/26/19 at 12:20 PM stated that the resident was transferred to acute care where he was on observation for 4 days, the facility saved his bed and he returned to the facility so he wasn't really discharged . 4. Medical record for R297 reviewed. The resident was discharged to an acute care hospital on [DATE] for fever and dehydration. No documentation was found in the record to indicate the LTC Ombudsman was notified of the transfer. 5. RR revealed R59 was transferred to the Emergency Department for acute [MEDICAL CONDITION] on 07/04/19. No documentation was found to indicate the LTC ombudsman was notified of the transfer. 6. RR revealed R348 was transferred to an acute care hospital on [DATE] because she was difficult to arouse and had a low blood pressure. She was admitted [MEDICAL CONDITION] due to a urinary tract infection. No documentation was found to indicate the LTC ombudsman was notified of the transfer. During an interview with RN70 on 07/29/19 at 08:20 AM was asked what the process was when a Resident is transferred to the hospital, and who they notify. RN70 stated, We call the family and report it to the supervisor. Asked it anyone else gets notified, and RN70 stated, It would be the supervisors that report them (transfers) to the State, adult protective services (APS) or anyone else. RN70 did not know if anyone was reporting transfers to the LTC ombudsman.",2020-09-01
435,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,638,D,0,1,Y2I511,"Based on record review and interview, the facility failed to do the Resident Assessment (RA) for Resident (R)1 using the quarterly instrument at the 3 month interval. Findings include: Record review for R1 revealed that the Resident Assessment (RA) that was due on 07/08/19 was incomplete and the quarterly review that was due on 02/11/19 was late. During an interview with the Minimum Data Set (MDS) coordinator on 07/08/19 stated that yes they are late for the quarterly RA for R1.",2020-09-01
436,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,655,D,0,1,Y2I511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review (RR) the facility failed to identify one Resident's (R)350 potential need for oxygen (O2) therapy in the baseline care plan. This deficient practice has the potential to affect all residents on admission when the baseline care plan is developed. There is the potential that problems are not identified and interim approaches are not established to meet the resident's immediate needs. Findings include: 1. R350 was a [AGE] year old female whose [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] for management of her medical problems and short term rehabilitation. 2. RR revealed R350 had an admission order written on 07/18/19 by physician (MD)3 for O2 therapy that read: O2 via nasal cannula PRN (as needed) SOB (for shortness of breath). (MONTH) titrate as needed to maintain O2 SAT (measurement of oxygen in the blood) 92% or above. 3. RR revealed the respiratory section of the initial care plan (base line care plan) dated 07/18/19 did not have any documentation that R350 required O2. The only documentation in the respiratory section of the care plan was N/A (not applicable). On 07/22/19 at 02:15PM, observed R350 resting in bed. She was breathing easy and in no respiratory distress. R350 did not have O2 on at that time and was breathing on room air. During an interview with RN70 on 07/25/19 at 09:09 AM discussed the admission process. RN70 said, The admission nurse completes a head to toe assessment. The RN reviews a copy of the discharge summary and Medication Administration Record [REDACTED]. The MD is called to complete the admission orders [REDACTED].",2020-09-01
437,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,657,E,0,1,Y2I511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure each residents' comprehensive care plan remained current and/or revised according to the resident's assessment and physical, functional status for three of three Residents (R)55, 18, 96, selected for review. The deficient practice had the potential to affect any development or revision of resident care plans. Findings Include: 1. Cross-reference to findings at F561. Resident (R) 55 was found to be alert and oriented and stated he has lived in the nursing home for [AGE] years. During an interview with R55 on 07/24/19 at 09:24 AM, stated he wished to have his bed side rails (side rails) placed back on. He said last week Thursday, facility staff came in and removed both of his bilateral upper half rails, but without his knowledge or permission. When he was asked if he wanted the side rails placed back, he said, Oh yes, absolutely. R55's family member (FM) was also present during the interview. The FM stated the side rails helped R55 with his bed mobility, especially the right side when the staff have to put him back to bed, he can help with his transfers. The FM further stated he could grab the bar to help himself, and makes him feel more normal too that he can do it, and it's better for him to be able to, right? Review of R55's Current Care Plan found a 09/21/15 falls plan of care that stated, At risks for falls/injuries due to (D/T) forgetfulness, impaired mobility/gait, left side paresisis (sic) related to (R/T) old stroke ([MEDICAL CONDITION]). The interventions included the use of upper rails to assist him for bed mobility, transfer and standing, per RN181 on 07/25/19 at 12:45 PM. Another ortho/mobility care plan dated 09/12/15 stated, Unsteady gait, able to bear weight with assist but non-ambulatory, at risks for falls, R/T [MEDICAL CONDITION] left [MEDICAL CONDITION], had interventions which included, Instruct him to hold on to his upper rails during transfers, while using the urinal when up in the chair, during bed mobility. Discontinued 7/14/19. Yet, with the discontinuation of R55's side rails noted on the care plan for ortho/mobility, it was found R55's current care plan was not further revised to indicate how the resident would now accomplish the stated interventions to meet his mobility goals. R55 currently had no device to assist him with bed mobility, transfers, weight bearing and to maintain his level of joint function. On 07/25/19 at 10:53 AM, RN181 confirmed that R55 side rails were part of the care plan to aid in his mobility. RN181 also affirmed the resident should have been involved in this aspect of his care planning, as it affects his mobility now without it. During an interview with the Nursing Home Administrator (NHA) on 07/26/19 at 09:45 AM, when asked what was done in the interim to replace R55's side rails which the resident stated he needed to move in bed. The NHA queried RN157 if there he (R55) was limited in his functional abilities? RN157 stated, Right now, without the side rails, yes it will affect his activities of daily living (ADL) function, acknowledging the potential for ADL decline, and that his care plan had not been revised to address this. 2. During an interview with Staff (S)36 on 07/23/19 at 09:30 AM reported that R18 was sent to the emergency department (ER) for complaint of pain and hematuria. Record Review (RR) for R18 and concurrent interview with S136 on 07/25/19 at 07:56 AM revealed that R18 was diagnosed with [REDACTED]. S136 agreed that the Careplan for peri-care had not been updated since 03/25/19. Peri-care is a procedure and a standard of care. It's supposed to be done every shift. I don't see that the Careplan was updated for Peri-care. RR reveals that resident had a previous UTI on 07/01/19. On further RR, the resident was found to have [MEDICAL CONDITION]. During an observation during R18's personal care on 07/25/19 at 08:10 AM R18 was non-verbal and laying in her bed with eyes open. S198 stated R18 is slightly wet but looks clean with clean sheets and good oral care. S198 verbalized to surveyor that she does peri-care when she changes R18's diaper. 3. During an interview with R96 family member (FM) on 07/23/19 at 12:34 PM when asked are you invited to participate in setting goals and planning R96 care? FM replied by asking what is a care plan? I have never been to a meeting or told about the care plan. Medical record reviewed. The Attendance sheet Interdisciplinary Team MDS/Care Plan Conference form did not indicate FM1 was present at the care plan meeting. During an interview with RN63, stated we invite the families to come in to attend the inter disciplinary team (IDT) meeting to discuss the care plan. The Social Worker (SW)132 sends the invitation to attend the IDT meeting to the primary contact person for the Resident. After the meeting the staff and resident representative sign off on the IDT attendance form. I believe R96 representatives were not able to attend the last care plan meeting. We make the effort to invite the representatives to the meeting but most of the time they don't come. Discharge management program policy reviewed. II. Kuakini Geriatric Care, Inc. Patient Management Procedure . The discharge plan is developed with the resident/ family by the interdisciplinary team which includes the physician, nurse, dietician, rehabilitation services staff . B. B. Persons attending the meetings include, but not limited to, the Medical Social Worker, charge nurse, . resident and/or family.",2020-09-01
438,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,676,D,0,1,Y2I511,"Based on observation, interview and record review, the facility failed to ensure that Resident (R)61's ability to ambulate did not decline and did not recognize that a re-evaluation was necessary to preserve and sustain ambulation. This deficient practice placed the resident at a potential risk of a decline in activities of daily living. Findings include: During an interview with R61on 07/24/19 at 08:03 AM who stated that she (R61) hasn't been walking. R61 referred to an employee no longer there Staff (S)196. Ever since S196 left I haven't been out of bed walking. During an interview with the physical therapy manager on 07/26/19 at 10:54 AM, stated the last time we saw R61 was in (MONTH) of last year (YEAR). We were ambulating her and then referred her for restorative therapy. During an interview with S68 and S72 on 07/26/19 at 11:15 AM stated, S196 used to walk R61 with the wheelchair but I haven't seen R61 walking around since S196 left. During an interview with LN6 on 07/26/19 at 11:23 AM stated S45 is out this week. LN6 stated float pool is in charge of S45. Surveyor asked who is in charge of her competency and who is she accountable to? LN6 stated that float pool is. During an interview with LN4 on 07/26/19 at 11:44 AM stated they didn't have a regular charge before. S45 told me that she would discuss it with the charge nurse if there is any declining in a patient or if someone needed more restorative care. I asked to meet with her once a week and she told me that is too much and wanted to meet with me once a month. S45 comes under all the nursing umbrella because she covers ICF/SNF. During an interview with S198 and S27 07/26/19 02:44 PM stated we transfer her from bed to chair and chair to the bathroom. R61 can walk about three to four steps. During an observation of R61 on (MONTH) 23, 24, 25 and 26 R61 was in a wheelchair. No ambulation was observed. Record review on (MONTH) 25, 2019 revealed the restorative program flow sheets for the months of December, January, February, (MONTH) of 2019 were missing. Queried with LN6 who stated that S45 had been out for those months and that no one was working the restorative program, so there was no documentation. During an interview with R61 on 07/26/19 at 02:57 PM stated that although she wants to walk she does not feel that she is ready, she is scared. S198 and S27 offered to walk R61 although she refused.",2020-09-01
439,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,695,D,0,1,Y2I511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review (RR), the facility failed to administer oxygen therapy according to the physician (MD)3 order to one resident (R)350 sampled. R350 was placed on continuours O2 via nasal cannula (NC) without notification or orders from the MD. This deficient practice has the potential to affect any resident that is receiving oxygen (O2) therapy, and puts the residents at potential risk of adverse effects associated with O2. Findings include: R350 was a [AGE] year old female whose [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] for management of her medical problems and short term rehabilitation. On 07/23/19 at approx 02:00PM, observed MD3 having a discussion in the 6th floor nursing station with RN70. MD3 was heard asking RN70 why R350 was on O2. RN70 replied, We were going to call you. Her daughter requested it. She (daughter) said she (R350) is on oxygen at home and her pulmonologist recommended it. We were gonna give you a call. MD3 stated She should probably have a titrated order (accurate adjustment of the amount of O2 delivered based on the O2 saturation level to reduce complications associated with oxygen therapy). I thought maybe she (R350) had some difficulty breathing or something happened. RN70 replied,No, she's been fine. RR revealed R350 had an admission order written on 07/18/19 by MD3 for O2 therapy that read: O2 via nasal cannula PRN (as needed) SOB (for shortness of breath). (MONTH) titrate as needed to maintain O2 SAT (measurement of oxygen in the blood) 92% or above. RR of MD3 history and physical note dated 07/19/19 included: [AGE] year woman with dementia, . asthma, . recent admission to an acute care hospital . Asthma : Patient denies wheeze, SOB. continues to use inhalers per nursing, no prn albuteral ([MEDICATION NAME][MEDICATION NAME] that relaxes muscles in the airway and increases air flow to the lungs) used. Currently saturating at 96%. RR of nursing notes revealed the following documentation of R350's respiratory status, oxygen saturation and delivery of oxygen: 07/18/19 noon . O2 sat 97% on room air, no SOB, no resp distress 07/18/19 2200 . O2 sat 98% on room air 07/19/19 800 . no SOB, O2 sat 96% 07/20/19 830 . sat 92%, no SOB 07/20/19 94% room air 07/21/19 630 . O2 at 1L(liter)/NC (nasal cannula) 96% O2 07/21/19 16:15 . O2 sat 96% 07/22/19 630 . O2 sat 96% 1L/NC No SOB or respiratory distress 07/23/19 0400 . O2 sat 98% 2 L/NC appears comfortable no distress RR of kardex (communication tool updated daily used by staff) revealed an entry on 07/20/19, daughter req (request) O2. At 1925 that day, O2 sat was recorded as 94% room air. R350 was placed on oxygen therapy 07/21/19. RR revealed MD3 progress note dated for encounter 07/23/19 that added On home therapy to diagnoses. The progress note also included: Asthma: the patient is currently on nasal cannula. Reportedly the patients pulmonologist wants the patient to be on continuous oxygen at all times, and the patient is on oxygen at home. NO wheezing, desaturation (low blood oxygen concentration), or shortness of breath. RR revealed new order on 07/23/19 at 03:58 PM from MD3, okay to use continuous O2 via nasal cannula per pulmonologist. Review of policy titled Oxygen therapy review dated 07/2001, directs staff tocheck physicians order for method of administration , liter flow and length of time patient is to receive medical gas. The oxygen was documented to be delivered continuously from 07/21/19 to 07/23/19, which was not what the active order stated.",2020-09-01
440,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,725,D,0,1,Y2I511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility, the facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure Resident (R) safety and maintain the highest physical and mental well-being of each resident as determined by resident assessments, acuity and [DIAGNOSES REDACTED]. Findings include: Review of Resident Council meeting minutes revealed staffing concerns residents brought up at the meetings. Concerns from Resident Council meeting on 04/19/19 a. Still needing more nursing especially at night, only three certified nurse aides, (CNA's). Day shift is also short b. People in wheelchairs .they will stand up and fall if staff don't get to them in a timely manner. c. Staff rush due to not having enough staff-it's an institutional issue, it's not any particular person's fault, there is not enough staff to care for everyone, sometimes staff will leave you in the middle of care to attend someone else. d. Staff demoralized because they are rushing. One staff came in almost in tears because another resident was calling for assistance every five minutes. Response addressing this issue in 06/21/19 minutes. Challenges of staffing will unfortunately always be an issue but we will do our very best. On 05/20/19 we had five CNA's out sick, three licensed staff out sick which affects staffing and creates challenges. There is no lack of wanting to hire more staff-it's lack of available qualified people. We also had staff on board and it's not what they expected so they have left. Concerns from Resident Council meeting minutes dated 05/17/19: a. You wait to go to the toilet, not enough workers b. You don't want to make a mess in your pants/diaper, night shift tells me that morning shift has to take me to the bathroom. Response .It's not ideal to have to use agency staff. We will try to have agency focus on individual likes/dislikes. c. I urinate frequently-the staff think I'm lying when I ask to go. d. It would be good if the agency staff can be acquainted with the unique problems of each resident (doesn't have to be everything). e. I call and call and no one comes, I get angry sometimes I tell them I don't want lunch. f. With agency staff, we try to teach them but they just get mad. g. Tray may be waiting outside but because staff helping 1st shift, the food just sits outside. 2. During a resident council meeting facilitated by MSW17 on 07/25/19 at 09:57 AM the following attended: R121, R104, R103, R93, R82, and R55. Minutes were reviewed from 06/21/19. MSW171 said, There were a lot of concerns regarding staffing issues last meeting. The Patient Care Coordinator (PCC)2 and Chief Nursing Officer (CNO) came in to address concerns. MSW171 asked how staffing has been. Holding up the minutes, R103 said, This is an authentic document and what I'm going to say today will be repetitious . each resident meeting almost the same. MSW171 confirms and explains things . We are safe and happy, but often there are only three on the floor. That means one will have to take care of 16 .Unique demand here. Geriatric floor needs special help. Have people reluctantly taking overtime, agency and floaters. This comes up often. Don't know how the hospital will solve it. R82 said. People don't come to help you. R103 said, I was satisfied with PCC2's response, but PCC2 is limited in what he can do. He now has more than one floor . When asked if staffing was more problematic on a particular shift, R103 said, Depends on the day, but weekends are the worst. Lack of staff is prevalent throughout the day . This is not a complaint, our empirical experiences are real. 3. During an interview with Registered Nurse (RN)181 on 07/26/19 at 02:42 PM, stated one of the reasons why the care plans could not be reviewed/revised timely was because they (the staff who review the care plans) were being pulled to other assignments/duties. An example was for R55's recent discontinuation of his side rails that was not reflected in his care plan to assure mobility was not affected to avert any potential declines in his activities of daily living (ADLs). On 07/29/19 at 10:18 AM, RN181 said again, their unit only had two licensed staff scheduled for the day shift. RN181 said she did not know how she would be able to look at things, such as the care plans, while having to pass medications. RN181 also verified for Thursday 07/25/19, they only had one licensed practice nurse (LPN) and herself working. This was also verified by the State Agency (SA) on the unit that day. RN181 said the facility census/staffing for that day was incorrect because it listed three licensed staff on duty for the day shift, but there were only two licensed staff working. 4) During an interview with S27 on 07/25/19 at 06:40 AM regarding how the staffing on the fourth floor is, stated I've been here since 11:30 last night and I am going home at 11:30 PM today. On Saturday and Sunday, I was the only CN[NAME] It is worse on the CNA's. When we are short staffed I have to triple my steps. We are expected to do everything short-handed. When asked if the range of motion (ROM) Is getting done on this floor, S27 looked down and stated, no, it is hard. During an interview with LN99 on 07/25/19 at 10:25 AM stated I call the staffing on the 4th floor a Band-Aid. We are lucky to get what we get. It's just . I mean we have so many out on medical and extended leave. We have staff that are not accountable. LN99 continued to explain the matrix, census and staffing. The census is 44 on day shift so there should be one RN, two LPN's and 5 CNA's. We float out 2 RN's, one LPN - 3 licensed from this floor. CNA's is 3.5 and then the orientee - she's strong so we put her there but it's still short. Everyday, it's a band aid. Some staff will see their schedules and when they see a fifth CNA, sometimes they will call out. We then will compliment the other floors with staff and then the fifth person calls in sick leaving our floor short. We have started to mandate those staff to get a doctor's slip. We have behavior of overtime and tardiness where staff will not come on time or they are tardy and staff that will leave before their shift is over. We are going with progressive discipline, staff are being placed on admin leave or they get suspended, they are starting to realize we are not fooling around. `",2020-09-01
441,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,726,D,0,1,Y2I511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, including the standard of practice for medication administration via a gastrostomy tube ([DEVICE]) for one of 25 residents (Resident (R) 130) selected for review. Findings Include: On 07/24/19 at 08:45 AM, a medication administration observation was done for R130. A licensed practice nurse (LN)183 was observed to administer three medications via R130's [DEVICE]. On 07/24/19 at 08:52 AM, after LN183 checked the for placement of the [DEVICE] and residual fluids (still in the stomach), she administered a 30 milliliter (ml) water flush followed by the first medication via the [DEVICE]. a second 30 ml water flush then a second medication was administered. A third 30 ml water flush, followed by a third medication with a fourth and final 30 ml water flush via the resident's [DEVICE] totaling 120 mls water. Review of the facility's policy, Medication Administration Enteral Tubes, provided by RN181 as their facility policy and standard of practice for their licensed staff. It stated on page two of five of Section 7.10, 9. Enteral tubes are flushed before administering medications and after all medications have been administered with at least 15 ml of water. 10b. The enteral tubing is flushed with at least 5 ml of water between medication administration. On 07/24/19 at 09:40 AM, LN183 stated she reviewed the medication administration policy for [DEVICE]s and said, It's supposed to be five ml flush between meds, sorry. Then during an interview with Registered Nurse (RN)181, verified this was the policy to follow for enteral medication administration, and LN183 should have given 15 ml water before and after the medications were administered and at least five (ml), between each medication administration. RN181 verified this procedure was not followed by LN183.",2020-09-01
442,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,757,D,0,1,Y2I511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the use of unnecessary medications include a review of the target behaviors being accurately monitored for one of five residents (Resident (R) 70) selected for review. This deficient practice had the potential to affect other residents prescribed with psychoactive medications. Findings Include: 1. Random observations of Resident (R)70 during the survey found this resident to be engaged in the daily activities/program offered by the facility. He was often quiet, but would appropriately respond to questions asked of him when interacting with the staff. Overview of R70's medication regimen found he was taking: [MEDICATION NAME] 10 milligrams (mg) one pill daily for his anxiety/behavior r/t (related to) dementia affecting his self-care; [MEDICATION NAME] 250 mg one pill twice daily for mood/behavior r/t dementia; [MEDICATION NAME] 25 mg one pill twice daily, but to hold if he was sleepy, for his [DIAGNOSES REDACTED]. Review of R70's (MONTH) 2019 Behavior/Intervention Monthly Flow Record found the target behaviors for all four medications were for [MEDICAL CONDITION] and getting out of bed without help. The [DIAGNOSES REDACTED]. During an interview with licensed practice nurse (LN) 64 on 07/26/19 at 02:28 PM, stated R70, would occasionally have behaviors like trying to get out of bed on his own but was easily re-directable. During a concurrent review of R70's flow record with LN64 acknowledged that the specific target behaviors for the [MEDICATION NAME] acid and [MEDICATION NAME] should be anxiety and mood. [MEDICAL CONDITION] for the [MEDICATION NAME] use. LN64 confirmed there was not separate flow record for each medication and all of the medications were grouped together as whole. LN64 said their pharmacy consultant taught them how to use the behavior monitoring sheet and they have been doing it this way.",2020-09-01
443,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,842,D,0,1,Y2I511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the medical record contained an accurate representation of a resident's medical treatment and device use for one residents (Resident (R) 55) selected for review. The treatment was being documented on the flowsheet but was not being done for R55. This deficient practice had the potential to affect any future residents with similar treatments and/or device use. Findings Include: During random observations of R55, was seen without the use of any splint device to his left upper extremity. The resident had left sided [MEDICAL CONDITION] (weakness) due to a stroke. R55 did have a blue cushion type lap tray however, when he was sitting in his wheelchair, and which he used to rest his arms upon. On 07/24/19 at 09:29 AM, during an interview with R55, he stated he wants and uses the lap tray because he is weak on the left side. A family member (FM) also present with him stated it helped to support R55's left side and he used the tray to place his Kleenex box on it and to do activity things. Record review found as part of the bed rail assessment, the use of R55's lap tray was noted within Other Device Assessment for 6a. Wheelchair lap table is not a restraint because: resident can ask to have it removed; resident can remove it on his/her own, and care planned. However, there was no physician's order for the use of [REDACTED]. On 07/26/19 at 08:12 AM, a concurrent record review was done with Registered Nurse (RN)157. After reviewing the orders, she stated, I don't see it and confirmed they should have an order for [REDACTED].>Also, it was found during the 07/24/19 09:52 AM observation of R55 that he had no left sided splint device or brace on. R55 had said his left side was weak. Record review however, found a physician's order dated 03/16/18 for a wrist brace to be used to his right hand and to be put on in the morning, and removed at night for support and pain. On 07/25/19 at 07:28 AM, during an interview with certified nurse aide (CNA) 71, she said R55 had a left hand splint, but since the room fumigation in early June, they could not locate it. CNA71 verified it was for the left hand and not the right, although the order was for a right wrist brace. On 07/26/19 at 08:20 AM, during a concurrent record review with RN157, the order was noted to be inaccurate and should have been written for a left wrist brace. In addition, the resident confirmed that it was for his left hand and not the right at 08:30 AM that morning. Further, the treatment document which the licensed staff had been signing as administered, showed it was for a wrist brace to the right hand. The nursing entries of 0 meant per the Chief Nursing Officer, means it's being put on, and further stated that they will need to get the order changed as it was inaccurate.",2020-09-01
444,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-07-29,880,D,0,1,Y2I511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document/policy review and interviews, the facility failed to have a system in place to ensure all policy/procedures for the infection prevention and control program were reviewed and revised as needed on an annual basis. The deficienct practice could affect staff, community and residents and put them at potential risk of developing a health-care associated infection that can have significant adverse consequences. Findings include: 1. The infection prevention program documents, and policy/procedures were reviewed. Three policies had not been reviewed annually. a. Influenza quarantine protocol Director of nursing (DON)/Medical Director guide was dated 04/06/18. This policy provides direction for staff to screen and report influenza. b. Guideline for the management of patients with [MEDICAL CONDITION] (MRSA), [MEDICATION NAME] intermediate/resistant staphylococcus aureus (VCRA), [MEDICATION NAME] resistant [MEDICATION NAME] (VRE) or extended spectrum beta lactamase gram negative bacilli organisms (ESBL) policy number C3600 with approval date 02/16/16. The policy's purpose was to prevent outbreaks and provide direction for staff to identify, screen and isolate resident's as needed and provide criteria to discontinue the isolation. c. Guideline for the management of patients with [MEDICAL CONDITION](C diff), policy number IC4100 had an approval date of 07/19/16. This policy provided operational guidelines for the prevention, control, and management of [MEDICAL CONDITION]. 2. On 07/29/19 at 08:59 AM during an interview with the Administrator, patient care coordinator (PCC)1, and PCC2 reviewed the infection prevention and control program and discussed the resources available to the facility. The Administrator said they utilize resources from the parent hospital for infection prevention a lot. The administrator validated the three policies did not have current review dates, and said they were Health System policies and would check with the hospital on the status.",2020-09-01
445,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-08-09,625,D,1,0,PR6411,"> Based on interviews, policy and procedure and record reviews, the facility failed to provide to the resident (R)1 and the resident's representative notice of bed-hold policy and return. Findings include: On 07/31/19 a complaint call came in from family regarding Resident (R)1 to the State Agency. The complainant stated that her mother-in-law was transferred to an acute facility and not allowed to come back to the facility. She was notified but she was not told about a bed-hold policy. Record review (RR) on 08/09/19 and concurrent interview with Staff (S)2 who stated that he was not aware of a bed-hold policy form. Although the family claimed that they were not notified regarding R1's escalating behaviors, documentation in the chart did reveal that on: 10/31/18, R1's brother was called and updated about his sister's situation. On 11/01/18, Nursing staff notified the family regarding R1 calling 911 due to her paranoia of staff. The family was informed of the escalating situation with R1 at that time. On further RR, orders were written to send patient to Queen's emergency room by the physician. Interview with S2 on 08/09/19 at 0100 PM who stated we did not issue or discuss a bed-hold and Agreement of Payment form. The resident was not at our level of care at that point. Facility's Policy and Procedure No: 01-03-02 under procedure statesPatient Care Coordinator (PCC) or Shift Coordinator (SC) will review the bedhold policy and Procedure with the resident and/or legal guardian prior to transfer or discharge from the facility. The PCC will review the Request for Bedhold and Agreement of Payment contract. Discussion with Staff (S)1 and S2 on 08/09/19 at 0200 PM regarding the regulation which states notices to be issued according to regulations the first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility's policy were to change. The second notice must be provided to the resident, and if applicable the resident's representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. During the exit conference on 08/09/19 at approximately 0230 PM, S1 and S2 acknowledged that the facility did not go over the bed-hold policy. R1 was unstable at the time of discharge.",2020-09-01
446,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2018-09-14,574,D,0,1,8R1211,"Based on resident interviews, staff interviews and observation, the facility failed to assist Resident (R165 and R171 and provide information regarding a list of names, telephone numbers of all pertinent State regulatory and informational agencies and informing the resident of their right to file a complaint with the State survey and certification agency. Findings include: Although, the information regarding how to contact the long term care ombudsman was in the lobby and residents' rights were posted in the lobby and there is a sign stating that the report of the last survey is in the lobby, R165 and R171 who attend resident council were not aware of the information's whereabouts. Interview on 09/13/18 at 03:00 PM with R165 who stated that he was not aware of the information posted in the hall regarding ombudsman and/or the report of the last survey that was in the lobby. R165 said, I am very interested in reading the report of the last survey. Interview on 09/13/18 at 03:30 PM with R171 who stated that he tried to go straight to Human resources (HR) with a complaint and then they brought us a poster regarding if you have an urgent concern and told us this is the way to file a grievance from now on. In summary, R171 was not aware he could contact State agency (SA) regarding any concerns and that the contact phone numbers were posted in the hall. Telephone interview on 10/04/18 at 8:36 AM with Staff member (SM)1 who stated we have resident council meetings once a month. If it falls on a holiday, they will vote for a reschedule per their preference. We review residents rights each month. The activities people post the information for those who do not attend. SM1 was asked how do they get the information if they can't make it to the bulletin board or resident council? SM1 stated that it's become an individual type of situation. For example, if a resident does not like something, we address it individually. I believe survey results are posted and the binders are available on each floor. There is a sign posted when they get out of the elevator. The resident council position has been vacant for two years now and no one wants to fill the resident council. SM1 acknowledged that the information posted was not reaching some of the residents at the time of the interview.",2020-09-01
447,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2018-09-14,578,D,0,1,8R1211,"Based on record review and interview, four residents (R)159, 148, 62 and 50 did not have an advanced directive and did not receive additional information about advanced directives during admission to the facility. Findings include: 1) During review of the record, the status of advance directive form is checked number 2 indicating resident does not have an advance directive. The box on the following line is left unchecked that indicates resident/ family given information about advance directive by social service. During an interview on 09/13/18 at 03:47 PM with the 6th floor patient care coordinator who stated it is the social worker who meets with the family/ representative to give them the information about advance directives. During an interview with the Director of Nursing (DON) on 09/13/18 at 03:49 PM who concurred that the SW will provide the information on advanced directives to the family during the admission/ intake process. 2) On 09/12/18 at 07:53 AM, review of R148's record reflected that Status of Advanced Directive indicated POLST in file, signed and dated 08/20/18. The POLST is not an advanced directive. No advanced directive in the record. On 09/14/18 at 08:29 AM, interview with Patient Care Coordinator(PCC)1 validated that R148 did not have advanced directive or there was no evidence that resident or resident's representative was informed of their right to formulate an advanced directive. 3) During a record review of Resident (R) 62, there was no Advance Health Care Directive (AHCD) in place. There were also no other forms or notes in the chart that would indicate if follow up was done. After staff interview with Social Work (SW) 1, on 09/13/18 at 10:06 AM, SW1 stated that follow up on AHCD usually takes place during quarterly Interdisciplinary Team (IDT) meetings. However, for this resident, SW1 acknowledged that no AHCD follow up was done. A review of facility policy titled Patient Self-Determination Act/Advance Directives, states that if a resident has not executed an AHCD a referral to SW will be made in the event the resident request a AHCD follow up. Again, there was no follow up. 4) During a record review of Resident (R) 50, there was a form titled Status of Advanced Directive (AD) which stated the resident/family declined assistance; dated 11/06/15. Further record review showed IDT meeting notes; dated 07/16/18, section on AD was not checked. This meant that further follow up on AD was not performed.",2020-09-01
448,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2018-09-14,641,D,0,1,8R1211,"Based on record review and staff interview the facility failed to assess four residents (Resident (R) 50, 78, 99, 100) section C Brief Interview for Mental Status (BIMS) on their last Minimum Data Set (MDS) 3.0 quarterly or annual assessment. The deficient practice does not give a complete and accurate assessment of R50, 78, 99 and 100 mental status assessments. This deficient practice does not provide a starting point to compare an improvement or decline in R50, 78, 99 and 100 mental status. This deficient practice had the potential to affect the 155 residents at the facility. Findings Include: Cross reference to F725 On 09/11/18 during initial assessment of residents on fourth floor it was noted that in some of the residents' MDS assessments, BIMS assessment and scores were missing from Section C of the assessments. On 09/11/18 at 02:17 PM interviewed Registered Nurse (RN) 1 and inquired why some residents on the fourth floor did not have complete BIMS assessments in their MDS assessments and he stated that if he did the MDS assessment on a day that he is scheduled to pass medications it is too hard and he stated he does not have time, he also stated he had been told that it was ok not to do that section. It was noted on 09/11/18 there were 45 residents on the fourth floor, as stated on the unit matrix that the facility provided, with two RNs and two Clinical Nurses Assistants (CNA) working. The facility's staffing matrix showed that there should have been one RN, two Licensed Practical Nurses (LPN) and 5 CNAs scheduled to work with 45 residents. This shift only had half of the staff that the facility's staffing matrix called for. On 09/13/18 Record review of R50, 78, 99 and 100 MDS Section B Hearing, Speech, and Vision was coded for these residents as not in a persistent vegetative state, had adequate hearing, did not use a hearing aid, had clear speech, are able to make self understood and has the ability to understand others. R50, 78, 99 and 100 were physically able to participate in a BIMS assessment during their last look back period. Review of R50, 78, 99 and 100 MDS section C Cognitive Patterns found all these residents last quarterly or annual assessments blank. Review of the facility's Interdisciplinary Care Management Process policy found Purpose: To describe the integrated processes and activities that comprise resident care and the process followed to assure completion of the Resident Assessment Instrument. Policy: 1. Assessment of Residents: a. An initial assessment is completed by the nursing staff on newly admitted residents within 24 hours of admission. c. The comprehensive assessment is conducted utilizing an interdisciplinary approach. Resident assessments will be completed by each discipline utilizing the Resident Assessment Instrument as well as departmental specific information. e. Roles and responsibilities for MDS assessment i. Nursing - Responsible for sections A through C, G, H, I, J, L, M, N, O, P, and Q of the MDS.",2020-09-01
449,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2018-09-14,656,D,0,1,8R1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, record review (RR), family member (F)1 and staff interview the facility failed to develop and implement a care plan (CP) for resident (R) 58's bed rail use for bed mobility, and for Resident (R)118's bed rail use for bed mobility, to attend activities and chest pain. Findings Include: 1) On 09/11/18 at 10:00 PM R58's bed was observed with bilateral upper half side rails. R58 was admitted to the facility on [DATE] and had the following [DIAGNOSES REDACTED]. On 09/14/18 at 12:35 PM during RR found that R58 has a Bed Rail assessment completed on 06/29/18 and had the informed consent for bed rail use. Noted on the Bed Rail Assessment that R58 has a history of right sided weakness and history [MEDICAL CONDITION] it was checked that R58 demonstrates using the bed rail or other device to assist in bed mobility, postural support, or transfers during ADL self-care. During RR of R58's CP it was noted that there was no CP for bed rail use for bed mobility. Interviewed Licensed Practical Nurse (LPN) 1 who confirmed that R58 did not have a CP for bed rail use for bed mobility and that she should have had a CP. 2) On 09/11/18 at 10:41 PM R118 was observed sitting up in his bed watching TV. Later in the day R118 was observed eating his lunch, in his room, in his bed with staff at his bedside assisting. On 09/12/18 at 09:25 AM during family interview with R118's F1 inquired if R118 attends activities at the facility and they stated that R118 goes to activity with staff who push him in his wheelchair. On 09/12/18 at 09:36 AM during family interview with R118's F1 inquired if R118 has pain and she stated R118 complained of chest pain twice this year and this goes away when he takes his medicine. Inquired when this occurred and F1 stated this occurred last month. F1 was unable to state the name of medication that R118 takes to alleviate his chest pain. On 09/12/18 at 12:17 PM R118 was observed in his bed with bilateral upper half side rails up on his bed. R118 was admitted to the facility on [DATE] and had the following [DIAGNOSES REDACTED]. On 09/14/18 at 02:43 PM RR found that R118 had a Bed Rail assessment dated [DATE] for top bed rails completed quarterly and informed consent for bed rails dated 08/10/18 which R118 signed. Reviewed R118's CP and did not find bed rail use for bed mobility and activities care planned for. Interviewed LPN1 who confirmed that R118 did not have a CP in place for bed rail use for bed mobility or activities and that these should have been on R118's CP. On 09/14/18 at 03:18 PM RR found that R118 had three documented incidents of chest pain on 08/07/18, 08/30/18 and 09/03/18. Medical Doctor (MD) was notified on 08/07/18 of R118 having chest pain and no orders were given. Each time R118 complained of chest pain this was documented by a nurse, the MD was notified, the pain subsided and was monitored by the nurse. LPN1 confirmed this with progress notes in R118's medical chart. LPN1 confirmed that R118 did not have a CP for chest pain and that he should have had one. Review of facility policy Interdisciplinary Care Management Process found 2. Interdisciplinary Plan of Care: . f. Roles and Responsibilities of the interdisciplinary team i. Nursing Addresses triggered Care Areas for all sections of the MDS, except those as outlined below, and develops the appropriate care plans with input from the interdisciplinary team. Presents and discusses the nursing treatment plan for the resident, including but not limited to the following: 1) Safety and accident prevention 2) Restraint use 3) Skin condition and integrity maintenance 4) Pain management 5) [MEDICAL CONDITION] medication use 6) Any other pertinent clinical issues.",2020-09-01
450,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2018-09-14,689,G,0,1,8R1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR) and staff interview the facility failed to assess resident (R)83 for safe Geri chair use prior to using a Geri chair, ensure R83's environment was free of accident hazards and received adequate supervision while sitting in a Geri chair to prevent an accident which resulted in harm to the resident, requiring a visit to the emergency room . This deficient practice had the potential to affect the other 79 residents at the facility who have been identified on the matrix with a [DIAGNOSES REDACTED]. Based on observation, staff interview and record review the facility failed to maintain safe water temperatures ranging from 100 to 120 degrees Fahrenheit facility wide placing the residents are risk for burns. This deficient practice had the potential to affect the 155 residents at the facility. Based on observations, staff interviews, and resident interview, the facility failed to identify foreseeable accident hazards from a bed mattress placed on the floor (in place of a bed mat) for 16 of 43 residents reviewed. As a result of this deficient practice, the facility put the safety and well-being of not only the residents, but the public and the staff at risk for accidents. Findings Include: 1) R83 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On 09/13/18 at 09:23 AM interviewed Registered Nurse (RN)1 regarding R83's fall on 09/10/18 which he stated occurred at approximately at 09:10 AM near the nurse's station on the fourth-floor unit. RN1 stated the fall was from a Geri chair in the reclined position and it was an unwitnessed fall. Prior to the fall, R83 was assisted into the Geri chair after she pulled down the privacy curtain and 2 ceiling tiles in her room. This caused damage to the privacy curtain rail and had to be fixed by maintenance staff. RN1 stated R83 was yelling, stating she wanted to get out of the facility, was angry and trying to grab RN1. RN1 stated when R83 grabs him it's a tight grip and he has to pry her hands off of him. Inquired with RN1 if R83 was on 1:1 supervision and RN1 stated no, R83 was left near the nurse's station unsupervised sitting in a reclined Geri chair. RN1 stated this was done so facility staff would be able to see R83 and react to help her if it was needed. This was reported by RN1 as something normally, routinely done on the unit. Inquired if R83's physician was notified of R83's behavior and RN1 confirmed that he reported the worsening behavior at 08:05 AM on 09/10/18 and an order was given for a one time dose of [MEDICATION NAME] 0.25 mg p.o. (by mouth) which was given to R83 while she was sitting in her Geri chair, prior to the fall, and this medication was documented and reported as ineffective. RN1 stated injury was sustained to R83's face from the fall with bleeding from her nose and pressure was applied to stop the bleeding. RN1 stated about an hour after the fall R83 started coughing up blood. Upon RR of R83's medical record with RN1 it was noted RN1 documented in R83's progress note, dated 09/10/18 at 10:30 AM, At approximately 10:30 AM, resident started coughing up blood, slimy and thick in appearance. RN1 stated R83 had a complete blood count (CBC) with differential lab draw done and RN1 stated R83's white blood count (WBC) lab result came back abnormally high. RN1 notified R83's physician immediately of this and the physician decided to send R83 to the emergency room (ER) for evaluation. R83 was transferred to an acute hospital ER at 11:00 AM. R83 was seen in the ER and moved to the Progressive Care Unit (PCU) afterwards. R83 was returned to the fourth-floor unit on 09/11/18 at 03:00 PM with Final [DIAGNOSES REDACTED]. Continued staff interview on 09/13/18 with RN1 found R83's [MEDICATION NAME], a medication that reduces anxiety was initially ordered at 7.5 mg p.o. BID (by mouth twice a day) then decreased to just daily and then discontinued on 09/10/18. RN1 stated R83's behavior appeared to have gotten worse as she was taken off the [MEDICATION NAME]. During interview, a review of physician orders for R83 did not reflect an order for [REDACTED]. Devices that need assessment and must be care planned and consents signed shall be used. These include: Bed rails, Reclining chair/Geri chair, Wheelchair seat buckle/Velcro belts, Wheelchair/reclining chair, Gurney straps/belts, Positional change (bed and chair) alarms. RR of R83's care plan (CP) found a CP in place for Resident has a need for Geri-chair usage for postural support while OOB (out of bed) to improve comfort. CP was initiated by RN1 on 07/18/18. RR found that R83 had a Bed Rail/ Other Device Assessment Record form completed by RN1 on 08/06/18 for Top bed rails. It was noted that Reclining chair was not checked as assessed for R83. Inquired with RN1 regarding this and he confirmed the assessment was only for bed rail use and should have included Geri chair use. RN1 confirmed that R83 did not have an assessment completed for Geri chair use. Inquired of RN1 if R83 should have had a completed Geri chair assessment prior to using a Geri chair and he confirmed this. On 09/13/18 during RR of R83's CP found Care Plan - Severe Behavioral Disturbances R/T Dementia under intervention 4. If the resident becomes restless and decides to roam the hallways, provide 1:1 assistance as necessary to maintain safety . Inquired with RN1 why R83 was not supervised on 1:1 as stated in her CP as she was agitated, exhibited aggressive, destructive behavior, and appeared restless and RN1 stated that they did not have any staff they could use to watch R83. Inquired if RN1 requested 1:1 staff for R83, to maintain her safety, from DON or supervisor and he stated no. Inquired of RN1 if R83 should have been supervised on 1:1 to maintain safety and RN1 concurred that R83 should have been monitored 1:1 for her own safety on 09/10/18 prior to her fall. 09/14/18 at 08:09 AM interviewed RN2 and inquired if she was asked to monitor R83 on 1:1 for her safety on 09/10/18 prior to R83's fall. RN2 stated she was not asked to observe R83 1:1 Monday, 09/10/18. RN2 confirmed that she started to monitor and observe R83 1:1 on 09/12/18 at 07:00 AM. RN2 stated she assessed R83 when she was helping the CNA help R83 with Activities of Daily Living (ADLs) and stated she felt R83 required 1:1 observation due to her restlessness. RN2 stated that she observed R83 1:1 from 07:00 AM - 01:20 PM on 09/12/18, with no breaks except to use the bathroom. RN2 stated this was the longest she has spent with a resident doing a 1:1 observation for the resident's behavior. On 09/14/18 at 09:36 AM interviewed Director of Nursing (DON) who confirmed that she was notified that R83 had pulled down her privacy curtain and two ceiling tiles but could not say if R83 was being monitored on 1:1 with staff when asked. DON confirmed that she was notified of R83's fall from the Geri chair soon after this occurred as she was on rounds with the facility administrator. Inquired why R83 was not monitored on 1:1 DON stated it is hard to find staff, staffing office tries by making phone calls and it is not easy, usually they have to take one staff off the floor and that floor would work short. DON explained R83 has had scheduled 1:1 monitoring in the past. DON stated that she has done one shift as a 1:1 with R83 in (MONTH) (YEAR) but unsure what day that was. When asked about how the facility determines staffing needs DON stated that it is based on numbers/census of the unit using the staffing matrix. DON shared a copy of the facility staffing matrix and noted that it states Intended as a guideline for staff levels. Specific resident care needs will always dictate actual staffing requirements. On 09/14/18 at 10:10 AM interviewed administrator regarding R83's fall that occurred on 09/10/18. Administrator stated she was doing rounds with DON on the unit after R83 had fallen from her Geri chair. She stated they went to the room to see R83. R83 had been assessed by the nurse and was being transferred to the ER. R83 was in bed with two CNAs in her room. Administrator stated R83 has had 1:1 staff in the past when she became agitated and confused. When asked why R83 was not placed on 1:1 that day prior to the fall and administrator stated I don't think that they anticipated that she needed 1:1 that day, 1:1 can happen any time. Administrator explained staff would notify management which is the DON and the staffing office, of the need for a 1:1 staff and staff could be pulled from another floor. Administrator stated the Patient Care Coordinator (PCC) could sit with the resident, and management could sit with her. Administrator stated she did 1:1 observation with R83 when she was first admitted , around late June. R83 was not as strong, not as agitated at that time. Review of R83's medical records progress notes and assessments found the facility did not assess safe Geri chair use with R83 prior to using the Geri chair, putting R83 at risk for harm. Review of staff interview found on 09/10/18 that R83 was agitated, exhibited aggressive, destructive behavior, and appeared restless prior to her fall requiring a one-time dose of an antianxiety medication to help her calm down. R83 was assessed by an RN on 09/10/18 prior to her fall but was not placed on 1:1 supervision based on shortage of staffing at the facility even though staffing requirements are based on specific resident care needs as stated on the facility's staffing matrix. The facility failed to provide a safe environment for R83, failed to provide adequate supervision while using a Geri chair resulting in harm to the resident, requiring an ER visit. 2) On 09/11/18 during initial walk through of the fourth-floor unit it was noted the water in the resident's room sinks were very hot to the touch when the hot water was turned on. At 04:15 PM met with maintenance staff (MS)1 to test water temperatures in the resident's rooms. tested rooms 404, 419, 420 and 423 and found water in room [ROOM NUMBER] was 122.3 degrees Fahrenheit using a digital thermometer. Rooms 404, 420 and 423 water temperature range were from 112.8 degrees Fahrenheit to 120 degrees Fahrenheit. On 09/12/18 at 11:10 AM met with facility maintenance manager to discuss spot checks of hot water temperatures and he showed his Daily Hot Water Temp Log from 06/01/18 - 09/10/18. Review of the log found hot water temperatures ranging from 112-127 degrees Fahrenheit. Facility maintenance manager was reminded that facility was cited last year for exceeding the safe hot water temperature as the facility's water temperature was also recorded above 120 degrees Fahrenheit during the (YEAR) survey. Inquired what was done with the room sinks that went over 120 degrees Fahrenheit on the logs that he shared with me, facility maintenance manager stated that his boss quit last month and that his boss was responsible for that part of the plan of correction. Upon observation, staff interview and review of hot water logs found the facility failed to maintain resident's hot water temperatures between 100-120 degrees Fahrenheit even after having been cited the previous year for this. This deficient practice puts the 155 vulnerable residents at risk [MEDICAL CONDITION] the elderly residents' skin are thinner, some of the residents are mute and unable to state that the water is too hot and 80 of the 155 residents have been identified with dementia on the facility matrix and might not be able to communicate to staff that the water is too hot or that they have hurt themselves with the hot water. 3) During an observation of Hale Pulama Mau 3rd floor, on 09/14/18 at 08:22 AM, 16 out of 43 residents had a bed mattress placed on the floor (floor mattress) next to their regular bed. According to the charge nurse (CN)1, the floor mattress was used to provide a soft pad in the event of a resident falling off their bed. CN1 also stated the staff would have to move the floor mattress out of the way whenever residents, staff, or visitors needed access to that space. During an interview with Resident (R)68 on 09/14/18 at 08:26 AM, R68 said he had concerns about the mattress being on the floor next to his bed. R68 said that he didn't want that mattress there and that it could cause an accident, mostly with the staff falling over it. During staff interview with Clinical Nurses Assistant (CNA) 4 on 09/14/18 at 08:45 AM, CNA4 relayed that it was a hassle to always move the floor mattress whenever they wanted access to the resident. CNA4 further stated that one couldn't just step on the floor mattress because that would be very dirty. Staff interview with CNA6 on 09/14/18 at 01:23 PM revealed a concern for extra clutter in resident's room along with the continued concern of residents and/or visitors falling over the floor mattress. CNA6 stated that when there are two residents assigned to one room, the floor mattress really took up a lot of space and that may cause anyone to trip and fall. Staff interview with licensed nursing staff (Nurse) 5 on 09/14/18 at 01:35 PM revealed a concern for potential accident hazard during emergency situations. Nurse 5 stated that the floor mattress always got in the way when you want to have access to the resident. Nurse 5 particularly stated that in emergency situations, the only option would be to step on the mattress and that may cause anyone to trip over the mattress and fall.",2020-09-01
451,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2018-09-14,725,E,1,1,8R1211,"> State Agency (SA) received Complaint(C)5579 and was investigated during this survey. Based on record reviews, staff interviews, family interviews and policy and procedures, SA concluded the facility did not provide nursing services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being. Findings include: 1) An anonymous complaint was made to the S[NAME] Complainant stated that there was a shortage of nursing staff on all shifts on the 4th floor of the Long-Term care unit. Complainant stated her mother who is a resident there would call for help and it takes staff 20-30 minutes or more to answer her call. Complainant further stated that she noticed staffing shortage for the past year and it is still on going and is the reason why she called. Interview with Registered Nurse (RN)1 on 09/11/18 at 10:00 AM who states they have no manager now for one year. RN1 is the charge nurse, acting manager at times and does the Minimum Data Set (MDS) assessments. Observation made on 09/11/18 at 01:00 PM. Seven residents sitting in wheelchairs surrounding the nurses station in an L-shape. One resident in a wheelchair is calling for help and stands up. Resident is attached to a large oxygen tank. This surveyor alerted the unit clerk (UC) and the UC attends to her. Observation made on 09/12/18 at 12:37 PM. Six residents sitting in wheelchairs surrounding the nurses station in an L-shape. The UC keeps an eye on residents and talks with them and attends to their questions and assists them if needed. UC tends to ancillary staff that approach with questions, telephone calls and residents in the wheelchairs. Interview on 09/13/18 at 0810 AM with Resident (R)165. R165 stated that he had concerns about finances resulting in significant understaffing. It's detrimental to the patients. Everyone is rushed here. The staff is doing their best they can. If they are in a procedure, we have to wait until the next person or next shift. I've had someone who was feeding me with the tube feeding and had to leave before pouring the feeding in. They just don't have enough people. On occasion, when I begin to regurgitate and I come up with phlegm and I'm not spitting it up, it could go back down. Interview on 09/14/18 at 0200 PM with R423 who stated that I wait sometimes an hour or more to brush my teeth. I needed someone to pull me up, I tried but I couldn't. I sit day in and day out in this bed. Interview with Unit Clerk (UC)1. The daily assignment sheet showed CNA3 written down as scheduled; however, UC1 says she is not here. It was clarified that although, the name of CNA3 appeared on the daily assignment sheet as present, the name was not lined out as if to show CNA3 was not on the floor, therefore leaving confusion in the actual assignment of ICF-4. UC1 stated we have CNA2 who is from another floor. When asked about how many CNAs are supposed to be on floor, she stated about four. When asked if they are short staffed, she said you have to talk with them downstairs. (refer F812). Record reviews (RR) on 09/13/18. Kuakini Staffing Matrix was obtained. Daily assignment sheets for ICF-4 for the month of (MONTH) and (MONTH) 01 through (MONTH) 12, (YEAR). The census during this survey dates of (MONTH) 11, (YEAR) through (MONTH) 14, (YEAR) was approximately 46-48. According to the staffing matrix for ICF residents with a census of 46-48, staffing should be as below: Staffing grid consists of: (Registered nurse (RN), Licensed practical nurse (LPN), and Clinical nurses assistant (CNA). Days RN - 1, LPN - 2 and CNAs - 5 Eves RN - 0, LPN - 2 and CNAs - 4 Nights RN 0, LPN - 1 and CNAs - 3 RR of Daily assignment sheets for the month of (MONTH) revealed that 28 days out of 31 days, ICF-4 was short-staffed and 10 days out of 12 days in (MONTH) ICF-4 was short-staffed. This meant that either they were short a Registered nurse, licensed nurse or CNA and a lot of times a combination shortage of a nurse and CN[NAME] Interview on 09/14/18 at 02:30 PM with DON and Administrator. Administrator stated We have been trying to advertise the position on the website. We are talking about it with friends. One of our major things we have done is go through senior administration and cross train these RNs from the acute hospital. They have to apply and be trained on this side. It took us a long time to negotiate because of the Hawaii Nursing Association (HNA). Five RNs are on board and the last three are going through orientation. We staff heavily with agency. We have four contracted LPNs from the mainland. One LPN stopped last week. The contracted LPNs are all on a three-month contract. We also have been processing other applications. We are expecting a new shift coordinator on board. We had a new CNA who resigned, and we worked with her to rearrange her schedule, so she would not leave. We have three new CNA applications per administration. 2) On 09/11/18 at 11:20 AM resident lunches were delivered to the fourth-floor unit. During this lunch observation it was noted that there were only two Registered Nurses (RNs) and two Clinical Nurses Assistant (CNA) working with the 45 residents on the unit. Followed RN1 and CNA3 to observe meal delivery and time last tray was delivered to resident who required assistance from staff. Inquired of CNA3 the meal tray delivery routine for the unit and she stated first staff deliver the meal trays to the residents in their rooms who do not require assistance from staff, next they deliver meal tray to residents in the solarium and then to residents in their rooms who require assistance with their meals. Inquired of RN1 how many residents on fourth floor unit require assistance at meal times and he identified 11 residents (R9, 46, 47, 51, 80, 81, 102, 104, 118, 119, and 166). Lunch meals were delivered to residents in their rooms and the solarium from 11:30 AM - 11:55 AM. First meal observed delivered to R118 at noon by CNA3. At 12:05 PM RN1 took a meal tray to R166 in the room and assisted the resident. At 1210 CNA3 took a meal tray to R102 and assisted the resident in the room. At 12:38 PM CNA3 took a meal tray to R102 and assisted the resident in their room. The last lunch tray was delivered by CNA2 at 12:55 PM to R51 and she assisted the resident in their room. Last meal tray was delivered to the resident an hour and 35 minutes after the meal trays were delivered to the unit. Staff assigned to work on fourth floor unit were the only staff delivering meal trays and assisting residents with their meals. It was noted that the unit that day was short an LPN and 3 CNAs per the facility's staffing matrix. The deficient practice puts all the residents on the fourth floor at risk for weight loss and significantly affects the resident's quality of life, with possibility of causing them to experience depression when presented with a late meal which may not be appealing to the resident who has waited a long time for staff to assist them with their meal. Cross reference to F641 3) On 09/11/18 during initial assessment of resident (R) 50, 78, 99 and 100 on fourth floor it was noted that the residents were missing Brief Interview for Mental Status (BIMS) scores in section C of the (Minimum Data Set) MDS assessments. On 09/11/18 at 02:17 PM interviewed Registered Nurse (RN) 1 and inquired why some residents on the fourth floor did not have complete BIMS assessments in their MDS assessments and he stated that if he did the MDS assessment on a day where he is passing medications it is too hard and he does not have time, he stated he had been told that it was ok not to do that section. It was noted that on 09/11/18 there were 45 residents on the unit with two RNs and two CNA working. The facility's staffing matrix shows that there should have been one RN, two Licensed Practical Nurses (LPN) and 5 CNAs. This shift only had half of the staff that the facility's staffing matrix called for. On 09/13/18 Record review of R50, 78, 99 and 100 MDS Section B Hearing, Speech, and Vision was coded for these residents as not in a persistent vegetative state, had adequate hearing, did not use a hearing aid, had clear speech, are able to make themselves understood and can understand others. R50, 78, 99 and 100 were physically able to participate in a BIMS assessment during their last look back period. Review of R50, 78, 99 and 100 MDS section C Cognitive Patterns found all these residents last quarterly or annual assessments incomplete. This deficient practice puts all the residents in the facility at risk for incomplete mental status assessments, making it impossible to determine if the resident has had an improvement or decline in their mental status. 4) During an interview with family member (FM)96, on 09/11/18 at 02:13 PM who stated one of the biggest concerns is under-staffing. I come here every day to deliver the paper. FM96's mother-in-law tells FM96 that it takes so long to get any help. FM96 said he attends the family forum and has asked several times what is being done about the short staffing and is always told the same thing that they're working on it. FM96's mother in law has been here for three years. FM96 said that other families have brought up the same issue at the family forum and some have privately hired individuals to come in to help their family members. FM96 said that sometimes the food is also late, and cold. FM96 has told me that on a few occasions his mother-in-law told him that she couldn't eat the saimin (a noodle dish served hot) because it was too cold. During an interview on 09/12/18 at 05:17 PM with FM136, who stated staffing is terrible here. There used to be five Clinical Nurses Assistant, (CNA's) now we only see a few. They work so hard. We started a petition to start a family forum to address staffing concerns and I finally gave up and quit going to the meetings. It seems like they hold steady on the eve shift but on the day shift it is the worst. The call lights are going off constantly and for a long time. During an interview with R96, 09/12/18 10:30 AM who stated that there aren't enough staff here, there just aren't enough. I always have to wait to use the bathroom I can see they are so busy. During an interview with an anonymous licensed staff member on 9/13/18 at 12:45 PM, who stated we really need five Clinical Nurses Assistant on this floor, but that rarely happens. On 09/13/18 at 08:45 AM observed R96 sitting up in wheelchair at the nurses' station. she stated to the surveyor. Yesterday when I spoke to you I meant that there aren't enough staff here to take care of the other residents, sometimes the CNA's have as many as 15 or 20 residents to take care of, that's just not enough. When we return from activities and sit up here waiting at the nurses' station to go to our rooms we really need to use the bathroom, it would be great to have enough staff to take us as soon as we get back, it's just not enough.",2020-09-01
452,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2018-09-14,758,D,0,1,8R1211,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview one resident (R) 43 received an PRN (as needed) [MEDICAL CONDITION] medication that was ordered for more than 14 days without a documented rationale to continue the medication due to a specific diagnosis/condition. Findings include: Reviewed the physician orders [REDACTED]. Reviewed the medication regimen review dated 7/24/18. The pharmacist recommended to discontinue the PRN [MEDICATION NAME] due to PRN [MEDICAL CONDITION] orders cannot exceed 14 days without rationale documented in the medical record. Progress notes reviewed from 3/30/18 to 8/19/18. R43 has a primary [DIAGNOSES REDACTED]. No documentation with rationale to continue the medication from the prescribing physician was found. Reviewed the Medication Administration Record [REDACTED]. R43 was administered [MEDICATION NAME] 1 mg every day from 7/01/18 to 8/19/18 until it was discontinued by the prescribing physician.,2020-09-01
453,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2018-09-14,812,F,0,1,8R1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, observation and policy and procedure, the facility failed to distribute and serve food in accordance with professional standards for food service safety. Based on observation during initial tour of the facility kitchen the facility tested their sanitizing solution test strips with expired testing strips. This deficient practice had the potential to affect the whole facility, putting the 155 residents at risk for foodborne illness. Findings Include: 1) On [DATE] at 11:43 PM during a lunch observation, RN1 observed staff passing trays without Handwashing (HW) and/or Hand Sanitizing (HS). Between pushing the lunch cart to the solarium and passing trays between residents, there was no HW or HS performed. The other staff assisting with passing trays was Clinical Nursing Assistant (CNA)1. After passing trays to two rooms, there was no HS done. At 11:49, CNA1 washed her hands after passing trays to rooms. Interview on [DATE] at 12:00 PM with CNA1 - explained to CNA1, this surveyor's observation during dining and that she did not perform hand hygiene (HH) before and after assisting a resident with meals and pushing cart to solarium from hall and then passing tray from cart to two residents without HH. CNA stated We are short staffed. Supposed to be 4 or five CNAs but we only have two. Record Review (RR) P&P obtained for HH - page 2, number 2, letter b - Alcohol based hand rubs are not an acceptable means of hand hygiene in the following situations. Hands are to be washed with antimicrobial soap and water. (c) Before and after assisting a resident with meals. Interview with Unit Clerk (UC)1. Daily assignment sheet which showed CN3 scheduled; however, UC1 says she is not here. UC1 said, We have CNA2 who is from another floor. When asked about how many CNAs are supposed to be on floor, UC1 stated about four. When asked if they are short staffed, UC1 said you have to talk with them downstairs. 2) On [DATE] at 08:27 AM during initial tour of the kitchen with the kitchen manager and kitchen supervisor we passed the sanitizing sink that was filled with water and sanitizing solution. Kitchen supervisor was asked to test the sanitizing solution. Kitchen supervisor tore off a piece of Hydrion QT-10 testing strip and submerged the testing strip for approximately 20 seconds. Kitchen supervisor then compared the test strip to the legend on the test strip package. The test strip matched the 200 parts per million (ppm) color on the legend. After this was done it was noted that the Hydrion QT-10 testing strip was outdated with an expiration date of Oct. 15, (YEAR). Kitchen manager stated that she was not aware that the testing strips had an expiration date. On [DATE] at 04:50 PM kitchen manager stated that on [DATE] the kitchen staff were able to retrieve a packet of testing strips from the hospital cafeteria kitchen and tested the sanitizing solution and this also registered at 200 ppm.",2020-09-01
454,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2018-09-14,880,D,0,1,8R1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and Policy and procedure, the facility failed to follow an infection prevention and control program designed to provide safe, sanitary conditions to help prevent the development and transmission of communicable diseases and infections. Findings include: On 09/12/18 at 07:53 AM Clinical Nurses Assistant (CNA)4 was observed in Resident (R)6 room without a gown or gloves on, sitting next to bed, talking with R6. R6 was flagged for contact precautions. Upon leaving the room, CNA4 stated that her supervisor stated that she does not have to wear a gown because she is not touching or handling her blood or urine. Record review of policy and procedure for isolation precaution on Page 2 of 9, section c states Contact precautions for infectious agents transmitted by direct contact with patient or with items in patient's environment, e.g., multidrug resistant bacteria such [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus), VRE ([MEDICATION NAME] Resistant [MEDICATION NAME]), or ESBL (Extended Spectrum Beta Lactamase) producing gram negative organisms, Scabies, [MEDICAL CONDITION] toxin positive and patients with abscess or draining wounds that are not covered by dressings. (1) Patient shall be placed into private room. (2) Gloves and gown shall be worn by anyone entering the patient room that may have patient contact or contact with potentially contaminated areas in the patient's environment. The area that the patient's room door spans/sweeps shall be considered the safe zone where the healthcare workers may step into to don PPE (personal protective equipment) (from the isolation caddy) or to check on the patient. Interview on 09/14/18 at 02:30 PM with Director of Nursing (DON) and administrator. DON acknowledged the incident of CNA4 in R6's PPE. DON stated that they were working with their Medical Director to look at all their isolation residents closely to lift the isolation precautions on some of the residents who have been on isolation for years. On 09/14/18, isolation precautions were discontinued for R6.",2020-09-01
455,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2018-09-14,921,E,0,1,8R1211,"Based on observation, and interview, the facility failed to provide a sanitary environment for Resident (R)110. The outcome was that the resident said she did not feel comfortable. Findings include: On 9/12/18 at 01:45 PM, privacy curtain observed on R110's side of room has stain on it. R110 noticed it also and said she thought it was blood and it made her uncomfortable. Interview with Patient Care Coordinator (PCC)1 on 09/13/18 at 07:07 AM who was taken to resident 110's room to see the stained curtain. PCC1 observed the stain and validated that the environment must be maintained in a sanitary condition, and the stain should not be there. PCC1 said she did not think the stain was blood, and opined it was a food stain.",2020-09-01
456,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2018-09-14,925,E,1,1,8R1211,"> State Agency (SA) received Complaint(C)5579 and was investigated during this survey. Based on record reviews, staff interviews, family interviews and review of facility's policy and procedures, SA concluded the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. Findings include: 1) An anonymous complaint was made to SA for which complainant stated that on two occasions, she saw small roaches (couple of them) in the area near her mother. Complainant stated one roach was on her shoulder which her husband swiped off. Complainant further stated that her mother had been a resident there for about five years but only during the last year where things have turned bad. Observation on 9/11/18 at 08:10 AM - while interviewing Resident (R423), this surveyor noticed a roach crawling on the trash. I brought the roach to R423's attention and he shrugged and continued talking about the subject he was on. 09/13/18 02:44 PM facility contracts with Ecolab for: roach, rodent, large fly and ant program. 2)On 09/12/18 at 08:48 AM while sitting at the nurses station on the sixth floor, two surveyor's observed a small black ant was crawling on the weight chart. On 9/13/18 at 2:16 PM a surveyor observed a cockroach crawling on the counter top. The RN squashed the roach and disposed of it in the rubbish.",2020-09-01
457,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-09-26,563,E,1,0,X3LS11,"> Based on record review (RR), and interviews, the facility failed to protect the resident's right to receive visitors of his or her choosing at the time of his or her choosing, and the resident's right to deny visitation when applicable. The facility must provide access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time. Findings Include: 09/25/19 at 08:45 AM, interview with the Vice President, Nursing Services & Chief Nursing Officer (VPCNO) who stated she understands that the Long Term Care (LTC) units are the residents' home and educational tours should not be going through the units without the residents' consent. VPCNO stated she will have Marketing/Public relations Manager (MPRM) drop off if any, policies, agendas, and contracts, that she may have. VPCNO confirmed as far as she knows, they do not have any policies, agendas, contracts, health screenings, and record keeping for the educational tours that visited the LTC sections of the facility. VPCNO and Director of Nursing (DON) confirmed there were no consents signed by the residents or their representatives agreeing to the educational tours. 09/25/19 10:45 AM, interview with MPRM who confirmed they do not have agendas, policies, and or protocols for the educational tours that visit the LTC section of the facility on a regularly basis. MPRM stated they have since stopped all educational tours to the LTC sections of the facility. MPRM provided surveyor copy of letter dated (MONTH) 11, 2019 from her to her Administration that stated Effective immediately, we will no longer be bringing Educational Study Visit participants to any of the long term care units or to Kuakini Home in the[NAME]Pulama Mau building. MPRM said they also do not have contracts with the tour companies/educational institutions, no record of health screenings and/or documentation by the facility of participants who visited the LTC sections. LTC facility residents did not sign any consents allowing the tours to visit their home. MPRM was unaware that any of the above were needed for the educational tours to visit the LTC sections of the facility. 09/26/19 01:30 PM, RR of facility resident rights pamphlet A Matter of Rights given to residents on admission, page 6 under section Visitors and Communications Your Right to have guests visit you . to have visits from family members or other relatives or friends, subject to your consent.",2020-09-01
458,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-09-26,835,D,1,0,X3LS11,"> Based on interviews, and record review (RR), the facility failed to have in place policies, contracts, procedures and protocols for educational tours related to Long Term Care (LTC). A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and their rights. Administration knew or should have known of the deficient practice and how the lack of administration involvement contributed to the deficient practice found in resident rights and infection control. Findings Include: 09/25/19 at 08:45 AM, interview with the Vice President, Nursing Services & Chief Nursing Officer (VPCNO) who stated she understands that the Long Term Care (LTC) units are the residents' home and educational tours should not be going through the units without the residents' consent. VPCNO confirmed they do not have any policies, agendas, contracts, health screenings, and record keeping for any educational tours that visited the LTC sections of the facility. VPCNO and Director of Nursing (DON) confirmed there were no consents signed by any of the residents or their representatives agreeing to the educational tours. 09/25/19 10:45 AM, interview with the Marketing/Public Relations Manager (MPRM) who provided the names of the participants in the educational tour that visited on 09/10/19. MPRM confirmed they do not have an agenda for the educational tours that visit the LTC section of the facility on a regularly basis. MPRM said they also do not have contracts with the tour companies/educational institutions, no documentation or record of health screenings by the facility of participants who visited. Facility residents did not sign any consent allowing the tours to visit their home. MPRM was unaware that any of the above were needed for the educational tours to visit the LTC sections of the facility. MPRM stated they have immediately stopped all educational tours to the LTC sections of the facility.",2020-09-01
459,"KUAKINI GERIATRIC CARE, INC",125026,347 NORTH KUAKINI STREET,HONOLULU,HI,96817,2019-09-26,880,E,1,0,X3LS11,"> Based on record review (RR), and interviews, the facility failed to have an infection control policy in place to prevent, screen, identify, report, investigate, and control infections and communicable diseases that cover educational tours that visit the Long Term Care (LTC) sections of the facility on a regular basis. The Infection Prevention and Control Program must include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that covers all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. This deficient practice has the potential to put LTC residents at high risk for infections and communicable diseases due to their immuno-compromised health. Findings Include: 09/25/19 at 08:45 AM, interview with Vice President, Nursing Services & Chief Nursing Officer (VPCNO) and Director of Nursing (DON) confirmed there are no policies and procedures (P&P) related to Infection Control and Prevention that govern educational tours from foreign countries. On 09/25/19 01:40 PM, RR of Policy No: 5070-Visitor Control in section under Policy: The Health System recognizes that visitors play an important role . ensuring the patient's/resident's right to safety, privacy, and care with dignity. RR of Policy No: 01-06-15-Infection Control and Prevention and Antibiotic Stewardship reflected no policy, protocol, and guidelines related to infection control and prevention for educational tours from a foreign country. The policy failed to have in place P&P on how to prevent, screen, identify, report, investigate, and control infections and communicable diseases that cover educational tours from a foreign country.",2020-09-01
460,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2019-02-22,689,D,1,1,H2LK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to identify potential accident hazards; where a sharp-edged object was accessible to the residents, in one room out of the five rooms selected for review. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards. Findings Include: During an observation of room [ROOM NUMBER] on 02/20/19 at 09:02 AM, the same sharp-edged object, remained in the same place as mentioned before. Nothing else was on the window sill. During a second observation of room [ROOM NUMBER] on 02/20/19 at 01:00 PM, a sharp-edged object which appeared to be a curtain hook, was noted on the window sill. Nothing else was on the window sill. At the time of these observations, two residents, (Resident (R) 19 and 20), were assigned to room [ROOM NUMBER] and both residents were diagnosed with [REDACTED]. On 02/20/19 at 09:05 AM, Registered Nurse (RN) 1 was queried about the sharp-edged object. RN1 acknowledged that it appeared to be a curtain hook and that it should not have been there. RN1 also acknowledged that the sharp-edged object could pose a risk for accident hazards, especially with R19 and 20 having Dementia. RN1 then stated that the sharp-edged object would be removed from the window sill and secured for safety.",2020-09-01
461,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2019-02-22,700,E,0,1,H2LK11,"Based on observation, record review (RR) and interview, the facility failed to review the risks and benefits of bed rails and obtain informed consent prior to installation for three of three sampled residents (Resident (R) 3, R9, and R35. This deficient practice had the potential to affect all residents because the facility did not have a process in place to review the risks/benefits of bedrails, obtain residents/representatives consent for use of the bed rails, and periodically review that the bed rails met the resident's needs. Findings Include: 1. On 02/20/19 at 10:00AM Observed bedrails installed on the beds of R3, R9 and R35. 2. Review of R3, R9, and R35's medical records did not contain evidence that appropriate alternatives were attempted prior to the installation of the bedrails and that those alternatives did not meet the resident's (R3,R9,R35) needs. The facility was unable to provide documentation that the risks and benefits of bedrails were reviewed with R3, R9, and R35 or their representatives. 3.On 02/21/19 at 02:35PM during an interview with the RAI Coordinator (RAI), asked what the facility process was to obtain consent for bedrail use, and if it was obtained prior to installation of the rails. RAI responded, We don't currently have a consent form, or a process to do that (obtain consent). 4.On 02/22/19 at 09:30AM during an interview with the Quality Coordinator (QC), inquired about the facility policy and process regarding bed rails. QC stated, The policy is more geared to acute care. We are working on a consent form now with the risks and benefits. QC stated, We never use them (bedrails) as a restraint, and almost all of the residents have some type of bed rail. They use them to assist moving around, reposition and getting out of bed. QC confirmed the facility currently did not have a process in place to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. The facility lacked a process for the consent and implementation of bed rails, which included attempts of alternatives to the use of bed rails. There was no evidence the use of bed rails was monitored or that they met the individual needs of R3, R9, and R35. There is a potential that the bed rails were not needed and that alternatives would have met the needs of R3, R9 and R35.",2020-09-01
462,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2019-02-22,755,D,0,1,H2LK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews, the facility failed to establish a secure and safe storage area for medications awaiting final disposition (process of returning and/or destroying unused medications). As a result, medications including controlled medications (substances that have an accepted medical use that have a potential for abuse and may also lead to physical or psychological dependence) were stored in an equipment storeroom that was assessible to unauthorized staff. Findings Include: On [DATE] at 09:51AM while inspecting the medication room, an interview was conducted with Registered Nurse (RN)2. Asked what the process was to dispose of expired and other unused medications, and RN2 stated, We take it to another room, and store it until someone comes to pick it up. RN2 accompanied surveyor to room [ROOM NUMBER] which was labeled Staff only and had an access keypad. Room (Rm)155 was filled with equipment and supplies. Asked RN2 what was kept in the room, and she replied, oxygen equipment and other supplies. Observed IV poles, and oxygen concentrators in the middle of the room, and metal racks with storage shelves on both sides of the room filled with medical supplies and equipment. RN2 verified Rm 155 was a storage room designated for equipment and supplies. Asked RN2 who had access to Rm 155, and she said, the CNA's have access. RN2 did not know who else had access. RN2 pointed to a large cardboard box (approximately 18 inches high by 18 inches wide) on the top of one of the shelves, and said the medications are in that box. The box had Home Depot in large print on it with Outdate Rx (MONTH) 2019 handwritten on one side. Because the box was heavy, RN2 obtained assistance from CNA1 to get the box off the shelf. Surveyor asked CNA1 if she had access to the room and she replied, Yes. Inside the box was a large plastic garbage bag filled with multiple medications, labeled with several different resident's names. RN2 picked out a couple of medication packages and said, this resident expired. Asked if all medications that needed to be disposed of including narcotics went into the box, and RN2 replied, Yes. Observed a plastic container labeled Sani wipes (commonly used to disinfect surfaces) in the bag. The outside of the plastic container was moist. Inside the Sani wipe container was a yellow liquid, approximately 1 cup in volume. Asked RN2 what the yellow liquid was, and she replied, liquid [MEDICATION NAME] or narcotics. Asked how narcotic pills were stored for disposal, and RN2 replied, we put them in the same container (with the liquid). RN2 did not know details of when the box of medications was picked up. On [DATE] 08:16AM during an interview with Quality Coordinator (QC), she stated, When we started our renovation of the nursing station, we had to relocate the storage of the unused medications, so it was temporarily put in Rm 155. It has been corrected now. The medications were moved to the RAI (Resident Assessment Instrument Coordinator's) office that is secure with a double lock. We only store the empty boxes to be used next in Rm 155. The QC stated, We use a contracted vendor who picks the box up every other month and disposes it properly. Disposal methods for medications must involve a secure and safe method to prevent diversion and/or accidental exposure.",2020-09-01
463,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2019-02-22,761,D,1,1,H2LK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to accurately document a controlled drug (Guaifen-[MEDICATION NAME] 100 milligram (mg)/5 milliliters (ml)) for resident (R)40 of one of two medication carts selected for review. This deficient practice has the potential to cause residents discomfort at a minimum or serious harm and/or death as a result of inaccurate documentation of controlled drugs. Findings include: ON 02/21/19 at 10:40 AM, during facility task medication cart (#2) check with assistance from Registered Nurse (RN)1. During controlled drug (narcotics) count, bottle of Guaifen-[MEDICATION NAME] 100-10mg/5ml for R40 was noted by surveyor to have 59ml remaining in the bottle. RN1 stated the controlled drug log book showed 69ml. Both RN1 and surveyor re-checked the Guaifen-[MEDICATION NAME] bottle and the log book and confirmed the Guaifen-[MEDICATION NAME] bottle only had 59ml, not 69ml as documented in the log book. RN1 stated she will inform the nursing supervisor and an incident report will be submitted. On 02/22/19 at 09:55 AM, interview with Long Term Care (LTC) Operations Manager (LTCOM) who stated R40's Guaifen-[MEDICATION NAME] has been corrected to reflect 59ml and not 69ml in the controlled drug log book. LTCOM stated she felt a dose was given by nursing staff but was not documented at the time it was given. LTCOM said the missing 10ml was exactly one dose that would have been given to R40. LTCOM stated the nursing staff needs to be more vigilant when counting narcotics at the end of each shift.",2020-09-01
464,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2019-02-22,812,E,1,1,H2LK11,"> Based on observation and interview, the facility failed to label and properly cover a half tray of cookies, label a tray with two pies in the walk-in freezer, and label two plastic containers of unidentified frozen food items in a freezer out in the kitchen area. This deficient practice has the potential to put residents at risk for serious complications from foodborne illness as a result of their compromised health status. Findings Include: On 02/19/19 at 10:05 AM, initial kitchen tour with Institution Food Service Manager IV (IFSM) revealed in the walk-in freezer on the tray rack, half a tray of poorly covered unlabelled cookies, and another tray beneath with two pies also unlabelled. Out in the kitchen area, one of the freezers had two plastic containers of unidentified frozen food items which were unlabelled. IFSM confirmed the as stated food items should have been labeled and will immediately have kitchen staff throw them out. IFSM stated moving forward, he understands food items need to be labeled and newly opened food items should be labeled with Open Dates.",2020-09-01
465,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2018-04-24,550,D,0,1,6J3M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, the facility failed to treat a Resident (R) 10 with a dignified existence by not providing frequent assistance for use of the toilet. Findings include: R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R10 was noted to be fully dependent on staff for activities of daily living (ADLs). During an interview with R10 on the morning of 4/10/18 at 11:17 [NAME]M., she reported that she sometimes has bowel accidents because the staff tell her she has to wait for assistance to the toilet. R10 stated, After awhile it stinks up the place. It's painful to have to hold it. I rather go to the commode and empty out totally instead of doing it in a diaper. When I have an accident, I still want to get on the commode because I still have more to go. I go every day. Sometimes they don't want to put me on the commode. A review of the last two Minimum Data Sets (MDS) with dates of 2/8/18 and 11/16/17, Section H Bladder and Bowel, found R10 was always continent of bowel and always incontinent of bladder. The MDS dated [DATE] noted Section C, Cognitive Patterns, R10's Brief Interview for Mental Status (BIMS) score was 15/15 indicating she was cognitively intact. An interview of the MDS Coordinator on the afternoon of 4/23/18 at 3:03 P.M. revealed the staff try hard to ensure they respond to R10. The MDS Coordinator noted R10 drinks a lot and the staff attempts to get her to the bathroom as soon as possible but it's hard to always get there on time.",2020-09-01
466,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2018-04-24,600,F,0,1,6J3M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and record review, the facility failed to prevent abuse from resident (R) 148 to three residents (R) 6, R149, and R3. The deficient practice has the potential to affect all residents residing at the facility as R148 is fully ambulatory, described as unpredictable, and observed to roam the facility freely. The facility was aware of R148's aggressive behaviors prior to the first resident to resident assault. The care plan interventions of monitoring and keeping R148 away from other residents was not effective as evidenced by continued resident to resident assaults. There was no root cause analysis conducted or psychiatric/geri-psychiatric consult made that could have guided the interdisciplinary team to effectively manage the resident with aggressive behaviors. Findings Include: Per R148 behavioral intervention flowsheet on 01/04/18, R148 attempted to hit staff twice. The facility was aware of R148's aggressive behavior prior to the first resident to resident assault which occurred on 02/09/18 against R6. R148's care plans initiated on 02/09/18 reflects that the facility initiated a gradual dose reduction of the antipsychotic, [MEDICATION NAME] and monitoring of R148 when amongst other residents. Behavioral intervention worksheets reflected that R148 continued to be aggressive when R148 attempted to hit residents on 02/14/18, and 02/20/18. From record review, and staff interview there is no indication that the facility evaluated whether interventions were effective in reduction of aggressive behaviors. The second resident to resident assault occurred on 02/27/18 against R149. R148's care plans on 02/27/18 reiterated the same ineffective intervention as the first resident to resident assault that occurred on 02/09/08. R148's aggressive behavior continued, behavioral intervention worksheet reflects that R148 assaulted staff on 03/02/18. There is no indication that the facility evaluated whether interventions were effective in reduction of aggressive behaviors. The third resident to resident assault occurred on 03/16/18 against R3. R148's care plan intervention entered on 03/02/18 was Keep away from co-resident. R148's behavioral intervention worksheets reflect that resident continued to exhibit challenging behaviors, entering other resident rooms on 04/06/18 and 04/07/18. On 4/12/18 Staff (S) 81 was interviewed, and said the facility was not aware of resident's challenging behaviors on admission. S81 was not sure if a psychiatric/geri-psych consult was sought. Per record review, there was no psychiatric/geri-psych consult sought for R148's aggressive behaviors. S81 said that the intervention was to keep the previously assaulted residents away R148 because they may say or do something to provoke him. S81 said she felt the interventions worked, but expressed that since they do not staff for 1:1 they cannot prevent the residents from walking around. S81 confirmed they did not perform a root cause analysis of resident's challenging behaviors.",2020-09-01
467,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2018-04-24,657,D,0,1,6J3M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to update and revise the care plans with effective interventions for four of 12 residents (R) 44, R36, R30 and R148 reviewed for facility reported incidents. In spite of the interventions provided, three resident's had multiple falls with injuries and the fourth resident R148 physically asaulted three other residents. Findings Include: 1. Review of R44's admission assessment revealed the following: diagnosed with [REDACTED]. Impulsive with balance difficulties due to left sided weakness and contractures, and no safety awareness. R44 can ambulate at the courtyard with one person assist and supervision. She can self-propel in the wheelchair which she uses for locomotion requiring constant close and/ or 1:1 supervision. She is difficult to redirect and on many occasions is un-directable she hits, slaps, kicks, and pinches nursing staff and has hit other residents. Review of R44's care plan revealed. High risk for falls. R44 has had 11 falls between 2/18/17 and 9/28/17 with four of the falls occuring on 7/27/17. Three of the falls resulted in the following injuries: Left shoulder fracture on 3/09/17; Left [MEDICAL CONDITION] on 7/27/17 and a 3 cm laceration to the left eye brow. Interventions included the following: Provide 1:1 supervision as able; provide clear instruction when reporting off when providing tag team care & supervision. R44 consistently needs 1:1 supervision from staff due to multiple falls and especially in the merry walker. Maintain consistent physical environment or living space & daily routine; keep changes to a minimum. Provide any timed/ scheduled toileting; provide prompt incontinent care prn. Provide assistive devices; enclosed rolling walker. Observe & report promptly to nurse & MD if any change in ability to wt. bear or walk; increase in agitation, restlessness. Keep daughter updated and encourage her to assist and provide 1:1 supervision as she can. Review of the facility incident reports completed for each fall revealed that at times R44 had a fall even while she had 1:1 supervision. R44 did not follow instructions given by staff and often agressive physically and verbally to staff. Several observation's were made during the survey on 04/09/18, 04/10/18, 04/11/18 and 04/12/18. R44 was often seen strolling in the enclosed rolling walker supervised by Certified Nurses Aide (CNA). R44 had an unsteady gait, wobbling from side to side and dragging her left foot. R44 appeared to walk for a few steps then impulsively start to run ahead of the CNA who was attempting to provide 1:1 supervision having to run to catch up. When R44 was not in her enclosed rolling walker she was observed to be lying in bed without 1:1 supervision. At 6:30 PM the Director of clinical services was interviewed and stated that R 44 is only on 1:1 supervision while in her enclosed rolling walker. She used to be on 1:1 supervision 24/7. 2. Review of the Inter disciplinary team (IDT) meeting notes dated 7/26/17 revealed R36 had 27 falls in (YEAR); seven falls in (YEAR) with one Fall on 5/26/17 resulting in scrotal laceration. R36 has ongoing cyclic outbursts of intrusive behaviors threatening physical harm making verbally abusive & inappropriate sexual comments to caregivers associated with dx of dementia and [MEDICAL CONDITION]. Social services notes state he has forgetfulness combined with fixation that often fuels agitation, making problem behavior difficult to redirect. He has been reported to have been aggressively demanding and has been verbally inappropriate to staff as evidenced by swearing and insulting comments. History of recurrent falls confounded by dx extrapyramidal & movement disorder. Review of incident report dated 05/12/17 R36 found on floor lying on left side in room, no chair alarm on his wheelchair. Assisted back to wheelchair by four staff. No injury noted. R36 verbally abusive to staff and refused to have chair alarm put in place, threatening to throw alarm at staff. Follow up comments state staff will try to clip alarm on back of R36 clothing. The Post-fall quality improvement form completed with following recommendations: Complete falls risk assessment form, assess footwear used at time of fall and review medications & regimen changes in last 30 days. Educate/ re-educate precautions to staff as appropriate. Review of incident report dated 05/26/17 stated R36 was calling for help and was in the process of transferring himself from the toilet to his wheelchair and slid down the wall. Staff noted a superficial abrasion to right hip and small opening under scrotum area 2.2 cm length x 1.2 cm width. The post-fall Quality improvement form was completed. Action taken includes complete the falls risk assessment form. Update care plan, review medication regiments and changes in last 30 days. Update care plan. Reviewed care plan dated 03/02/18 for falls due to increased risk due to unwanted medication side effects and resident with history of recurrent falls, with injury. Initiation date 03/02/18: Approaches: In addition to standard falls risk, high fall risk. Communicate to all caregivers increased fall risk and need for increased surveillance of R36. Anticipate medication side effects. Follow up with MD, APRN & Pharmacy for poly-pharmacy concerns. Set bed alarm, chair alarm, and respond promptly. Anticipate toileting needs especially after prn bowel regimen given; remove wheelchair from bathroom when he is on toilet. Medication Administration Record [REDACTED]. [MEDICATION NAME] (for mood) 300 mg three times per day. [MEDICATION NAME] with [MEDICATION NAME] ordered as needed for pain although R36 takes two to three times per day. Noted R36 is also taking [MEDICATION NAME] (Diuretic) 25 mg tablet 1 tab daily. 3. Review of resident #30's (R30) electronic medical record reflected that resident fell on [DATE], and assessed at 40 with the Morse Falls Scale (0-24 No Risk/ 25-50 Low Risk/ x >50 High Risk). The record reflected that R30 was assessed the next day on 03/02/18 at a 65. Review of R30's care plan for falls reflects the care plan was not initiated when resident fell on [DATE], and the care plan was not revised after R30's falls assessment changed on 03/02/18. On 04/12/18 at 1015 a.m. staff #127 (S127) was interviewed and asked why R30 fell so often. S127 answered that the resident is independent, and combative. S127 stated that she felt the interventions were effective since the resident has fewer falls. Care plans were not revised because interventions were perceived as effective. Furthermore, S127 was not able to show where the documentation reflected that the interventions were done and were effective. 4. During an investigation of a facility reported incident it was discovered that Resident (R) 148 asaulted three residents (R) 6, R149, and R3. The care plan interventions of monitoring and keeping R148 away from other residents was not effective as evidenced by continued resident to resident assaults, and interventions did not change despite their ineffectiveness. There was no root cause analysis conducted or psychiatric/geri-psychiatric consult made that could have guided the interdisciplinary team to effectively manage the residents with aggressive behaviors. Per R148 behavioral intervention flowsheet on 01/04/18, R148 attempted to hit staff twice. The facility was aware of R148's aggressive behavior prior to the first resident to resident assault which occurred on 02/09/18 against R6. R148's care plans initiated on 02/09/18 reflects that the facility initiated a gradual dose reduction of the antipsychotic, [MEDICATION NAME] and monitoring of R148 when amongst other residents. Behavioral intervention worksheets reflected that R148 continued to be aggressive when R148 attempted to hit residents on 02/14/18, and 02/20/18. From record review, and staff interview there is no indication that the facility evaluated whether interventions were effective in reduction of aggressive behaviors. The second resident to resident assault occurred on 02/27/18 against R149. R148's care plans on 02/27/18 reiterated the same ineffective intervention as the first resident to resident assault that occurred on 02/09/08. R148's aggressive behavior continued, behavioral intervention worksheet reflects that R148 assaulted staff on 03/02/18. There is no indication that the facility evaluated whether interventions were effective in reduction of aggressive behaviors. The third resident to resident assault occurred on 03/16/18 against R3. R148's care plan intervention entered on 03/02/18 was Keep away from co-resident. R148's behavioral intervention worksheets reflect that resident continued to exhibit challenging behaviors, entering other resident rooms on 04/06/18 and 04/07/18. On 4/12/18 Staff (S) 81 was interviewed, and said the facility was not aware of resident's challenging behaviors on admission. S81 was not sure if a psychiatric/geri-psych consult was sought. Per record review, there was no psychiatric/geri-psych consult sought for R148's aggressive behaviors. S81 said that the intervention was to keep the previously assaulted residents away R148 because they may say or do something to provoke him. S81 said she felt the interventions worked, but expressed that since they do not staff for 1:1 they cannot prevent the residents from walking around. S81 confirmed they did not perform a root cause analysis of resident's challenging behaviors.",2020-09-01
468,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2018-04-24,689,G,0,1,6J3M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assess and supervise three residents (R) 30, R36 and R44 with dementia and at risk for falls, train direct care staff on dementia care prior to and after residents were admitted , and provide an environment free of accidents for three residents with facility reported incidents. The deficient practice resulted in harm for three residents (R)30, R36 and R44 who had multiple falls with serious injuries. Findings Include: 1. Review of R44's admission assessment revealed the following: diagnosed with [REDACTED]. Impulsive with balance difficulties due to left sided weakness and contractures, and no safety awareness. R44 can ambulate at the courtyard with one person assist and supervision. She can self-propel in the wheelchair which she uses for locomotion requiring constant close and/ or 1:1 supervision. She is difficult to redirect and on many occasions is un-directable she hits, slaps, kicks, and pinches nursing staff and has hit other residents. Review of R44's care plan revealed that R44 had 11 falls between 2/18/17 and 9/28/17 with four of the falls occurring on 7/27/17. Three of the falls resulted in the following injuries: Left shoulder fracture on 3/09/17; Left [MEDICAL CONDITION] on 7/27/17 and a 3 cm laceration to the left eye brow. Review of the facility incident reports completed for each fall revealed that at times R44 had a fall even while she had 1:1 supervision. R44 did not follow instructions given by staff such as put your shoes on, or wait there in your chair until I can help you get back to bed. R44 had impulsive behavior like jumping up out of her chair and losing her balance, or climbing up on a chair in the auditorium and losing her balance. She often became physically and verbally aggressive to staff when they attempted redirection. Review of the MDS Quarterly update dated 1/04/18: Section V: care area assessment (CAA) summary R44 triggered for Cognitive loss/ dementia, Communication, ADL functional/ rehabilitation potential, Urinary incontinence, psychosocial well being, Behavioral symptoms, activities, falls, nutritional status, Dehydration/ fluid maintenance, pressure ulcer, [MEDICAL CONDITION] drug use, and pain. Review of the Nurses notes dated 7/27/17 8:32 AM revealed that [MEDICATION NAME] 0.5 mg given @ 0040 for anxiety, restlessness, wandering to point of fatigue with leaning gait and unwilling to stop. Assisted to bed and fell asleep until 0240 when resident woke up due to incontinent of urine, lost balance, falling backward toward dresser and slid down dresser landing on her butt. Says she hit her head against the dresser. Slept rest of noc, easily awakened, responsive, behavior in am as usual. 7/27/17 at 9:39 revealed R44 had 2 falls at 8:55 AM then 9:05 AM. The second fall occurred while on 1:1 supervision with the CNA, the bed alarm on and education to R44 to please stay in bed and use bell for transfer assist. R44 stood up and fell into wardrobe dresser hitting back leaving 2 lines of redness and some skin abrasion. 7/27/17 at 14:57 revealed that R44 had multiple falls throughout the shift with bed alarm on. R44 was placed at Nurses station with 1:1 supervision. 07/27/17 at 20:23. R44 in bed resting. 07/27/17 at 21:49 R44 was showered by CNA and resident's daughter when she complained of pain all over body and right hip pain. MD was notified and gave orders to do right hip X-ray in the AM and NP to examine R44 also in AM. 7/28/17 at 10:00 AM R44 transported to X-ray this am report reviewed/ fracture noted. R44 sent via AMR to ER for further exam and tx daughter to meet ambulance at hospital. 7/28/17 20:46 R44 was admitted to an acute care setting, after a total hip replacement for a right hip femoral neck fracture. Review of the care plan revealed that interventions updated on 1/18/18 with the following: Provide 1:1 supervision as able; provide clear instruction when reporting off, when providing tag team care & supervision. Maintain consistent physical environment or living space & daily routine; keep changes to a minimum. Provide any timed/ scheduled toileting; provide prompt incontinent care prn. Provide assistive devices; Enclosed rolling Walker. Observe & report promptly to nurse & MD if any change in ability to wt. bear or walk; increase in agitation, restlessness. When agitated, allow her to settle down before re-approaching. Review type of foot wear- if daughter unable to provide shoes without straps, assist to wear non-skid socks. Request MD evaluation to rule out s/s acute health condition, medication side effect, change in condition. Behavioral flow sheets were reviewed from 03/01/18 to 04/12/18. More than half of the behaviors monitored documented that R44 refused treatment, meds, food, hit, slapped, pinched, at staff. Interventions included redirect, 1:1, change position, provide PRN medications, try again later. The outcomes were improved at times although at times no change. Review of R44 MAR indicated [REDACTED]. R44 also received PRN [MEDICATION NAME] 0.5 mg PO prn anxiety on 7/27/18 at 0040 and at 1800. The same day of the multiple falls resulting in a right [MEDICAL CONDITION]. [MEDICATION NAME] (for mood stabilization) 250 mg tab po BID was increased to 500 mg tab po BID on 7/17/17. Root cause analysis (RCA) and action framework dated 08/04/17 was reviewed. After each fall, there was a plan to modify care to ensure that patient did not continue to fall including placing resident on 1:1 care. In spite of the action plan, R44 continued to fall and have injuries. There has been many discussions with the family about the long term care (LTC) setting the resident is currently in. The team feels it is the wrong setting for her. However, family is not able to care for her at home due to her behaviors. Inservice training records were reviewed. Common diseases affecting the elderly, Falls management and Geriatric Head to Toe Assessment were conducted from 8/29/17. The Falls management protocol training was conducted by direct care staff from 2/01/18 to 3/31/18. Review of the Training content revealed a review in the physical changes and conditions in the elderly and did not include dementia care. An interview was conducted with Clinical Nursing Director at 6:30 PM stating R44 is only on 1:1 supervision while in her enclosed rolling Walker. She used to be on 1:1 supervision 24/7 when she was having all of the falls. A root cause analysis (RCA) was done after R44 had four falls on 7/27/17 with a fracture. The DON was interviewed and stated that the CNA's direct care staff did not receive the dementia care but received other inservice training. Several observation's were made during the survey on 04/09/18, 04/10/18, 04/11/18 and 04/12/18. R44 was often seen strolling in the enclosed rolling walker supervised by a Certified Nurses Aide (CNA). R44 had an unsteady gait, wobbling from side to side and dragging her left foot. R44 appeared to walk for a few steps then impulsively and start to run ahead of the CNA who was attempting to provide 1:1 supervision having to run to catch up. When R44 was not in her enclosed rolling walker she was observed to be lying in bed without 1:1 supervision. At 6:30 PM the Director of clinical services was interviewed and stated that R 44 is only on 1:1 supervision while in her enclosed rolling walker. She used to be on 1:1 supervision 24/7. 2. Review of the Inter disciplinary team (IDT) meeting notes dated 7/26/17 revealed R36 had 27 falls in (YEAR); seven falls in (YEAR) with one Fall on 5/26/17 resulting in scrotal laceration. R36 has ongoing cyclic outbursts of intrusive behaviors threatening physical harm making verbally abusive & inappropriate sexual comments to caregivers associated with dx of dementia and [MEDICAL CONDITIONS]. Social services notes state he has forgetfulness combined with fixation that often fuels agitation, making problem behavior difficult to redirect. He has been reported to have been aggressively demanding and has been verbally inappropriate to staff as evidenced by swearing and insulting comments. History of recurrent falls confounded by dx extrapyramidal & movement disorder. Review of incident report dated 05/12/17 R36 found on floor lying on left side in room, no chair alarm on his wheelchair. Assisted back to wheelchair by four staff. No injury noted. R36 verbally abusive to staff and refused to have chair alarm put in place, threatening to throw alarm at staff. Follow up comments state staff will try to clip alarm on back of R36 clothing. The Post-fall quality improvement form completed with following recommendations: Complete falls risk assessment form, assess footwear used at time of fall and review medications & regimen changes in last 30 days. Educate/ re-educate precautions to staff as appropriate. Review of incident report dated 05/26/17 stated R36 was calling for help and was in the process of transferring himself from the toilet to his wheelchair and slid down the wall. Staff noted a superficial abrasion to right hip and small opening under scrotum area 2.2 cm length x 1.2 cm width. The post-fall Quality improvement form was completed. Action taken includes complete the falls risk assessment form. Update care plan, review medication regiments and changes in last 30 days. Update care plan. Reviewed care plan dated 03/02/18 for falls due to increased risk due to unwanted medication side effects and resident with history of recurrent falls, with injury. Initiation date 03/02/18: Approaches: In addition to standard falls risk, high fall risk. Communicate to all caregivers increased fall risk and need for increased surveillance of R36. Anticipate medication side effects. Follow up with MD, APRN & Pharmacy for poly-pharmacy concerns. Set bed alarm, chair alarm, and respond promptly. Anticipate toileting needs especially after prn bowel regimen given; remove wheelchair from bathroom when he is on toilet. Medication Administration Record [REDACTED]. [MEDICATION NAME] (for mood) 300 mg three times per day. [MEDICATION NAME] with [MEDICATION NAME] ordered as needed for pain although R36 takes two to three times per day. Noted R36 is also taking [MEDICATION NAME] (Diuretic) 25 mg tablet 1 tab daily . 3. R30's record reflected that resident had a witnessed fall on 03/01/18. The progress note written on 03/01/18 at 0224 p.m. reflected that the resident fell after his recliner flipped over when he attempted to get up and the foot rest was still up. On 04/01/18 R30 had a second witnessed fall from his recliner. R30's care plan reflects the intervention initiated on 04/01/19 was, If resident is willing, offer to put him on his recliner after a.m. care. There was no investigation that ruled out the recliner as being contributory to resident's fall risk. On 04/12/18 at 1015 a.m. Staff (S) 127 was interviewed and asked why the resident fell so often. S127 answered that R30 is more independent, and combative. The care plan interventions were effective since the resident falls less often. When asked how the behaviors are being monitored for this resident S127 stated that the activities of daily living and behavior flow sheets is where the facility documents that the interventions in the care plan were being performed. S127 was unable to show the documentation for R30 which interventions were being performed. There is no proof that resident is being adequately supervised to prevent resident from continuing to fall.",2020-09-01
469,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2018-04-24,725,G,0,1,6J3M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to appropriately train direct care staff on dementia care prior to and after the residents were admitted to the facility and provide an environment free of accidents for three of 12 residents (Resident (R)44 and R36) investigated for facility reported incidents selected for review. The deficient practice resulted in harm for two residents having falls with serious injuries. Findings Include: 1. Review of R44's admission assessment revealed the following: diagnosed with [REDACTED]. Impulsive with balance difficulties due to left sided weakness and contractures, and no safety awareness. R44 can ambulate at the courtyard with one person assist and supervision. She can self-propel in the wheelchair which she uses for locomotion requiring constant close and/ or 1:1 supervision. She is difficult to redirect and on many occasions is un-directable she hits, slaps, kicks, and pinches nursing staff and has hit other residents. Review of R44's care plan revealed that R44 had 11 falls between 2/18/17 and 9/28/17 with four of the falls occurring on 7/27/17. Three of the falls resulted in the following injuries: Left shoulder fracture on 3/09/17; Left [MEDICAL CONDITION] on 7/27/17 and a 3 cm laceration to the left eye brow. Review of the facility incident reports completed for each fall revealed that at times R44 had a fall even while she had 1:1 supervision. R44 did not follow instructions given by staff such as put your shoes on, or wait there in your chair until I can help you get back to bed. R44 had impulsive behavior like jumping up out of her chair and losing her balance, or climbing up on a chair in the auditorium and losing her balance. She often became physically and verbally aggressive to staff when they attempted redirection. Review of the MDS Quarterly update dated 1/04/18: Section V: care area assessment (CAA) summary R44 triggered for Cognitive loss/ dementia, Communication, ADL functional/ rehabilitation potential, Urinary incontinence, psychosocial well being, Behavioral symptoms, activities, falls, nutritional status, Dehydration/ fluid maintenance, pressure ulcer, [MEDICAL CONDITION] drug use, and pain. Review of the Nurses notes dated 7/27/17 8:32 AM revealed that [MEDICATION NAME] 0.5 mg given @ 0040 for anxiety, restlessness, wandering to point of fatigue with leaning gait and unwilling to stop. Assisted to bed and fell asleep until 0240 when resident woke up due to incontinent of urine, lost balance, falling backward toward dresser and slid down dresser landing on her butt. Says she hit her head against the dresser. Slept rest of noc, easily awakened, responsive, behavior in am as usual. 7/27/17 at 9:39 revealed R44 had 2 falls at 8:55 AM then 9:05 AM. The second fall occurred while on 1:1 supervision with the CNA, the bed alarm on and education to R44 to please stay in bed and use bell for transfer assist. R44 stood up and fell into wardrobe dresser hitting back leaving 2 lines of redness and some skin abrasion. 7/27/17 at 14:57 revealed that R44 had multiple falls throughout the shift with bed alarm on. R44 was placed at Nurses station with 1:1 supervision. 07/27/17 at 20:23. R44 in bed resting. 07/27/17 at 21:49 R44 was showered by CNA and residents daughter when she complained of pain all over body and right hip pain. MD was notified and gave orders to do right hip X-ray in the AM and NP to examine R44 also in AM. 7/28/17 at 10:00 AM R44 transported to X-ray this am report reviewed/ fracture noted. R44 sent via AMR to ER for further exam and tx daughter to meet ambulance at hospital. 7/28/17 20:46 R44 was admitted to an acute care setting, after a total hip replacement for a right hip femoral neck fracture. Review of the care plan revealed that interventions updated on 1/18/18 with the following: Provide 1:1 supervision as able; provide clear instruction when reporting off, when providing tag team care & supervision. Maintain consistent physical environment or living space & daily routine; keep changes to a minimum. Provide any timed/ scheduled toileting; provide prompt incontinent care prn. Provide assistive devices; Enclosed rolling Walker. Observe & report promptly to nurse & MD if any change in ability to wt. bear or walk; increase in agitation, restlessness. When agitated, allow her to settle down before re-approaching. Review type of foot wear - if daughter unable to provide shoes without straps, assist to wear non-skid socks. Request MD evaluation to rule out s/s acute health condition, medication side effect, change in condition. Behavioral flow sheets were reviewed from 03/01/18 to 04/12/18. More than half of the behaviors monitored documented that R44 refused treatment, meds, food, hit, slapped, pinched, at staff. Interventions included redirect, 1:1, change position, provide PRN medications, try again later. The outcomes were improved at times although at times no change. Review of R44 MAR indicated [REDACTED]. R44 also received PRN [MEDICATION NAME] 0.5 mg PO prn anxiety on 7/27/18 at 0040 and at 1800. The same day of the multiple falls resulting in a right [MEDICAL CONDITION]. [MEDICATION NAME] (for mood stabilization) 250 mg tab po BID was increased to 500 mg tab po BID on 7/17/17. Root cause analysis (RCA) and action framework dated 08/04/17 was reviewed. After each fall, there was a plan to modify care to ensure that patient did not continue to fall including placing resident on 1:1 care. In spite of the action plan, R44 continued to fall and have injuries. There has been many discussions with the family about the long term care (LTC) setting the resident is currently in. The team feels it is the wrong setting for her. However, family is not able to care for her at home due to her behaviors. Inservice training records were reviewed. Common diseases affecting the elderly, Falls management and Geriatric Head to Toe Assessment were conducted from 8/29/17. The Falls management protocol training was conducted by direct care staff from 2/01/18 to 3/31/18. Review of the Training content revealed a review in the physical changes and conditions in the elderly and did not include dementia care. An interview was conducted with Clinical Nursing Director at 6:30 PM stating R44 is only on 1:1 supervision while in her enclosed rolling Walker. She used to be on 1:1 supervision 24/7 when she was having all of the falls. A root cause analysis (RCA) was done after R44 had four falls on 7/27/17 with a fracture. The DON was interviewed and stated that the CNA's direct care staff did not receive the dementia care but received other inservice training. Several observation's were made during the survey on 04/09/18, 04/10/18, 04/11/18 and 04/12/18. R44 was often seen strolling in the enclosed rolling walker supervised by Certified Nurses Aide (CNA). R44 had an unsteady gait, wobbling from side to side and dragging her left foot. R44 appeared to walk for a few steps then impulsively start to run ahead of the CNA who was attempting to provide 1:1 supervision having to run to catch up. When R44 was not in her enclosed rolling walker she was observed to be lying in bed without 1:1 supervision. At 6:30 PM the Director of clinical services was interviewed and stated that R 44 is only on 1:1 supervision while in her enclosed rolling walker. She used to be on 1:1 supervision 24/7. 2. Review of the Inter disciplinary team (IDT) meeting notes dated 7/26/17 revealed R36 had 27 falls in (YEAR); seven falls in (YEAR) with one Fall on 5/26/17 resulting in scrotal laceration. R36 has ongoing cyclic outbursts of intrusive behaviors threatening physical harm making verbally abusive & inappropriate sexual comments to caregivers associated with dx of dementia and [MEDICAL CONDITION]. Social services notes state he has forgetfulness combined with fixation that often fuels agitation, making problem behavior difficult to redirect. He has been reported to have been aggressively demanding and has been verbally inappropriate to staff as evidenced by swearing and insulting comments. History of recurrent falls confounded by dx extrapyramidal & movement disorder. Review of incident report dated 05/12/17 R36 found on floor lying on left side in room, no chair alarm on his wheelchair. Assisted back to wheelchair by four staff. No injury noted. R36 verbally abusive to staff and refused to have chair alarm put in place, threatening to throw alarm at staff. Follow up comments state staff will try to clip alarm on back of R36 clothing. The Post-fall quality improvement form completed with following recommendations: Complete falls risk assessment form, assess footwear used at time of fall and review medications & regimen changes in last 30 days. Educate/ re-educate precautions to staff as appropriate. Review of incident report dated 05/26/17 stated R36 was calling for help and was in the process of transferring himself from the toilet to his wheelchair and slid down the wall. Staff noted a superficial abrasion to right hip and small opening under scrotum area 2.2 cm length x 1.2 cm width. The post-fall Quality improvement form was completed. Action taken includes complete the falls risk assessment form. Update care plan, review medication regiments and changes in last 30 days. Update care plan. Reviewed care plan dated 03/02/18 for falls due to increased risk due to unwanted medication side effects and resident with history of recurrent falls, with injury. Initiation date 03/02/18: Approaches: In addition to standard falls risk, high fall risk. Communicate to all caregivers increased fall risk and need for increased surveillance of R36. Anticipate medication side effects. Follow up with MD, APRN & Pharmacy for poly-pharmacy concerns. Set bed alarm, chair alarm, and respond promptly. Anticipate toileting needs especially after prn bowel regimen given; remove wheelchair from bathroom when he is on toilet. Medication Administration Record [REDACTED]. [MEDICATION NAME] (for mood) 300 mg three times per day. [MEDICATION NAME] with [MEDICATION NAME] ordered as needed for pain although R36 takes two to three times per day. Noted R36 is also taking [MEDICATION NAME] (Diuretic) 25 mg tablet 1 tab daily .",2020-09-01
470,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2018-04-24,741,F,0,1,6J3M11,"Based on staff interview, and record review, the facility failed to ensure staff were appropriately trained to manage a resident with aggressive behavior Resident (R) 148. Per review of R148 behavioral intervention flowsheet on 01/04/18, R148 attempted to hit staff twice. On 4/12/18 Staff #81(S81) was interviewed and said that direct care staff were not trained in Crisis Prevention Institute (CPI) prior to three incidents of resident to resident assault.",2020-09-01
471,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2018-04-24,755,D,0,1,6J3M11,"Based on observation, and interview, the facility failed to dispose of nine doses of expired drugs for one resident. Findings Include: On 04/12/18 at 1126 a.m. while inspecting the medication room, nine doses of expired Potassium Chloride 10 mEq were found. The medication was ordered for Resident #43 (R43), at daily frequency via the oral route. The medication packaging reflected that the medication expired on 03/18. On 04/12/18 at 11:31 a.m. staff (S) 116 was interviewed and confirmed that the medication should have been discarded and that all licensed nurses are responsible to check for expired medication in their carts, refrigerator and medication room and to dispose it. S116 also confirmed via record that the medication was discontinued for resident on 03/2018 and the Medication Administration Record [REDACTED].",2020-09-01
472,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2018-04-24,756,D,0,1,6J3M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and facility staff interview, the facility failed to act upon the Pharmacist's recommendations for a trial dose reduction of the use of an antipsychotic for one of five residents reviewed for unnecessary medications Resident (R) 46. Findings Include: R46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the morning of 4/12/18 at 10:00 [NAME]M., a medical record review for R46 revealed the resident had physician's orders [REDACTED]. The physician did not indicate a [DIAGNOSES REDACTED]. The Pharmacist did a Medication Regimen Review (MRR) for R46 on 3/22/18 when she sent a note to the physician informing him/her that Centers for Medicare and Medicaid Services (CMS) requires the evaluation of antipsychotic usage within two weeks of a resident's admission. The pharmacist further recommended that the physician consider a trial dose reduction to assess continued need for treatment and check an option for the reason for continued use of the medication for R46. The facility did not provide the physician with the MRR for R46. On the morning of 4/12/18 at 10:00 [NAME]M., an interview with the Assistant Administrator revealed the process for MRR included the pharmacist providing her recommendations to the Assistant Administrator for review. After reviewing the MRR, the Assistant Administrator then passes the recommendations on to the physician for review. On the morning of 4/12/18 at 10:00 [NAME]M., the Pharmacist's MRR for R46 dated 3/22/18 was located on the Assistant Administrator's desk and had not been passed on to the physician. The physician, therefore, never reviewed the MRR for R46.",2020-09-01
473,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2018-04-24,760,D,0,1,6J3M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility policy review, the facility failed to ensure residents are free of significant medication errors for one resident (R 35) observed during medication pass. Findings include: An observation of Staff (S) 117 on the morning of 4/12/18 at 8:47 [NAME]M. found her passing medications to Resident (R) 35. S117 gave R35 her oral medications followed by [MEDICATION NAME] (an inhalant containing steroids) for asthma. S117 did not instruct R 35 to rinse her mouth after she took [MEDICATION NAME]. The instructions on the [MEDICATION NAME] box noted, Rinse mouth after use. An interview of S117 on 4/12/18 at 8:50 [NAME]M. found she forgot to rinse R35's mouth. S117 stated she usually rinses R35's mouth but forgot this time. A review of the facility policy for Medication Administration, Oral Inhalations, noted 15. For steroid inhalers, provide resident with cup of water and instruct him/her to rinse mouth and spit water back into cup.",2020-09-01
474,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2018-04-24,880,F,0,1,6J3M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility policy review, the facility failed to maintain a safe, sanitary environment for residents. Findings include: 1. Observation of Resident (R) 23 on the morning of 4/11/18 at 9:09 [NAME]M. found Staff (S) 83 providing a bed bath to the resident. S83 started out washing R23's face and finished by wiping down the resident's private areas. Without removing her gloves and performing hand hygiene, S83 proceeded to place clean clothing on R23. After dressing R23, S83 returned unused supplies and clean clothing back into R23's drawer: waterproof disposable bed liners; clean clothing (shirts, pants); and toiletries (soap, lotion). Without removing her gloves and performing hand hygiene, S83 proceeded to get the Hoyer lift strap and placed it under R23. S83 and another staff member lifted R23 out of bed and into a recliner chair. With the same gloves on, S83 wheeled R23 next to a window. With the same gloves on, S83 proceeded with removing the old linens and placing new linens onto the resident's bed. An interview of the Infection Control Coordinator on the morning of 4/13/18 at 9:00 [NAME]M. revealed that S83 should have removed her gloves and performed hand hygiene after wiping down her private areas. On the morning of 4/13/18 at 8:30 [NAME]M., a review of facility policy titled Hand Hygiene Procedure dated 7/14/14 noted, D. Use of Gloves .4. When wearing gloves, change or remove during patient care if moving from a contaminated body site to a clean body site within the same patient or to the environment (leaving the room). 2. During a tour of the facility on the morning of 4/10/18 at 10:30 [NAME]M., two medication carts were each noted to have a plastic container on top with the label Thick It (liquid thickener) on the outside. Both plastic containers were noted to have a small plastic scoop placed in the powder. Observation of three medication carts on the floor on the the morning of 4/12/18 at 8:30 [NAME]M. found each cart with a Thick It plastic container on top with the plastic scoop stored in the powder of each container. An interview of a Licensed Nurse on the evening of 4/12/18 at 6:18 P.M. revealed the facility always stores the scoop in the Thick It powder. An interview of the Infection Control Coordinator on the morning of 4/13/18 at 9:00 [NAME]M. revealed the facility did not have a policy for storing plastic scoops. The Infection Control Coordinator stated the expectation was that staff stored the scoop separate from the the powder. 3. An observation of medication pass on the morning of 4/12/18 at 8:47 [NAME]M. found Staff (S) 117 providing Resident (R) 35 with an asthma inhaler. R35 was on contact isolation for [MEDICAL CONDITION] (MRSA). Upon returning to the medication cart, S117 wiped the inhaler with alcohol wipes. An interview of the Infection Control Coordinator on the morning of 4/13/18 at 9:00 [NAME]M. revealed alcohol wipes were not sufficient to wipe down reusable equipment/multiple dose medication containers for someone on contact isolation [MEDICAL CONDITION]. The Infection Control Coordinator stated the purple top PDI wipes was a more appropriate sanitizing wipe [MEDICAL CONDITION]. The Infection Control Coordinator further noted the facility needs a policy to address sanitization of reusable equipment/multiple dose medication containers. 4. An interview of the Infection Control Coordinator 1 and Infection Control Coordinator 2 (ICC 1 and ICC 2) (ICC 1 will leave in a few months) on the morning of 4/13/18 at 9:00 [NAME]M. found the Infection Control program at the facility was not complete. The facility's infection control program was not fully intact with the staff collecting information piece by piece from various sources. The ICC 1 stated she has to manually collect data from the nursing units and the contracted pharmacy. The ICC 1 further noted that if she hears that a resident had a culture/specimen collected, she has to contact the contracted laboratory to ask for results. The ICC 1 noted the previous contracted laboratory would always send lab results to her. The ICC 1 realizes that her data collection is only as good as if/when she gets the information from the laboratory.",2020-09-01
475,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,174,E,0,1,LDC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and facility policy review, the facility did not ensure the residents have the right to retain and use personal possessions, of which possessions such as clothing and jewelry, are kept safe in the facility for 5 of 21 residents (#24, #38, #53, #5 and #50) in the Stage 2 sample. Findings include: 1. A family interview was done on 10/05/2016 at 10:02 [NAME]M. for Resident #24. The family member stated that on admission, she brought in a blanket, clothing, shoes, and slippers for the resident. She stated these items went missing but talked to the social worker (SW). She stated that she cried to the SW. The facility stated they could not locate those items. The family member said, I bought him again new clothes (T-shirts & golf shirts), a new [NAME]et and a blanket, but it has gone missing. I brought a large bottle of Dove in and it disappeared in one week and I questioned them. They tried to look for these items but they lost it. During an interview with CN#1 on 10/06/2016 at 2:06 P.M., CN#1 stated, We did do the ERF. If they report to us, we try to look for it at bedside. We let the family know if they don't already know and then tell the SW and we generate an ERF. A review of the facility's policy & procedure (P&P) was done on 10/06/2016 at 6:31 P.M. The policy, Loss Prevention of Residents Valuables and Possession in the Long Term Care Unit (effective 12/1/2011) stated, Purpose: [NAME] To provide guidelines for receipt and storage of resident's personal belongings and reported missing personal items. B. To protect the hospital from claims for lost personal possessions . Procedure III, section 3. Nursing staff will conduct a personal inventory to the resident's belongings and record it on the Inventory of Personal Effects sheet . The inventory sheet will be kept in the residents medical chart and updated as needed. 4. Family and Nursing will insure that all resident's clothing will be properly marked with a permanent marker/label with the resident's last name and SMMH . 6. If a resident reports that they are missing one of their personal belongings, an Event Report Form will be completed and a search of the missing item will be initiated. The ERF reporting protocol will be initiated. IDG team and Risk Manager will be notified of the missing item for follow and resolution. Interview of the SW was done on 10/07/2016 at 10:13 [NAME]M. He said that the missing items have been a chronic problem. He was not aware of the missing items for Resident #24 approximately one month ago. He stated, We ask the family to take items home to clean; however, if they don't take items home, then for infection control purposes, they are sent to (facility contracted laundry service). The SW stated he has gone to the laundry service to watch how they did the laundry and it seemed okay. However, he validated the residents' missing items remains a chronic problem. The SW stated that Infection Control (IC) person should have the ERF. The IC and CNE were interviewed on 10/07/2016 at 10:33 [NAME]M. regarding Resident #24's missing items. The CNE stated they are getting rid of the event report paper stuff and moving into the Midas program for event reports. The IC was not aware of Resident #24's missing items and/or any ERF filed. She stated she could try to track it down from their sister facility. Record review on 10/07/2016 at 11:00 [NAME]M. revealed an Inventory of Personal Effects originally dated 6/10/13. An update was made on 9/8 (without a year) of black eye glasses received by the family member. The Inventory of Personal Effects did not have the resident's or the resident's representative's signatures on it. 2. Res #38 was interviewed on 10/04/2016 at 12:21 PM, during which time he said he reported a couple of missing personal items. He said those items had his name on it. One item was a big, bulky navy blue blanket and the other blanket had a animal face on it with mixed colors. Res #38 said he told staff about it, and staff asked the laundry people to look for it. He said he was not satisfied and asked them if they could also check every room, before telling him they could not locate his blankets. Res #38 said there has been no resolution by anyone telling him what's going on about his missing blankets. He said its been missing for about two months now and nothing has happened. During an interview with the unit clerk on 10/06/2016 at 9:32 AM, she said if they have an ERF, or if they overhear things, all the staff will try to get the ball going to look and will also help to replace missing items. She stated staff usually will look first, but with our laundry service (contracted vendor), it takes time for items to return. She was asked how long, and replied, Can't really say, maybe the CNAs know better. But I know it's awhile. So we advise families to properly label it. She looked into the computer system and said there was no ERF for Res #38's missing items. On 10/06/2016 at 9:47 AM an interview with the SW was conducted. He said he was aware that Res #38's blankets were apparently missing about two months ago and he had documented this in the resident council minutes. The SW was asked what their time frame was by which a resident's missing personal property was addressed by the facility. He said, Normally the staff would check his closets and linen closets to see if it was misplaced. He verified that staff should have done an ERF for this when it was noted to be missing and if they could not account for the blankets. 3. Res #53's interview on 10/04/2016 at 1:22 PM revealed she had missing jewelry, a bracelet and earrings. Since I came here, it went missing. Res #53 said, Only once I told someone. But I didn't tell her exactly that it was stolen or missing. I hate to accuse them because it's my fault too for leaving it in the drawer. She didn't recall which staff she reported it to. On 10/06/2016 at 9:51 AM, the SW was interviewed. He vaguely recalled Res #53 may have had some missing jewelry. Upon query as to what was done, he replied, She likes jewelry and stuff and we had mentioned to her family that we try to discourage valuables, but so .I can't recall if family came by to pick up her excess jewelry, but I can double check with grandson. According to the unit clerk on 10/06/2016 at 9:37 AM, she said no ERF was generated for Res #53's missing jewelry. 4. During an interview with Res #5 on 10/04/2016 at 1:38 PM, she said, Someone took away my blue bag when I went out of my room today. She was upset and stated no one was supposed to have taken it and described it as being a big, blue gray colored, hanging basket type, given to her by a family member. She said,had a lot of stuff in there that belonged to me .three watches inside. Res #5 told staff about it and they were looking for the missing items. On 10/06/2016 at 9:38 AM, the unit clerk stated she was looking for an ERF regarding the resident's missing bag, but only found an ERF done in 2013. She said staff searches first, lets the charge nurse know, and if they are not successful, then they would generate the ERF. On 10/06/2016 at 9:53 AM, interview with SW was conducted. The SW stated they were just discussing Res #5's missing item this morning and he spoke to the resident yesterday. He said the staff did not recall it being there and the resident still thinks she has it, but it's not there anymore. The SW stated the resident also told him she kept the bag behind her cabinet and it may have been removed by the nursing staff during de[DIAGNOSES REDACTED], so they were going to check the warehouse. The SW stated before they generate an ERF, we do a search, contact the family. The search is still going on. Surveyor queried how long they waited to report anything and he stated, within 72 hours. The SW was asked if their policy stated that, and he replied he was not sure if it stated that specifically. 5. In a family interview for Resident (R) #50, it was revealed that he items missing including hearing aids and a wallet The family member thought the hearing aids had been missing for about 4 months or so. She informed the facility that they were missing and was assured that they would look for them. They notified her that the hearing aids had not been located and would be replaced. She stated that no one has contacted her since and he is still without hearing aids. She went on to report that about a week ago his wallet was missing with several cards and it was reported to nursing. No one has contacted her since to inform her if the items were located. Per Unit Clerk (UC), she had not heard that the wallet was missing. LN#____ was asked by UC if she knew of it to which she responded I think there was but I don't remember. When asked what the process is for reporting missing items, she stated, We try to look for it, if we cannot find the item we do an incident report. We have a few residents that wander into rooms and try to watch them close. Per UC, an Event Report Form (ERF) is generated after we try our best to look for it. The ERF is logged in the system and goes to Utilization review and chain of command. If we can try to remedy we go through the process to replace the item. In a record review the report to the Veteran's Administration (VA) was completed on 9/28/2016 for replacement of R#50's hearing aids that were lost on 5/30/2016. In an interview with the Chief Nursing Officer on 10/06/2016 at 2:50 P.M., the facility had a policy on personal belongings but they are working on a new policy to better address resident belongings. The CNO verified that the policy is not 100% clear and there is no standard operating procedure (SOP) for staff to follow. As evidenced by the residents informing the State Agency (SA) of multiple missing personal items, the facility did not ensure a system was in place to safeguard and allow the residents to retain their personal possessions. Many of the residents' personal items remain unaccounted for and no ERFs were generated, contrary to what the facility's own policy states. In addition, interviews of various staff verified this was not being done, and a system to track the residents' missing personal items had not been identified as a quality improvement measure either.",2020-09-01
476,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,272,D,0,1,LDC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure that a comprehensive assessment of each resident's functional capacity, including the use of the resident's prescribed medications and knowledge of significant side effects was completed for 1 of 21 residents (Res #5) in the Stage 2 sample. Finding includes: On 10/06/2016 at 11:09 AM, Res #5 was observed attending group activities. Her record review revealed she has [DIAGNOSES REDACTED]. The resident is also on [MEDICATION NAME] therapy, with her current prescription being 0.5 mg every evening on Tuesdays and Thursdays and 1 mg every evening on all other days. On 10/06/2016 at 11:33 AM, during a concurrent electronic health record (EHR) review with the educational coordinator (EC), it was found that there was no care plan specific for the use of Res #5's [MEDICATION NAME]. The EC stated they should have one and although there was a care plan for her medical condition, it did not include the medication and side effects. She stated, it's generalized. The EC verified for this resident, the interventions would include the risk for bleeding and easy bruising especially because she gets up and sometimes she has bruising and when she has labs drawn she bruises easily. During a concurrent EHR review with the MDS-C on 10/06/2016 at 2:55 PM, with regard to Res #5's [MEDICATION NAME], she said, it was not labeled as a problem for the anticoagulant therapy and this assessment was missed. She stated she just added the anticoagulant therapy in as a problem and said, So it wasn't there.",2020-09-01
477,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,280,D,0,1,LDC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and electronic medical records (EMR)reviews, the facility failed to utilize interdisciplinary expertise to develop a plan of care to improve functional abilities for 2 of 21 residents (R#15 and R#54), in the Stage 2 sample resident list; and to evaluate and revise the care plan as the residents' status changed. Cross to F323 for R#15 Findings include: 1) In a staff interview on 10/04/2016 at 2:40 P.M., regarding Resident (R)#15, she stated that he had experienced 2 falls without injuries within that past 30 days. She stated that the KARDEX contains information for staff to refer when caring for residents and shows all care plan updates. In reviewing the KARDEX it was noted that resident last had an update to the KARDEX on 9/28/2016 which showed he had his 41st fall and 12th fall in (MONTH) - with plan to answer bed and wheel chair alarm promptly. No further information on falls entered into the KARDEX although resident had falls after (MONTH) 28th. No updated interventions listed. Care plans not updated and revised based on continued falls for resident with measurable goals and interventions. Interventions do not progress and are not reviewed by the team to more aggressive measures once it is determined that the interventions are not effective as shown by the continuation of falls for R#15. In a review of R#15's Care Plan updates: * 9/01/2016: Apply bed/tab alarm. Be sure WC alarm in on; respond promptly to WC alarm; anticipate need for help w/toileting/attempt to return to bed after dinner meal. * 9/07/2016: Environmental Safety Management Bed Wheels in locked position, crash mat on floor next to bed; check lighting, minimize clutter in room; limit furniture to simple desk. Call Light within reach, if mattress placed on floor, replace on bed frame when resident has calmed down. * 9/18/2016: Assist Resident with transfers, offer transfer training at bedside with PT 1-2 x weekly. close monitoring when out of bed. Provide 1:1 supervision on PM shift as able. * 9/19/2016: alarm on, respond promptly when alarms. Anticipate resident needs and pay attention to nonverbal cues, call bell within reach, reminders to use call bell to request assistance out of bed * 9/22/2016: Safety device on wheelchair, report promptly for repair/service PRN: anti- rolling WC brakes. Proper fitting footwear, none-skid soles. 2) On 10/06/2016 at 2:37 PM, reviewed the EMR for R#54 and noted that the Physician order [REDACTED]. Under the EMR Care Plans (CP) tab were care plans for: [MEDICAL CONDITION] Drug Use dated 12/10/2015 and Coping Impairment dated 12/10/2015. The CP Expected Outcomes column listed: No signs of distress; I will accept your reassurance and redirection; I will not swear or say abusive or inappropriate comments towards others; I will tolerate dose reduction of [MEDICATION NAME]; Resident will adjust to new environment; and, I will participate in out of room activities daily I wish. Under the Plan of Care column there was listed: Psychological consults as needed; Monitor for Effectiveness and Side Effects of [MEDICAL CONDITION] medications such as extra-pyramidal symptoms, dry mouth, lethargy, blurred vision, constipation,shuffling gait, drooling, tremors, nausea, loss of appetite, difficulty voiding; Maintain eye contact with resident when speaking; Maintain positive manner when inviting resident; Provide least restrictive environment, assist to keep paper towels, napkins she hoards neat & uncluttered in her drawers, closet; Redirect resident with meaningful activities; Frequently check on resident for safety and agitated behaviors; Provide emotional support and reassurance to resident and family. The Psychiatry consult evaluation dated 01/05/16 included, Psychiatry consult because on [MEDICAL CONDITION] medications: [REDACTED]. Tendency towards hoarding such as paper towels, and suffers from dementia. According to nursing staff, he/she sometimes resists taking medications in the evening (spitting them out). The Combined Notes under the Clinical Summary tab, Clinical Notes section dated 09/27/2016, it was written, Resident was given [MEDICATION NAME] 12.5 mg PO prior to shower. He/She refused to be showered and resistive in changing clothes. Need four people to assist resident to shower. One person wrapped her body around to hold him/her go in the shower. Resident was striking staff in the face, and continue throwing his/her fit until he/she under the shower. He/She grabbed and does not stopped until done with the shower. He/She also continue to swears while doing his/her care. PRN [MEDICATION NAME] didn't help to slow him/her down. The Behavior monitoring flowsheet collected on the date of 09/27/2016 at these times: 04:51; 13:08; 21:22 noted under the Target Behavior column Calm, and the Behavior Observed column Calm, in contrast to the above notes as written under the Clinical Summary tab. The Behavior Monitoring Flowsheet listed all these [MEDICAL CONDITION] medications: [REDACTED]. The Targeted Behavior was Calm, and the Behavior Observed included behaviors of: Calm; and on 10/04/16 resistive with nursing care. The Interventions included: Redirect; change position; assure safety. The CP did not include how the facility attempted to accommodate both the resident's right to refuse showers including exploring of alternatives through a thorough process in which the resident/representative may participate.",2020-09-01
478,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,309,J,0,1,LDC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of a self-reported incident report (IR) submitted to the State Agency (SA) and investigated through record review, staff interviews and policy and procedure review during the recertification survey, the facility failed to ensure that each resident must receive and the facility must provide, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. For Resident #42, this was not provided, and as a result, this resident suffered undue pain and harm. Finding includes: On [DATE], an IR was filed with the SA regarding Resident (R) #42's injury of unknown origin. The IR documented this resident was identified with pain to her right hip region on [DATE]. The resident was not able to verbally express her discomfort. An x-ray was ordered for her on [DATE], and it confirmed a dislocation of the resident's right hip. On [DATE], R#42 was then transferred to an offsite hospital's emergency department for an orthopedic consult. R#42's closed clinical record review on [DATE] revealed she was a [AGE] year old female with a history of a right [MEDICAL CONDITION] and prosthesis in 2014. R#42 also has a [DIAGNOSES REDACTED]. On [DATE], R#42 started exhibiting/ demonstrating pain symptoms manifested by her facial grimacing, grabbing of the staff's arms, and guarding with any turning or repositioning involving her right hip and/or leg. A pain management review revealed in the resident's Medication Administration Record (MAR), that there were inconsistencies in the documentation in comparison to the nursing notes. Additionally, the clinical documentation revealed R#42 continued with on-going pain without adequate pain relief as evidenced by the nursing entries. The documentation revealed the following: 1. There was no documentation on the MAR that R#42 received Tylenol on [DATE]. Yet, there was documentation in the nursing notes that she received Tylenol 325 mg by mouth at 1:20 P.M. for moaning with turns (MD notified); Tylenol 325 mg at 4:45 P.M. for facial grimacing of ,[DATE] (pain level) with some effect. In addition, the notes also stated Tylenol 325 mg was also given by mouth at 10:00 P.M. for grimacing and moaning (MD notified). On [DATE] at 11:28 P.M., the resident was grabbing rails and staff arms with attempt to move right leg. MD ordered physical therapy with evaluation and treatment. 2. On [DATE], documentation on the MAR noted that R#42 received Tylenol 325 mg by mouth at 4:30 [NAME]M. and 9:00 [NAME]M. Documentation in the nursing notes at 7:53 [NAME]M. noted the resident was grimacing ,[DATE] with turning of her right leg with minimal effect. Documentation in the nurse's notes at 3:30 P.M. states, moaning and grimacing when being turned. Tylenol given at 9:30 [NAME]M. with minimal effect. There was no documentation the attending physician (or any other physician or nurse practitioner) was notified. 3. On [DATE], documentation on the MAR showed [MEDICATION NAME] 200 mg by mouth was given to the resident at 7:45 [NAME]M. and Tylenol 325 mg was given at 11:45 P.M. A nursing entry at 2:07 P.M. stated [MEDICATION NAME] was given at 7:45 [NAME]M. for grimacing with turns. Again, no documentation that a physician or other practitioner was notified. 4. On [DATE], documentation on the MAR noted [MEDICATION NAME] 200 mg given by mouth at 8:15 [NAME]M. A nursing entry at 4:19 [NAME]M. on [DATE] stated Tylenol 325 mg by mouth was given at 11:45 P.M. for facial grimacing during care and noted a slightly swollen right ankle, and, per MD to put pillow in between legs to decrease contractions to the hip. A nursing entry on [DATE] at 4:42 P.M. stated, Resident has been with facial grimacing when right leg being repositioned. Guarding right leg area when care provided. Notified MD. Ordered x-ray of right hip and right knee. There was no documentation by the attending physician that he saw the resident and physically assessed the condition of her right hip and leg and/or the effectiveness of the pain medications given to her prior to ordering the x-ray. 5. On [DATE], the MAR and nursing notes for pain medication administration were consistent. However, R#42 continued to exhibit facial grimacing, grabbing of staff's arms, and guarding with movement. Yet, there was no other nursing or medical interventions being provided to R#42, which was already day 5 since her pain had been identified. Interview on [DATE] at 9:00 [NAME]M. with the Educational Coordinator (EC) and concurrent record review was done. The EC verified the dates the medications were administered on the MAR and she also confirmed on [DATE], the MAR's entry by licensed staff was left blank for medication administration. The EC also verified the resident's Pain Score Post Intervention (PSPI) was missing clinical documentation as well. The PSPI tool was to be used to reassess the resident's pain before and after each intervention (medication administration), using a scale of 0 to 10, with 0 being pain free and 10 being most intolerable. The record showed on [DATE], the resident's PSPI pain score post medication administration was not charted at 5:00 P.M. Again, on [DATE] the PSPI was not charted at 9:34 P.M. For medications given on [DATE] on three separate occasions, there only was one entry of the PSPI charted on the assessment flowsheet at 9:31 P.M. Then again, on [DATE] the PSPI was not documented at 11:16 P.M Finally on [DATE], the PSPI was not charted at 4:48 [NAME]M. and 2:24 P.M The EC stated, If it's not documented, it was not done. Further, on [DATE] at 10:50 [NAME]M., an interview of the physical therapist (PT) was done. He remembered R#42 and said, Yes, she kind of declined and went downhill. When I got the order for PT evaluation and assessment, I went to assess the resident. She was in bed and she was in a lot of pain. We barely got her to sitting, she was in a lot of pain and we could not get her up. We stopped the evaluation. The PT stated it was a protocol to notify the charge nurse regarding the results of the assessment. In addition, he stated he charted his assessment in the nursing notes. However, both nursing and rehabilitation staff could not find the PT's clinical documentation in the resident's record. Nor did the PT attempt to contact the physician himself as a licensed professional, despite his knowledge that this resident was in a lot of pain. Interview on [DATE] at 11:38 [NAME]M. with the CN#1 and Educational Coordinator (EC) was done regarding R#42. CN#1 was asked about her encounter with R#42 on (MONTH) 5th, 6th and 7th. She stated, I was the charge nurse for (R#42) on the 6th. Her recollection of the resident's pain during the shift report was, I went to assess her. The CNA stated that she was in too much pain, so I told her to leave her in bed. During my assessment, I noted that it was unusual for her to be in pain with her turns. She was grabbing the side rails. She always goes into a fetal position but this was unusual with her grimacing with her turns and grabbing of the side rails. She was asked if she tried calling the attending physician and replied, No, I thought because they had called him already, it was not necessary for me to call him because they had already done so. CN#1 felt she met the standard for nursing care. She was then asked if she was aware of the order for physical therapy, and replied, No, I do not recall. CN#1 was asked if she was aware that on the 9th, the resident had an x-ray and the x-ray showed that she had a dislocation of her hip. She replied, Yes. She was then asked if there were any antecedents that would warrant her pain, and CN#1 stated, There was no report filed for falls or anything, so we weren't aware. On [DATE], the record showed R#42 was sent to the adjoining Critical Access Hospital (CAH) emergency department (ED). She was identified to have a dislocation of her right hip with a referral to orthopedics. It was also mentioned in the ED report, there is a concern she had an unwitnessed fall as she had pain after a night of sleeping and has bruises and leg pain now. A review of the P & P for pain management states: I. PURPOSE: To provide guidelines when indicated to collaboratively provide aggressive and appropriate pain management for comfort and well-being for the patients and residents receiving care. II. POLICY: [NAME] Pain shall be assessed on admission and shall include pain history, its related disabilities and ratings of pain intensity and relief. B. Ongoing assessments shall be done to evaluate the changing nature of pain a well as the effectiveness of treatments . E. Provide the patient with optimal pain relief with prescribed [MEDICATION NAME]. It was evident the licensed staff were aware R#42 was in pain, but she suffered harm as the facility failed to effectively recognize and manage her on-going pain. Licensed staff noted it was not her usual presentation by their clinical documentation. In addition, the facility failed to follow their policy on pain management as they did not aggressively seek to find out the underlying cause of her pain, although the resident was verbally moaning, guarding, reaching out to grab staff's arms, etc. The licensed staff's charting was also inconsistent and incomplete, and thus, the facility failed to accurately track and monitor her pain intensity to determine if any pain relief was being achieved, which is a basic nursing standard. As a result, this R#42 suffered harm. She did not receive additional, needed pain relief in a timely manner, nor was any initiative taken by the staff to escalate her care needs such as notifying the physician if pain relief was minimally effective despite continued presentation of on-going pain. There also were no additional interventions such as a consideration for stronger [MEDICATION NAME] or expediting her care to involve an x-ray to rule out a traumatic event or an underlying emergency medical condition with her unrelieved pain. The x-ray was ordered five days later, upon which time she had to be transferred to the CAH ED and then to a larger hospital for admission and treatment. The resident did not return to the facility but later expired at the hospital. Thus, the facility neglected to provide the necessary nursing and medical care and services to maintain the resident's highest practicable physical, mental and psychosocial well-being for R#42. An immediate jeopardy (IJ) was identified based on the findings and the facility provided a final IJ abatement plan to the SA on [DATE].",2020-09-01
479,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,323,J,0,1,LDC711,"Based on staff interviews and record review the facility failed to ensure that resident #15's environment remained as free of accident hazards as is possible; and the resident received adequate supervision and assistance devices to prevent accidents. Findings include: In a staff interview on 10/04/2016 at 2:40 P.M., regarding Resident (R)#15, she stated that he had experienced 2 falls without injuries within the past 30 days. In a record review of R#15 on 10/06/2016, falls documentation showed that he had experienced 44 falls from (MONTH) 01, (YEAR) to present, with the last 3 falls occurring on 10/05/2016. Resident fractured the 3rd metatarsal on the left hand during one of the falls on 10/05/2016. In an interview on 10/05/2016 with charge nurse, she stated that R#15 was a difficult resident to monitor for falls as he is reminded to use the call light but he just gets up without any warning. She stated that they had tried various things such as chair and bed alarms, close monitoring, reminders to use the call button when wanting to toilet, and reminding him to wait until staff arrived before trying to get up. She further stated that he has been here for a long time and won't listen to any redirection, has a history of schizophrenia, and can be combative and strike out at times. When asked what new interventions they have implemented after the falls, she stated, we try to monitor him closely and he was moved closer to the nursing station. In an interview with the Chief Nursing Officer regarding root cause analysis after resident falls, she stated that she wasn't sure if they were consistently being done for this resident but they should be, and we are going to be implementing new software to track Event Report Forms (ERF). The Director of Nursing (DON) confirmed there are incidents within the facility which continue to recur and she shares it with nursing staff to correct the problem. For falls, such as what was identified for R#15, the DON stated they are above the State average for falls. Although the 6/01/16 IDT performance improvement review for falls and unnecessary drugs was provided, she stated, And yes, we did not make one step beyond what we're doing to continue to look for other measures to prevent falls. One thing I asked Occupational Therapy (OT) was to look at residents to identify a person trying to get up. Re-educating the staff. In a review of R#15's Care Plan updates, the following interventions were written: on 9/01/2016 : Apply bed/tab alarm. Be sure WC alarm in on; respond promptly to WC alarm; anticipate need for help w/toileting/attempt to return to bed after dinner meal. 9/07/2016 : Environmental Safety Management Bed Wheels in Locked Position, with crash mat on floor next to bed; check lighting, minimize clutter in room; limit furniture to simple desk. Call Light within reach, if mattress placed on floor, replace on bed frame when resident has calmed down. 9/18/2016: Assist Resident with transfers, offer transfer training at bedside with PT 1-2 x weekly. close monitoring when out of bed. Provide 1:1 supervision on P.M. shift as able. 9/19/2016 reads: alarm on, respond promptly when alarms. Anticipate resident needs and pay attention to nonverbal cues, call bell within reach, reminders to use call bell to request assistance out of bed. 9/22/2016 reads: Safety device on wheelchair, report promptly for repair/service PRN: anti-rolling WC brakes. Proper fitting footwear, none-skid soles. In an interview with LN #4 on 10/06/2016, she stated R#15 falls all of the time, it doesn't matter what we do, yesterday he was at the nursing station and he fell right in front of us before we could catch him. Physical Therapy (PT) evaluation was performed on 10/07/2016 after resident had fallen 3 times on 10/05/2016, the last resulting in a fracture of the left 3rd metacarpal. Recommendations from the evaluation included: WC brakes lock and release properly; nonskid footwear on for out of bed (OOB); Occupational Therapy (OT) Assessment and recommendations; physical therapy (PT) treatments to focus on strength, and safe transfers, and wheel chair (WC) propulsion, x 3 weeks, Monday - Friday; transfers with gait belt and max assist from staff; 1:1 sitter ongoing; PT inservices or caregiver trainings with interdisciplinary staff. In a review of the facility Fall Reduction Program Policy lists steps and interventions to implement for fall risk residents and high fall risk residents. 1. The IDT will review circumstances surrounding the fall and the completed Event Reporting Form (ERF) and provide additional recommendations and/or revisions to the resident's care plan as necessary at the next IDT meeting. 2. The IDT will review resident's falls monthly to identify patterns, assess the effectiveness of interventions, and modify care plans as necessary. Based on record reviews, staff interviews, and continuation of R#15 falls the program is not reducing falls. A review of the Interdisciplinary Resident Care Planning Policy reads under: 4. C. 1. identifies resident care outcomes and whether or not resident specific care plan goals were achieved and/or what modifications need to be made so that adjustments are made to address changes in the resident's status, goals, or improvement or decline. An immediate jeopardy (IJ) was identified based on the findings and the facility provided a final IJ abatement plan to the SA on 10/07/2016.",2020-09-01
480,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,329,E,0,1,LDC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of resident during the survey, record reviews, interviews and review of the facility's policy and procedure, the facility did not ensure each resident's drug regimen must be free from unnecessary drugs. Residents were found to be on [MEDICAL CONDITION] medications with no clear indication for use and, the facility failed to ensure that for those residents who use antipsychotic drugs, the behavioral monitoring flowsheets were accurately documented for 8 of 21 residents (#11, #62, #54, #1, #7, #50, #12 and #56) in the Stage 2 sample. Findings include: Cross reference to F501, F520. 1. Observation and record review done on 10/06/2016 at 10:51 AM, found R#11 to be a 58 y/o male who was admitted in (MONTH) 2013, left the facility and then re-admitted on [DATE]. His [DIAGNOSES REDACTED]. The resident's current medications include [MEDICATION NAME] 1 mg every 4-6 hours as needed for agitation or restlessness, [MEDICATION NAME] 100 mg three times daily, [MEDICATION NAME] 20 mg 3 tablets daily, [MEDICATION NAME] 0.5 mg at noon and afternoon, and 1 mg every morning, [MEDICATION NAME] ER 500 mm 1 tab every morning and 2 at bedtime, and [MEDICATION NAME] 300 mg 1 cap twice daily. On 10/06/2016 at 1:56 P.M., an interview and concurrent EHR review with the MDS-C was done regarding the indication for use for R#11's multiple psychoactive medications. The MDS-C said the resident had a mood disorder with behaviors from the [MEDICAL CONDITIONS]. His last psychiatric evaluation was done 9/08/2015, but to answer what the indication for his [MEDICATION NAME] was for, as well as his other medications, she said the psychiatric consult note doesn't really say but that the patient is really stable and recommend they be continued as follows. She was asked how staff monitors the resident's response to any of these medications if there was no clear indication for use listed, including specific target behaviors, to determine the efficacy of each drug. She said for this resident, they attempted a [MEDICATION NAME] reduction, but then it was restarted on 7/28/2016 due to a deterioration in his behavior. When the MDS-C was asked again what behaviors were being targeted, specific to the [MEDICATION NAME] use, she confirmed there was no real indication for use. She said this resident used to have violent behaviors in the past, but we haven't really seen it when he returned back to the facility, but we did the gradual dose reduction. A concurrent review of R#11's Behavioral Intervention Flowsheet found all five medications: [REDACTED]. The sole target behavior was listed as Calm. The MDS-C nurse affirmed this was not a target behavior they were tracking and said, I can tell you we don't have that .our nurses aren't that specific. It's part of the professional grooming that we lack and I cannot disagree with you there. When queried whether the Medical Director was reviewing this as well the pharmacist, she confirmed the Medical Director should be reviewing the use of the [MEDICAL CONDITION] medications, including the appropriate indication for use. She verified this was not being done by the Medical Director nor by licensed staff and nursing was entering the target behavior into their system incorrectly. Record review also found the pharmacist did not note these discrepancies although the monthly drug regimen review was being done. 2. R#62 was recently admitted on [DATE] with [DIAGNOSES REDACTED]. This resident was prescribed [MEDICATION NAME] 10 mg 1 daily as well as [MEDICATION NAME] 25 mg 1/2 tab every morning and 1 tab every evening. On 10/06/2016 at 9:02 [NAME]M., clinical record review found the resident's prescribed [MEDICAL CONDITION] medications were for behavior monitoring of paranoia, delusions, etc. On 10/06/2016 at 9:58 [NAME]M., interview with the SW was conducted. He acknowledged the resident's use of [MEDICAL CONDITION] medications did not have specific triggers which identified the cause of the resident's frustration, anxiety, keep separate and apart from men as best as you can. In addition, there was no indication for use for the resident's [MEDICATION NAME]. The behavior monitoring flowsheet for R#62 listed her target behavior as calm instead of the actual behaviors to be monitored, in order to monitor the efficacy of the medication. On 10/07/2016 at 9:31 [NAME]M., this was validated by the MDS-C that the resident's [MEDICATION NAME] had no indication for use, with no accurate monitoring of the medication being done by staff or the Medical Director. 3. Observation and record review was done on 10/07/2016 at 8:30 [NAME]M. found R#54 to be a [AGE] year old female who was admitted in (MONTH) (YEAR). Her [DIAGNOSES REDACTED]. On 10/07/2016 at 8:48 [NAME]M., an interview and concurrent EHR review with the EC was done regarding the indication for use for R#54's [MEDICAL CONDITION] medications, including [MEDICATION NAME]. It was found during the review, that R#54's Behavioral Intervention Flowsheet found [MEDICATION NAME] and PRN [MEDICATION NAME] on the same flowsheet. The sole target behavior was listed as Calm. The EC confirmed that there was no specific target behavior being tracked. An order on the MAR for Quetiapine [MEDICATION NAME] 25 mg tab, 1 tab by mouth twice daily was also found with no indication for use. On the MAR, the Quetiapine [MEDICATION NAME] 25 mg tab 1/2 tab was given by mouth daily whenever agitation noted. The EC acknowledged the discrepancies in the documentation. Record review of 10/07/2016 revealed the resident has a care plan for the [MEDICATION NAME]. However, there was no care plan for [MEDICATION NAME] which is an anti-depressant and sedative. The MAR indicated [REDACTED]. In summary, the facility failed to ensure that R#54 who is on an antipsychotic drug and sedative has adequate monitoring; or adequate indications for the psychoactive medications being prescribed. 4. On 10/06/2016 at 8:30 [NAME]M., the EMR for R#1 found that the interdisciplinary team had a meeting on 9/29/2016 and conducted a [MEDICAL CONDITION] Medication Review for the resident's use of [MEDICATION NAME] three times daily and as needed for severe agitation, [MEDICATION NAME] Acid for [DIAGNOSES REDACTED]. It was written in the RAI Coordinator comments: No med changes: Psych consult done 9/07/2016. No change in plan of care. Ongoing cyclic episodes of loud verbal insults toward caregivers (swearing, name-calling), attempting to hit, pinch & mood swings when care being provided. Remains on daily [MEDICATION NAME] & [MEDICATION NAME]; no PRN [MEDICATION NAME] in observation period. History of successful [MEDICATION NAME] GDR & dc'd Aug (YEAR). [MEDICATION NAME] DR increased to 1000 mg PO BID 10/08/15 then dc'd & changed to [MEDICATION NAME] 6/24/2016 . Daily Cynbalta (no changes) . Management of labile & intrusive behaviors includes placement in private room. On 10/06/2016 at 10:30 [NAME]M. observed R#1 in the auditorium with eyes closed lying in geri-chair for religious activity and later exercise activity. The resident appeared to be sleeping and unable to determine if passively participating. On 10/06/2016 at :26 P.M. the EMR for R#1 found that the Behavior Monitoring flowsheet documented [MEDICATION NAME]; [MEDICATION NAME]; [MEDICATION NAME] 1 mg PO 6 hr PRN severe agitation; [MEDICATION NAME]; [MEDICATION NAME] Acid under one column. The Target Behavior was Calm and cooperative, for all of the [MEDICAL CONDITION] medications. Under the Behavior Observed that was documented three times a day, were these observations: Quiet; calm, quiet; calm and quiet; yelling at times . The Interventions included: Redirect, move to area with decreased stimulation; assure safety; try again later The Psychiatry consult note dated 09/0720/16, .recommended that [MEDICATION NAME] reduction to discontinuation could be undertaken however fragile balance psychiatrically and any change of medication could effect that. Valproate level in (MONTH) (YEAR), 60 which is therapeutic range for [MEDICAL CONDITION] control but rather low to control affect dysregulation. I will not write order to reduce [MEDICATION NAME] dose, believing that to (attending physician). The facility did not monitor signs/symptoms of depression for the continued use of [MEDICATION NAME] and [MEDICATION NAME]. 5. On 10/06/2016 at 10:30 [NAME]M. observed R#7 in auditorium at religious activity and R#7 threw a magazine at a male resident because he apparently placed it on the chair that R#7 wanted to sit on. The CNA intervened and at the same time the physical therapist (PT) came to take R#7 for PT. On 10/06/2016 at 6:48 P.M., the EMR for R#7 noted that a Psychiatry Consult was done on 9/08/2015 for an annual psychiatric evaluation update. Under the psychological/behavioral heading there was noted, Depression/Sadness: none, and Overwhelmed or Hopeless: None. Noted in the HPI: This patient has been doing reasonably well on her current regimen of medication and it should be continued as follows: Thioridazaine 25 mg 2 tabs twice a day at 8 and 1700; and, [MEDICATION NAME] 30 mg. The interdisciplinary team did a [MEDICAL CONDITION] Medication Review for the use of: Thiroidazine, [MEDICATION NAME] and [MEDICATION NAME] as needed, for the [DIAGNOSES REDACTED].[MEDICATION NAME][MEDICATION NAME] needed at bedtime for [MEDICAL CONDITION] related to the [DIAGNOSES REDACTED]. In the RAI Coordinator Comments section it was written, Ongoing cyclic episodes of anxiety; P.M. [MEDICATION NAME] 5x in observation period ; see IDT review 7/22/2016; Action plan: continue plan of care. The Behavior Intervention Flowsheet from 10/04-05/2016 listed these medication under one column: [MEDICATION NAME]; [MEDICATION NAME]; [MEDICATION NAME] PRN;[MEDICATION NAME]. The Target Behavior for all of the med's were, Calm, cooperative. The Behavior Observed included: increased yelling and pacing; asking for money; calm; yelling, pacing; restless at times; calm, sleeping, calm . The Intervention included: Redirect; Activity; Move to area with decreased stimulation; assure safety, get additional help; Redirect, medication (should not be first intervention) . The resident had a CP for [MEDICAL CONDITION] drug use; and, anxiety but none for [MEDICAL CONDITION] and the use [MEDICATION NAME] is a hypnotic drug. Also the facility did not monitor R#7's sleep pattern to track the use [MEDICATION NAME]. The expected outcomes in the CP section included: - I will tolerate psychoactive med GDR; - No Drug related side effects; - I will not c/o headache, tremors, lethargy, I will continue to walk & not fall; - I will maintain my daily routine & my sleep pattern and/or yelling out in agitation; - I will not hit caregivers; - I will not swear at you or others. 6. In a record review for R#50, it was noted in the Electronic Medication Administration Record [REDACTED]. None of the medications listed have indications written on the EMAR. On the right hand bottom of the EMAR the following [DIAGNOSES REDACTED]. In an interview with the pharmacy consultant per phone on 10/07/2016, she stated that all of the [MEDICAL CONDITION] medications on the resident EMAR were indicated for [MEDICAL CONDITION]. She stated that the indication for each medication did not need to be listed on the EMAR. In a review of consultations, one was noted for a psychiatry consult for management of behavioral health problems secondary to Dementia, Parkinson Disease Dementia vs Dementia with Lewy Bodies, written on 7/03/2016. In a review of the Psychiatry Inpatient SOAP note dated 7/05/2016 it was noted that the psychiatrist saw the resident for increased aggressive and assaultive behavior. The recommendation was for the [MEDICATION NAME] dosage to be increased because the therapeutic range was at the low therapeutic level 408 (therapeutic range 400-700). If the dangerous behaviors increased the recommendation was to draw a [MEDICATION NAME] acid level and adjust the oral dose accordingly as the target level of valproate level. The psychiatrist goes onto state that for patients with [MEDICAL CONDITIONS] therapeutic level can be as high as 125. R#50's level had been previously measured at 101 and 110. No documentation of [MEDICAL CONDITIONS] [REDACTED]. No mention of Parkinson Disease Dementia Vs Dementia with Lewy Bodies was documented in the consultation note. On 9/12/2016 a [MEDICATION NAME] Acid Level was drawn and noted to be 73/0 mcg/mL and then states For manic episode associated with [MEDICAL CONDITION] disorder, Reference range; (2). 50.0-125.0. 7) In a record review on 10/07/2016 for R#12 of medications, it was noted that on the physicians order the following [MEDICAL CONDITION] medications were written without indications: [MEDICATION NAME] 1 mg tablet PO at bedtime; [MEDICATION NAME] 10 mg tablet daily at bedtime (along with 20 mg = total 30 mg daily at bedtime); Quentiapine [MEDICATION NAME] 100 mg tablet at bedtime (along with 2X 400 mg = total 900 mg at bedtime); [MEDICATION NAME] Dec. 50 mg/ml vial, inject 2ml (100mg) IM every 4 weeks; Trazadone 100 mg tablet, 2 tablets (200 mg) PO at bedtime. The [DIAGNOSES REDACTED]. No psychiatric [DIAGNOSES REDACTED]. In a record review of the consent for psychoactive medication use, the following medication and indications had been signed giving consent for use: [MEDICATION NAME] 2 mg by mouth every 2 hours as needed for agitation; [MEDICATION NAME] 900 mg by mouth at bedtime for agitation; [MEDICATION NAME] 100mg injection every 4 weeks for agitation; and [MEDICATION NAME] 30 mg by mouth at bedtime for agitation. 8) In a record review of R#56's medication record the following medications were listed with no indications: [MEDICATION NAME] DR 250 mg table (1 tab at 0800 and 2 tabs at 2100); and Quetiapine 25mg PO BID. On 10/06/2016 an order was written to increase [MEDICATION NAME] to 50 mg PO BID but no indication for use is written.",2020-09-01
481,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,353,F,0,1,LDC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews, and facility policy review, the facility failed to provide sufficient, qualified nursing staff available on a daily basis to meet the residents' needs for nursing care in a manner and in an environment which promotes each resident's physical, mental and psychosocial well-being, thus enhancing their quality of life. Findings include: 1) The cumulative findings in the area of Quality of Care determine there is isolated harm to R#15 and #42, in addition to the other cited regulatory areas, which are interdisciplinary and includes the involvement of nursing services, dietary services, physician services, infection control, administrative services, resident rights and resident assessment. This is evidenced and is cross-referenced to the findings at: F174, F272, F280, F329, F371, F386, F441, F490, F501 and F520. Furthermore, interviews with residents, family members and staff validated the lack of delivery of adequate and necessary care and services to the residents at this facility. There is also the failure by the Medical Director and administration to ensure their staff are trained and knowledgeable to provide individualized care required to achieve the highest practicable physical, mental and psychosocial well-being for each resident, current and/or discharged . Again, this was not found as evidenced by the deficient practices found in the cited regulatory areas. 2) In addition, on 10/06/2016 from 10:32 AM to 11:25 [NAME]M., there was no staff present to monitor the second nursing unit. At 10:59 [NAME]M., room [ROOM NUMBER]-2's routine call light was ringing several times, but no one was there to answer it. CNA #3, who happened to come to the nurse's station to wash her hands was asked what was ringing. She was surprised and confirmed it's the resident call light, and acknowledged no one was around to answer it. She said usually the ward clerk answers, but being a floater .I go and check what's going on. CNA #3 returned at 11:07 [NAME]M. with R#7 with her and said the another resident was calling to return back to bed, which she did. Yet, it was not until 11:25 [NAME]M. when a licensed nurse (LN #5) came into the unit, but did not realize there was no staff around until she was asked about it. LN #5 said, Oh, the unit clerk she's sick today, and they know she's sick. They will send (the CNE), or someone, I think our boss? and turned around to continue on with her task before leaving the unit. Thereafter, during an interview with the CNE, she acknowledged the lack of staff on nursing unit 2. She stated it should not be left unattended for nursing on both sides. She further said for all the shifts, including evening and nights, When someone is on break they are not to leave any area unattended. If someone leaves the station, they need to call us going forward. The DON stated when she was notified of this, she went down right away to cover the station. The CNE agreed it needed to be staffed due to those residents who frequently walked around and for the overall safety of their residents.",2020-09-01
482,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,371,E,0,1,LDC711,"Based on observation, record review, and interview, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions. Findings include: On 10/06/2016 at 1:09 P.M., during an observation and a review of the food temperature log, temperatures were not logged for any food items before, during, or after the dinner meal on 10/03/2016; lunch on 10/04/2016; and no milk temperatures were logged for meals on 10/05/2016. The kitchen helpers verified that temperatures must be taken and logged to ensure that the food remains at a safe temperature during meal preparation and service. In an observation of the kitchen on 10/06/2016 at 12:43 P.M., a cook was preparing Styrofoam to go trays for the residents' outing on 10/07/2016. He was writing on the trays by picking them up, one by one; holding the inner part of the container up next to his stomach against his apron; then with a sharpie writing on the trays. During this process he was observed touching several items on the table, wiping sweat from his forehead, and touching his face. He did not wash or sanitize his hands at any time before or during this process. When asked if holding the trays against his clothing was sanitary he verified that he should not be holding them in this manner and agreed that he should have washed his hands before touching the trays. In a meeting with the CNO and DON on 10/07/2016 both acknowledged this would be addressed with dietary and the cook as he verified that he should have washed his hands and should not be holding the trays next to his clothing, but continued this practice after acknowledgement that it was not sanitary.",2020-09-01
483,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,386,F,0,1,LDC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of a self-reported incident report (IR) submitted to the State Agency (SA), record review, staff interviews and policy and procedure review, the physician failed to take an active role in the supervision of care for one resident (R #42), including the lack of a thorough evaluation of the resident's condition of continued pain, and subsequent delay in the treatment of [REDACTED]. Finding includes: Cross reference to findings at 309. Closed record review and staff interviews revealed that Resident #42 was not able to verbally express her discomfort. However, her pain was documented on numerous occasions by licensed staff as facial grimacing, guarding, grabbing staff's arms, grabbing the side rails, and moaning with turns. Staff stated the resident was exhibiting unusual behavior. In addition, it was found that her pain was not managed timely nor effectively by the clinical documentation. The timeline of events revealed the attending physician was called on 8/05/2016 at 1:20 PM where he was initially notified of the sudden change in Resident #42, and that she was moaning when she was turned. The resident was given one tab (325 mg) of Tylenol which three hours later, the nurse charted minimal effect. The physician was notified again on 8/5/16 at 10:00 PM. Resident #42 was given another tab of (325 mg) Tylenol for her pain level of 8 out of 10 (8/10) with grimacing and moaning, grabbing of the side rails and staff's arms when they attempted to move her. At that time, the attending physician ordered physical therapy. According to the nurse's notes, four days later on 8/08/2/16, there was an order by the physician for staff to place a pillow between Resident #42's legs. The nurse's notes also stated that the resident's right ankle was slightly swollen and that she continued to exhibit facial grimacing with no pain relief. During an interview with CN #1, she stated they left her in bed because the resident could not tolerate movement or perform her activities of daily living. On 8/08/2016 at 4:42 P.M., the physician ordered an x-ray of the right hip and right leg, 5 days after the pain to the resident's right hip region had been identified. The results showed a dislocation of Resident #42's right hip and she was later transferred to an acute care hospital. During a telephone interview with the attending physician on 10/07/2016 at 9:37 [NAME]M., he stated regarding Resident #42, that if the nurses had told him this resident was having so much pain, he would have ordered her x-ray much sooner. Yet, he also confirmed he only came to the facility every other Friday to see his residents. The attending physician did not actively involve himself in the care of this resident including the management of her pain, although nursing entries show he was notified, but only ordered PT, a pillow between her legs, etc. Moreover, there was no evidence supported by clinical documentation that he came to assess his resident during the entire 5 days she remained in pain.",2020-09-01
484,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,441,F,0,1,LDC711,"Based on interviews and record review, the facility failed to ensure it established and maintained an Infection Control (IC) Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Findings include: On 10/07/2016 at 10:31 [NAME]M., the RCQO, the new Infection Control Preventionist (IP) assigned to the facility, and the Regional Quality Risk Manager (RQRM) were interviewed about the facility's IC program. It was revealed the previous IP had left the facility sometime in the Spring, and the previous DON also left the facility sometime in (MONTH) (YEAR). The current administrative staff were unable to provide documentation to demonstrate the components of the facility's current IC program to include how it investigates, controls, and prevents infections in the facility, and how it maintains a record of identified IC problems/occurrences and corrective actions taken related to the development and/or prevention of infections. At 11:11 [NAME]M., the IP and RQRM verified they currently had no data with quality indicators/metrics, nor surveillance data or reviews/analyses related to their IC program. In the interim, the RCQO was trying to locate the data which the previous IP and/or DON had, but was unable to produce it.",2020-09-01
485,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,490,F,0,1,LDC711,"Based on observation, record review, interviews and review of the facility's policies and procedures, the facility failed to ensure it is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Finding includes: There is non-compliance with this regulation based on the negative outcomes related to the findings cited at F309, F323, F353, F441, F501 and F520. The immediate jeopardy (IJ) was identified for R#15 at F323, and for R#42 at F309, which is the area of Quality of Care, with substandard quality of care identified. Thus, based upon the interviews, record reviews, record reviews, and review of the facility's policies and procedures, it was found the administrative oversight,which should have been provided by the Medical Director and the Administration, was ineffective and failed to ensure that each resident's health and safety was maintained in order for each resident to reach his/her highest level of functioning.",2020-09-01
486,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,501,F,0,1,LDC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of the facility's policies and procedures, the facility failed to ensure the medical director is responsible for implementation of resident care policies; and the overall coordination of medical care in the facility. Finding includes: On 10/07/2016 at 9:37 [NAME]M., an interview of the facility's Medical Director was conducted via teleconference. He was informed the survey team identified an IJ on 10/06/2016, which he said he was made aware of. He became the Medical Director at this facility either this (MONTH) or April. He said his role, is held on the quality of care of all residents in the facility that included the performance of the physicians and having a role in the quality improvement process. He said the quality improvement process requires the Medical Director to be present at quarterly meetings and awareness of the policies and review of the policies and procedures, the clinical policies and procedures and reviewing any outside contracts that directly relate to care and tolerability. He was asked to describe what actions he has taken in the quality improvement process and his knowledge of the I[NAME] The Medical Director described what he termed a backdrop of events, and then said, There's no quality meetings being conducted and reports given, and I felt that it needed to be restarted again .I remember the Medical Director needs to be present at least quarterly by federal regulations and as you begin to review the MEC from March, I told them (administration) we'll need to get this kick started. He stated through the IDT, there was obviously a spike in the falls with and without injuries and also there were bruises, skin tears and so forth and so I recommended an ad hoc quality meeting to address the problem. The Medical Director stated it was mostly informal meetings to address the falls and had told the interdisciplinary team and the current RCQO he would be happy to participate, but acknowledged missing these meetings since no one coordinated it with his schedule. Upon query if it was due to a lack of time, he stated, I'm saying there is no one to do it. The problem was there was no one at the table to do quality who was responsible for it. I can direct it, but it's not my responsibility to do the ground work, and the program fell apart when (previous RCQO person) left. He said they want him to participate but the meetings are scheduled every other Friday. He acknowledged he would be available by phone, but still had his clinic patients to see. He said it was a completely separate type of service, and said as a result, he could not participate. He said it was recorded in the hospital MEC minutes. Surveyor explained to the Medical Director that a hospital's MEC minutes are not reviewed as this is the long term care facility being reviewed. He was asked how many quality improvement meetings he has attended to date, and he replied, There's been no meetings .This is the first meeting (today), but unfortunately I'm going to be there next Friday and there's an informal emergency meeting to address the issue with falls in the middle of the week. That's all there's been as far as I know. The Medical Director affirmed that he was not in compliance with this tag. He said he has done as much as he could, but, I knew that at some point the question is why aren't you doing quality. As for the policies and procedures, I have put in a request, but they were not able to be located. For example, I wanted the policy on [DEVICE]s .No one really knew where the policies were. So I don't know. He was asked if this was brought up to the DON, and he said because of this he had to start a mission to see who is in charge or responsible. He stated he is present at this facility every other Friday, So I'm there. So that's one time, but yeah you're right, it's an issue. With regard to his role and oversight of the high use of [MEDICAL CONDITION] medications in this facility, he said, The challenge is there is an overutilization of the [MEDICAL CONDITION] and when I saw it, I realized the problem, so started to look at it. So the trend now since I came on board, the number of use of [MEDICAL CONDITION] have declined maybe by 10% so the trend line is downward. He was asked about the missing indications for use of the [MEDICAL CONDITION] medications the survey team found. He said, What I did was, my assumption was the psychiatrist had a psychiatric [DIAGNOSES REDACTED]. So what staff have been doing is making sure an annual documentation on all patients that they've had a psych eval if psych started them on the meds. He was asked if he reviewed the behavior monitoring flowsheets. The Medical Director stated, I read the notes and when I read the psych diagnosis, for the most part I thought it was appropriate, in terms of monitoring the patients' responses and I communicate with the nurses through the SBAR method in writing. He said though about the written communication he receives from the nurses, It's easily missed because it gets scanned in the EMR and gets buried. With a cross-reference to F309, F323, F441, F490 and F520, and based on the Medical Director's own validation that he has been non-participatory in the quality assurance and assessment reviews. As to the overall coordination of medical care in the facility, the Medical Director has failed to fulfill his role based on his lack of involvement as evidenced by the finding of harm and substandard quality of care found during this survey.",2020-09-01
487,SAMUEL MAHELONA MEMORIAL HOSPITAL,125029,4800 KAWAIHAU ROAD,KAPAA,HI,96746,2016-10-07,520,F,0,1,LDC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews and review of facility policies, the facility failed to maintain a quality assessment and assurance (QA&A) committee consisting of a physician designated by the facility and demonstrating active participation in the facility's QA&A program. In addition, the QA&A committee did not have a quality assurance program that showed specific standards for quality of care and outcomes, nor have documentation to identify and show the study and improvement of processes to better resident care services and outcomes, or to prevent/decrease problems identified with respect to which quality assessment and assurance activities have been necessary to correct identified quality deficiencies. Findings include: Cross-reference to findings at F501. On 10/07/2016 at 8:05 AM, the QA&A interview was conducted with the CNE and DON. The CNE shared she's only been in her position since 10/1/16, but they do have a quality review committee called HPIC. Regarding the use of [MEDICAL CONDITION] medications, the DON stated they identified the high use of [MEDICAL CONDITION] medications related to the incidence of falls. She also acknowledged their facility has a large number of residents with behaviors as well and as such, their team is exploring the delivery of care and services for these types of residents. She stated the Medical Director, the MDS-C and their IDG are looking at it as well. However, it was brought to their attention that the residents' [MEDICAL CONDITION] medications do not have a clear indication for use, with the medications being grouped together on one behavior monitoring flowsheet with the target behaviors being listed as calm. The DON stated the Medical Director will have to look at this. The DON confirmed there are incidents within the facility which continue to recur and she shares it with nursing staff to correct the problem. For falls, such as what was identified for the IJ case (Res #15), the DON stated they are above the State average for falls. Although the 6/1/16 IDT performance improvement review for falls and unnecessary drugs was provided, she stated, And yes, we did not make one step beyond what we're doing to continue to look for other measures to prevent falls. One thing I asked OT (occupational therapy) was to look at residents to identify a person trying to get up. Re-educating the staff. Thus, based on the survey findings, including the validation by the Medical Director of the lack of his participation in the QA&A meetings, the facility has failed to show that it maintains an effective quality assurance and management program. The CNE and DON affirmed this, based on the IJ identified on 10/6/16 with a cross reference to the citations at F309, F323, F329, F353, F371, F386, F441, F490 and F501.",2020-09-01
488,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2017-05-12,247,D,0,1,N9FU11,"Based on interview and medical record review, the facility failed to provide Resident #71 with a written notice of a new roommate coming in to the room. Resident #71 reported during the Stage 1 interview that she was not given notice about new room mate coming in. Nothing was found in chart to say she had been notified during the medical record review. Interview with DON on 5/11/2017 at 2 PM to ask her how residents are notified of roommate changes. DON said it is done verbally with notation put in chart that the resident was notified. DON also checked the medical record and could not find any documentation to say resident had been notified about new roommate coming in. Resident #71 did not receive written notice that a new roommate was being admitted into her room.",2020-09-01
489,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2017-05-12,253,E,0,1,N9FU11,"Based on observations and staff interview the facility failed to provide effective housekeeping and maintenance services for the residents to maintain a sanitary, orderly and comfortable interior. On 05/11/2017 at 7:345 AM met and interviewed staff #84. We toured a resident's room on the Plumeria unit and checked the bathroom which has a shower and it was seen with white substance on the shower floor and shower head handle. Staff #84 stated this was calcium build up when asked what it was. On 05/11/2017 at 9:02 AM met and interviewed staff #86. Staff #87 was shown the ceiling tile in the Beauty Salon room and he stated the tile has black substance and reported that he will change out the ceiling tile and that the chill water line caused the damage. During this time it was brought to his attention that there was one more ceiling tile in the hallway leading to the Plumeria unit that also had brown staining. On 05/11/2017 at 10:05 AM while walking around the 3 units (Plumeria, Lehua and Maile) with staffs #85 and #86 there were areas that required houskeeping and maintenance services . While in the Plumeria women's shower and Lehua Men's shower rooms there was a dark orange substance on the bottom of the door jams near the floor and staff #85 stated it was rust when asked what it could be. While touring the Maile unit shower room staff #86 confirmed that the dark orange colored substance on the handrails was rust. Also, noted in the Maile shower room, was a shower gurney that had a build up of dark orange material on the wheels and staff #86 confirmed that this was rust on two of the gurney wheels. On 05/11/2017 at 2:29 PM met and interviewed staff #36 who stated that the 8 ceiling tiles near the AC in the Maile nurses station looks like mildew. This was brought to staff #86 attention. On 05/12/2017 at 9:02 AM while walking from the Beauty Salon and going to the elevator surveyor noted the handrail on the wall across from the Beauty salon had jagged edges. It appeared not to fit well with the next handrail, the jagged edges prevented it from forming a smooth rail. On 05/12/2017 at 10:54 AM tour of the clean and dirty laundry rooms presented with peeling paint on the hallway walls and this was confirmed with staff #85 who stated that the walls had peeling paint. This was noted outside of the clean laundry room. In the hallway it was noted that the ceiling tiles had moisture stains as stated by staff #85 and that the ceiling tile does not fit well. The clean laundry room was seen with what appeared to be a layer of grey substance on the wall above the door. Staff #85 stated this was dust on the wall above the door inside the room The facility failed to provide effective housekeeping and maintenance services which may result in an unsanitary, unorderly and uncomfortable interior.",2020-09-01
490,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2017-05-12,272,D,0,1,N9FU11,Based on oberservation of 1 of 29 residents from the Stage 2 sample of residents the facility failed to correctly fill out the Minimum Data Set (MDS) Resident Assessment and Care Screening Nursing Home Comprehensive (NC) Item Set. Finding includes: On On 05/12/2017 at 9:06 AM reviewed Resident #46 (Res #46) MDS which was filled out on 1/24/2017 and there was an error noted on Section G0300. Balance During Transitions and Walking D. Moving on and off toilet which was coded 0 which is steady at all times. Res #46 is a paraplegic and does not have use of her legs. The facility failed to fill out correctly the resident's MDS which may result in poor care planning.,2020-09-01
491,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2017-05-12,493,D,0,1,N9FU11,"Based on interviews, the facility did not have a legally responsible designated person who is licensed by the State of Hawaii for establishing and implementing policies regarding the management and operation of the facility. Findings include: 05/09/2017 at 9:00 [NAME]M. Interview with Staff#7. Staff #7 stated that she was appointed as interim administrator. She also has applied to become licensed as a Nursing Home Administrator in Hawaii and is currently being processed by the Hawaii Professional Vocational Licensing Division. Staff #7 further stated that the previous Long Term Care Administrator resigned on (MONTH) 12, (YEAR) and that a letter was filed with the Office of Health Care Assurance.",2020-09-01
492,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2019-07-19,550,D,0,1,CNSY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, and staff inquiry, the facility failed to provide care for two residents (Residents #46 and #39) in a manner to promote enhancement of his or her quality of life. Findings include: 1) On 07/18/19 at 10:00 AM, Resident (R)31 reported staff members take his tray before he is done eating, then they offer me a sandwich. R31 further reported there is no discussion, the meal tray is just removed. R31 has asked to speak to someone about this; however, has not had anyone come to follow up. On 07/18/19 at 01:24 PM a review of R31's quarterly Minimum Data Set with an assessment reference date of 05/08/19 found R31 yielded a score of 15 (cognitively intact) when the Brief Interview for Mental Status was administered. 2) During an interview with R39 on 07/16/19 at 02:11 PM, R39 stated that a staff member was mean and did not treat him/her like a regular person. R39 spoke about a situation where the staff member was providing peri-care appropriately; but was rough when assisting to turn side to side. R39 further reported that this happened several times, a few months ago and has not happened recently. A review of the comprehensive history for R39 showed a past medical history of [REDACTED]. During the interview on 07/16/19 at 02:11 PM, R39 was alert and oriented to name, person, place and answered questions appropriately. On 07/18/19 at 10:10 AM, Nurse Manager (NM) 1 was queried about the situation, previously mentioned, and stated they had no reports of staff being mean or reports of R39 being treated rough. NM1 immediately stated that they will look into the situation further and perform appropriate actions and/or follow up.",2020-09-01
493,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2019-07-19,561,D,0,1,CNSY11,"Based on interviews with resident and staff member and record review, the facility failed to promote a resident's (Resident 46) right to make choices about his or her life that are significant to the resident. Findings include: On 07/17/19 at 09:01 AM a resident interview was conducted with Resident (R)46. R46 reported she is provided with showers three times a week and would prefer to shower daily. R46 further clarified that she doesn't have so much concern about her upper body, but would like a shower to cleanse her bottom (pointing to her groin area). R46 also reported she does not choose her waking time, she is awakened by the nurses for medication then brushes her teeth and then has to wait for her breakfast to be served. A record review was done on 07/18/19 at 08:37 AM. A review of R46's admission/comprehensive Minimum Data Set (MDS) with assessment reference date of 06/12/19 found R46 yielded a score of 15 (cognitively intact) when the Brief Interview for Mental Status was administered. In Section F - Preferences for Customary Routine and Activities, R46 was interviewed. R46 rated the importance of choosing between a tub bath, shower, bed bath or sponge bath as very important. On 07/18/19 at 03:15 PM an interview was done with the Director of Nursing (DON). The DON reported when residents are admitted they are placed on a routine twice a week shower and asked how many times they would like to shower, as well as, when they prefer to take a shower. The DON reviewed R46's record and reported the resident prefers to have showers in the morning; however, there is no documentation of preferred shower frequency. The DON agreed to follow-up and at 03:57 PM reported there is no documentation that R46 was asked how frequently she would like to shower.",2020-09-01
494,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2019-07-19,578,D,0,1,CNSY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review, and review of policy, the facility failed to ensure a physician's order was consistent with one resident's (R) 214 treatment of [REDACTED]. Findings include: During an interview with R214, on [DATE] at 09:46 AM, R214 stated that he/she did not want CPR in the event of their heart stopping. R214 also remembered filling out and signing a POLST form which indicated the same wish as above. A review of the POLST form, which was in the electronic health record (EHR), was consistent with R214 not wanting CPR. However, further review of the EHR, on [DATE] at 10:00 AM, revealed a doctor's order of Full Code. The Full Code order meant that CPR would be provided, by the facility, in the event of an emergency. This was in direct conflict with the resident's wishes. A review of R214's comprehensive medical assessment revealed that R214 was recently admitted on [DATE] for [MEDICAL CONDITION] (bacterial skin infection) of the lower extremities, and needing antibiotic therapy. R214 had a past medical history of [REDACTED]. During the interview on [DATE] at 09:46 AM, R214 was alert and oriented to person, place, and time, and answered all questions appropriately. On [DATE] at 10:20 AM, Nurse Manager (NM) 1 was queried about the conflicting orders. NM1 acknowledged that the doctor's order should have followed R214's wish for DNAR (Do Not Attempt Resuscitation). NM1 stated that they will immediately look into the situation, contact the doctor, and make the necessary corrections. Review of the facility's policy titled, Copy of Advance Health Care Directives (Living Wills and Durable Powers of Attorney) stated the following: the facility recognizes and supports the fundamental rights of each individual adult and emancipated minor to control his or her health care . The federal law provides that individuals have rights to be informed, in writing, of their rights under Hawaii state law to make their own health care decisions, including the right to accept or refuse medical or surgical treatment .",2020-09-01
495,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2019-07-19,610,D,0,1,CNSY11,"Based on interviews, record review, and abuse policy and procedure (P&P) review, the facility failed to thoroughly investigate an alleged violation of verbal abuse for one of eight residents (R61) interviewed in the initial pool sample. Findings include: On 07/17/19 at 09:23 AM, interviewed R61 as resident sampled for initial pool. When queried about any abuse issues, R61 stated that a certified nursing assistant (CNA1) swore at her twice couple of months ago while getting resident out of bed. R61 reported the alleged incident to facility staff and was told that human resources (HR) would investigate. The HR investigation found that there wasn't enough proof because the witness (CNA2) said it didn't happen. Since the alleged verbal abuse, CNA1 doesn't work with R61 anymore. R61 was still upset and claimed that the facility didn't do anything about it because both CNAs are good friends. On 07/17/19 at 02:07 PM interviewed the facility's social worker (SW), and she stated that R61's case of alleged verbal abuse went directly to the administrator (ADM). Interviewed ADM, and she stated that the alleged verbal abuse happened on a weekend and was reported by R61 to licensed practical nurse (LPN1) on 12/22/18 (day after incident). Initially, R61 didn't want LPN1 to report the incident and became angry when LPN1 reported to the DON. The DON joined the interview and clarified that she was on leave at time of the reported incident but LPN1 called her at home on 12/22/18, and she was directed to inform NM1. On 12/24/18 NM1 investigated the alleged verbal abuse reported by R61 and per the incident report (IR-HI 238) sent to the state agency (SA), R61 didn't claim abuse but requested that CNA1 not work with her. On 12/26/18, R61 requested to speak with ADM and filed a formal complaint claiming abuse. The SA received and closed the incident report on 12/27/18. On 07/18/19 at 10:36 AM, interviewed ADM further and queried about HR investigation and documentation. The ADM stated that HR records are kept at the main medical center and would request copy of HR investigation. According to ADM, R61 wanted CNA1 fired but explained to resident that the facility cannot just fire personnel without investigation and validate claims. The HR director received statements from CNA1 and CNA2, and deemed that CNA2 corroborated that incident did not occur and further investigation by HR was not necessary. On 07/18/19 at 11:32 AM, interviewed NM1 and she recalled interviewing R61 on a Monday regarding CNA1 swearing at her. R61 didn't want to tell anybody because feared retaliation but LPN1 reported to NM1 anyway. NM1 moved CNA1 to a different unit and was told not to enter R61's room. R61 was informed of what was done and what will be done. HR was called and interviewed both CNAs that provided care during the incident. NM1 couldn't recall who from HR interviewed the CNAs but both staff denied that the incident happened. NM1 further elaborated that during time of the incident it was the holidays and R61 was upset with her son, and tends to swear at staff when personally frustrated. NM1 stated that both staff very good workers and currently CNA2 is on maternity leave and CNA1 on emergency vacation leave. On 07/18/19 at 03:12 PM, interviewed CNA1 (alleged perpetrator) regarding verbal abuse on 12/21/18 to R61. CNA1 stated she worked on evening shift with R61 and resident always vented to her, and on that date, R61 was venting that son doesn't answer his phone and missed grandsons. CNA1 further elaborated that R61 always uses call-light and she was the usual CNA to answer R61's call with whoever was working on shift with her. There are usually three CNAs during evening shift and R61 requires two CNAs. CNA1 recalled that at time of alleged verbal abuse, R61 used call-light to change brief as had large bowel movement due to soap enema given at beginning of the shift. CNA1 was eight months pregnant at the time and cleaned one side of R61, and CNA2 cleaned the other side. CNA1 denied any pregnancy symptoms such as queasiness or nausea at the time. Queried of CNA1 if she ever joked around with R61 being she felt close with resident and perhaps used the F word in jest. CNA1 stated that she would never swear at work because so unprofessional. That whole week CNA1 noticed that R61 appeared quiet and sad due to not being able to see family. CNA1 confirmed that NM1 and nursing supervisor interviewed her right after interviewed R61 on 12/24/18 but no one from HR interviewed her. CNA1 stated that when she returned to work on 12/24/18, R61 was in the dining room and looked mad and didn't look at her. When CNA1 asked R61 if she was eating in dining room, R61 didn't answer her and CNA1 thought how strange because R61 always talked with her. CNA1 stated, So weird all of a sudden (R61) doesn't want me to care for her. According to CNA1, R61 complained about another CNA in the past and that CNA wasn't allowed to care for R61. CNA1 stated that R61 used to describe that CNA as a B and now that CNA1 cannot help her, she allows that CNA to help her again. R61 had a care plan on EMR, I may demonstrate manipulative behaviors in the form of consistent repetitive requests of staff as evidenced by excessive use of of my call belland interventions included, 10/6/17 Please have 2 staff members at all times when providing care. On 07/19/19 the ADM provided an HR memo to document the investigative findings and resolution of the SA IR-HI 238 reported on 12/24/18. The HR investigation consisted of employee statements provided on the IR and credibility of both CNA1 and CNA2 to conclude that the alleged incident of verbal abuse could not be substantiated. The facility's P&P, Allegations of Abuse/Neglect/Exploitation: Acute Inpatient, Outpatient & Long Term Care, last revised on 05/2019, under paragraph III. Policy, [NAME] All reports of actual, threatened or alleged incidents of patient/resident abuse within the . long term care setting, shall be thoroughly investigated and documented. Also noted, under paragraph IV. Procedure: [NAME] Assessment of Abuse: 5 .For HMC LTC: Administrator or designee on call is notified by staff. Administrator or designee puts staff member on immediate administrative leave, and notifies HR. The facility did not have evidence that the IR-HI 238 was thoroughly investigated and documented as per their allegation of abuse P&P.",2020-09-01
496,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2019-07-19,684,D,0,1,CNSY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with resident and staff members and record review, the facility failed to implement the bowel regimen for one resident (Resident 46). Findings include: On 07/17/19 at 09:00 AM an interview was done with Resident (R)46. R46 reported having constipation (no bowel movement longer than three days) and was provided with suppository. A record review on 07/18/19 at 08:37 AM found R46 was re-admitted to the facility on [DATE] following hospitalization due to worsening of fracture at the T9-T10. R46 had surgery on 04/22/19. The admission [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set with assessment reference date of 06/12/19 notes R46 is totally dependent on staff with two plus persons physical assist for toilet use. The resident is also coded as being frequently incontinent (two or more episodes) of urine and bowel. The physician orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A review of the intake and output documents R46 had a bowel movement on 07/12/19 then was provided with a suppository four days later on 07/16/19. There is no documentation that the prescribed [MEDICATION NAME] tablet was provided prior to the use of a suppository. On 07/18/19 at 03:15 PM concurrent record review and interview was done with the Director of Nursing (DON). The DON confirmed the physician orders [REDACTED]. The DON confirmed the physician orders [REDACTED].",2020-09-01
497,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2019-07-19,812,E,0,1,CNSY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview the facility failed to ensure that safe food handling for the prevention of foodborne illnesses continued throughout the facility's food handling processes. The facility residents were put at risk to exposure to the hazardous nature of mayonnaise that can be potentially hazardous food and/or time/temperature controlled for safety (PHF/TCS). Findings Include: During the initial kitchen tour on [DATE] at 10:10 AM, checked the refrigerator labeled System D, and found that three gallon sized containers of light mayonnaise had expired on [DATE]. Another three gallon sized containers of mayonnaise were observed to be white and yellow in color with the oil separating from the mayonnaise. The institutional food services manager (FSM) immediately removed all six gallons of mayonnaise from the refrigerator. On [DATE] the FSM reported that the three gallons of mayonnaise that were observed with oil separation, became that way when the kitchen staff mistakenly placed the containers into the freezer when they were received. When the containers of mayonnaise were placed into the refrigerator the thawing made the oil separate. The facility's policy for Storage of Refrigerated, Frozen and Dry Foods, included under the paragraph, III. PR[NAME]EDURE: .All food will be discarded after it reaches the use by or expiration date; Dry storage, and Refrigerators will be monitored daily to identify any food that needs to be used or be discarded. The facility failed to keep track of when to discard PHF/TCS food such as mayonnaise that was expired.",2020-09-01
498,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2018-08-06,550,D,0,1,Q6EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, the facility failed to provide one resident (R163) with respect and dignity while providing care. Findings include: R163 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident requires assistance with daily care due to her large size, extreme swelling and weakened state. An interview of R163 on the morning of 7/31/18 found her sitting up in bed. R163 was noted with tight skin from fluid retention and had a nasal cannula to deliver oxygen. When asked about resident care, R163 stated that the staff were great aside from one Certified Nurses Aide (CNA) who often rushed and caused discomfort when providing care to the resident. R163 stated the extreme swelling makes her skin tight which increases her sensitivity to touch. When the CNA rushes, R163 sometimes experiences discomfort. Additionally, when R163 attempted to discuss her concern with the CNA, she became argumentative. The resident noted the CNA is obviously not happy with her job. The resident stated she had a good relationship with the Administrator and would therefore have a discussion with her about that CN[NAME]",2020-09-01
499,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2018-08-06,574,E,0,1,Q6EX11,"Based on observation and interview with resident council members, the facility failed to ensure residents have been informed of their right, including information on how, to formally complain to the State Agency. Findings include: On 08/02/18 at 2:00 PM an interview was conducted with the resident council representatives. Queried members whether they were aware of contacting the State Agency to file a complaint. The members were not aware they could call the State Agency to file a complaint. Following the interview, observation found a bulletin board posted by the entrance to the solarium with resources for the residents. The phone number for the State Agency was not current. Concurrent observation was made with the Administrator and the Director of Nursing to confirm the phone number for the State Agency required updating.",2020-09-01
500,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2018-08-06,578,D,0,1,Q6EX11,"Based on record review and interview with staff member, the facility failed to ensure a resident (Resident #53) without an advance directive was provided with information to formulate an advance directive. Findings include: On 08/01/18 at 09:35 AM a record review was done for Resident #53. The review found no documentation of an advance directive on file. On 08/01/18 at 02:07 PM a concurrent review of the electronic medical record (EMR) was done with the Charge Nurse. The Charge Nurse confirmed there is no documentation of the advance directive in the resident's EMR. The Charge Nurse was agreeable to follow up with medical records. On 08/01/18 at 02:17 PM the Charge Nurse stated the resident does not have an advance directive. Further review found there was no documentation in the admission note (12/08/17) regarding the right to formulate an advance directive.",2020-09-01
501,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2018-08-06,655,D,0,1,Q6EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview and observation, medical record review and staff interview, the facility failed to create an acute care plan to address one resident's (R 163) acute health care needs. Findings include: Interview of R163 on the morning of 7/31/18 at 11:28 AM found her sitting up in bed. R163 was admitted to the long term care facility on 7/26/18 with [DIAGNOSES REDACTED]. She had a nasal cannula which was delivering oxygen. The resident stated she was on a fluid restriction of 1500 ml per day. R163's legs were noted with blisters/[MEDICAL CONDITION] which the resident attributed to her extreme fluid retention. The resident was noted to have slightly labored breathing with her nasal cannula in place. Her cheeks were splotchy and with purple markings. Her nose was splotchy and purple. Her lips were also purplish. Her toes were noted to be bluish at the tips. A review of R163's medical record found physicians orders: [MEDICATION NAME] (diuretic) 60 mg intravenous every four hours; [MEDICATION NAME] (blood thinner) 5000 units subcutaneous twice daily; Regular diet and a fluid restriction was not noted. A review of R 163's acute care plan found there was no documentation of her use of oxygen, her difficulty breathing and the swelling she was experiencing. Additionally, the acute care plan did not indicate R163's use of an antidiuretic and blood thinner. An interview of the Nurse Manager on the morning of 8/3/18 at 10:30 AM revealed R163 is noncompliant with her fluid restriction. The Nurse Manager was made aware that R163 refused to comply with her fluid restriction and asked to speak with her physician to discuss it. The Nurse Manager stated the facility was working on her comprehensive assessment and therefore didn't have all of R163's health issues included on the acute care plan.",2020-09-01
502,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2018-08-06,656,D,0,1,Q6EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to develop a comprehensive person-centered care plan for 1(Resident 49) of 21 sampled residents. Findings include: Cross F757 and F758. On 08/01/18 at 02:10 PM a record review was done for Resident 49 (R49). R49 was admitted to the facility on [DATE]. A review of the physician's orders [REDACTED]. daily for depression following a gradual dose reduction, with a start date of 05/25/18) and klonopin (1 mg. every night for sleep with a start date of 05/25/18). On the morning of 08/02/18 the facility provided a copy of the resident's care plan. The interdisciplinary team developed a care plan for [MEDICAL CONDITION] drug use (start date 02/28/18). The identified goal is no complications related to [MEDICAL CONDITION] drug use. The interventions include the monitoring of adverse effects related to the use of [MEDICATION NAME] and klonopin; behavioral monitoring every shift; monthly psychopharmacological summary; and remind the physician to assess for periodic dose reduction. The care plan did not include non-pharmacological interventions to address the resident's depression or sleep issue. On 08/02/18 at 10:55 AM an interview and concurrent review of the resident's care plan was done with the Minimum Data Set Coordinators. The coordinators confirmed the facility did not develop behavioral interventions (non-pharmacological approaches) to provide support and care related to the resident's depression and sleep issues.",2020-09-01
503,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2018-08-06,757,D,0,1,Q6EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members and resident, the facility failed to ensure 1 (Resident 49) of 5 residents sampled for unnecessary medication review received klonopin (benzodiazepine) to aide in sleeping. Findings include: Cross Reference to F656 and F758. On 08/01/18 at 02:10 PM a record review was done for Resident 49 (R49). A review of the physician's orders [REDACTED]. R49 has a care plan for the use of [MEDICAL CONDITION] drug, noting a [DIAGNOSES REDACTED]. The care plan included interventions to monitor the resident for side effects related to the use of klonopin; complete behavior monitoring sheet every shift; and remind the physician to assess for periodic gradual dose reduction. Based on a sleep assessment, there was no documentation of non-pharmacological interventions to aide in the resident's sleep. On 08/02/18 at 09:58 AM an interview was conducted with R49. Inquired whether the resident has difficulty with sleep, the resident responded that she has no problems sleeping, but has thick mucous which interrupts her sleep to clear her throat. R49 is aware that she is taking medication at night to help her sleep and further reported she used this medication at home. On 08/02/18 at 10:55 AM an interview and concurrent review of the resident's care plan was done with the Minimum Data Set Coordinators. The coordinators confirmed the facility did not develop behavioral interventions (non-pharmacological approaches) to aide in the resident's ability to sleep (i.e. falling asleep, staying asleep, sleep hygiene).",2020-09-01
504,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2018-08-06,758,D,0,1,Q6EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with resident and staff member, the facility failed to ensure 1 (Resident 49) of 3 residents sampled with [MEDICAL CONDITION] medication (antidepressant) included behavioral interventions to address depression. Findings include: Cross Reference to F656 and F757. On 08/01/18 at 02:10 PM a record review was done for Resident 49 (R49). R49 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. The resident had a significant change Minimum Data Set (MDS) with an assessment reference date of 06/26/18. R49 yielded a score of 15 (cognitively intact) on the Brief Interview for Mental Status. The resident was also coded as receiving antidepressant and antianxiety medication during the last seven days. A review of Section D. Mood noted the resident did not report symptoms of depression or displayed any behaviors. The facility provided a copy of the resident's care plan on the morning of 08/2/18. The resident has a care plan for [MEDICAL CONDITION] drug use, noting R49 has a [DIAGNOSES REDACTED]. The care plan includes interventions to monitor for side effects related to the use of [MEDICATION NAME]; monitoring for behavior; and monthly completion of psychopharmacological summary. There was no documentation of a care plan to address non-pharmacological interventions related to the resident's depression. Further review found one entry by social services dated 07/09/18 to document the delivery of mail. On 08/02/18 at 09:58 AM an interview was conducted with R49. The resident was not aware of taking an antidepressant. R49 reported wanting to go to heaven to be with her spouse. Further queried whether staff come to visit with her, the resident responded that staff members don't have time to visit as they are busy working, they usually come to give medication and leave. The resident reported that she does not participate in activities and spends most of the time in her room. On 08/02/18 at 10:55 AM an interview and concurrent review of the resident's care plan was done with the MDS Coordinators. The coordinators confirmed the facility did not develop behavioral interventions (non-pharmacological approaches) to provide support and care to address R49's depression to maintain her highest psychosocial well-being.",2020-09-01
505,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2018-08-06,812,E,0,1,Q6EX11,"Based on observation and interview, the facility failed to ensure food was properly stored. Findings include: On 07/31/18 at 9:40 AM during the initial tour of the kitchen with the Food Service Manager (FSM) observed a brown box stored on the floor of the freezer. The FSM removed one of four carts blocking the entrance to the freezer and reported it was a box of chicken leg meat. Further queried whether there were two boxes on the floor. The FSM stated there were two boxes of chicken leg meat placed on the floor of the freezer. The FSM confirmed food items are not to be stored directly on the floor of the freezer.",2020-09-01
506,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2018-08-06,880,D,0,1,Q6EX11,"Based on observation, staff interview, and review of facility policy, the facility failed to exchange suction equipment/cannister for two of twenty residents (Resident (R) 39, and R54) reviewed. This deficient practice put the resident at risk for the development and transmission of communicable diseases and infections. Findings Include: 1. During an observation of the suction equipment in R39's room, on 07/31/18 at 11:55 AM, the suction equipment cannister contained approximately 100cc of greenish liquid contents. The cannister was marked with the date 06/18/18. This would mean that the suction equipment has been in use for 43 days. 2. During an observation of the suction equipment in R54's room, on 07/31/18 at 11:57 AM, the suction equipment cannister contained approximately 100cc of clear liquid contents. The cannister was marked with the date 06/25/18. This would mean that the suction equipment has been in use for 36 days. After staff interview with Registered Nurse (RN) 4 and review of facility policy, the suction equipment/cannister for both R39 and R54 should have been replaced after one week of use. Also, RN 4 acknowledged that the contents should have been properly discarded. During an interview with the Facility Administrator on 08/03/18 at 09:25 AM, all staff for Long Term Care had received on-going education and training for the changing of suction equipment. The training specifically stated that changing of suction cannisters are done weekly and as needed. Also, it stated to empty cannisters when they are half full.",2020-09-01
507,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2018-08-06,908,E,0,1,Q6EX11,"Based on observations and staff interview, the facility failed to maintain door lock for one of two Soiled Utility rooms surveyed. The door lock for the Lehua Nursing Unit Soiled Utility room was stuck and did not secure the door. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk. Findings Include: 1. During an observation of the Soiled Utility room (located on Lehua Nursing unit) on 07/31/18 at 11:50 AM, it was noted that the door lock for the Soiled Utility room was stuck open and anyone could have entered the room freely. There was also no staff in the immediate vicinity to prevent anyone from entering the room. The room had two large containers for soiled utility, two containers for trash, two red hazard containers, one sharps container, and one container for contaminated body waste. During an interview with Registered Nurse (RN) 4 on 07/31/18 at 12:15 PM, RN4 stated that the door to the Soiled Utility room should have been locked and secured. RN4 double checked the door locked and verified that it was not functional and did not secure the room.",2020-09-01
508,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2017-12-15,641,D,1,0,BOD411,"> Based on record review and interview with facility, the facility failed to ensure 1 (Resident #2) of 3 residents reviewed was accurately assessed. Findings include: Cross Reference to F686. Resident #75's admission Minimum Data Set with an assessment reference date of 9/27/17 notes in Section M. Skin Conditions, the resident has one Stage 2 pressure ulcer and one Stage 1 pressure ulcer. A review of the progress notes and skin assessment reports found documentation Resident #75 has three Stage 1 pressure ulcers on the lower back. Interview and concurrent record review done on the morning of 12/15/17 confirms the resident had three Stage 1 pressure ulcers; therefore, the admission assessment was inaccurate.",2020-09-01
509,HALE HO'OLA HAMAKUA,125032,45-547 PLUMERIA STREET,HONOKAA,HI,96727,2017-12-15,686,G,1,0,BOD411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Medical Record Reviews, interviews and observations the facility failed to provide care and services to prevent pressure ulcer development and promote healing of pressure ulcers for 3 out of 3 residents. Findings: 1) Resident #1 was admitted to the facility on [DATE]. He was discharged on /,[DATE] for 1 night and was readmitted [DATE]. His [DIAGNOSES REDACTED]. Care Plan Conference Conducted on [DATE] had documented that Resident #1 is at risk fro pressure ulcer because he had a history of [REDACTED]. Review of Skin assessments for (YEAR) and (YEAR) showed documentation of reoccurring pressure ulcers during this time. Skin check completed on [DATE] had documented that skin was intact and no skin issues noted. On [DATE] the skin assessment had documented an open area to the right buttock that was covered with DD. Also dry healing abrasion to right upper thigh measuring 2 x 3 cm, 2 x 2 cm and 0.5 x 0.5 cm. This was after a one day hospital admission to Hilo Medical Center. APRN documented in a miscellaneous note on [DATE] that resident had a stage II pressure ulcer he got during his hospital stay and noted resident was on an air mattress and ordered Vitamin C BID and Zinc 220mgs PO daily and [MEDICATION NAME] supplement BID. Skin assessment on [DATE] had documented the coccyx area was open to air and pinkish in color with no open areas noted. On [DATE] the skin assessment had documented 2.3 cm x 3.2 cm pressure ulcer with possible deep tissue injury to left ishial tuberosity. The wound nurse was notified and examined the site, ordering duoderm to be applied every Monday, Wednesday, Friday and PRN. Resident had a speciality mattress. [DATE] miscellaneous note by APRN noted the wound to the left ischium measured 3 cm x 3 cm, circular with a black soft cap over 75% of the wound with 25% pink base. Yellow drainage with no odor. Dressing orders changed to mesalt after irrigating wound with normal saline. Mesalt was to cover black cap of wound only and then cover with folded ABD pad to cushion wound daily. [DATE] APRN documented in miscellaneous note that the resident had 3 pressure ulcers, 1 on his left ischium and the other 2 on the left side of the coccyx. Treatment ordered for all three pressure ulcers was Safegel and dry dressings. [DATE] APRN documented in miscellaneous note that the resident had another deep tissue injury located on the right trochanter. This area measured 5 x 5 cm with an open center that measured 2 x 2 cm. Serous sanguineous drainage was noted and was unable to stage at that time. Orders were to clean with normal saline and apply a [MEDICATION NAME] dressing to the open area and pad entire ulcer with an ABD pad daily. [DATE] is was documented on the skin assessment that there were three pressure wounds, on on the left ischial 1 x 1 cm with pink wound bed and minimal drainage with safgel dressing covered by dry dressing, one on right ischial 5.2 x 3.3 cm blackened wound bed no odor and minimal drainage unstageable wound with safe gel and dry dressing and one on the sacrum 1 cm x 1.2 cm with pink wound bed with minimal drainage and no odor being treated with safe gel and dry dressing. [DATE] had four pressure ulcers documented. one on the coccyx measuring 1 x 2 cm partial thickness with pink base. Minimal serous drainage, cleaned with normal saline, patted dry, [MEDICATION NAME] applied and covered with dry dressing. Second pressure wound was on sacrum 0.5 x 1 cm partial thickness area with pink wound bed, minimal serous drainage, cleaned with normal saline, [MEDICATION NAME] applied and covered with dry dressing. Third pressure wound was on right trochanter, unstagable 5 x 4 cm with eschar and scant amount of slough. No drainage or odor was noted. Fourth pressure wound was on left ischium measuring 0.5 x 0.5 cm with pink bed and no drainage or odor. [DATE] was documented on the skin assessment that the left ischium, sacrum and coccyx wounds had resolved. The wound to the right trochantar continued with 5 x 4 cm black eschar boggy center with slough to the edges. Wound was being cleaned with normal saline. [MEDICATION NAME] was being applied to wound and covered with a dry dressing. [DATE] it was documented on the skin assessment that the sacrum stage II wound had reopened 0.2 x 0.2 cm with pink wound bed. [DATE] it was documented on the skin assessment that the right trocahntar unstagable pressure ulcer had 100% yellow gray slough, measuring 3.7 x 3.5 x 0.1 cm with moderate amount of brownish drainage with mild odor. Left trochantar stage II pressure injury had reopened measuring 1.5 x 1 cm with pink wound base and no drainage. Sacrum area remained resolved but fragile. [DATE] it was documented on the skin assessment the right trochantar pressure injury measured 1 0.5 0.5 cm with pink wound bed. Minimal serous drainage and no odor. Wound was cleaned with normal saline, patted dry, saturated 2 x 2 with safe gel and applied to wound bed, covered with folded 4 x 4 secured with tape and then covered with [MEDICATION NAME]. Left trochantar there were no open areas or discoloration and duoderm was applied to the area. Buttocks had no open areas or discoloration, [MEDICATION NAME] #3 applied as ordered for protection. [DATE] it was documented on the skin assessment that the right trochantar pressure injury was resolved and duoderm had been applied for protection. [DATE] it was documented on the skin assessment that the resolved right trochantar pressure injury area was dry and intact. When the duoderm was removed a small skin tear was noted and new order was obtained to pain area with [MEDICATION NAME] BID. Old pressure area to left trachantar remained resolved with scar tissue present. Skin prep was applied to the area. A new stage 2 pressure injury to the right sacrum measuring 2 x 2 cm. an order was obtained to cover with [MEDICATION NAME] and secure with duoderm. [DATE] skin assessment had documented that no openings in the skin at this time. [DATE] skin assessment had documented that the left trochantar had a stage 1 pressure injury measuring 0.5 x 0.5 cm. The area was cleansed with normal saline, skinprep applied and was covered with duoderm for protection. [DATE] skin assessment had documented that on left side of buttocks there was an opening measuring 1 x 1 cm with pink wound bed and no drainage or odor. [MEDICATION NAME] #3 being applied QID. There was another superficial open area top of butt crack measuring 0.5 x 0.5 cm with pink wound bed with nor drainage or odor. [MEDICATION NAME] #3 applied as ordered. A third opening was on right side of sacrum measuring 0.5 x 0.5 cm with pink wound bed and no drainage or odor. [MEDICATION NAME] #3 was applied. [DATE] skin assessment had documentation that there was a stage II pressure injury to left ischium measuring 1.7 x 1.3 cm with pink wound bed with no drainage and sensicare was applied. Also present was an unstagable pressure injury to the sacrum measuring 4.5 x 3 cm open area. To the right side of the open area there was dark slough/eschar present. Left side of open area was pink to bright red with small amount of drainage with no odor. Wound was cleansed with normal saline and dried. [MEDICATION NAME] was applied to wound and covered with duoderm. [DATE] skin assessment had documented the stage II pressure injury to the left ischium measured 1.5 x 1 cm with pink wound bed with no drainage. Sensicare was applied as ordered. Unstagable pressure injury to sacrum measured 4.5 x 3 cm open area with dark/slough/eschar to right side of wound and pink to bright red area on left side of the wound. There was a small amount of drainage with no odor. [MEDICATION NAME] was applied to the wound and covered with duoderm. A third open area measuring 0.5 cm was noted on the site of the old right trochantar pressure injury area. Duoderm was applied. [DATE] wound assessment had documented that the resident continues to be monitored for old wounds to coccyx and ischium and no new skin issues were noted at this time. On [DATE] it was documented on the skin assessment that the resident refused wound care and skin assessment that shift due to nausea and vomiting. The next wound assessment completed ten days later on [DATE] had documented that the old right trochantar pressure injury remained closed, a stage IV pressure injury to the sacrum measuring 1.5 x 1.5 x 0.5 cm with tunneling at 12 o'clock. Wound bed pink to bright red with moderate amount of sero-sang drainage and no odor. Wound was irrigated and gently dried. Skin prep was applied and silver cel was packed into the tunneling and was to be changed every Monday, Wednesday and Friday. Documentation by APRN on [DATE] states Patient's condition continues to deteriorate and skin breakdown has become unavoidable. On [DATE] and [DATE] a physician had documented pressure injuries are unavoidable and development of pressure ulcers is not only inevitable but unpreventable. With this information documented along with documentation from care plan conference on the [DATE] the facility failed to ensure weekly skin assessments were maintained to help prevention and promote healing of pressure injuries. On [DATE] it was documented on the skin assessment that a skin assessment was unable to be done that shift due to resident being out of facility. Next skin assessment was completed [DATE] after this time. Previous one was conducted on [DATE] leaving 21 days with no skin assessment being conducted on a high risk resident. Again on [DATE] skin assessment was not completed to resident refusing at time and next skin assessment was completed on [DATE] with previous one completed on [DATE] leaving 12 days with no skin assessment being completed on a high risk resident. Lab results for right hip wound culture on [DATE] showed 2 organisms were present. Organism 1 was [MEDICATION NAME] Avuim Group D and Oraganism 2 was Staphylococcus Aureus. Wound culture taken from buttock wound on [DATE] showed two organisms present. Organism 1 was Staph [MEDICAL CONDITION] and organism 2 was Entercoccus faeculis. Interview with Staff #8 who is the wound clinic nurse for the facility last saw Resident #1 on [DATE]. With Resident #1 being a high risk pressure injury resident, deteriorating in month of (MONTH) and had a documented Stage IV pressure injury to his sacrum, the wound nurse should have been overseeing the management of this wound on a more frequent basis to prevent deterioration of the pressure injury and be actively working towards healing. Resident was transferred to North Hawaii Community Hospital on [DATE]. He arrived at the hospital at 1824 hrs. Medical record notes from North Hawaii Community Hospital have documented on [DATE] that He was initially admitted with a chronic small bowel obstruction which was due to adhesions from [MEDICAL CONDITION] ulcer surgery many years ago. Patient had perforated ulcers and had to be allowed to heal by secondary intention. He started taking a turn for the worse yesterday becoming more and more confused blood pressure dropping. Patient has some draining decubiti on his pelvis which appear to be infected. He is hypotensive. He is also somewhat hypoxic. He appears to be septic. [DATE] at 9:57 PM it was documented in the medical record of Resident #1 a [DIAGNOSES REDACTED]. Documentation in the Medical record at North Hawaii Community Hospital on [DATE] at 0301 hrs stated He had multiple potential sources of this [MEDICAL CONDITION] his small bowel obstruction he had infected decubitus ulcers an he also had masses in the right lung which were surrounded infiltrate which could be infectious. Resident was full code status and was intubated in the emergency room before being transferred to the ICU. He was listed as critically ill. Patient expired at 1452 hrs on [DATE]. Discharge summary completed [DATE] at 1514 hrs stated patient [DIAGNOSES REDACTED]. He has received 2L IV bolus and started on maintenance fluid. Lactic acid 2.8>1.7. Source at this time could be post-obstructive PNA vs aspiration PNA, infected decubitus ulcer, [MEDICAL CONDITION], GI with SOB. Patient has a suprapubic catheter in place. -comfort is primary goal of therapy. Documented in medical record is the presence on admission of an unstageable sacral decubitus ulcer with purulent drainage and a second decubitus ulcer was present. Based on this information the facility failed to monitor through weekly skin assessments development of pressure injuries and progress of healing of present pressure injuries on a regular frequent basis. The facility to have their wound nurse monitor and oversee the care and monitoring of a resident who was assessed as being high risk for pressure injuries and had a documented history of reoccurring pressure injuries. The facility failed to prevent a facility acquired pressure ulcer/injury from becoming infected with various bacteria causing osteo[DIAGNOSES REDACTED] and may have contributed to the Resident developing Septic Shock. . 2) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. While residing in the facility, Resident #3 developed a Deep Tissue Injury (DTI) on her right and left heels. Over a six month period, the DTIs resolved and formed on both of Resident #3's heels. At the time of this abbreviated survey, Resident #3 had a DTI on her left heel with the right heel DTI being resolved. An observation of Resident #3 on the morning of [DATE] found her lying in bed wearing mid calf high foam boots to bilateral legs. Resident #3 was unable to turn herself and was aphasic, being unable to make her needs known. Resident #3 had a dark, large (approximately 6 cm x 7 cm) round eschar patch on the bottom of her left heel. Foam boots were placed on both feet and rose to mid calf. Resident #3 had upper and lower extremity contractures and wedges and pillows were utilized to maintain comfortable positions. A review of Resident #3's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] on the morning of [DATE] revealed she was totally dependent on staff for bed mobility (2+ person assistance), transferring (2+ person assistance), eating (1 person assistance), and bathing (1 person assistance). The [DATE] MDS further noted Resident #3 had severely impaired cognitive skills for daily decision making and short and long term memory problems. A review of Resident #3's body diagram assessment on the morning of [DATE] revealed her fluctuations in the resident's skin which ranged from being intact, to stage 2 pressure injury, to Deep Tissue Injury (DTI) over a six month period (July to (MONTH) (YEAR)). The Electronic Medical Record (EMR) was difficult to navigate and to gather information. Facility staff (Administrator, Director of Nursing (DON), and Nurse Manager) were all available to surveyors to obtain/print information from the EMR. The facility initiated the use of Multipodus Boots on [DATE] with the body diagram assessment noting, Right lateral leg no open areas, dry flaky skin. [MEDICATION NAME] #3 applied. New Multipodus boots in place. Highlights from review of the body diagram assessments found discrepancies from one week to the next. For example, the assessment dated [DATE] noted , No skin issues, while on [DATE] the assessment noted, Continues with DTI to right heel. On [DATE] the body diagram assessment noted, Left heel discoloration with 1.5 L x 1.5 W (cm) soft area; No discoloration noted to area but area remains to be soft and boggy to touch. This note indicated Resident #3 was beginning a new DTI on her left heel. The following body diagram assessment dated [DATE] noted Resident #3 Continued with left heel DTI; Podus boot in place; Wound Nurse aware and will continue to monitor. On [DATE], the body diagram assessment noted, Right plantar heel blanchable light purple discoloration, indicating the right heel was again breaking down. The body diagram assessment dated [DATE] noted, Left plantar heel DTI and right plantar heel DTI. The assessment on [DATE] indicated Resident #3's right plantar surface DTI had progressed to two stage 2 pressure injuries. A week later, Resident #3's body diagram assessment dated [DATE] noted, Left plantar heel DTI continues. Dry hard stable eschar measures 5.5 cm x 5 cm. Painted with [MEDICATION NAME] per order. Right plantar heel resolved. A review of Resident #3's Pressure Ulcers care plan found an entry dated [DATE] indicating, Per Wound Nurse, Multipodus boots discontinued. The Wound Nurse's last visit with Resident #3 was on [DATE]. A late entry for the [DATE] visit was noted on [DATE], when the Wound Nurse stated, Wound to patient's right heel assessed today. Patient has hard stable eschar on the right heel due to medical device, Podus boot. Recommend patient not use Podus boot and continue with [MEDICATION NAME] twice daily to keep eschar stable. Heel boots were also recommended. Please see wound record for wound description. A late entry by the Physical Therapist dated [DATE] (for [DATE] visit) noted, (Resident #3) had right heel deep tissue injury develop during treatment episode. An interview of the three Certified Nurses Aides, CNAs, on the morning of [DATE] at 11:45 [NAME]M. revealed Resident #3 developed the DTIs/stage 2 pressure injuries to bilateral heels after use of the Podus boots. The CNAs all noted Resident #3's Podus boots remained on her heels without removal all day during their day shifts. The CNAs reported that they did not receive instructions to remove the Podus boots during the day shift hours. An interview of the Nurse Manager on the morning of [DATE] at 9:33 [NAME]M. revealed Resident #3 had a history of [REDACTED]. After admission, Resident #3 has had recurring DTIs and pressure injuries. The Nurse Manager reported that Resident #3 was referred for Occupational Therapist (OT) screening due to her contractures. The OT recommended the use of Podus boots, which was used to prevent skin breakdown but instead caused skin breakdown for Resident #3. When asked when the boots were removed to allow her skin to rest, the Nurse Manager reported the boots remained on 24 hours per day. The Nurse Manager stated that the Podus boots were discontinued due to the DTIs and reported the resident now used foam boots. On the morning of [DATE] at 9:33 [NAME]M., the Surveyor asked the Nurse Manager to provide a copy of Resident #3's physician's orders [REDACTED]. Resident #3 started use of the Podus boots on [DATE], when the skin on her heels were intact. From use of the Podus boots, she developed a DTI on her right heel on [DATE] (first documented note). Since developing a DTI on her right heel, the facility continued use of the Podus boots despite the initial skin breakdown. Podus boots were discontinued on [DATE], three months since start of use. The facility failed to provide the necessary treatment and services for Resident #3 to prevent new DTIs and pressure ulcers from developing on both heels. 3) Cross Reference to F641. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 expired on [DATE]. Record review done on [DATE] found an admission Minimum Data Set with assessment reference date of [DATE]. In Section C. Cognitive Patterns, the Brief Interview for Mental Status was conducted. Resident #2 yielded a score of 15 (cognitively intact). In Section M. Skin Conditions, Resident #2 was documented with unhealed pressure ulcer, Stage 1 or higher with one Stage 1 pressure ulcer and one Stage 2 pressure ulcer (dated [DATE]). In Section [NAME] Functional Status, Resident #2 was found to require extensive assistance with two person physical assist for bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture). The resident was not coded with a life expectancy of less than six months (J1400. Prognosis). A review of the resident's care plans (provided by the facility on the afternoon of [DATE]) found a care plan for potential for skin breakdown and pressure ulcers. The potential for skin breakdown notes the resident is at risk for skin breakdown related to dependence on staff for mobility and [DIAGNOSES REDACTED]. Interventions included: reposition every 2 hours in bed and weight shift when in wheelchair; use pillows to keep heels off bed and to aid in positioning; consult dietary as needed; and keep resident hydrated per dietitian. The care plan for pressure ulcers (Stage 2 to coccyx, admitted with and [DATE] DTI to left heel) found the following interventions: left heel DTI - [MEDICATION NAME] swab BID; coccyx - duoderm change every 4 days and prn; foam boots while in bed; APP mattress; measure weekly; turn every 2 hours; and refuses to use the foam boot. The documentation of [DATE] notes, Resident #2 was admitted with a Stage 2 pressure ulcer to the coccyx (measurement was 6 cm x 7 cm). On [DATE] the ulcer measured 6 cm x 7 cm with superficial opening, measuring 1 cm x 0.8 cm. Subsequent documentation for [DATE], [DATE]/ [DATE] and [DATE] does not document further measurements, description of wounds or whether the Stage 2 pressure ulcer to the coccyx healed. On [DATE], the weekly skin assessment notes three Stage 1 pressure injuries to the lower back, each measures 3 cm x 1 cm, non-blanchable. The progress note for [DATE] notes three Stage 1 pressure injuries that the resident was admitted with continues, each red and non-blanchable, measuring 3 cm x 1 cm On [DATE] an air mattress was provided. Further documentation on [DATE] notes the pressure injuries to the lower back resolved. Resident #2 was also noted to have deep tissue injury (DTI) to left heel. The first documentation was dated [DATE] which measure the injury as 2 cm x 2 cm. On [DATE], the injury was measured as 1.8 cm (length) x 2.0 cm (width), [MEDICATION NAME] was ordered (swab twice a day). Subsequent note of [DATE] notes deep tissue injury to left heel continues, open area to left ear continues with foam boots and [MEDICATION NAME] to left heel area. The note dated [DATE] by the Registered Dietitian (RD) was reviewed. The RD notes Resident #2 with good intake (75% of meals) but does not accomplish kcal/protein needs at this time due to increased protein needs with wounds. The recommendations included magic cup three times a day with meals; speech therapy consult; wound supplements added, [MEDICATION NAME] twice a day and zinc sulfate for increased wound healing. A review of the care plan identifies Resident #2's problem as nutritional risk due to ill-fitting dentures, mechanically altered diet, advanced age, increased needs due to wounds and BMI On [DATE] at 9:30 [NAME]M. an interview and concurrent record review was done with Staff Members #7 and #8. Queried whether Resident #2 was provided with the supplements ([MEDICATION NAME] and zinc sulfate) as recommended by the RD. The staff member reported if there is an order for [REDACTED]. Following review of the record, Staff Member #7 stated it healed, based on the note that there are no open areas. Inquired whether the wound assessments should include the measuring of the injury/ulcer, Staff Member #2 confirmed that the assessor should document the wound measurements and confirmed this was not being done. Staff Member #2 commented when Resident #2 was admitted , the facility considered placing the resident on hospice. The facility failed to provide care/services for the treatment of [REDACTED]. The facility failed to accurately assess the resident's skin as the resident was admitted on [DATE] and four days later ([DATE]) there is documentation of three Stage 1 pressure ulcers on admission to the resident's lower back. Also the facility failed to ensure thorough assessment of the wounds were done to include size, description of wound (exudate present, color and type of tissue, slough or eschar present) and pain assessment.",2020-09-01
510,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2019-04-26,550,D,0,1,IMVP11,"Based on observation, interview, and record review, the facility failed to provide four residents out four residents who require such services, consistent with the resident rights to dignified existence, self determination, and communication with and access to persons and services inside the facility. Findings include: During the initial pool of the survey, an interview with Resident (R)32 was conducted on 04/23/19 at 09:19 AM who stated I am getting physical therapy (PT) today but I did not know what time. They just come and get me. I would like to know. R32 further stated that she does not attend activities because she has PT twice a day. Interview with R136 and daughter in room as well. R136 stated that she does not know what time her PT is scheduled today and I can't plan my day? R136's daughter stated we would like to know because I would like to be here for her therapy and she can plan her day and I can plan my day. Interview with R137 regarding her PT time and stated it would be good to know my schedule. Interview with R134 stated I think they do the schedule daily. They have the schedule and I don't know when my time is. Record review and concurrent interview with Physical therapy (PT)1 on 04/23/19 at 10:00. Surveyor obtained a schedule from PT1 who stated that the times can change depending on how the day goes. Interview on 04/26/19 at 11:00 with PT1 and discussed patient daily rehab schedule and concerns brought up by the residents. PT1 stated we can figure something out to accommodate the residents. In summary, the facility failed to provide a schedule of times for physical therapy appointments for four residents out of four which did not ensure their dignified existence, self determination, and communication with and access to persons and services inside the facility.",2020-09-01
511,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2019-04-26,584,E,0,1,IMVP11,"Based on observations and interviews, the facility failed to provide a clean, properly maintained environment for four rooms out of four rooms (Rm) (Rm 15, 19, 21-2 and 23-1) This has the potential to affect all of the other resident's. Findings Include: 1. On 04/25/19 at 03:00 PM, observed a large amount of black oblong particles on the window sill outside the window screen in R31's Room (Rm) 21-2. R31's privacy curtain (side facing the window) also was noted to have some black streaks on the curtain. 2. On 04/25/19 at 03:10 PM, observed a large amount of reddish-brown coating with some flakes on a pipe attached at the bottom of the wall to the right as you enter Rm. 23-1 (R2's). 3. On 04/26/19 at 10:06 AM, inspected Rm 21-2 and Rm 23-1 with the Director of Nursing (DON). The DON took a picture of the window sill in Rm 21-2 and agreed it needed to be cleaned and would contact maintenance immediately. The DON also agreed the pipe in 23-1 needed to be addressed. 4) On 04/26/19 07:36 AM, observation of Rm19 showed a large amount of scattered oblong particles on the window sill. Also noted on the privacy curtain (side facing the window) was a large amount of scattered round-like brown particles. Further inspection in Rm 15 revealed the floor under the air conditioning unit with two tiles that had sharp cracked edges. These findings were discussed with the DON who stated that we have already started to work on this. In summary, the facility failed to provide a clean, properly maintained environment for Rn 15, 19, 21-2 and 23-1.",2020-09-01
512,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2019-04-26,657,D,0,1,IMVP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interviews, and record review (RR), the facility failed to timely revise and update the care plan of one of one resident (R30) sampled. R30's care plan was not revised with the most recent recommendations from Physical therapist (PT) and did not include a recent respiratory condition. As a result of this deficient practice, R30 was at risk of not meeting some of her targeted goals. Findings Include: 1. R30 had [DIAGNOSES REDACTED]. She was observed to have a nebulizer at her bedside and had two physician orders [REDACTED]. (oxygen per cannula as needed for shortness of breath or oxygen saturation 2. On 04/23/19 at 10:00 AM, during an interview with R30, she said she was no longer getting PT, but they gave me a paper with some exercises I should continue to do, but I can't do them by myself. RR of R30's care plan dated 07/19/18 included, Nursing rehab #1: In bed, assist with AROM (active range of motion) exercises to BLE (bilateral lower legs) x3 sets of 10 repetitions . RR revealed physician order [REDACTED]. for 30 days . and HEP (Home exercise program/restorative or maintenance program) instructions. On 04/25/19 at 12:09 PM, Certified Nursing Assistant (CNA1) documented exercises were completed with R30. During an interview with CNA1 on 04/25/19 at 01:21PM, she stated she had completed the leg exercises with R30. Asked if she was familiar with the instructions in the task and care plan and she replied, Yes. CNA1 demonstrated how she completed the exercises while R30 was in her wheelchair this morning by doing kicking out exercises to BLE. CNA1 stated, I think she (R30) has a instructions of what she's suppose to do, that may include flexion of her foot. Asked if CNA1 had seen any illustrations of exercises provided to R30, or been taught specifically what they were, and CNA1 replied. No. 04/25/19 at 03:41 PM an interview was conducted with PT2. Inquired what the process was to maintain range of motion and exercises to meet goals after a resident completes PT sessions, and how this is communicated to staff. PT2 stated, . I make a restorative nursing program (document outlining recommendations) to nursing staff. I give a copy to the DON (Director of Nursing) and put one in the binder in the nursing station. PT2 was not sure what the process was to educate staff or how these recommendations were incorporated into the care plan. PT2 said CNA's (Certified Nursing Assistants) have a task list generated in the computer what to do. PT2 obtained a copy of R30's Nursing Care Plan: Restorative program from the binder that was dated 09/28/19. PT2 said. I usually include illustrations but forgot to attach them to the restorative program form. PT2 provided a copy of the illustrations of exercises she had given to R30 and said, this is what I gave her and should be in the room. After review of the exercises and restorative program developed on 09/28/18, it revealed the exercises currently being provided to R30 were not the most recent exercises recommended by PT. Informed PT2 what was currently in the care plan, and task list for CNA's and what CNA1 had stated she did for exercises with R30 this am. PT2 stated, I think the care plan still had the old ones and wasn't updated. 04/26/19 at 08:37 AM during an interview with the DON, she stated, We have a nursing rehab program. Once the resident is done with therapy, they recommend what exercises nursing should continue. DON stated either she or RN3 would get the copy of the restorative nursing program and put it in the care plan. When asked how staff are informed of updates or changes, DON said, it's in the care plan and generates a task list in the computer for the CN[NAME] DON provided the restorative care plan dated 09/28/19 for R30, which did not include the illustrations of exercises as discussed with PT2. The Restorative program form goal included, HEP in bed, 2x daily. Illustrations in room (R30's room). Informed DON PT2 said she forgot to add the illustration of exercises to the binder. The current recommendation for exercises was as follows: Gluteral squeeze, lower trunk rotation stretch, Heel slide, bridging for trunk stability and bent leg lift. All exercises were to be repeated 2x daily, complete 10 repetitions. DON agreed the care plan and task list had not been updated with the new recommendations. The care plan must be reviewed and revised based on changing goals and needs of the resident in response to current interventions. R30's recommended exercises did not get incorporated into the care plan or task list for CNA's, so direct care staff were not aware of changes. Although R30's respiratory issues had resolved, it was not care planned when she had symptoms and receiving treatment, and required ongoing monitoring for potential reoccurrence.",2020-09-01
513,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2019-04-26,689,D,0,1,IMVP11,"Based on observation, and policy review, the facility failed to ensure the environment of one of one sampled resident (R31) was safe and free of potential hazards. R31 used an oxygen concentrator to supply oxygen. The concentrator needs enough space (away from walls or enclosed areas) to continuously draw in room air to work optimally. R31's oxygen concentrator was located too close to the privacy curtain and as a result there was a potential of the concentrator overheating and risk of fire. The deficient practice had the potential to affect other resident's who used an oxygen concentrator. Findings Include: 1. On 04/23/19 at 03:13 PM, observed an oxygen concentrator in R31's room. The oxygen concentrator was turned on and R31 was receiving oxygen via nasal cannula. Observation was made that R31's privacy curtain was directly behind the oxygen concentrator. 2. On 04/24/19 at 09:44 AM, observed R31's privacy curtain directly behind the oxygen concentrator. 3. On 04/25/19 at 10:00 AM, observed R31's privacy curtain flush against the back of the oxygen concentrator, which had the potential to block the airflow into the concentrator. 4. Review of the facility policy titled, Oxygen Concentrator revised date of 11/17, directs staff to Keep concentator away from wall and curtains to prevent overheating. R31's oxygen concentrator was not stored properly when in use. The privacy curtain was too close and did not allow enough space which created a potential safety hazard.",2020-09-01
514,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2019-04-26,695,D,0,1,IMVP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy review and interviews, the facility failed to ensure that one of one sampled resident's (R30) respiratory equipment was properly cleaned and stored. As a result of this deficient practice, the necessary infection control measures were not in place which put R30 at risk of infection. This had the potential to affect all residents using oxygen/respiratory equipment at risk of infection. Findings Include: 1. Record Review revealed R30 had an order for [REDACTED]. 2. On 04/23/19 at 10:01 AM, observed a nebulizer on R30's bedside table with oxygen tubing attached. The oxygen mask attached to the tubing was stored in R30's bedside table drawer with other personal items. The tubing/mask did not have a label or date on it, and it could not be determined when the tubing/mask had last been changed. 3. The facility policy titled, Nebulizer revised 03/17, states Disconnect the air tubing from the nebulizer .replace weekly. Infection control measures of handling, cleaning, storage and disposal of respiratory supplies should be in place to protect the resident from potential infection.",2020-09-01
515,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2019-04-26,697,D,0,1,IMVP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that pain management is provided to one out of one residents who require such services, consistent with professional standards of practice, the resident's care plan and the residents goals and preferences. Findings include: R 32 has a [DIAGNOSES REDACTED]. Interview and observation on 04/23/19 at 08:53 AM with Resident (R)32 who states I have back pain and it takes the edge off but it doesn't last. I only get it twice day. They give me [MEDICATION NAME] which is a mild pain pill and sometimes that helps as much as the other one. Surveyor asked Do they ask you if the medication works? Do they offer you something else? R32 stated no, never. I take [MEDICATION NAME] and [MEDICATION NAME]. Right now, it's working really good but right now my tail bone has so much pressure and the pressure radiates to my legs. R32 goes on to say I'm really upset about it because I did not need the second surgery. The doctor left a piece of bone in and I have more pain than I did before my first surgery and they are having to do surgery again. Observation during medication pass with Nurse RN2 during medication pass on 04/25/19 at 07:07 AM. R32 received [MEDICATION NAME] 15 mg by mouth as routine every morning medication administration. R32 rated her pain at 8/10. Interview on 04/25/19 at 08:34 AM with RN2. Surveyor asked How do you assess, R32's pain after the medication is given? RN2 stated we kinda know. We ask prior to therapy for treatment. For followup, we ask them how is their pain in a couple of hours or three hours. We chart on our followup button on our progress note. Observation and concurrent interview on 04/25/19 at 09:10 (2 hours later) with R32 who stated that no one had asked her about her pain level. She told this surveyor that it is at a 6/10 now. No one ever asks me about my pain after the meds, never. Query with RN2 at 10:30 AM regarding pain followup which she said was reported at 0/10. Query with R32 at 12:00 PM who stated no one came back to ask her if the pain med worked and what her pain level was at. Interview with RN1 04/25/19 at 09:28 AM. Surveyor asked what is your understanding for assessment of pain? RN1 replied If the resident is alert and oriented, we use the pain scale 0-10 and they can usually give the number. From there, we assess if this is new pain, update doctor, is it chronic. Do they have a [DIAGNOSES REDACTED]. For example, the resident in 14.1 - its not her back but cramping in her extremity. In that sense, we try to do things like warm compress and it does take the edge off her pain. Sometimes its not effective in managing enough, then we go to medication. Depending on where they are rating it. Sometimes, they may ask for a certain pain med, especially with pain management. For followup, we should be going back within half hour to one hour. It should be part of our charting and we do need to sign off on that because it will show up as yellow on our computer screen. We should be following up to see if the medication for pain is working or if we need to tweak it . Surveyor asked RN1 what do you do for breakthrough pain for R32? We increased her [MEDICATION NAME] two days after her admission. She was still having complaints then she was increased [MEDICATION NAME] to 200 mg and it helped her to sleep. She gets her [MEDICATION NAME] 15 mg q12 hours. We offer her warm compresses. We do have Tylenol for mild pain and she got the last dose on (MONTH) 8th. We do have the liquid [MEDICATION NAME] 0.5 ml every three hours for moderate to severe pain as needed. The last time she got liquid [MEDICATION NAME] was on the 15th. For her breakthrough [MEDICATION NAME] is what she likes to take because she was taking that in the hospital, one tab bid as needed for pain. She took [MEDICATION NAME] last on (MONTH) 24th at 05:51 PM. Interview with RN3 on 04/25/19 at 09:39 AM queried regarding followup assessment on pain medication administration who stated Depends on if it's [MEDICATION NAME] coated but 45 minutes to one hour. 04/26/19 09:34 AM and concurrent review of records reveals that [MEDICATION NAME] sulfate given at 07:00 AM was numbered 8/10, however, R32 states that they never come and ask her about her pain after the medication is given. Record Review (RR) on (MONTH) 26 at 11:42 AM which reveals the pain medication management care plan which states The resident will be free of any discomfort or adverse side effects from pain medication. Resident's pain is rated using Numeric rating Scale (0-10); with 0 = no pain and 10 = worse pain she can imagine. Interview with Director of Nursing (DON) who queried regarding followup pain assessment who stated it should be done in 30 minutes to one hour. Findings were shared with DON re followup assessment and management of breakthrough pain not being assessed and and none of the breakthrough medications were offered although there were orders for them.",2020-09-01
516,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2019-04-26,812,F,0,1,IMVP11,"Based on observation, document review and interviews, the facility failed to ensure food that requires time control to limit pathogenic microorganism growth or toxin formation was dated and stored safely. The kitchen refrigerator contained unlabeled produce and leftovers. The facility also failed to maintain the walk-in freezer in good working condition. This deficient practice could potentially result in all residents being exposed to foodborne illness. Finding Include: 1. On 04/23/19 at 08:25 AM, observed a large tray covered with tin foil in the walk-in refrigerator that was unlabeled. The Food Services Supervisor (FSS) said he was not sure what was in the tray. The FSS inspected the tray and identified it was left-over sliced ham that was probably from Sunday's brunch. The FSS agreed the tray should be labeled with a date. 2. Review of the facility policy Date Marking included the following definition: Leftovers-Food items prepared for service that were not served and subsequently stored for use within three days. 3. On 04/23/19 at 08:30 AM observed several boxes and plastic bags of perishable produce in the walk-in refrigerator that were not labeled or dated. During an interview with the FSS, asked if he knew when the produce was delivered, and he stated, I'd have to back track and check the invoice. It probably came in Saturday. 4. Review of the facility policy Date Marking states, Time/temperature control for safety foods (TCS) items are date-marked when received, when manufacturer package is opened Dates are monitored to ensure food safety and quality for all foods at the location . Produce is a TCS. 5. On 04/23/19 at 09:00 AM, during a tour of the kitchen observed several pieces of wet cardboard under a rubber mat outside the freezer door. The black seal at the bottom of the freezer door was noted to have a tear in it. There was a large amount of frost inside the freezer. The heaviest frost inside the freezer was located in the area closest to the door. One metal shelf was entirely covered with frost. Food was frozen to touch, but several items were covered with frost. During an interview at this time with the FSS, he stated, We need to scrape the frost off the freezer three times a day. FSS also stated, We have had consultants in to recommend how to fix or replace it. Not all food of the food in the kitchen refrigerator was date marked or monitored to ensure safety and quality. When food, or food products are delivered facility staff must inspect the items and ensure their proper storage, keeping track of when to discard perishable foods, and labeling/dating all TCS foods stored in the refrigerator. Residents are at potential risk of food born illness if this process is not in place. Although the temperatures are within range, the facility's freezer must be in good working condition. Food could not be visualized under the frost to visibly see and monitor if there was any damage or freezer burn to the food.",2020-09-01
517,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2017-07-14,241,D,0,1,NTZG11,"Based on observations and staff interview, the facility failed to maintain respect and dignity for two residents, Resident #38 and Resident #57. Findings include: 1) During the lunch hour on 7/12/17, at approximately 12:40 P.M., an observation of Staff #26 found her passing medications to Resident #38. The staff member was reviewing Resident #38's electronic Medication Administration Record, [REDACTED]. Staff #26 replied, (Resident #38) has medications ordered for 12:00 P.M. When (Resident #38) doesn't receive his medications at exactly 12:00, his wife gets mad. At that moment, an observation found Resident #38's wife seated next him at a table in the dining room looking over at Staff #26. Resident #38 and his wife were seated approximately 20 feet away from Staff #26. Resident #38's wife was not smiling and appeared upset. Resident #38 and his wife were within earshot of the nurse's statement. After Staff #26 made the comment about Resident #38's wife being mad, the wife turned to face Resident #38 and said something to him. When Staff #26 finally got to Resident #38's table, she apologized for being late. Resident #38's wife stated, I would say this is really late. Staff #26 did not smile, did not interact with the resident and her facial expression appeared irritated and unfriendly. 2) Resident #57 was seated in the dining room at a table with 3 other residents during the lunch meal on 7/12/17 at approximately 12:50 P.M. Staff #26 brought Resident #57's medications to the table and announced that he was receiving a laxative for your bowel movements while his 3 table mates watched her giving Resident #57 his medications. 3) During the same medication pass for Resident #57 on 7/12/17 at approximately 12:50 P.M., Staff #26 administered an inhaler to him. After puffing the inhaler, Resident #57 rinsed his mouth and spit into an empty cup. Staff #26 placed the backwashed water on the table in front of Resident #57. She then gave him his pills, which he put in his mouth then picked up the backwashed water and drank that to wash down the pills. The nurse didn't notice Resident #57 drinking the backwash as she was distracted with uncoiling the blood pressure cuff. An interview of the Director of Nursing, DON, on the morning of 7/14/17 at approximately 11:15 [NAME]M. revealed her displeasure in hearing of Staff #26's behavior. The DON further noted Staff #26 was a per diem nurse who was called in when needed. The DON was unaware that Staff #26 was behaving in this manner and stated she would be working with her.",2020-09-01
518,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2017-07-14,279,D,0,1,NTZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with facility staff, the facility failed to develop a comprehensive care plan with measurable objectives and timeframe for 1 of 24 residents reviewed for care plans in Stage 2 (Resident #61). Findings include: Cross Reference to F329 Resident #61, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted from home. Record review done on 7/14/17 of the admission Minimum Data Set (MDS)with an assessment reference date (ARD)of 6/20/17, Resident #61 scored a 1 for mood and behavior which indicates infrequent episodes of sadness. The care area assessment summary noted [MEDICAL CONDITION] drug use was triggered and the decision to develop a care Plan. Review of the care plan found there were no goals or objectives documented to monitor for anti-depressant drug use or mood. A review of the progress notes in the skilled nursing section of the electronic medical record (EMR)did not contain documentation about the resident's mood. During an interview, Staff #11 stated that Resident #61 was admitted as a short stay with weight loss, back pain and generalized weakness, and came into the facility on [MEDICATION NAME] 7.5 mg that was being taken at home. Staff #11 stated the [MEDICATION NAME] is often prescribed to residents to increase appetite. Resident #61 had a loss of appetite and lack of interest in activities. There is no care plan for use of an anti-depressant, appetite stimulant and / or sad mood. The facility did not develop a comprehensive care plan for anti-depressant use for Resident #61.",2020-09-01
519,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2017-07-14,281,E,0,1,NTZG11,"Based on observation, medication administration report reviews and interviews, the facility failed to ensure administration of medications were being provided by nursing staff to meet professional stands of quality and care. Findings include: Cross Referenced to F353, F333, F332 & F520. Observation of Staff #26 on 7/12/2017 observed 11 out of 25 medication administration opportunities were administered late. Medication administration reports were reviewed for the 7/1/2017, 7/8/2017 and 7/12/2017. The report for 7/1/2017 showed 51 medications were administered late for 18 residents. The report for 7/8/2017 showed 152 medications were administered late for 31 residents. The report for 7/12/2017 showed that 95 medications were administered late for 22 residents. The medication administration reports showed that Staff #26 was the administrating nurse for the stated dates. An interview of the Director of Nursing, DON, on the afternoon of 7/12/17 revealed that staff were allowed to administer medications one hour before and one hour after the ordered medication times. The DON further noted that 16 of the 42 residents did not receive their medications on time on 7/12/17. A review of the facility's policy for Medication Administration with revision date of (MONTH) (YEAR) revealed: Administer medications within at least 60 minutes on each side of ordered time, except for 'Stat' medications which must be given immediately or other time-sensitive medications. An interview of Staff #26 on the morning of 7/14/17 at approximately 9:44 [NAME]M. revealed she recently graduated from nursing school and reported this was her first job as a Registered Nurse. Staff #26 reported that she did not have a regular shift and usually filled in for nurses who were off. Staff #26 reported that she wasn't supposed to work on 7/12/17 but filled in for the nurse who was supposed to be there. Staff #26 reported that it's difficult for her to administer medications to the entire population of residents (current census: 42; certified for 44 beds). Staff #26 reported that she's unable to see the times of when all the medications are due (because of electronic records, she has to go into each resident's profile). She further noted that she starts her shift at 6:00 [NAME]M. and takes report until approximately 6:30 to 6:45 [NAME]M. Staff #26 then has to be in the dining room by 7:30 [NAME]M. She is expected to take residents' blood pressures and sometimes the blood pressure machines don't work. When the machines don't work, she has to manually check blood pressures. She stated, It's challenging. In terms of prioritizing, Staff #26 reported, everything is pretty much a priority. Every single person's medications are priorities. I'm not just cruising and ignoring the residents. She noted that she's very busy and tries really hard to keep up. Staff #26 further noted that she has to wait for the eMAR to load before she can begin her tasks. She admitted that ideally she would document and administer medications at the same time. Realistically, Staff #26 noted, she sometimes documented the administration of medications at a later time because she has so much to do. Staff #26 reported her understanding of the facility's policy was to administer medications one hour before and up to one hour after the medication order time. An interview of the Medical Director on the morning of 7/14/17 at approximately 10:50 [NAME]M. revealed his understanding that the facility was experiencing staffing problems this week. He further stated his desire to eliminate the problem. Reference to Lipincott Safe Administration Practices states To promote a culture of safety and to prevent medication errors, avoid distractions and interruptions when preparing and administering medications and adhere to the five rights of medication administration: identify the right patient by using at least two patient-specific identifiers, select the right medication, administer the right dose, administer the medication at the right time, and administer the medication by the right route. The facility failed to ensure that the nursing professional standard of administrating medication at the right time occurred.",2020-09-01
520,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2017-07-14,323,D,0,1,NTZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to provide adequate supervision to prevent avoidable accidents for 1 of 2 residents. (Resident #53) Findings include: Resident #53, was admitted to the facility on [DATE] with generalized weakness related to cervical and lumbar/ sacral stenosis with [DIAGNOSES REDACTED] included in his diagnosis. He was admitted from home. On 7/12/17 at 1:00 PM Staff #50 was observed assisting Resident #53 transferring from the wheelchair onto the toilet. Staff #50 closed the bathroom door which left Resident #53 unsupervised while using the toilet. Staff #50 waited outside of the bathroom until Resident #53 was finished. Staff #50 assisted Resident #53 to clean himself and assisted him back onto the wheelchair then to bed. When asked if Resident #53 has ever had a fall Staff #50 reported that Resident #53 had a fall during the evening shift in the past month and didn't know what the circumstances were or if Resident #53 was injured. Record review done on 7/13/17 found an annual Minimum Data Set (MDS) with assessment reference date (ARD) of 3/23/17 On the functional status, Section [NAME], Resident #53 scored 3 in all categories of the activities of daily living (ADL) requiring extensive assistance while resident involved in activity, staff to provide weight bearing support. A review of the medical record revealed that Resident #53 had a fall documented on 6/29/17 that resulted in a skin tear to the right elbow. During a review of the care plan revision dated 07/11/2017 and Kardex, it stated Resident requires 1 person assist w/ cleaning self and transfers on/off toilet. Do NOT leave resident unattended during toileting. During an interview on 7/13/17 the Director of Nursing (DON) stated that resident #53 is being monitored for significant changes in his overall functional mobility for the past 2 weeks. When asked why the resident shouldn't be left unattended in the bathroom she reported that Resident #53 recently had a fall and is at risk for falls. If the main door to the room is closed, staff can leave the resident in the restroom allowing privacy while leaving the bathroom door partially open so visual observation is possible. The Kardex is a CNA's reference for treatment. The DON also stated that in order to do a root cause analysis when a resident has a fall the team will meet to review the details of the fall, assess for injuries, and ask the resident what was needed at the time the fall occurred. When Resident #53 fell he may have had to go to the bathroom and forgot to use the call light. During the interview with Staff #11, the staff concurred with the DON that the resident should not be left unattended while in the bathroom. The staff member recalled Resident #53 forgot to use the call light and was trying to reach over to put his shoes on, lost his balance and fell . The facility failed to provide adequate supervision of Resident #53 by not following the resident care instructions noted on the Kardex the resident was left unattended while using the toilet.",2020-09-01
521,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2017-07-14,329,D,0,1,NTZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a record review and staff interview 1 of 5 residents reviewed in stage 2 (Resident #61) is using unnecessary drugs without adequate monitoring or indications for its use. Findings include: Cross Reference to F279 Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During observation on 7/11/17 at 9:30 AM Resident #61 was observed in bed sleeping. At 2:00 PM resident was observed to be sitting in activities area at the large table with 2 staff members. Resident #61 appeared to be engaged in active conversation talking, smiling, and using hand gestures. On 7/13/17 at 8:00 AM Resident #61 was sitting up in a chair at the bedside. The resident smiled and said Good morning. At 8:45 AM Resident #61 was observed ambulating in hallway with a walker and gait belt on with the Physical Therapist. A review of the physician's orders [REDACTED].#61 was prescribed [MEDICATION NAME] 15 mg give 1 tablet at bedtime for sad mood. A review of a single Pharmacy note dated 6/20/17 stated only [MEDICATION NAME] 7.5 mg no suggestions. The medical record was reviewed on 7/11/17. The care plan noted resident #61 was being monitored for poor oral intake and risk for falls due to an unattended fall with no injuries that occurred on 7/08/17. There was no documentation of a care plan for the use of [MEDICATION NAME]. Upon review of the medical record on 7/14/17, Resident #61 scored a 1 for mood and behavior on the minimum data set (MDS) with an assessment reference date (ARD) of 6/20/17 indicating infrequent episodes of sadness. The care area assessment summary triggered [MEDICAL CONDITION] drug use and the decision to develop a care plan. Review of the care plan did not have goals or objectives to monitor for Resident #61's mood, behavior or side effects of the [MEDICAL CONDITION] drug use. Review of the progress notes in the skilled nursing section of the electronic medical record ( EMR) did not contain documentation about signs and symptoms of a sad mood. There were no problems identified with the medication regimen review (MRR), per pharmacy notes on 6/20/17; [MEDICATION NAME] 7.5 mg no suggestions. On 7/14/17 at 8:22 AM an interview with staff #11 stated that this resident was admitted as a short stay with weight loss, back pain and weakness and came into the facility with [MEDICATION NAME] 7.5 mg that was being taking at home. After Resident #61 was admitted to the facility, the dose was increased to 15 mg. Staff #11 stated that the [MEDICATION NAME] is often prescribed to increase appetite. Resident #61 has loss of appetite and a lack of interest in activities. Staff #11 confirmed that Resident #61's anti-depressant medication is not being monitored in the care plan for either weight loss or sadness. Staff #11 stated the documentation to monitor the medications can be found in the skilled nursing progress notes section in the EMR. Concurrent record review with staff #11 confirmed there is no documentation of sad mood in the progress notes. Care plan was not developed and could have been a better collaboration with the MDS to revise the [DIAGNOSES REDACTED]. The facility failed to indicate the use of an anti-depressant and did not develop a care plan to monitor the medication to identify adverse consequences.",2020-09-01
522,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2017-07-14,332,E,0,1,NTZG11,"Based on observations, staff interviews, review of the electronic Medication Administration Record [REDACTED]. Findings include: An observation of Staff #26 on the afternoon of 7/12/17 found that 11 out of 25 medication opportunities were administered late resulting in an error rate of 42.3%. An interview of Staff #26 revealed that she failed to administer the morning medications for Residents #38 and #57 because she was giving medications to other residents. Staff #26 stated the facility's policy indicated an acceptable time frame for medication administration was one hour before and one hour after the ordered medication times. An interview of the Director of Nursing, DON, on the afternoon of 7/12/17 revealed that staff were allowed to administer medications one hour before and one hour after the ordered medication times. The DON further noted that 16 of the 42 residents did not receive their medications on time on 7/12/17. A review of the facility's policy for Medication Administration with revision date of (MONTH) (YEAR) revealed: Administer medications within at least 60 minutes on each side of ordered time, except for 'Stat' medications which must be given immediately or other time-sensitive medications. The facility had a medication error rate of 42.3% based on the delay of morning medications on the day of 7/12/17.",2020-09-01
523,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2017-07-14,333,E,0,1,NTZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interviews and facility policy review, the facility experienced significant medication errors for 2 of 42 residents, Resident #116 and Resident #118. Findings include: Observation of Staff #26 performing medication administration on the afternoon of 7/12/17 revealed she failed to provide 16 of 42 residents with their morning medications. Of the 16 affected residents, two residents (Residents #116 and #118) experienced negative outcomes which may have been related to the delay in receiving their morning doses. 1) A medical record review for Resident #118 found she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interview of Staff #11 on the morning of 7/11/17 found Resident #118 was experiencing poor oral intake and had received 1 liter of intravenous (IV) fluids on the night of 7/10/17 to maintain her hydration status. According to Staff #11 she completed the IV fluids and would be reassessed on the morning of 7/11/17. Resident #118's physician's orders [REDACTED]. and remove per schedule; 3) [MEDICATION NAME] Solution 10 mg/5 ml, Give 1.25 ml orally every 2 hours as needed for mild pain/discomfort, Give 1.25 ml to equal 2.5 mg dose po/sl PRN; 4) [MEDICATION NAME] 10 mg/5 ml, Give 2.5 ml orally every 2 hours as needed for moderate pain/discomfort, Give 2.5 ml to equal 5 mg dose po/sl PRN. A review of the nurses notes found an entry dated 7/12/17: .Denies pain or shortness of breath at rest but with any turning her pain goes up to 8-10 (10=highest amount of pain) to the left arm and lower back/pelvis. The resident received her routine MS Contin. [MEDICATION NAME] applied to her lower back and her left arm. Left arm continues in ace wrap with soft cast intact . A review of the eMAR for 7/12/17 revealed Resident #118 did not receive her routine pain medication, [MEDICATION NAME] release 15 mg tablet oral twice daily, per the physician's orders [REDACTED]. Instead the [MEDICATION NAME] given at 12:33 P.M. Resident #118 had physician's orders [REDACTED]. The delayed administration of 3 hours and 33 minutes on 7/12/17 may have contributed to increased pain for Resident #118. 2) Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. From admission to the time of survey, Resident #116 had already experienced extreme declines - no longer able to make facial expressions, unable to sit independently, and becoming completely dependent on staff for assistance with Activities of Daily Living (ADL's). A review of the eMAR for 7/12/17 revealed Resident #116 received his blood pressure medication late that day. The physician's orders [REDACTED]. A review of Resident #116's vital signs on the morning of 7/13/17 revealed that during the week of 7/6/17 to 7/13/17, he typically had low blood pressures. Over 22 different blood pressure takes, Resident #116's blood pressure averaged 126/81. On the morning of 7/12/17, Resident #116's blood pressure was 152/100 when it was taken at 11:47 [NAME]M. He received his dose of [MEDICATION NAME] at 12:06 P.M. Resident #116's blood pressure was taken again on 7/12/17 at 4:23 P.M. when it was 113/75. The delay of medication administration for Resident #116 to receive [MEDICATION NAME] was delayed for 4 hours and 51 minutes on 7/12/17. The delayed administration of [MEDICATION NAME] may have contributed to Resident #116's high blood pressure reading on 7/12/17 at 11:47 [NAME]M. A facility policy review on the afternoon of 7/13/17 revealed, Medications will be scheduled to: Maximize the effectiveness (optimal therapeutic effect) of the medication (e.g. antibiotics, antihypertensives, insulin, pain medication). A review of Staff #26's work schedule found two other days when she had delays in medication administration. An interview of the DON on the afternoon of 7/12/17 at approximately 2:00 P.M. revealed her lack of knowledge that Staff #26 was struggling to complete the task of medication administration. The DON noted that Staff #26 did not report this struggle to her and she therefore was unaware. An interview of Staff #26 on the morning of 7/14/17 at approximately 9:44 [NAME]M. revealed she recently graduated from nursing school and reported this was her first job as a Registered Nurse. Staff #26 reported that she did not have a regular shift and usually filled in for nurses who were off. Staff #26 reported that she wasn't supposed to work on 7/12/17 but filled in for the nurse who was supposed to be there. Staff #26 reported that it's difficult for her to administer medications to the entire population of residents (current census: 42; certified for 44 beds). Staff #26 reported that she's unable to see the times of when all the medications are due (because of electronic records, she has to go into each resident's profile). She further noted that she starts her shift at 6:00 [NAME]M. and takes report until approximately 6:30 to 6:45 [NAME]M. Staff #26 then has to be in the dining room by 7:30 [NAME]M. She is expected to take residents' blood pressures and sometimes the blood pressure machines don't work. When the machines don't work, she has to manually check blood pressures. She stated, It's challenging. In terms of prioritizing, Staff #26 reported, everything is pretty much a priority. Every single person's medications are priorities. I'm not just cruising and ignoring the residents. She noted that she's very busy and tries really hard to keep up. Staff #26 further noted that she has to wait for the eMAR to load before she can begin her tasks. She admitted that ideally she would document and administer medications at the same time. Realistically, Staff #26 noted, she sometimes documented the administration of medications at a later time because she has so much to do. Staff #26 reported her understanding of the facility's policy was to administer medications one hour before and up to one hour after the medication order time. An interview of the Medical Director on the morning of 7/14/17 at approximately 10:50 [NAME]M. revealed his understanding that the facility was experiencing staffing problems this week. He further stated his desire to eliminate the problem. An interview of the Director of Nursing, DON, on the morning of 7/14/17 at approximately 10:43 [NAME]M. revealed she did not have a system in place to monitor/audit staff nurses. The DON reported that she will now figure out a means to ensure that medications are being administered properly, including the correct times. Until this discovery, the DON relied on feedback from staff nurses to help her understand how the nurse was doing. The DON noted Staff #26 was hired in (MONTH) (YEAR) and only worked as a call-in and therefore she did not have a permanent shift. The facility failed to prevent significant medication errors as evidenced by the negative outcomes for two of the sixteen residents who received their medications late on 7/12/17. The facility failed to have a quality assurance monitoring system in place to prevent such errors.",2020-09-01
524,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2017-07-14,353,F,0,1,NTZG11,"Based on interviews, medication administration reports and observation the facility failed to ensure that sufficient qualified nursing staff were available on a daily basis to meet residents' needs for nursing care in a manner and in an environment which promotes each resident's physical, mental and psychosocial well-being to enhance their quality of life. Findings include: 1) Cross Referenced to F281, F520, F332 & F333 Observation of Staff #26 on 7/12/2017 observed 11 out of 25 medication administration opportunities were administered late. Medication administration reports were reviewed for the 7/1/2017, 7/8/2017 and 7/12/2017. The report for 7/1/2017 showed 51 medications were administered late for 18 residents. The report for 7/8/2017 showed 152 medications were administered late for 31 residents. The report for 7/12/2017 showed that 95 medications were administered late for 22 residents. The medication administration reports showed that Staff #26 was the administrating nurse for the stated dates. An interview of the Director of Nursing, DON, on the afternoon of 7/12/17 revealed that staff were allowed to administer medications one hour before and one hour after the ordered medication times. The DON further noted that 16 of the 42 residents did not receive their medications on time on 7/12/17. A review of the facility's policy for Medication Administration with revision date of (MONTH) (YEAR) revealed: Administer medications within at least 60 minutes on each side of ordered time, except for 'Stat' medications which must be given immediately or other time-sensitive medications. An interview of Staff #26 on the morning of 7/14/17 at approximately 9:44 [NAME]M. revealed she recently graduated from nursing school and reported this was her first job as a Registered Nurse. Staff #26 reported that she did not have a regular shift and usually filled in for nurses who were off. Staff #26 reported that she wasn't supposed to work on 7/12/17 but filled in for the nurse who was supposed to be there. Staff #26 reported that it's difficult for her to administer medications to the entire population of residents (current census: 42; certified for 44 beds). Staff #26 reported that she's unable to see the times of when all the medications are due (because of electronic records, she has to go into each resident's profile). She further noted that she starts her shift at 6:00 [NAME]M. and takes report until approximately 6:30 to 6:45 [NAME]M. Staff #26 then has to be in the dining room by 7:30 [NAME]M. She is expected to take residents' blood pressures and sometimes the blood pressure machines don't work. When the machines don't work, she has to manually check blood pressures. She stated, It's challenging. In terms of prioritizing, Staff #26 reported, everything is pretty much a priority. Every single person's medications are priorities. I'm not just cruising and ignoring the residents. She noted that she's very busy and tries really hard to keep up. Staff #26 further noted that she has to wait for the eMAR to load before she can begin her tasks. She admitted that ideally she would document and administer medications at the same time. Realistically, Staff #26 noted, she sometimes documented the administration of medications at a later time because she has so much to do. Staff #26 reported her understanding of the facility's policy was to administer medications one hour before and up to one hour after the medication order time. An interview of the Medical Director on the morning of 7/14/17 at approximately 10:50 [NAME]M. revealed his understanding that the facility was experiencing staffing problems this week. He further stated his desire to eliminate the problem. The facility failed to ensure there were sufficient licensed nursing staff to administer residents their medications on time. 2) During an interview with Resident #59 on the 7/11/2017 at 10:40 AM, she responded to the question Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time? with Depends on length of time, sometimes waits 10-40 minutes. She did go onto say she had never soiled herself waiting for assistance but often waits 40 minutes which she stated is too long. The facility failed to ensure there is sufficient nursing staff to meet the resident's daily basic needs. 3) On 7/11/17 at 10:51 AM, during an interview of Res #2, she had the following response to whether there was sufficient staff available to make sure she received the care and assistance without having to wait a long time: No, no period! That's because of the rules of what we're allowed to have, which is only so many people. That's one of my things I keep trying to tell them they don't have enough staff. I've had to wait a long, long time for a lot of times. I know it's not because they don't want to help me, it's because they don't have enough people to do it. I think it's important for them to have more people. And they can't do anything about it. The morning shift, definitely, it always takes a long time for anyone to help you. And when you think you have to go to the bathroom and you feel like you're going to explode, it's very uncomfortable. It's when you're awake, waking up in the morning. 4) On 7/13/17, surveyor observed the night to early morning shift transition at 5:37 AM in the facility. It was revealed there were two certified nurse aides (CNAs) and one licensed nurse for the night shift. Also, a restorative nurse aide (RNA) (Staff #50) and another CNA floater arrived at 5:30 AM. During the observation of care for Res #22 at 5:42 AM, Res #22 was sitting in his wheelchair in his bedroom. He was placed in front of his wash basin and was staring in the mirror. There was a small dixie cup with water placed on the top of the basin. At 6:00 AM, Res #22 was still sitting in the same spot. He also had a small white wash cloth on his lap and a blue towel, but no oral care or other personal care/grooming items were seen. The resident stated he was okay and said he was waiting for the staff to pick me up. There was no call light within reach for the resident to use. Although the CNA floater who came in at 5:30 AM was in the hallway starting showers for other residents, she did not realize this resident was waiting to be picked up. At 6:12 AM, the resident was still in the same spot sitting in his wheelchair in front of his wash basin. At 6:19 AM, surveyor asked Res #22 if he brushed his teeth. He replied he did and opened the mounted cabinet door to show where his oral care items were. Res #22 then said, they're supposed to come and get me. He acknowledged the staff was to come and get him. On the same morning, 7/13/17 at 6:22 AM, Staff #45 stated with just the two night shift CNAs, sometimes it's very hard because only the two of us, and doing our very best to answer our lights. Staff #45 said the charge nurse also helped out, but we are running, yes and said even though at 5:30 AM, an additional RNA and CNA came in to help them, Staff #45 said it really was not a relief for them. Staff #45 said this was because during the last morning rounds, the residents start awakening at 5:00 to 5:30 AM; that they start using the bathroom, you know getting up. Expectation is 2-3 minutes to answer (call lights) most of time, but we are brisk walking. Staff #45 said some of the residents ask them, How come so long? So I have to tell them, and I have to prioritize. Staff #45 was then asked about Res #22. Staff #45 said she thought the CNA floater was taking care of him and said, I have to set him up to brush his teeth, comb his hair and if I have enough time, to pick up him, but I expect the floater to pick him up or the RNA because he supposed to be outside. I don't know who is the RN[NAME] Staff #45 then said, (Staff #50) is to pick him up because he's been set up. I think he's (Staff #50) busy. At 6:31 AM, Staff #45 then went to check on Res #22 and saw him still sitting in front of his wash basin. Staff #45 apologized to the resident and said the RNA was supposed to have come to get him. Staff #45 then stated she would take the resident to the love of your life and wheeled him into the activity/TV room to sit beside his spouse, who had been sitting in the activity/TV room upon surveyor's arrival at 5:37 AM. Once Res #22 was positioned next to his spouse, they held hands and watched TV. He had been waiting for close to an hour in his room, and had it not been brought to Staff #45's attention, none of the staff would have attended to him sooner. The resident had no call light available for him to use as well and stated twice that he was waiting for the staff to come and get him. On 7/13/17 at 6:33 AM, Staff #50 said, Yes, I was supposed to get him but I was busy answering the lights. The early morning observations found this staff answering the residents' call lights along with the other two night shift CNAs and that it was a very busy time for them. Amongst Staff #50, Staff #45 and Staff #33, Staff #33's face was full of perspiration as she was running in and out of the residents' rooms to get water, to get them up and to answer the next resident's call light, etc., during the morning rounds. Staff #45 said she wore a knit cap to absorb the perspiration around her forehead, but her face was also glistening with beads of perspiration. Staff #50 was also busy bringing residents out of the room in addition to constantly going into different residents' rooms to answer the morning call lights. 5) Res #29 was observed with her breakfast tray on 7/13/17 at 7:54 AM. The resident's dietary order was for a Level 3 bite size consistency. However, her plate consisted of one french toast, no crust, but cut into three long strips (not bite sized), and a whole, unpeeled banana. At 7:56 AM, licensed staff #11 acknowledged that Res #29's food was not of the bite sized consistency. Staff #11 also stated at 8:09 AM that her expectation was that at all levels of care, i.e., the kitchen, licensed staff, the CNAs, they were responsible to ensure the menu and diet consistency was correctly served to the resident. Staff #11 stated, And also looking at her tray, we should be doing a check--a process that should be from the start of the tray (service) to the finish line when it meets the resident. On 7/13/17 at 8:14 AM, Staff #52 said, It's my mistake, I know it's not chopped, I normally don't chop it because she always say she can do. I supposed to have chopped it up for her. 6) On 7/11/17 during stage 1 resident interview when asked if you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time? Resident #31 stated It takes a while to get help when you call, if calling during meal times it takes longer. It's worse for him (she pointed to Resident #53 in the bed next to hers) because he just can't wait and will have an accident. Resident #53 he replied Sometimes I have to wait a long time and I have to let it go. 7) On 7/14/17 during Resident Council Interview with Resident #2 when asked if appropriate facility staff respond to the resident's /group's concerns? Resident #2 stated If they can, the problem is theres not enough people working here, the residents can't wait for 20 minutes when they call for help.",2020-09-01
525,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2017-07-14,431,D,0,1,NTZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to properly store medications. Findings include: Observations of Staff #26 on the afternoon of 7/12/17 revealed her failure to properly store medications. An observation of medication administration on the afternoon of 7/12/17 at approximately 12:40 P.M. found Staff #26 passing medications to Resident #38 in the dining room. Staff #26 left the following blister packs of medications out, on top of her medication cart: Carbidopa-Levodopa 25-100 tablets; Carbidopa-Levo ER ,[DATE] tablets; and Entacaprone 200 mg tablets. Staff #26 did not lock her medication cart when she went to Resident #38's table to give him his medications. Resident #38's wife informed Staff #26 that the resident disliked chocolate pudding and would prefer vanilla pudding. Since she didn't give Resident #38 his medications, Staff #26 needed to place the medications somewhere. She decided to place Resident #38's medications into a small plastic bag and placed the bag into her shirt pocket and took it with her to get the vanilla pudding. Upon return, Staff #26 removed the plastic bag from her pocket and poured the medications into a medication cup then gave Resident #38 his medications. These observations occurred during the lunch hour on 7/12/17 when there were several visitors and at least 15 residents in the dining room. An interview of the DON on the morning of 7/14/17 revealed that Staff #26 should have labeled Resident #38's medications and placed them in a drawer of the medication cart, locked it, then moved on to the next task. The DON further noted that Staff #26 should have placed Resident #38's medication blister packs back into the medication cart then locked it. The DON further clarified that nurses were expected to lock their medication carts anytime it would be unattended. The facility failed to properly store/secure medications, leaving residents and visitors at risk for injury.",2020-09-01
526,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2017-07-14,441,D,0,1,NTZG11,"Based on observations and staff interview, the facility failed to maintain a safe and sanitary environment. Findings include: An observation of Staff #26 on the afternoon of 7/12/17 at approximately 12:45 P.M. found a break in infection control. During medication administration to Resident #57, Staff #26 dropped his inhaler on the floor, picked it up, wiped it down with a PDI wipe, opened the inhaler, placed it on Resident #57's mouth and administered the puffs. Staff #26 did not allow the PDI solution to dry and did not sanitize her hands prior to administering the medication. An interview of the DON on the morning of 7/14/17 at approximately 10:43 [NAME]M. found that she expected Staff #26 to allow the PDI solution to dry and to wash/sanitize her hands before going forward with administering the medication to Resident #57. The facility failed to maintain a safe and sanitary environment for Resident #57 during medication administration on the afternoon of 7/12/17.",2020-09-01
527,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2017-07-14,520,F,0,1,NTZG11,"Based on observations, medication administration reports interviews and review of facility policies, the facility failed to maintain a quality assessment and assurance (QA&A) committee which included analyses of the identified performance improvement measures. This included specific standards for quality of care and outcomes related to the administration of medications at the correct time. In addition, nursing services was found to have no quality oversight as the nurses were not being monitored to identify care deficiencies for the resident population. Findings include: Cross Referenced to F281, F333, F332 & F353. Observation of Staff #26 on 7/12/2017 observed 11 out of 25 medication administration opportunities were administered late. Medication administration reports were reviewed for the 7/1/2017, 7/8/2017 and 7/12/2017. The report for 7/1/2017 showed 51 medications were administered late for 18 residents. The report for 7/8/2017 showed 152 medications were administered late for 31 residents. The report for 7/12/2017 showed that 95 medications were administered late for 22 residents. The medication administration reports showed that Staff #26 was the administrating nurse for the stated dates. An interview of the Director of Nursing, DON, on the afternoon of 7/12/17 revealed that staff were allowed to administer medications one hour before and one hour after the ordered medication times. The DON further noted that 16 of the 42 residents did not receive their medications on time on 7/12/17. A review of the facility's policy for Medication Administration with revision date of (MONTH) (YEAR) revealed: Administer medications within at least 60 minutes on each side of ordered time, except for 'Stat' medications which must be given immediately or other time-sensitive medications. An interview of Staff #26 on the morning of 7/14/17 at approximately 9:44 [NAME]M. revealed she recently graduated from nursing school and reported this was her first job as a Registered Nurse. Staff #26 reported that she did not have a regular shift and usually filled in for nurses who were off. Staff #26 reported that she wasn't supposed to work on 7/12/17 but filled in for the nurse who was supposed to be there. Staff #26 reported that it's difficult for her to administer medications to the entire population of residents (current census: 42; certified for 44 beds). Staff #26 reported that she's unable to see the times of when all the medications are due (because of electronic records, she has to go into each resident's profile). She further noted that she starts her shift at 6:00 [NAME]M. and takes report until approximately 6:30 to 6:45 [NAME]M. Staff #26 then has to be in the dining room by 7:30 [NAME]M. She is expected to take residents' blood pressures and sometimes the blood pressure machines don't work. When the machines don't work, she has to manually check blood pressures. She stated, It's challenging. In terms of prioritizing, Staff #26 reported, everything is pretty much a priority. Every single person's medications are priorities. I'm not just cruising and ignoring the residents. She noted that she's very busy and tries really hard to keep up. Staff #26 further noted that she has to wait for the eMAR to load before she can begin her tasks. She admitted that ideally she would document and administer medications at the same time. Realistically, Staff #26 noted, she sometimes documented the administration of medications at a later time because she has so much to do. Staff #26 reported her understanding of the facility's policy was to administer medications one hour before and up to one hour after the medication order time. An interview of the Medical Director on the morning of 7/14/17 at approximately 10:50 [NAME]M. revealed his understanding that the facility was experiencing staffing problems this week. He further stated his desire to eliminate the problem. Reference to Lipincott Safe Administration Practices states To promote a culture of safety and to prevent medication errors, avoid distractions and interruptions when preparing and administering medications and adhere to the five rights of medication administration: identify the right patient by using at least two patient-specific identifiers, select the right medication, administer the right dose, administer the medication at the right time, and administer the medication by the right route. The facility failed to ensure that the QA&A committee had oversight of nursing staff were being monitored through quality and assessment to ensure that quality care deficiencies for the resident population were identified in the area of medication administration.",2020-09-01
528,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2018-07-27,580,D,0,1,1ZOD11,"Based on record review, and interview, the facility failed to immediately inform resident's physician of a significant change in resident's physical status, a weight loss of 7.6% in one month. Findings include: Review of the record reflected the following weight's for R4: 153.2 lbs on 04/19/18; 145.6 lbs on 05/22/18; 152 lbs on 06/25/18 and 140.4 lbs on 07/24/18 indicating a 7.6% loss in the past month. During an interview with staff (S)82 on 07/26/18 at 10:11 AM who was asked what a significant weight change is? S82 said that the facility's policy and procedure defines that a three percent weight loss is a significant weight change. The procedure is the re-weight of the resident, and add that resident to a group of residents identified with nutritional concerns. S82 stated that she was aware of R4's weight loss although did not update the care plan. S82 stated that the facility notifies the physician when there is a five percent weight change. Per protocol the nurse reports the weight changes to the physician. S82 then searched the electronic health record and confirmed that there was no documentation that the nurse notified the physician of the change in physical status, or physician documentation that acknowledged that the weight loss was communicated. Review of the record on 07/26/18 at 11:15 AM reflected that the weight change was not communicated to the physician and no new orders from the physician were noted.",2020-09-01
529,HARRY AND JEANETTE WEINBERG CARE CENTER,125033,45-090 NAMOKU ST,KANEOHE,HI,96744,2018-07-27,641,D,0,1,1ZOD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review the facility failed to accurately assess one resident (R22's) dental status on the comprehensive assessment dated [DATE]. Dental was not coded for loose or broken dentures. During an observation on 07/25/18 at 10:09 AM R22 was talking and his top denture was loose flapping up and down while he was talking. R22 stated that his denture often comes loose and he needs to put more glue on it, it usually stays pretty well. Review of the MDS admission assessment with an assessment reference date (ARD) of 06/06/18 Section C: Brief interview for mental status (BIMS) was coded 13. Section D: Poor appetite coded yes. Section G: Eating requires supervision. Section K: swallowing/ nutritional status: Height is 68 inches and weight is 128. Section L: loosely fitting or broken full or partial dentures is coded No. Care area assessment (CAA) Dental is triggered no. Review of the Care plan dated 06/04/18 revealed that R22 has potential nutritional problem due to the need for mechanically altered diet related to poor condition of dentures; body mass index (BMI) is 19.2 and advanced age. Resident has order for a texture modified diet, weigh weekly or as needed. Reweigh if 5% weight changes occur. Provide daily select menu at breakfast meals. Assorted juice 120 ML Review of the intake sheet revealed that R22 refused juice on seven out of 18 times between 07/13/18 to 07/26/18 (Juice). During an interview on 07/27/18 at 09:20 AM with S42 who stated, I didn't realize that R22 had a loose fitting denture at the time of his assessment, I see him and talk with him every morning and I never noticed it and he never mentioned it. I wasn't aware that it is on the care plan.",2020-09-01
530,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2020-02-18,623,D,0,1,TGSF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a copy of the notice of transfer or discharge was sent to a representative of the Office of the State Long-Term Care (LTC) Ombudsman for two of 24 Residents, (R)52, and R[AGE], selected for review. This deficient practice had the potential to affect any and all other residents being transferred or discharged from the facility. Findings Include: 1) During a family interview conducted for R52 on 02/11/20 at 01:50 PM, the family member (FM) stated the resident had been discharged to the hospital in November 2019 for an acute injury and most recently, on 02/01/20 for an acute respiratory condition. He was readmitted to the facility on [DATE] per the FM. Record review however, found there was no documentation indicating the facility forwarded a copy of either of R52's hospitalization s for November 2019 and February 2020 to the State LTC Ombudsman. During an interview with the Health Information Management (HIM) manager on [DATE] at 04:50 PM, she stated, We don't have it. She verified R52's recent transfers to and discharges to the hospital from the facility were not sent to the State LTC Ombudsman. The HIM manager said it was something they will start working on. 2) Surveyor reviewed the electronic medical record (EMR) for R[AGE], who was hosptalized on [DATE] for urinary tract infection [MEDICAL CONDITIONS]. Transfer summary for R[AGE]'s 0[DATE] transfer not found in the record. No documentation found to indicate the State LTC ombudsman was notified of R[AGE]'s transfer on 0[DATE]. Surveyor interviewed the Assistant Facility Administrator (AFA) on 02/18/20 at 02:26 PM, Clarification received that the resident was admitted back to the facility on [DATE] after being hospitalized and went back to acute care on 12/13/19. The AFA stated there is no documentation for either transfer that the State LTC Ombudsman was notified.",2020-09-01
531,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2020-02-18,880,E,0,1,TGSF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of the facility's policy and procedure, the facility failed to ensure it maintained infection prevention precautions designed to prevent the development and transmission of communicable diseases and infections for three of 24 residents (Residents (R) 67, 65 and [AGE]) selected for review. This deficient practice had the potential to expose other residents, facility staff and/or other non-facility individuals to a respiratory illness for which R67 was isolated with droplet precautions in place. In addition, the deficient practice placed residents with wounds who are residing in the facility at an increase risk for infection due to improper hand hygiene by licensed staff during dressing changes. Findings Include: 1) R67 was identified on the facility matrix to be on transmission based precautions. Initial tour of the unit where R67 resides was done and found signage was posted to alert people to check with nursing prior to entering his room. Personal protective equipment (PPEs) was also found placed in a plastic tiered container in the hallway for use and staff were observed wearing the PPEs when they entered the room to care for R67. However, on 02/12/20 at 09:35 AM, R67's family member (FM) was observed visiting the resident in his room without wearing any PPEs. The FM was sitting on a foldout chair nearby the resident, who was sitting on his bed talking to the FM. The Licensed nurse (LN1) attending to R67 stated she had spoken to the FM and said, He told me no, won't wear the mask or gown. LN1 initially said the FM should at least have a mask and/or be three (3) feet away since R67 was on droplet precautions. The surveyor asked what their droplet precaution protocol was and LN1 then stated that according to their infection preventionist (IP) nurse, one would not need to wear a mask if you stood three feet away and did not touch anything. Surveyor further queried whether if it was okay for any visitor to not wear PPEs while visiting R67. The LN1 said, No, and then said she needed to ask their infection preventionist (IP) and went to inquire about it. On 02/12/20 at 09:41 AM, LN1 returned and said she had to try and have R67 wear a mask per their IP nurse's recommendation and that standing at 3 feet away, it's still a risk. LN1 then went into R67's room and had a discussion with R67's FM, who again declined to wear a mask. R67 also told LN1 he would not wear a mask. R67's FM also said he had a towel to cover his face and that it worked better than a mask. Eventually, the FM agreed to wear a disposable face mask during his visitation. Shortly thereafter, the IP nurse arrived on the unit and after a discussion of this observation, the IP nurse stated, Yes, there's a breach. She acknowledged the nurse should have provided more education to the FM and that she would follow-up on this with the nursing staff. During an interview with R67 on 0[DATE] at 08:50 AM, he said he was, quarantined, because I'm sick with something. He was aware he had to complete his antibiotics before he was taken off isolation. He stated the staff wore the PPEs because it was to prevent the spread of germs. He acknowledged the importance that visitors should too. Review of the facility's policy and procedure, Transmission-Based Precautions (Contract, Droplet, Airborne, effective 2017), it stated, Droplet Precautions . Use of Personal Protective Equipment (PPE) A. Don a mask upon entry into the resident room or cubicle . This was not observed nor implemented by the nursing staff during the 02/12/20 observation of the visiting FM. 2) Surveyor observed R [AGE]'s dressing change with LN22 on 0[DATE] at 09:03 AM, who stated R[AGE] is diagnosed with [REDACTED]. The new order states to clean the wound with [MEDICATION NAME] due to the wound being vascular and non-healing. R[AGE] has a left leg contracture which puts pressure on the lateral left ankle. LN 22 stated R[AGE] usually has a lot of pain so she was pre-medicated prior to the dressing change with [MEDICATION NAME]. R[AGE] appeared in bed and drowsy during the procedure. LN22 sanitized hands and put gloves on prior to changing the dressing. After removing the dressing, LN22 cleaned the wound with NS and pat dry with clean gauze. The wound appeared approximately 3 inches in diameter with no drainage, white slough with granulating edges. LN22 changed gloves several times during the dressing change and did not hand sanitize between glove changes, after removing the old dressing, and cleaning the site with NS. Surveyor reviewed electronic medical record (EMR). Physician (MD) orders stated, R[AGE] diagnosed with [REDACTED]. Dressing change every day (QD) with [MEDICATION NAME] applied. Apply a large soft boot to the foot to protect the ankle. Surveyor interviewed the IP Nurse (IP) on 0[DATE] at 09:53 AM for clarification of hand hygiene procedures. Surveyor asked IP to describe the process for dressing changes and what the expectations and standards of practice are for the nursing staff. First of all staff will sanitize the table top, and let it dry, then gather the supplies and go into the residents room. Hands should be sanitized before beginning the dressing change. The old dressing is removed, and usually there is a bin next to them to discard the old dressings. When asked if the staff are to hand sanitize between glove changes, the wound nurse responded, it depends, If there is drainage or it is a stage 4 wound I expect them hand sanitize between glove changes. When asked how the staff are monitored for proper technique she replied that she's always available. On Tuesday she does rounds with the wound clinic team who come every Tuesday morning. The nursing staff who are working with each resident usually go into that room to observe with the team to see the technique and what the new recommendations are. I document my notes in the EMR, under wound assessment so the evening and night shift nursing staff can review my notes. Reviewed Wound team clinical notes dated 02/11/20, that states both wounds are smaller this visit. Left ankle injury length 3 cm (3.5 previously. width is 3.5 cm (4 cm previously. [MEDICATION NAME] applied. Coccyx wound. length: 0.6 mg. ( improved from 2 cm on 01/21/10. width 0.4 cm (improved from 0.6 mg. Non healing wound. Improving. 3) Surveyor observed a dressing change for R65 on 0[DATE] at 10:17 AM for R65 with LN15 and S10. LN15 stated R65 had a stage 4 pressure injury to his coccyx but has improved and is healing. The diameter appears 1-2 inches, white slough and pink wound bed. Supplies set up on table, LN 15 sanitized hands and applied gloves before beginning the dressing change. LN15 removed the old dressing and discarded it in the trash can, changed gloves (small amount of drainage noted from wound) and did not sanitize hands between glove changes. LN15 placed the alginate into the wound without first cleaning the site with the NS. Surveyor asked LN15 if he is supposed to clean it first before placing the alginate. He responded, oh yes, its a good thing you are here. He removed the alginate, changed gloves and rinsed the wound with NS. He dried the wound with gauze. LN15 reapplied gloves and inserted the alginate into the wound bed. Surveyor reviewed EMR for wound care orders. Wound consultation dated 02/11/20 stated wound length 2.5 centimeters (cm) long by 2 cm wide by .2 cm deep wound surface area 5 cm. Non healing wound into subcutaneous tissue layer. Pressure injury of sacral region, stage 4 functional [MEDICAL CONDITION]. Orders dated [DATE]. Cleanse coccyx wound with Normal saline, (NS), pat dry, pack with [MED], and cover with border foam. Diagnosis (DX): Coccyx wound stage 4.",2020-09-01
532,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2020-02-18,908,D,0,1,TGSF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation and interview, the facility failed to maintain patient care equipment with cleaning and routine maintenance for one Resident (R)58 of 32 residents in the sample. The deficient practice has the potential to place the resident at an increased risk for illness. Findings include: R58 is a female resident with a [MEDICAL CONDITION] on 2 liters oxygen (02) via trachea collar. Surveyor observed an oxygen (O2) concentrator on 02/12/20 at 10:04 AM next to the head of R58 bed. a Dust was noted on the back of the unit, and the filter with thick gray dust. A service date label was not found on the concentrator. Surveyor questioned the Maintenance Supervisor ([CONDITION]) on 02/18/20 at 10:02 AM who is responsible for the cleaning and maintenance of the O2 concentrator. The [CONDITION] stated the equipment is cleaned and maintained when the resident is discharged . The Filters are changed and dated routinely, although we don't keep a log. Surveyor reviewed the Facility Policy on preventative maintenance program. Page 2 states Upon Admission/ Discharge Maintenance tasks. Medical equipment i.e. concentrator, pumps, suction machines and nebulizers are inspected upon discharge. Cleaning procedures and timelines for the concentrators, filters, etc. was not listed in the policy. Surveyor revealed the 02 concentrator in R58 room with the Facility Adminsitrator (FA) on 02/18/20 at 1:30 PM, who agreed there is a possibility the resident is at a potential risk for illness with the presence of the dirty O2 concentrator.",2020-09-01
533,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2018-12-10,578,E,0,1,GU9811,"Based on staff interview, and record review, the facility failed to obtain documentation that resident's or resident's representative was given opportunity to formulate advanced directives or had a valid Advanced Directive (AD) for Resident(R)6, R31, R53, R78, R96, R117, R123, and R327, and one resident's (R67) AD documented wishes did not match the MD order. Findings Include: 1. On Record Review (RR) review of R6, R53, R78, R123, and R327 records, did not reflect documentation that the resident or resident's representative was given opportunity to formulate advanced directives or had an AD. R67 had an AD that was marked Do not resuscitate, and the MD order was a full code (full resuscitation). On 12/05/2018 at 09:00AM Social Work Director (SWD) interviewed. Asked facility process for advanced directives. She stated. We ask on admission and we're working on a process now for follow up. We are doing an audit now. SWS stated, In the future we'll document follow up in the chart. The SWD confirmed R6, R53, R78, R123, and R327 did not have documentation they or their representative was given opportunity to formulate an advanced directive or had an advance advanced directive in the medical record. On 12/05/2018, R67's chart was reviewed with the SWD, who confirmed the AD, and MD order had a discrepancy of R67's wishes. The MD order, and care plan summary indicated full code (all resuscitation measures), and the AD was marked do not resuscitate. On 12/07/2018 at 11:38AM, the SWD reported, I met with R67. She wants to be a full code, so I pulled the AD from the record. 2. On 12/06/2018 at 09:01 AM Record review (RR) for R96 showed POLST only dated 08/20/18, no AD noted. 3. On 12/06/2018 11:42 AM review of R31, and R117 records did not reflect documentation that resident or resident's representative was given opportunity to formulate advanced directives or had an advanced directive. On 12/07/2018 09:00 AM, SWD was interviewed and she validated that R31, and R117 did not have documentation that they or their representative was given opportunity to formulate advanced directive or had an advanced directive.",2020-09-01
534,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2018-12-10,583,D,0,1,GU9811,"Based on observation the facility failed to provide privacy to one resident (R)123 of a sample of 44. Findings Include: On 12/04/2018 at 02:56PM observed wound nurse (RN183) perform wound care/dressing changes of R123's pressure ulcers. The ulcers were located on R123's left thigh and leg. R123 also required medication application to his scrotum. R183 attempted to pull the curtain around the bed to provide privacy. Observed the curtains did not close all the way, leaving approximately a three-foot open spac. R183 was in bed one, closest to the door. During the procedure, resident located in bed 2 had a visit from the therapy dog brought in by two people. On 12/07/2018 surveyor requested Director of Nursing (DON) to inspect R123's room (129). At that time, it was noted the curtain in bed two also did not close all the way to provide privacy needed for that resident. DON stated, they are missing a panel. All residents have the right to privacy, which includes during medical treatment and personal care.",2020-09-01
535,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2018-12-10,684,D,0,1,GU9811,"Based on interview and record review (RR), the facility failed to ensure three residents (R) 26, R40, and R123 of 44 sampled residents selected for review were turned/repositioned in a timely and consistent manner . This deficient practice had the potential to cause a negative outcome to a resident's physical, mental, and or psychosocial health and well-being. Findings Include: 1.On 12/10/2018 at 11:00 AM RR of Completed Care Task dated 12/03/2018 through 12/10/18 provided by CIS Director6 for R26 and R40 showed large time gaps and inconsistent documentation for turning/repositioning every two hours by staff for R26 and R40. On 12/10/2018 at 01:00 PM Interview with DON about the Completed Care Task dated 12/03/2018 to 12/10/2018 for R26 and R40 regarding the large time gaps and inconsistent documentation every two hours by staff for turning/repositioning R26 and R40. DON confirmed that staff are supposed to document very two hours that they turned/repositioned the residents. DON stated What is not documented isn't done or possibly not done. 2. R123 was identified as high risk for pressure ulcers and skin breakdown. R123 had two recently healed pressure ulcers (left flank, and left thigh), and Stage 4 pressure ulcer on his left hip. RR123's care plan interventions include: if resident is dependent, but alert, assist with transferring weight q (every)/hour, q/2 hours N[NAME] (night), and if resident is dependent but not cognitively intact, assist with weight shifting q 2 hours per turning wheel.(indicates position to turn). Review of R123's completed care task record dated 12/01/2018 through 12/06/2018, revealed gaps of documentation R123 was turned or shifted weight every two hours. On 12/01/2018 documentation R153 had been turned four times. On 12/10/2018 at 08:17AM during interview with RN Manager (RN 55), confirmed gaps in documentation, and stated, It looks like it wasn't done. R123 is dependent on staff to remind him, or to turn him every two hours. He is at high risk to reopen healed wounds and /or develop new pressure ulcers if not done.",2020-09-01
536,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2018-12-10,688,D,0,1,GU9811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation and record review (RR), the facility failed to have a system in place to monitor the implementation of Range of Motion (ROM) exercises to one resident (R)53 of 44 sampled residents. This deficient practice has the potential to effect R53's ability to reach his identified goal of increasing independence. Findings Include: R53 [DIAGNOSES REDACTED]. During an interview with R53 on 12/05/2018 at 12:13PM observed R53 using an exercise band to stretch his left leg. Asked if he received Physical therapy (PT), and R53 stated, I'm going to Straub for therapy. Asked R53 if facility staff did range of motion(ROM)/exercises with him to support his therapy goals. R53 replied, CNA84 is the only one who really does it. Asked R53 if he knew how often staff was supposed to do exercises, and he replied, No. Record review of R53's care plan revealed a goal to become independent with ADL's. CNA's were responsible to do exercises with R53 every shift (three times a day). Instructions were to assist resident with hamstring, achilles & hip adductor stretch, hold each stretch for 1-2 minutes. During an interview with CNA77 on 12/05/2018 at 02:15PM, CNA77 was observed documenting task completion. Observed several tasks highlighted in red. CNA77 explained they turn red if they are overdue. He's (R53) stressing me now because he wants a shower. It's suppose to be done by 02:00PM. R53's care plan revealed prefers morning showers The task for R53's exercises was not listed. CNA77 stated, It's not listed because I already checked it off. Asked CNA77 to explain what the task specifically said, and if she completed the exercises. CNA77 stated, I didn't do all of them. Requested to demonstrate in R53's room what she had completed. CNA77 verbalized and motioned how she did hip adduction with R53. CNA77 stated, I was going to do the rest of them when I got him up to shower. Asked CNA77 if any issues with staffing today, and she replied, Yes, today we have 11 people each, and we normally have 8 or 9. Asked if it was difficult to complete all tasks, CNA77 replied yes. During an interview with R53 on 12/06/2018 at 08:20AM, informed R53 the exercises were to be done once every shift, per day. Asked if evening and night CNA's did exercises 12/05/2019, and he replied, No. During an interview with CNA84 on 12/07/2018 at 02:30pm, CNA84 said, I know how important the exercises are for R53, I make sure it gets done. Asked if there was enough time to get the task done, and she said, it is difficult sometimes, but I make sure I get it done. Asked CNA84 if R53 had expressed concern exercises were not consistently done by other staff, and she replied, Yes, he did mention it, I do them every time I'm assigned to this unit, and sometimes even when I'm on the other area. Even if I don't have time, I find the time. Asked if the unit was short staffed today and CNA84 said, Yes. Asked if it was hard to complete tasks, she replied, Yes, a little, but gets harder getting people up and doing showers. On 12/10/2018, at 08:13AM, during an interview with RN Manager (RN)55 asked if she was aware that R53 verbalized he is not receiving exercises consistently, and she replied, No. Discussed CNA documentation of exercises that included entries of exercises being completed in the middle of the night (12/03/2018 at1:00AM, 12/04/2018 at 03:03AM, 12/05/2018 at 01:27AM, and 12/07/2018 at 3:59AM). Asked R55 who was responsible to monitor and ensure the task was completed. RN55 stated, It is the nurse assigned to R53. Asked how CNA knows what to do, how educated and to show surveyor what specifically taught for R53. RN55 stated, we use to have a restorative program. The therapist writes the instructions and trains some people who are signed off, and staff go to them to be taught. Asked what process used now, and RN55 stated, it's on the shift report. CNA91 was taught by our PT and is on today, he might be the best one to show you. During an interview with CNA91 on 12/10/2018 at 01:00PM, CNA91 demonstrated the exercises. Asked how the CNA's are trained. CNA91 stated, it's kind of hard to have training on that, and R53 doesn't always allow someone to shadow. He knows exactly what needs to be done, and he talked one of the agency CNA's through it. I do tell others to let me know if they need help. A lot of the others signed off as trained are no longer here. The facility did not have a system in place to monitor staff provided ROM exercises as ordered and according to the care plan.",2020-09-01
537,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2018-12-10,689,D,0,1,GU9811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review (RR), the facility failed to provide adequate supervision and implement interventions to prevent one resident (R)78 of a sample of 44 from multiple falls. Interventions implemented were not successful putting R78 at risk for additional falls and injury. Findings Include: R78 [DIAGNOSES REDACTED]. R78 was assessed as high risk for falls with poor safety awareness. Record review (RR) completed with RN Manager (RN55) and further record review revealed R78 fell on [DATE], 06/04/2018, 06/21/2018, 07/19/2018, 08/18/2018, 09/12/2018, 09/14/2018, 10/01/2018, 10/19/2018, 10/24/2018, 11/10/2018, 11/13/2018, and 11/15/2018. On 12/06/2018 at 09:06AM, during interview with RN Manager/MDS Coordinator(RN55), she stated, I'm aware of the falls. Asked how facility reviewed falls, and interventions implemented to prevent falls for R78. RN55 stated, After a fall, it's reviewed at IDT (interdisciplinary team) meeting. Care plan's (CP) reviewed and updated with interventions as needed. RN55 stated, R78 has tab alarm, floor mats, and bed alarm. We don't do one to one's, but give recommendations to family, who sometimes hire someone to sit with resident if they could afford it. We had families stay in the past, and would hire for only four hours if that's what they could afford. We do frequent visual checks. With staffing its hard sometimes. RR of R78's care plan revealed revisions with the following interventions/actions to be implemented to prevent additional falls: 06/04/2018 - nursing to continue monitor for any changes and consult with MD as needed 06/05/2018 - continue with fall precautions 06/22/2018, 07/20/2018, 10/29/2018 - nursing to continue monitor and update MD as needed 08/20/2018 - nursing will monitor and consult with MD as needed 09/14/2018 - MD ordered lab test (UA), pending results. Nursing to continue to monitor. 09/17/2018 - nursing staff to ensure that caution signs are removed from room promptly to free of clutter. 10/02/2018 - nursing to ensure bed and WC (wheel chair alarms in place & working and to provide routine toileting. 10/22/2018 - nursing to ensure res is being toileted every 2 hours 11/14/2018 - rehab to assess for appropriateness of picking up for Part B therapy 11/16/2018 - licensed nurses to monitor CNA staff for safe transfers RR of IDT note revealed R78's 11/15/2018 fall occurred when RN attempted to assist Resident from the wheel chair to the toilet. Interventions identified at the IDT meeting to be implemented were, MDS to follow-up to ensure RNs are following transfer protocols. RN's to also shadow CNA staff. All other fall and injury prevention measure are in place. On 12/10/2018 at 09:00AM, during interview with RN55 inquired if she attended IDT meetings. RN55 replied, yes. RN55/MDS coordinator asked if interventions of MDS to follow-up to ensure RN's following transfer protocols, and RN's shadowing the CNA staff had been implemented, RN55 replied I can't say for 100% sure. RN55 did not have any evidence the interventions were implemented. Asked if there had been any additional education regarding transfers and if she could confirm RN's were shadowing CNA's, RN55 stated, No, not for sure. On 12/10/2018 at 10:11AM during interview with Director of Nursing (DON) discussed R78's falls. DON stated, We've done the low bed, matts and rounding to check on him. Asked DON for additional thoughts to prevent falls. DON stated, Educate the staff on [MEDICAL CONDITION], and R78's condition. He doesn't have the strength to pull himself up once he moves. R78 has no control to pull himself back up. Even with all the alarms, he continues to fall. We've tried to see what position he normally turns to. Staff need to anticipate his needs. Inquired if family had been asked stay with R78, or ability to pay for a someone. DON stated, I've personally not asked. Everything is a ripple effect of our situation. DON asked if was referring to staffing, and DON replied, Yes. On 12/10/2018 at 10:45AM during interview with Social Worker (SW)127 discussed IDT notes he documented on 11/15/2018. SW127 documented, MDS to follow-up to ensure RN's following transfer protocols, and RN's shadowing the CNA staff. Asked SW127 who was responsible to implement the interventions. SW127 replied, that would be nursing. Asked SW127 if he could confirm the interventions were implemented. SW127 replied, No, I don't know if the care team has done that. RR revealed R78's family attended IDT meeting on 11/15/2018. Asked SW127 if family was asked to consider staying with R78 part of the day, or able to afford a sitter. SW127 replied, No, she works full time, and I don't think she could. I could ask. SW127 stated, I think he might be better supervised in a foster home. I discussed that with her. R78's VA (Veterans Health Administration), so there are issues with payment. IDT note documented by SW127, IDT discussed the Resident's on-going falls and the daughter confirmed that the cause of some of the falls is likely related to hallucinations, which she states he was having prior to admission. Addendum documentation 11/15/2018, This writer offered Section Q alternative placement options. Daughter declined to discuss at this time but agreed to approach this writer if she chooses to explore this. Reviewed Facility assessment dated (MONTH) (YEAR). The facility assessed themselves to have the services, and competencies to provide care to individuals with [MEDICAL CONDITIONS] and with the conditions of falls since admission or prior assessment. R78 had been assessed to be an appropriate resident for the facility. Facilities are obligated to provide adequate supervisions to prevent accidents. Adequate is based on type and frequency of individual's needs. Despite implementation of routine interventions, the facility did not provide the supervision and implement precautions to prevent R78 from falling.",2020-09-01
538,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2018-12-10,690,D,0,1,GU9811,"Based on interviews and observation, the facility failed to provide timely treatment to one resident (R)53 of a sample of 44. R53's wet suprapubic catheter dressing was not changed timely. Because of this deficient practice R53 was at risk to develop skin problems associated with moisture from irritation to skin breakdown or infection. Findings Include: On 12/10/2018 at 08:20AM during interview with R53, he stated, I need a dressing change, it's soaked. Observed R53's suprapubic urinary catheter dressing was wet. R53 said, it's (catheter) been leaking. I was supposed to get it changed this morning, but changed the appointment. Follow up at 12:00PM, R53 stated, I just got it (dressing) changed. The nurse popped in earlier and said she didn't forget me, but didn't come back until just now. On 12/10/18 at 01:41PM during interview with RN25, discussed R53's dressing. Asked if she was aware R53 waited for dressing change this morning. RN25, replied Yes, I just changed it. Shared R53 stated he waited a long time. RN25 replied, Yes, quite a while. Confirmed with RN25 it took over three and a half hours to change R53's dressing. RN25 stated, That was because of my poor time management.",2020-09-01
539,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2018-12-10,725,D,1,1,GU9811,"> Based on interviews and observation, the facility failed to provide sufficient nursing staff to provide nursing and related services to assure resident safety and as determined by resident assessments and individual plans of care. This deficiency puts the residents at risk of accidents and is a barrier to attain the highest practicable physical, mental and psychosocial wellbeing. Findings Include: Cross reference tag 0684. Based on interview and record review (RR), the facility failed to ensure three residents (R) 26, R40, and R123 were turned/repositioned according to their individualized care plan. Cross reference tag 0688. Based on interviews, observation and record review (RR), the facility failed to have a system in place to monitor the implementation of Range of Motion (ROM) exercises to one resident (R)53. Cross reference tag 0689. Based on interviews and record review RR, the facility failed to provide adequate supervision of one resident R78 resulting in 13 times during the period of (MONTH) 1, (YEAR) and (MONTH) 1, (YEAR). Cross reference tag 0755. Based on interviews, RR and facility policy, the facility failed to administer medications in a timely manner for R53. 1. On 12/05/2018 at 10:00AM, resident council interview was conducted. Several residents expressed concerns there was not enough CNA's and a lot of agency. The residents reported there were mostly agency nurses on nights. The residents reported this is not a new problem, and the staff work shorthanded a lot, with Nurses called in to do CNA work. Residents felt agency nurses don't know them, have argued with them, and don't know what to do. Residents feel pay might be the reason there is not enough CNA's. Resident expressed concern about going to the bathroom alone which might result in a fall. Residents felt they had to wait to get dressed and go to the bathroom. Review of the Resident Council Minutes dated (MONTH) 11, (YEAR) revealed discussion on staffing with facility respresentatives. On 12/07/18 at 02:30 PM observed Director of Nursing(DON) working on staffing for the remainder of the day. During interview, DON stated, I mandated one of the RN's to stay. It's facility policy. We can mandate the RN's but not the CNA's or LPN's because they are union. Asked it the facility was using agency to supplement staffing, and she replied, recently a lot at night. Informed DON staffing was a concern brought up at resident council interview. And if DON was aware of concerns. She stated, They feel agency don't really know them. I know one resident had a medication they wanted to be given at a certain time, and wasn't being done. Basically, they don't know what's going on. On 12/10/18 at 09:43 AM during interview with DON, shared she had been observed on the unit assisting nursing staff throughout the survey. Asked what she did when on the unit. DON replied, Running to get coffee, putting residents on the toilet, repositioning, talking with them and getting to know them. Rounds, checking safety and environment of room, assist with meals. I've been coming in on weekends quite a bit. Asked DON if the staffing situation was the reason she was doing that, and she replied, Yes, we do have a lot of new grads, but just finishing training. Discussed agency use and asked DON if residents had expressed any concerns about agency staff or if there were any incidents reports. DON replied, I would have to look. Nursing staff are uncomfortable with some of the agency staff. There are some we didn't bring back. Just don't feel safe with them here. Asked DON for specifics of safety concerns, and she replied, Labeling, prepouring medications. Not comfortable doing a procedure. We requested three or four not to return due to concerns. Missed meds, not giving medication. Asked DON if she would define all of those as competency issues, and she replied, Yes, and I have done numerous reviews of 5 rights. (right medication, right dose, right time, right person, right route). On 12/10/2918 at 09:04AM interviewed Administrative Assistant(AA), whose responsible for the schedule the past two years. Vacancies reviewed with A[NAME] AA stated, Yes, there are a lot of vacancies with CNA's. The CNA vacancies were confirmed to be as follows: Day shift has seven open positions for CNA's, and two staff off due to workman's compensation. Evening shift has six vacant positions, five staff off on workman's compensation and one on temporary disability. Night shift has no vacant positions with one staff off on workman's compensation. Asked AA what strategies were done to provide needed staff. She replied, We are offering bonus and double pay for picking up shifts. We can't mandate LPN, s or CNA's. We can mandate RN's and have been doing that. They get compensated, but I'm sure it frustrates some. Some of them don't mind. Sometimes the RN's work as a CN[NAME] Asked status of RN staffing. AA replied, the struggle feels like it is with the CNA's. Asked if they had contracts with more than one agency, and AA said, Yes, and we just added another agency. Inquired if reports were generated to the quality committee on the hours of agency use.AA replied, that would be HR (Human Resources). We have a lot more now, there's a lot. On 12/06/2018 at 10:00AM Interview with CNA90 12/06/2018, asked if they were short staff today, and CNA90 stated. Yes, CNA's. We are suppose to have 8, and we have 5. Asked if able to complete all tasks, CNA90 stated, if you have good teamwork. On 12/07/2018 at 07:53AM, observed no staff in or around the nursing station. The phone rang 26 times without being answered. Observed a visitor at the end of the nursing station, who waited for a while and left after no one was available. The facility is aware of the staffing situation, and documentation of turnover rate has improved. (CNA 52% (MONTH) 1-June 30, (YEAR) to 18.8% (MONTH) 11-December 10, (YEAR) and RN 45.16% (MONTH) 1-June 30, (YEAR) to 10.9% (MONTH) 11-December 10, (YEAR).) Although facility reduced turnover rate, monitored staffing, and implemented several strategies, there was not sufficient and competent staff to provide tasks of positioning, administering medications in a timely manner, monitoring residents to prevent accidents, and routine care.",2020-09-01
540,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2018-12-10,726,D,0,1,GU9811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observation, the facility failed to provide sufficient and competent nursing staff to provide nursing and related services to assure resident safety and as determined by resident assessments and individual plans of care. This deficiency puts the residents at risk of accidents and is a barrier to attain the highest practicable physical, mental and psychosocial wellbeing. Findings Include: 1. On 12/05/2018 at 10:00AM, resident council interview was conducted. Several residents expressed concerns there were not enough CNA's and a lot of agency. The residents reported the night shift was mostly agency nurses. The residents reported this was not a new problem, and the staff work shorthanded a lot. The residents said Nurses are often called in to do CNA work. The Residents felt agency nurses don't know them, have argued with them, and somtimes don't know what to do. 2. On 12/07/2018 at 03:15PM during an interview with R6, he stated, An agency nurse tried to give me a crushed [MEDICATION NAME] pill through my peg tube. There are some medications you can crush and some you can't. I take that pill by mouth in apple sauce. Asked if R6 recalled name of RN, and if he had informed anyone. R6 said, I told my doctor and one of the staff. I don't recall the date. It was a couple of months ago. R6 stated, RN gave me a hard time about it, and argued. I didn't see that agency nurse again. 3. Cross referemce tag 0725. Based on observations, record review, and interviews with residents and staff, the faciity did not provide sufficient and competent nursiing staff to provide care. 4. Cross reference tag 0688 Based on interviews, observation and RR, the facility failed to have a system in place to monitor the implementation of Range of Motion (ROM) exercises to one R53. 5. Cross reference tag 0689 Based on interviews and RR, the facility failed to provide adequate supervision of one resident R78 resulting in 13 falls during the period of (MONTH) 1, (YEAR) and (MONTH) 1, (YEAR). 6. Cross reference tag 0690 Based on interviews and observation, facility failed to provide a timely dressing change to R53's suprapubic catheter. Although the facility implemented several stategies, there was not sufficient and competent staff.",2020-09-01
541,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2018-12-10,755,D,0,1,GU9811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, Record Review (RR) and facility policy, the facility failed to administer medications in a timely manner for one resident (R)53 of a sample 44. Schedules are developed for administering medications to maximize effectiveness, and to prevent potential significant medication interactions. On 12/05/2018 at 12:28PM during an Interview with R53, he stated, I'm not getting my 8AM medications on time. Inquired how often this occurred, and how long it took to get the 8AM medications. R53 stated, It happens a lot. Sometimes it's two hours. Sample of R53's 08:00AM medications reviewed. The administration history revealed the following times the 08:00AM dose of [MEDICATION NAME] (antibiotic for infection) administered: 11/27/2018 09:18AM 11/30/2018 10:40AM 12/03/2018 10:40AM 12/05/2018 09:20AM 12/09/2018 10:07AM The administration history revealed the following times the 08:00AM dose [MEDICATION NAME](pain medication) was administered: 11/28/2018 09:24AM 11/30/2018 10:40AM 12/03/2018 10:40AM 12/05/2018 09:20AM 12/10/2018 09:08AM Facility policy/procedure titled, Pharmacy services-Medication administration was reviewed. Policy statement is: Medications shall be administered in a safe and timely manner and as prescribed. Guideline 4 states, Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. The facility did not administer R53's medications in a timely manner. Facility did not follow standard of practice which includes administration of medication at the correct time. In addition they did not meet the time range identified (within one hour) in their own policy.",2020-09-01
542,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2018-12-10,812,D,0,1,GU9811,"Based on observation and interview, the facility failed to label an opened bag of frozen chicken tenders sitting on the shelf of the walk-in freezer. This deficient practice had the potential to put residents at risk for serious complications from foodborne illness as a result of their compromised health status. Findings Include: On 12/05/2018 at 08:10 AM Initial tour of kitchen with Kitchen Manager (Mgr) 135 revealed a half full opened clear plastic bag of frozen chicken tenders with no labels of any kind such as open or used-by date in the walk-in freezer. Mgr135 asked one of the cooks in the kitchen when and what meal the chicken tenders were used, the cook stated she did not know. Mgr135 told the cook she needs to throw it out. Mgr135 confirmed the chicken tenders should have been labeled or thrown out.",2020-09-01
543,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2018-12-10,880,D,0,1,GU9811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy, the facility failed to exchange the suction equipment/cannister for two of twenty five residents (Resident (R) 74, and R11) reviewed. This deficient practice put the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: 1. During an observation of the suction equipment in R74's room, on 12/05/2018 at 09:41 AM, the suction equipment cannister contained approximately 50cc of white liquid contents. The cannister was not marked with any date, as required by facility, and there was no way to tell when the contents were collected and how long the suctioned cannister was in use. 2. During an observation of the suction equipment in R11's room, on 12/05/2018 at 09:44 AM, the suction equipment cannister contained approximately 200cc of clear/white liquid contents. The cannister was marked with the date 11/20/2018. However, this would mean that the suction equipment has been in use for 15 days and overdue to be changed out. After staff interview with Registered Nurse (RN) 20 and review of facility policy, the suction equipment/cannister for both R74 and R11 should have been replaced after one week of use. Also, RN 20 acknowledged that the contents should have been properly discarded. After review of the facility policy on Suction Machine, the policy stated The suction canister is to be completely clean and dry before storing. As previously mentioned, the facility follows a process to change out the suction cannisters every week or on the 7th day. Again, this was not done. Based on observation, staff interview, and policy review, the facility failed to maintain Contact Precautions (as ordered by the Physician) for R79. This deficient practice put other residents, staff, and visitors at risk of being exposed to R79's known illness of [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). Findings Include: 1. During an observation of R79, on 12/06/2018 at 08:16 AM, Certified Nurse Assistant (CNA) 101 was noted to have entered R79's room without donning gloves or wearing a gown; as required for residents on Contact Precautions. CNA101 was also noted to have had direct contact with R79's bedside table and call bell. Also, it was observed that hand hygiene was not done by CNA101 upon exiting the room. Upon questioning CNA101 on 12/06/2018 at 08:20 AM, CNA101 stated that R79 was on Contact Precautions and acknowledged that a gown and gloves should have been used upon the previous entry to the room. CNA101 went on to say that it was confusing because there was no isolation cart outside of R79's room. CNA101 then stated that the isolation cart would be obtained and placed outside the room. During review of facility policy on Transmission-Based Precautions, it stated Use of personal protective equipment (PPE); Gloves, a. Wear gloves whenever touching the resident's intact skin or surfaces and articles in close proximity to the resident (e.g. medical equipment, bed rails). b. Don gloves upon entry into the room or cubicle. Gowns, a. Wear a gown whenever anticipating that clothing will have direct contact with the resident or potentially contaminated environmental surfaces or equipment in close proximity to the resident. Don gown upon entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the resident-care environment. b. After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganism to other residents or environmental surfaces.",2020-09-01
544,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2017-12-11,656,D,0,1,TOM611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record and staff interview, the facility failed to implement measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (R #96). Findings include: R #96 was admitted with Persistent [MEDICAL CONDITION] and the following Diagnoses: [REDACTED]. Review of the minimum data set ((MDS) dated [DATE] concurred with R #96 medical diagnosis. A review of the Medication Administration Record [REDACTED]. Review of the Resident's care plan dated 8/18/17 revealed the following interventions: Resident to be monitored for the following symptoms; unexplained bruising, black stool and rectal bleeding with the following interventions; administer medication as prescribed, obtain labs as ordered, monitor Resident's bowel movement (BM) for rectal bleeding, dark tarry stools, monitor skin for signs and symptoms of internal bleeding or hemorrhage, including abnormal or unexplained bleeding, unexplained or excessive bruising, ecchymosis, petechiae, purpura. However, the interventions with measurable goals and objectives were not implemented. During an interview on 12/11/17 09:08 AM, staff #27 stated that the Residents are monitored for bruising and bleeding when they are taking Eliquis, [MEDICATION NAME] and Aspirin. Staff #27 stated the flow sheet where the symptoms are documented can be found on the Resident's MAR. A review of the MAR indicated [REDACTED]. During an interview on 12/11/17 at 10:12 AM staff #8 looked for the missing documentation in the Residents EMR. There were no flow sheets or progress notes found to indicate Resident was being monitored for bleeding. Staff #8 stated that documentation for the bleeding precautions should be in the MAR but they are not here. The facility failed to implement the interventions to adequately measure R #96 progress of the goals and objectives outlined in the care plan.",2020-09-01
545,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2017-12-11,658,D,0,1,TOM611,"Based on observations, staff interviews and electronic medical record (EMR) reviews, the facility failed to ensure that care and services were provided according to accepted standards of clinical practice for 1 of 24 residents (R#273) on the survey sample list. Findings include: On 12/07/17 at 09:51 AM, observed Staff#167 do medication administration for R#273 who had a gastrostomy tube (GT) for feeding . Staff#167 prepped R#273's medications by crushing the tablets and poured water into a small plastic cup. At the bedside, without washing hands, Staff#167 put gloves on, and grabbed the syringe that was hanging from the tube feeding bag pole. The nurse then placed the cellophane wrapper with the syringe plunger onto the resident's bed, while she poured water into the syringe attached to the GT to flush by gravity. The water wouldn't go down, so Staff#167 poured the water back into the plastic cup and tried to check for residuals with the syringe and pulling back on the plunger. There were no residuals and surveyor noticed that the syringe was still capped. When Staff#167 attempted to flush the GT with water again, the surveyor informed the nurse that the syringe cap was still on. Staff#167 poured the water back into the plastic cup, removed the cap from the syringe and then reconnected the syringe to the GT. After removing the syringe cap the nurse was able to flush the GT with water, administer the crushed medication, and flush the GT with water again. Staff#167 just poured water from the plastic cup into the syringe indiscriminately and did not measure the amount of water flush to administer before and after administering the crushed medication. During the procedure, R#273's daughter was present and told Staff#167 not to place the syringe in the cellophane wrapping onto the bed again because felt it was unsanitary. On 12/07/17 at 10:55 AM interviewed Staff#167 and queried whether GT placement was confirmed prior to pouring med's into syringe by gravity. According to Staff#167, she checked residuals and there was none. Reminded her that the syringe cap was still on when she tried to check for residuals and she had to pour water back into the plastic cup twice before was successful. Staff#167 stated that she had a big audience and was rushing because the resident was going out of facility with the daughter. On 12/11/17 at 11:19 AM reviewed R#273's EMR, and under the Physicians Orders tab it was written, Flush GT with H20, 30 ml before med's and 60 ml after medications. The facility's policy for, Enteral Tube Feeding, effective date of 06/01/90 and revision date of 08/01/04, under Procedure Guidelines; .4. Check for residual formula prior to each intermittent tube feeding administration . Attach the syringe to the end of the feeding tube, withdraw and measure the stomach or jejunal contents. Reinstill gastric contents into the stomach to prevent disturbance of electrolyte imbalance . 5. Determine the correct placement of the tube by aspiration of gastric contents or residual formula as stated above or by auscultation methods . 6. Pour 15 to 30 ml of water into the syringe, remove the tube clamp and allow water to flow into the tube to determine patency. If the water does not flow freely, notify the Charge Nurse and/or the physician.",2020-09-01
546,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2017-12-11,760,D,0,1,TOM611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record reviews the facility failed to ensure that medications were properly administered through the gastrostomy tube (GT) for 1 of 6 residents (R#98) observed during medication administration for a 11% medication error rate. Findings include: On 12/07/17 at 09:51 AM, observed Staff#167 during medication administration for R#98 through his/her GT. Staff#167 prepped R#98's medications by crushing the [MEDICATION NAME], Atorvastatin and Aspirin tablets and poured them into a medication cup to mix with water. The nurse attached the residents syringe to the GT and poured water into the syringe from a small plastic cup to flush the GT by gravity. The water wouldn't go down, so Staff#167 poured the water back into the plastic cup and tried to check for residuals with the syringe and pulling back on the plunger. There were no residuals and surveyor noticed that the syringe was still capped. When Staff#167 attempted to flush the GT with water again, the surveyor informed the nurse that the syringe cap was still on. Staff#167 poured the water back into the plastic cup, removed the cap from the syringe and then reconnected the syringe to the GT. After removing the syringe cap the nurse was able to flush the GT with water, administered the crushed medication, and flushed the GT with water again. Staff#167 also flushed the GT by pouring water from a plastic cup into the syringe indiscriminately, and the resident's physician orders [REDACTED]. The facility failed to limit medication errors by staff combining crushed medications, administering via R#98's feeding tube, and not flushing between each medication in accordance with current accepted professional standards of practice.",2020-09-01
547,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2017-12-11,812,D,0,1,TOM611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to properly store and serve food in accordance with professional standards for food service safety. Findings include: Observation during the initial kitchen tour on [DATE], it was observed that in one of the refrigerators there were expired items which included lettuce, tomatoes and pickles to use by [DATE]. Another refrigerator included expired items of onions to use by [DATE], prunes to use by [DATE] and cherries to use by [DATE]. Staff #31 was present during the intial tour and validated that the items were outdated. The facility failed to ensure to follow safe food storage for the prevention of foodborne illnesses pathogens being passed to residents.",2020-09-01
548,ALOHA NURSING & REHAB CENTRE,125038,45-545 KAMEHAMEHA HIGHWAY,KANEOHE,HI,96744,2017-12-11,880,E,0,1,TOM611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, 3 out of 28 residents sampled, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Findings include: Infection Control 1)Observation on 12/05/17 at 0809. During an interview with Resident #270 (R#270), it was noted that a suction cannister apparutus was set up at the side-table of the resident's room. The cannister contained remains of suctioning floating in water. Upon further investigation, there was no apparent label on the tubing or cannister. The yankeur portion of the apparatus was placed inside the top drawer of the side-table. Staff #44 (S#44) was asked how do they label and when they change the suction apparatus. She stated We suctioned her last week and we change it everyday and it should be labeled. Upon query of S#44 of the the contents and suction apparatus, S#44 realized that the contents was sitting there for a week. S#44 stated oh, let me take care of this. 2) On 12/07/17 at 01:49 PM the EMR review on R#278 was done, as included in sample for [MEDICAL CONDITION]/ ventilator resident. The resident had a care plan (CP), Resident is unable to care for [MEDICAL CONDITION]; admitted with advanced [MEDICAL CONDITION]; continue max assistance for all cares and needs. The CP interventions included: [MEDICAL CONDITION] daily with 50% hydrogen peroxide and 50% sterile water; Change collar as needed on Tu Th Sa Su; [MEDICAL CONDITION] cannula ( size 8 every Sat [MEDICAL CONDITION]; Hydrogen peroxide 3% soln; MWF change collar after shower. On 12/08/17 at 10:54 AM observed Staff#154 [MEDICAL CONDITION] on R# 278. Staff#154 washed her hands in the bathroom, and went to the resident's bedside table and prepared [MEDICAL CONDITION] supplies, stored on the bedside table. The supplies included containers of sterile water, hydrogen peroxide, [MEDICAL CONDITION] kits. The nurse opened [MEDICAL CONDITION] kit, removed sterile gloves and placed sterile drape across the resident's chest, used sterile cotton-tipped applicators to clean [MEDICAL CONDITION], removed the inner cannula, opened package of sterile gloves, opened package of new cannula, put on sterile gloves, replaced inner cannula and placed gauze under [MEDICAL CONDITION]. Staff#154 then took off the sterile gloves, got a suction kit, put on clean gloves and opened suction kit with 14 Fr tubing, removed sterile gloves from kit, put sterile gloves on, and held tubing with left gloved hand. After procedure verified with Staff#154 that didn't observe her sanitize hands between glove changes. Staff#154 stated that she washed hands in bathroom before doing procedure. The facility's policy, GLOVES: STERILE/NONSTERILE, effective date 06/01/90; revision date 1101/05; page 1 of 2 pages; .Putting on Sterile Gloves .2. Open the package. Do not touch the gloves; 3. Wash hands; 4. With one hand, grasp a glove by the inside of the cuff. Insert the opposite hand into the glove. Leave the cuff turned down . 3) On 12/11/17 at 01:04 PM interviewed Staff#8 on the facility's Infection Control program. There was an Influenza A outbreak during the survey on the second floor. The facility placed face masks and hand sanitizer on a table at the entry of the hallways leading to residents' rooms with signage for staff and visitors to use before entering area. Informed Staff#8 that during the course of the survey observed that staff were not consistently using face masks. Shared observations of staff removing their mask in the hallways, staff removing the face mask as they spoke to a resident and/or the face mask hanging from their neck. According to Staff#8, the Influenza A started with a resident on the second floor unit, who had alot of visitors. Staff#8 who heads the facility's infection control program, stated that, staff were to use face masks when entering the hallways to the residents rooms, and nurses should have been using masks while on those units with active outbreak and changed every hour. The facility's policy for, MASKS; Nursing Services department; effective date 06/01/90; revision date 09/01/05; page 1 of 2; Policy: It is the policy of this facility to use masks: (1) to prevent transmission of infectious agents through the air, (2) to protect the wearer from inhaling droplets, (3) to prevent transmissions of some infections that are spread by direct contact with mucuous memberanes, . Procedure: .Key Procedural Points. 1. Put the mask on before entering the room. Be sure hands are clean before putting on a face mask; 2. Be sure that the face mask covers the nose and mouth while performing treatment or services for the resident; .4. Do not let the face mask hang around the neck; .6. Do not remove the mask while performing treatment or services for the resident; 7. Mask may be used only once and then discarded . The facility did not have proper contact precaution measures to prevent transmission of the Influenza [MEDICAL CONDITION] from one unit to another.",2020-09-01
549,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,164,D,0,1,HB3G11,"Based on family and roommate interviews, the facility failed to maintain confidential personal and clinical information for 1 of 32 residents (R#50), on the Stage 2 sample resident list. Findings included: On 06/13/2017 at 01:43 PM during Stage 1 of the survey, a family interview was conducted for R#50. When the family representative was queried whether the facility staff informed the family member about the resident's condition(s) privately, the reply was, No. According to the family member, on several occasions the nursing staff have reported the residents blood pressure with the roommate in bed and able to hear everything being said about R#50. On 06/16/2017 at 8:33 AM went to observe R#50 and the room shared with the roommate. The resident's bed was empty and the roommate was sitting in a wheel chair watching TV with hrer breakfast tray on an overbed table. The roommate stated that R#50 went to the eye doctor and will be back later. Queried roommate how she knew this information. Roommate stated that their was room so small, and able to hear everything told to R#50 when staff come in to provide care. The facility staff did not ensure R#50's right to privacy that included privacy of personal and clinical information from the roommate.",2020-09-01
550,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,223,G,0,1,HB3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review (MRR) and staff interviews, the facility failed to ensure that female residents were not subjected to sexual harrasment from a male resident in the same locked special care unit. Findings include: Interviewed Staff #136 on 6/13/17 who stated that R#249 continues to follow the female resident and continues to try to touch and be close. A couple of the female residents are disturbed by the resident's behavior. When sitting in their chairs and R#249 approaches them, they will fold their arms across their bodies and not make eye contact. They also try to move away but he follows. Staff #136 further stated that two female residents in particular do not like anyone in their space. One female resident is easily agitated with anyone and everyone and R#249 needs constant redirection. This is a dementia unit. Moods change as soon as you drop a pen on the floor. Some residents like their space. It is not black or white. Medical record review on 6/15:17 at 8:32 [NAME]M. for resident(R) #249 was conducted, and it was noted that the resident was admitted to the facility in 10/2016 for custodial care and behavioral management. R#249 was admitted with a history of [MEDICAL CONDITION], aggressive behaviors towards males and liked touching females. Pharmacy along with the MD were adjusting medications to control behaviors in the months of (MONTH) and (MONTH) In March, gradual dose reduction (GDR) was looked at by the behavior enhancement committee and GDR was attempted. R#249 did have a dose reduction of his [MEDICATION NAME] in (MONTH) from 1 mg Am/1 mg midday/2mg at night to 1 mg three times a day. Review of Psychopharm Committee Minutes dated 5/11/17 discussed R#249 and suggested increasing [MEDICATION NAME], adding Tylenol, monitor 3-4 weeks behavior per MD. It stated that R#249 continues to approach female residents personal space. Staff to redirect and effective. A note written by MD on 5/17/17 noted that staff had noticed increase in behavioral disturbances since [MEDICATION NAME] and [MEDICATION NAME] were reduced. Record review for the months of (MONTH) and (MONTH) revealed R#249 exhibited aggressive and desire to touch females on the following dates: 5/20/17 - Hanging around females, trying to touch the females. 5/21/17 - Trying to touch the females 5/24/17 - Trying to touch females, touching hair, trying to kiss. 5/25/17 - Trying to touch females. 5/26/17 - Trying to touch females On 6/2/17 - R#249 [MEDICATION NAME] was increased to 1.5 mg at lunch. 6/18/17 - Trying to touch females. 6/19/17 - eating others food if not supervised and trying to touch females. 6/10/17 - Trying to touch females. 6/12/17 - R#249 punch a resident in stomach 6/14/17 - R#249 grabbed a females buttocks. Psychopharm Committee Minutes dated 6/8/17 were reviewed. Documentation for R#249 per the minutes stated that R#249 is hyperactive, sexual behaviors (touching). The team was recommending to continue medication [MEDICATION NAME] along with interventions. Redirect resident when approaching female residents personal spaces, provide snack. Have staff ask resident if he needs assist with something. Interview on 6/15/17 at 10:18 [NAME]M. with Staff #136 to clarify R#249's behaviors, and staff member related that R#249 gets jealous. For example, one of the incidents that occurred was of the female unit manager talking with another male resident in the hall and R#249 came walking by and without provocation, hit the other male resident in the stomach, out of jealousy as he was talking to the female unit manager. R#249 seemed to get aggravated and jealous. Staff#139 further stated that R#249 likes to hang around woman and protect them, however, the resident has been getting better with medications. Interview with Staff #167 regarding R#249 and asked what the goal was for R#249. Staff #167 stated our goal is for R#249 to be able to wander about the unit safely to prevent and decrease incidents of any altercations because of his impulsiveness. When asked if there is a care plan for R#249, Staff #167 stated I don't see a specific care plan for the touchy feely with the females. They should be charting on the behavior monitor sheet. A review of the Behavior Monitoring Form demonstrated the behaviors documented in the progress notes of the records did not collaborate with the care plan. This form lists codes for behavior, location code, intervention code and resident response. The form also had not been updated since (MONTH) 10, (YEAR) although the recommendation to monitor for 3-4 weeks per MD in psychopharm committee minutes was suggested on (MONTH) 11, (YEAR). This was pointed out to a staff member who did not have any answer except yea, we're supposed to document on that form. The female residents in the same secured unit as R#249 were subjected to unwelcome touching and attention from this male resident. The facility failed to provide care and have safe-guards in place to ensure these female residents were not subjected to sexual harrasment and inappropriate sexual behaviors. The facility staff stated that the female residents have dementia and their cognitive deficits make them unaware if anything untoward happened. The facility practice was harmful to these female resident's who should have been safe from inappropriate sexual behaviors towards them and ensured their psychosocial well-being.",2020-09-01
551,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,241,D,0,1,HB3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, the facility failed to ensure that care was provided in a manner that promoted, maintained and/or enhanced a resident's quality of life, and recognized each resident's individuality, for 4 of 32 residents (R#78, #286, #143, #145) on the survey Stage 2 resident sample list, and 2 random residents. Findings include: 1) Crossed with F441. During observation of the dining on 06/13/2017, two residents were observed being fed simultaneously by Staff #123 in the 1st floor North unit dining room. Staff #123 was seated between the two residents and would feed one resident one or two mouthfuls of food and then feed the other resident a mouthful and continued to do so for the entire meal. Staff #123 used the same hand to feed both residents. Staff #123 did not provide both residents with any dignity or individualized care by feeding them in this manner. 2) On 6/13/17 at 11:25 P.M. observed two staff members preparing to deliver lunch trays. One staff member was heard stating that he/she needs to wash his/her hands. The two staff members announced themselves and entered room [ROOM NUMBER] and washed their hands at the sink. Observed R#78 was seated in the room during this time. While washing their hands, the staff members continued to have a conversation which did not include Resident #78. On 6/14/17 at 11:50 [NAME]M. an interview was done with Staff Member #225 to inquire whether the unit has a hand washing sink at the nurse's station to wash their hands. The staff member confirmed there is a sink at the nurse's station, the sink is labeled Eyewash Station and has soap and paper towels dispenser to perform hand washing. 3) Observation on 6/14/17 at 8:27 [NAME]M. Staff #241 was at the medication cart, and queried staff member whether the resident sitting by the doorway was R#286. The staff member confirmed it was R#286 and warned the surveyor not to be concerned as the resident yells. The staff member commented that R#286 is a squeaker. 4) On 6/15/17 at 8:04 [NAME]M. observed Staff #265 assist R#143 with breakfast. The staff member assisted the resident to place a large napkin on the resident's lap and chest, remarking to the resident that the napkin would be placed so you don't make a mess. A record review done on 6/15/17 at 10:45 [NAME]M. found an annual Minimum Data Set with an assessment reference date of 3/27/17 documenting R#143 requires extensive assistance for eating with one person physical assist. 5) On 6/16/17 at 10:07 [NAME]M. while standing at the nurse's station, Staff #241 was heard stating in a loud voice, saying to Staff#225 that R#145 took off his/her brace and threw it down and the guy picked it up. Staff#241 was at the medication cart outside of room [ROOM NUMBER]. As Staff #225 approached the cart, Staff #241 spoke in a softer voice. During this time, there were two residents seated in the hall between rooms [ROOM NUMBERS] that overheard the staff members conversation.",2020-09-01
552,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,247,D,0,1,HB3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and medical record reviews the facility failed to ensure that 1 of 32 residents (R#332) on the Stage 2 Resident Sample List. Findings include: On 06/14/17 interviewed R#332 on Stage 1 of the suvey and the resident stated that in the last nine months had a roommate change and was not provided prior notice. 06/16/2017 7:57:30 AM interviewed Staff#220 and queried how residents are provided notification of a new roommate. According to Staff#220, R#332 was admitted on [DATE] and the facility would have had resident sign Room Change Notification form and/or notify family. The resident's roommate had a Room Notification form in the medical record as transferred on 5/31/17 to R#332's room [ROOM NUMBER]A but Staff#220 could not find a Room Notification form for R#332. The facility did not give R#332 notice and information prior to moving a new roommate into his/her room.",2020-09-01
553,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,253,D,0,1,HB3G11,"Based on observation and staff interview the facility failed to maintain resident care equipment and resident environment in sanitary condition and good repair. Findings include: 1) On 06/16/2017 at 8:02 AM while interviewing laundry staff #89 the two dryers were running. Staff #89 was asked if they could stop the dryers and check the lint traps. Staff #89 turned off the dryers and opened the lint traps. Lint traps for both dryers were filled with lint requiring Staff #89 to use a brush to sweep the lint out of the lint traps into the rubbish can. Queried when the dryer was turned on that day and staff stated When we first start at 5 AM. Staff #89 was reminded that the laundry had to be washed first prior to going into the dryer at 5 AM and laundry staff #89 clarified that the laundry was done last night and when we came in this morning we put it in the dryer. Staff #89 was asked to clarify this, did the laundry finish by midnight when the night shift staff are done with work and the laundry sits till 5 AM to be dried when the day shift staff start their shift? Laundry staff #89 confirmed this. Laundry staff #89 was asked when was the dryer lint trap cleaned last and they showed this surveyor the lint trap cleaning log and the last time the 2 dryer lint traps were cleaned was on 06/15/2017 at 11:15 PM by night shift staff. The next scheduled lint trap cleaning was for 9:30 AM that day. 2) On 06/16/2017 at 8:40 AM walked through the North Second unit's shower room with Staff #99 and observed darkened spots on the seat belt of the shower chair. Staff #99 was asked what the dark spots were but they were unable to determine what the darkened spots were. Staff #27 stated that the seat belt on the shower chair can be removed and washed. 3) On 06/16/2017 at 8:57 AM interviewed Staff #54 as we walked in the first floor shower room. It was noted that there were peeling non-skid adhesives on the floor that appeared to have been partially taken off of the floor. Staff #54 confirmed that these needed to be replaced. The South First shower room had a damaged baseboard that appeared to have some dark orange areas which Staff #54 confirmed that this needed to be fixed. When we went to the North Second shower room it was noted that the tile needed to be replaced as there were 4 tiles that were chipped, Staff #54 confirmed this. 4). On 06/16/2017 at 9:20 AM met with Staff #54 on South Second and asked him what they observed on the AC ducts, Staff #54 stated that it was condensation and dust. Interview with Staff #54 found that housekeepers are responsible for cleaning the AC ducts. The facility failed to maintain clean dryer lint traps, sanitary shower chair, shower room tile and baseboard and AC ducts at the facility which may result in injury or spread of infection to the residents.",2020-09-01
554,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,258,D,0,1,HB3G11,"Based on confidential resident interview and interview with staff member the facility failed to ensure the maintenance of comfortable sound levels for 1 of 13 residents that were interviewed. Findings include: Confidential resident interview on 6/13/17 at 12:35 P.M., the resident reported that the noise level at the facility which affects his/her comfort. A follow up interview was conducted on 6/16/17 at 8:20 [NAME]M., the resident reported that the noise sounds like trucks at night. The resident reported it occurs at least once a week and the noise will wake him/her from sleep. Observation found the resident's room is the last room on the end of the North unit with a parking lot next to the building. On 6/16/17 at 8:35 [NAME]M. an interview was conducted with the Administrator. The Administrator confirmed the parking lot is for employee parking and vendors to make deliveries to the kitchen. The Administrator further explained that the vendors usually come to deliver between 7:00 and 9:00 [NAME]M.",2020-09-01
555,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,274,D,0,1,HB3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to complete a significant change reassessment for 1 (Resident #286) of 16 sampled residents of the 32 residents included in the Stage 2 sample. Findings include: Cross Reference to F280 (care plan revision) and F310 (Activities of Daily Living). A record review on the afternoon of 6/14/17 and morning of 6/15/17 found R #286 was admitted to the facility on [DATE]. A review of the the admission Minimum Data Set (MDS) with assessment reference date (ARD) of 2/15/17 documents the resident required extensive assistance in self-performance for bed mobility (how the resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleeping furniture); dressing; and eating. A quarterly MDS with an ARD of 5/12/17 documents the resident is now assessed to be totally dependent on staff for bed mobility, dressing and eating. On 6/15/17 at 8:30 [NAME]M. an interview was conducted with the MDS Coordinators, Staff#84 and Staff #150. The coordinators confirmed R #286 had a decline in activities of daily living (ADL). Further queried whether an ADL decline in three areas would require a significant change reassessment. Staff #150 responded based on the assessments the difference in ADL abilities requires a significant change reassessment was indicated. Staff #84 stated when there is a change in two or more areas, a significant change reassessment needs to be done. The facility failed to do a comprehensive significant change reassessment for R #286 with an ADL decline in three areas (bed mobility, dressing and eating); therefore, a care plan revision was not done.",2020-09-01
556,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,278,D,0,1,HB3G11,"Based on record review and interview with staff members, the facility failed to accurately assess 1 (Resident #286) of 16 sampled residents of the 32 residents in the Stage 2 sample. Findings include: Cross Reference to F279 and F313. On the morning afternoon of 6/14/17 and morning of 6/15/17 a record review was done for R #286. The initial Minimum Data Set (MDS) with assessment reference date (ARD) of 2/15/17 documents R #286 has adequate vision (sees fine detail, including regular print in newspapers/books). The subsequent quarterly assessment with an ARD of 5/12/17 notes R #286 has moderate impairment (sees large print but no regular print in newspapers/books). A review of the care plan found no documentation of a plan to address the resident's moderate visual impairment. On 6/15/17 at 8:30 [NAME]M. an interview was conducted with the MDS Coordinators. Staff #84 confirmed the resident does have a visual deficit. The staff member further reported the resident probably had a visual impairment on admission and it was missed on the initial assessment; therefore, it was not triggered by the initial assessment to develop a care plan. The facility initially failed to accurately assess R #286's vision; therefore, a care plan was not developed and services/treatment were not provided.",2020-09-01
557,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,279,E,0,1,HB3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 3 residents (R#286, #262, #249 ) of 16 sampled residents of the 32 residents in Stage 2 developed a comprehensive person-centered care plan for each resident. Findings include 1) Cross Reference to F278 and F313. A record review for Resident #286 was done on the afternoon of 6/14/17 and the morning of 6/15/17. A review of the quarterly Minimum Data Set (MDS) with assessment reference date of 5/12/17 documents Resident #286 has a moderate visual impairment. A review of the resident's plan of care provided by the facility on 6/14/17 at 3:00 P.M. found no documentation of a care plan for Resident #286 to identify care/approaches to address the resident's visual impairment. On 6/15/17 at 8:30 [NAME]M. an interview and concurrent record review was done with the MDS Coordinators. A review of the electronic medical record and hard copy of the resident's care plan found no documentation of a care plan to address the resident's moderate visual impairment. Staff Member #84 reported vision was not triggered on the initial assessment in (MONTH) (YEAR); therefore, a care plan was not developed. Inquired whether following the quarterly assessment if a care plan is indicated for this resident. Staff Member #84 confirmed a care plan to address the resident's impaired vision is indicated. 2) Cross Referenced to F309 On 06/14/2017 at 3:00 PM , MRR for R#262 was done. No care plan for hospice care was found in his medical record. Physician referral order to hospice was dated 01/18/2017, and hospice physician signed the hospice certification on 01/23/2017. On 06/15/2017 at 9:422 AM, Staff # 150 was interviewed about the care plan for hospice for resident. She stated It hadn't been done and they were currently formulating a care plan for his hospice care. Significant change MDS dated [DATE] had the response yes to question J1400 asking if resident had anticipated life expectancy of less than six months. The resident had been on hospice care since (MONTH) and the facility had not developed and implemented a care plan for hospice services. Cross reference from F223 3) Record Review on 6/15:17 at 8:32 [NAME]M. Resident #249 (R#249) was admitted to the facility 10/2016 for custodial care and behavioral management. R#249 has a history of [MEDICAL CONDITION]. R#249 had aggressive behaviors towards males and liked touching females. Pharmacy along with the MD were adjusting medications to control behaviors in the months of (MONTH) and (MONTH) In March, gradual dose reduction (GDR) was looked at by the behavior enhancement committee and GDR was attempted. R#249 did have a dose reduction of his [MEDICATION NAME] in (MONTH) from 1 mg Am/1 mg midday/2mg at night to 1 mg three times a day. A note written by MD on 5/17/17 noted that staff had noticed increase in behavioral disturbances since [MEDICATION NAME] and [MEDICATION NAME] were reduced. Review of Psychopharm Committee Minutes dated 5/11/17 discussed R#249 and suggested increasing [MEDICATION NAME], adding Tylenol, monitor 3-4 weeks behavior per MD. It stated that R#249 continues to approach female residents personal space. Staff to redirect and effective. Record review for the months of (MONTH) and (MONTH) revealed R#249 exhibited aggressive and desire to touch females on the following dates: 5/20/17 - Hanging around females, trying to touch the females. 5/21/17 - Trying to touch the females 5/24/17 - Trying to touch females, touching hair, trying to kiss. 5/25/17 - Trying to touch females. 5/26/17 - Trying to touch females On 6/2/17 - R#249 [MEDICATION NAME] was increased to 1.5 mg at lunch. 6/18/17 - Trying to touch females. 6/19/17 - eating others food if not supervised and trying to touch females. 6/10/17 - Trying to touch females. 6/12/17 - R#249 punch a resident in stomach 6/14/17 - R#249 grabbed a females buttocks. Psychopharm Committee Minutes dated 6/8/17 was reviewed. Documentation for R#249 per the minutes states that R#249 is hyperactive, sexual behaviors (touching). The team was recommending to continue medication [MEDICATION NAME] along with interventions. Redirect resident when approaching female residents personal spaces, provide snack. Have staff ask resident if he needs assist with something. Interview with Staff #167 regarding R#249. Surveyor asked what the goal was for R#249. Staff #167 stated our goal is for R#249 to be able to wander about the unit safely to prevent and decrease incidents of any altercations because of his impulsiveness. When asked if there is a careplan for R#249, Staff #167 stated I don't see a specific care plan for the touchy feely with the females. They should be charting on the behavior monitor sheet. In summary, R#249 was admitted with behaviors that were addressed in the psychopharm committee minutes with the team. However, there was no care plan developed for behaviors of touching females, staff redirection. The facility failed to develop and implement a comprehensive person-centered care plan for R#249.",2020-09-01
558,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,280,D,0,1,HB3G11,"Based on record review and interview with staff members, the facility failed to ensure a care plan was revised for 1 of 16 sampled residents (R#286) of 32 in the Stage 2 resident sample list. Findings include: Cross Reference to F274 and F310. Record review was done on the afternoon of 6/14/17 and morning of 6/15/17. A review of the initial Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/15/17 with the most recent quarterly MDS with an ARD of 5/12/17, R#286 was assessed to have a decline in three areas (bed mobility, dressing and eating) of activities of daily living. A review of the resident's plan of care provided by the facility on 6/14/17 noted a care plan was developed for activities of daily living. The initial target date was 5/13/17 and later changed to 8/14/17. The goal was for the resident to continue to participate as able with daily ADLs with assistance of staff. There is no revision to the care plan based on an assessment (identifying contributing factors) to reflect the resident's decline in ADLs as assessed on 5/12/17. On 6/15/17 at 8:30 [NAME]M. an interview and concurrent record review was done with the MDS Coordinators. Inquired whether R #286's care plan was updated following the ADL decline. Staff#84 reported there was no update to the resident's care plan in the electronic medical record or hard copy. Staff #150 reported that the resident's decline may have been attributed to mood/behavior and the resident had a fall in (MONTH) which required a CT scan of the head and cervical spine. However, there was no documentation of the interdisciplinary team's discussion of the decline and decision to revise the resident's care plan. Based on the reassessment of R#286's activities of daily living, the facility failed to revise the care plan to provide the necessary care or services that are consistent with the resident's abilities in activities of daily living.",2020-09-01
559,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,309,D,0,1,HB3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and medical record reviews, the facility failed to establish an agreed upon coordinated plan of care with outside providers for 2 of 32 residents on the Stage 2 resident sample list, (R#313 [MEDICAL TREATMENT] and R#262 hospice). The facility failed to ensure that both residents obtained optimal improvement or did not deteriorate within the limits of a resident's right to refuse treatment, and within the limits of recognized pathology. Findings include: 1) On 06/14/2017 at 2:30 PM interviewed R#313 and spouse at bedside. The resident received 3.5 hours of [MEDICAL TREATMENT] treatment on Monday, Wednesday, and Friday at 5:00 AM and was transported to the [MEDICAL TREATMENT] provider. The resident described that facility staff would take weight before left the facility and that the [MEDICAL TREATMENT] center staff re-weighed before & after [MEDICAL TREATMENT] treatment. The resident described fluid restriction as 1/2 cup between meals and that would drink soda once in awhile. The resident also stated that facility staff checked the fistula site daily. According to R#313 and spouse, resident admitted to facility for physical therapy after falling at home. The resident was diagnosed with [REDACTED]. The resident hoped to go home in a couple of weeks, As long as able to stand enough to go into wheelchair. The R#313 also had a [MEDICATION NAME] Catheter, the spouse provided the card description, this is a [MEDICATION NAME] Catheter which is used for drainage of recurrent pleural effusions or ascites. It has a unique valve that can only be accessed with a special access tip. See back for emergency instruction. According to the spouse, a specialist placed the catheter after the resident was hospitalized after being seen in ED for shortness of breath (SOB), due to pleural effusion. The resident no longer needs oxygen since the catheter is drained every 3 days by the spouse. According to the spouse, who comes in to drain the [MEDICATION NAME] with the drainage kit that is stored in the resident's room, the staff never asked about the [MEDICATION NAME] catheter. On 06/14/2017 at 2:58 PM, a MRR on R#313 was done. The resident's [DIAGNOSES REDACTED]. The physician orders (PO) included: Check Thrill & bruit Q shift +present/- absent (notify MD); [MEDICAL TREATMENT] 3x/wk on MWF & Prn Holidays at Hilo Liberty [MEDICAL TREATMENT]; [MEDICATION NAME] 80 mg tab PO twice daily for CKD Generic: [MEDICATION NAME] . On 06/15/2017 at 7:59 AM the MRR noted communication between the facility and [MEDICAL TREATMENT] provider was documented on a PRE/POST [MEDICAL TREATMENT] COMMUNICATION form. Started with the most recent [MEDICAL TREATMENT] Communication form and found missing documentation on: 6/14/17 - [MEDICAL TREATMENT] Center no assessment of Condition of access/site and Bruit 6/12/17 - Incomplete, [MEDICAL TREATMENT] center had vital signs (VS) but did not assess condition of access/site; post [MEDICAL TREATMENT] by facility had no VS or weight (wt) of resident, but did assess condition of access site and bruit. 6/2/17 - No documentation by [MEDICAL TREATMENT] Center 5/24/17 - No post-[MEDICAL TREATMENT] wt by [MEDICAL TREATMENT] Center 5/17/17 - Pre-[MEDICAL TREATMENT] wt 147.4; [MEDICAL TREATMENT] Center post-[MEDICAL TREATMENT] (66.3 kg) = 146.166 lbs; SNF ,Post-[MEDICAL TREATMENT] wt 157.6 lbs. Queried Staff#225 regarding wt discrepancy between the [MEDICAL TREATMENT] Center and facility. Staff#225 looked in R#313's electronic medical record (EMR) and could not find information and called Staff#57 for resident's wts and unable to find. The EMR progress notes documented 66.3 kg upon return, which was also noted on the post [MEDICAL TREATMENT] form by the [MEDICAL TREATMENT] Center. Queried Staff#225 if 10 lbs over pre-[MEDICAL TREATMENT] treatment would be alarming to staff and she felt that it should have been but could not find any documentation that staff called the MD. On 06/15/2017 at 9:46 AM interviewed Staff#71 and was informed by him that a care plan (CP) meeting was to be held on this date with R#313 and spouse. The CP meeting was to discuss discharge planning and Staff#71 planned to ask spouse if [MEDICAL TREATMENT] Center providing [MEDICATION NAME] injections because typically done at [MEDICAL TREATMENT]. Staff#71 was concerned about [MEDICAL CONDITION] and prescribed a higher dose of [MEDICATION NAME] for R#313 because the resident was anuric and felt not enough fluid was being removed at the [MEDICAL TREATMENT] Center. Queried Staff#71, if prescribed [MEDICATION NAME] done in collaboration with resident's nephrologist, and he replied, that in a similar resident it was successful. Queried if R#313 had the same nephrologist and Staff#71 stated that it was a different nephrologist, but I also did this at (acute health care agency) and am comfortable with the outcome. Staff#71 further stated that R#313 was more complex medically and that spouse still wants to take R#313 home, and Staff#71 relied on spouse for information because akamai about R#313's health care. On 06/15/2017 at 10:38 AM met with Staff#71 and Staff#57, as Staff#71 wanted to clarify that R#313's labs were reviewed and repeated due to concerns about resident's increasing confusion during the evenings. Staff#71 also stated that R#313 on [MEDICAL TREATMENT] for several years and labs are actually stable. Also, Staff#57 monitors resident with renal dietitian and that R#313 being provided [MEDICATION NAME] and other renal medications at [MEDICAL TREATMENT] Center. Discussed resident's post-[MEDICAL TREATMENT] wt on 5/17/17 being 10 lbs. over pre-[MEDICAL TREATMENT] wt and whether MD was notified. Staff#71 looked in resident's EMR for any documentation and only found that R#313's Wt. of 145 lbs on 05/19/17. Staff#71 further reiterated that he ordered [MEDICATION NAME] based on how R#313 looked [MEDICAL CONDITION] and felt that not enough fluid being pulled off. When queried if there was any collaboration with the resident's nephrologist and Staff#71 stated that this particular nephrologist would contact him only regarding behaviors but cannot tell nephrologist what to do so diuretic ordered on his part, as R#313's nephrologist was not receptive to other Dr's suggestions. Queried whether staff should have alerted Staff#71 when R#313 returned from [MEDICAL TREATMENT] 10 lbs more than pre-[MEDICAL TREATMENT] Wt. Staff#71 stated that staff should have let him know and cannot speak for staff on why they didn't. Staff#71 further stated that R#313's confusion at night probably due to use of [MEDICATION NAME] for pain and had to increase [MEDICATION NAME] for sciatica pain. On 06/15/2017 at 11:09 AM interviewed Staff#225 and asked for R#313's intake/output (I/O) sheets. Staff#225 could not provide I/O sheets and later stated that there were no physician orders for fluid restriction. Went to ask Staff#71 whether staff should be monitoring fluid intake/output since resident receiving [MEDICAL TREATMENT] and prescribed [MEDICATION NAME] for [MEDICAL CONDITION]. According to Staff#71, the facility believes in liberalizing resident's diets for quality of life so I/O monitoring was not being done for R#313. On 06/15/2017 at 11:14 AM interviewed Staff#57 who confirmed that R#313 was not on fluid restrictions. According to Staff#57 the [MEDICAL TREATMENT] center did not order fluid restrictions for the resident and Staff#57 printed out the dietary progress notes dated 04/18/17, Addendum: MD stated no need to start fluid restircition at this time. Will monitor weight trend for now. On 06/15/2017 at 1:13 PM interviewed Staff#57 and she provided R#313's estimated dry weight (EDW) to be 148.5 lbs. Staff#57 stated that she communicated monthly with the [MEDICAL TREATMENT] Center's RD and after speaking with the renal RD today, she found out that the resident's fluid gains between treatments have been acceptable. 2) Cross Referenced to F279 On 06/14/2017 at 3:00 PM, MRR on R#262, found that there was no hospice care plan (CP). The Physician referral order to hospice was dated 01/18/2017, and the hospice physician signed the hospice certification on 01/23/2017. On 06/15/2017 at 9:422 AM, interviewed Staff #150 about the hospice CP for R#262, and she stated that they were currently formulating a hospice CP for the resident. The MDS 3.0 dated 01/23/2017 for significant change on R#262, had the response yes to question J1400 anticipated life expectancy of less than six months. The facility staff did not collaborate with the [MEDICAL TREATMENT] center to ensure that R#313 obtained optimal improvement within the limits of his/her [MEDICAL CONDITION] diagnosis; and, R#262 had been on hospice care since (MONTH) and the facility had not developed and implemented a hospice CP to ensure highest possible level of well-being for end-of-life care.",2020-09-01
560,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,310,D,0,1,HB3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 1 of 3 residents (R #286) sampled for a decline in activities of daily living, experienced an unavoidable decline. Findings include: Cross Reference to F274 and F280. Record review done on the afternoon of 6/14/17 and morning of 6/15/17 found R#286 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comparison of the resident's initial and quarterly Minimum Data Set (MDS) found the resident had a decline in bed mobility, dressing and eating in self performance. Resident #286 went from extensive assistance to total dependence. A review of the Care Plan Conference Record dated 5/23/17 notes a care plan meeting was held with interdisciplinary team members and family member. There is no documentation of the resident's decline in activities of daily living (ADL). Further review found the resident's care plan was not revised to specify the approaches or how much support the resident currently requires. On 6/15/17 at 8:30 [NAME]M. an interview was conducted with the MDS Coordinators. The coordinators confirmed the ADL decline was not discussed in the care plan conference. The coordinators also confirmed the resident's care plan was not revised. Staff Member #150 reported there was a period of time when the certified nurse aides were not coding the functional levels correctly; however, acknowledged it is the MDS Coordinators responsibility to ensure accurate coding. Therefore, Staff Member #150 reported the resident may not have had an actual decline, it may be an error in coding. Staff #150 also reported R #286 may have had a fluctuation related to mood/behavior, urinary tract infection in February, and a fall in March. There is no documentation of contributing causal factors related to the decline in the resident's abilities for bed mobility, dressing and eating. The facility failed to assess R #286's decline in activities of daily living to determine causal factors contributing to the decline, ensuring the decline was unavoidable. The facility further failed to revise the resident's care plan to include care and services R #286 required to maintain the resident's quality of care and life.",2020-09-01
561,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,313,D,0,1,HB3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 1 of 3 residents (R#286) sampled for visual impairment received the proper treatment and assistive devices to maintain the resident's vision. Findings include: Cross Reference F278 and F279. A record review done on the afternoon of 6/14/17 and morning of 6/15/17 found R#286 was admitted to the facility from an acute hospital on [DATE]. The admission [DIAGNOSES REDACTED]. A review of the resident's quarterly assessment found the resident is moderately impaired-limited vision, not able to see newspaper headlines but can identify objects with no corrective lenses (contacts, glasses, or magnifying glass). There is no documentation of the necessity of assistive devices to maintain her vision or whether the resident requires assistance to gain access to vision services by making appointments and arranging for transportation. An interview was done with the MDS Coordinators on 6/15/17 at 8:30 [NAME]M. The coordinators confirmed on the initial assessment the visual impairment was missed; therefore, a care plan was not developed. Also, there is no documentation of the interdisciplinary team discussion of whether the resident would benefit from an appointment to assess the vision or acquisition of a visual device. The facility failed to ensure accurate assessment of R#286's vision; therefore, an assessment of the resident's need for an assistive device or appointment with an optometrist/ophthalmologist was not discussed.",2020-09-01
562,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,329,D,0,1,HB3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with staff members and review of the facility's policy and procedures, the facility failed to ensure 1 of 5 residents (R#286) selected for medication regimen review received adequate monitoring for specific targeted behaviors and efficacy. Findings include: Resident #286 was admitted to the facility from an acute setting on 2/8/17 with the following Diagnoses: [REDACTED]. Resident #286 was admitted to the locked unit due to concerns with elopement. On 3/27/17 the order for a locked unit was discontinued. Record review done on 6/14/17 at 2:30 P.M. found physician orders [REDACTED]. tablet PO twice daily at 7:00 [NAME]M. and bedtime for [MEDICAL CONDITION], unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition, adjustment disorder with mixed anxiety and depressed mood (order date 5/11/17) [MEDICATION NAME] 0.5 mg. tablet PO daily 1/2 tablet (0.25 mg) at 1:00 P.M. for adjustment disorder with mixed anxiety and depressed mood, unspecified [MEDICAL CONDITION] not due to a substance of known physiological condition; and (order date: 2/8/17) [MEDICATION NAME] prn 0.5 mg. PO every 4 hours for agitation/anxiety for dementia. A review of the care plan found a plan for the use of antipsychotic medication related to altered thoughts with [DIAGNOSES REDACTED]. The goal is R#286 will not display psychotic behaviors such as hallucinations or yelling out for the quarter and will have less than 1-3 episodes per week of altered thoughts, repetitive thoughts, repetitive concerns for the next 90 days. The plan for the use of antianxiety medications identifies behavior of repetitive concerns or actions and the identified behavior for the use of an antidepressant includes crying and calling out. A review of the Behavior Monitoring Form (Revision 7/21/14) documents the use of [MEDICATION NAME] and [MEDICATION NAME]. The listing for Targeted Behavior(s) for Medication for these medications were blank. The form also lists codes for behavior, location code, intervention code and resident response. The forms filed in a folder, did not specify the behaviors listed in the resident's care plan for the use of antipsychotic, antianxiety and antidepressant medications. The monitoring form for Resident #286 has one entry 4/2/17 documenting verbal aggression and disruptive behavior in the hallway. An interview and review of the form was done with Staff #225 on 6/15/17 at 10:20 [NAME]M. The staff member reported any staff member can document a behavior (housekeeping, maintenance, licensed nurses, certified nurse aides, etc.); however, this doesn't always occur. The staff member also confirmed the listing of targeted behaviors should be documented. A review of the PRN Administration Record for (MONTH) (YEAR) found documentation of prn administration of [MEDICATION NAME] on 6/2/17, 6/3/17, 6/4/17, 6/5/17, 6/8/17, and 6/10/17. There is no documentation of the result (efficacy) for the prn administration for 6/8/17, 6/10/17 and 6/12/17. A review of the progress notes in the facility's electronic medical record (EMR) found no documentation for the aforementioned dates. Further review found the prn administration of [MEDICATION NAME] for the month of April, the prn was administered 36 times. There is no medication notes regarding the result/efficacy for 30 of the entries on the PRN Administration Record. A review of the EMR found 6 entries for the 36 times the prn administration of [MEDICATION NAME] was given. On 6/16/17 at 8:15 [NAME]M. an interview and concurrent review of the (MONTH) record was done with Staff Member #255. The staff member confirmed the missing documentation for the result and reported the nurses are to document the result of prn medications. Subsequent interview with the Assistant Director of Nursing (ADON) found that the nurses oftentimes document the results in the progress notes in the EMR. On 6/14/17 at 8:27 [NAME]M., Staff #241 reported R #286 may yell and is a squeaker. On 6/15/17 at 10:05 [NAME]M. an interview was done with Staff #255. the staff member reported R #286's behavior has improved as the resident is not as noisy. On 6/15/17 at 2:00 P.M. an interview was conducted with Staff #39 who provided direct care to R #286, the staff member shared the resident does make screeching sounds. The staff member also reported that she/he believes the resident makes this sound for attention or to communicate discomfort. The facility failed to ensure monitoring of medications for efficacy of prn administration ([MEDICATION NAME]) as evidenced by the lack of documentation on the PRN Administration Record and electronic medical record. The facility also failed to monitor the targeted behavior related to the use of medications ([MEDICATION NAME] and [MEDICATION NAME]).",2020-09-01
563,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,332,D,0,1,HB3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to ensure that administration of drugs and/or biologicals were in accordance with the physicians orders. 1) On 06/15/2017 at 9:29 AM observed Staff #241 administer medications to R#184. During the medication pull it was noted that Staff #241 pulled out Artificial Tears Ung 1/2 inch intraocular Q HS (every bedtime) to both eyes. Queried Staff #241 if this is only applied at night and staff #241 stated No the doctor said we could also do it in the morning also. Staff #241 gave morning medications to R#184 and applied eye ointment at that time. Review of R#184 medical record showed a doctor's order for Artificial Tears Ung 1/2 inch intraocular Q HS to both eyes with a [DIAGNOSES REDACTED]. There was no doctor's order to apply Artificial Tears Ung in the AM as Staff #241 stated. 2) On 06/15/2017 at 10:12 AM observed Staff #241 pull medications for R #180. During this medication pull it was noted that Staff #241 pulled out two [MEDICATION NAME] 500 mg tablets which was to be given at 7 AM and 5 PM for pain. Staff #241 gave R #180 this prescribed 7 AM medication at 10:12 AM. Record review was done and order was written for Tylenol Extra Strength 500 mg tablet po twice daily two tablets at 7 am and 5 pm for pain Generic: [MEDICATION NAME] Other chronic pain. On 06/15/2017 at 10:51 AM interviewed Staff #225 regarding medication times at the facility. Staff #225 stated medication can be given up to one hour before and one hour after the ordered time. Staff #225 was shown that R #180 received a 7 AM medication after 10:12 AM. Reviewed the facilities' policy and procedure on Administration of Medication which stated under Standard All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in diagnosis. Also under Policy it states A physician order [REDACTED]. Under Procedure 6. it states If there is any discrepancy between the MAR and the label, check physician orders [REDACTED].",2020-09-01
564,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,371,E,0,1,HB3G11,"Based on observation and interview the facility failed to store, distribute and serve food under sanitary conditions. Findings include: 1) During a tour of the kitchen on 06/13/2017, it was observed in the pantry 4 large containers, approximately 5 gallon ( 1 that contained flour, 1 that contained sugar and 2 that contained rice). These containers had no labeling on them to say when the ingredients had been placed in them nor any expire date for them. Interview with Staff # 242 confirmed that these containers had no labeling with dates to say when ingredients were placed and expire dates. In the pantry there was also an opened box of tomato ketchup packets. The box had on the outside a date marked 06/01 with no year. This date did not state if if was the opening date or the expire date. The labeling on the box and lack of labeling on the containers did not ensure storage of foods under sanitary conditions. 2) On 6/13/17 at 11:52 [NAME]M. observed Staff Member #45 assisting with the distribution of lunch trays in the dining room. The staff member assisted Resident #11 to reposition in the wheel chair. The staff member slipped both arms and hands between the resident's back and wheel chair to assist in the repositioning of the resident. The staff member assisted with Resident #11's tray set up. Staff Member #45 returned the tray and plate cover to the cart. The staff member did not hand sanitize and removed Resident #57's lunch tray from the cart. Staff Member #45 handed the napkin to the resident and removed the plate cover and affixed a plate guard for the resident. The staff member also removed the plastic wrapper from the resident's plate.",2020-09-01
565,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,431,D,0,1,HB3G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to store biologicals with an appropriate expiration date. Findings include: On [DATE] at 1:49 P.M. Medication storage check done with Staff #212. A box of expired Juven with expired dates of ,[DATE] was found on medication shelf. Staff #212 replied we dont use it, it's used to hold the meds from falling. The facility failed to store biologicals in medication room with an appropriate expiration date.",2020-09-01
566,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2017-06-16,441,F,0,1,HB3G11,"Based on observation and staff interviews the facility failed to prevent and control cross-contamination using transmission-based precautions in addition to standard precautions. Findings include: 1) Crossed with F241. During observation of the dining on 06/13/2017, two residents were observed being fed by Staff #123 in the dining room on Floor 1 North Unit simultaneously. Staff #123 was seated between the two residents and would feed one resident one or two mouthfuls of food and then feed the other resident a mouthful, and continued to do so for entire meal. Staff #123 used the same hand to feed both the residents. Staff #123 did not conduct any hand hygiene between feeding the residents, and continued to feed the residents continuously with the same hand with no hand hygiene done between each resident contact. 2) On 06/16/2017 at 8:02 AM walked into the laundry room and noticed that a different door leading out of the laundry room into what appeared to be a storage or maintenance area was wide open even though there was a sign on door which stated to keep door closed. Laundry staff #89 confirmed that the door was supposed to be closed. While interviewing laundry staff #89 the 2 dryers were running. Staff #89 was asked if they could stop the dryers and we could check the lint traps. Laundry staff #89 turned off the dryers and opened the lint traps. Lint traps for both dryers were filled with lint requiring staff #89 to use a brush to sweep the lint out of the lint traps into the rubbish can. Laundry staff #89 was asked when the dryer was turned on that day and they stated When we first start at 5 AM. Staff #89 was reminded that the laundry had to be washed first prior to going into the dryer at 5 AM and Staff #89 clarified that the laundry was done last night and this morning we put it in the dryer. Staff #89 confirmed, that the laundry was done by the night shift staff and the laundry sat till 5 AM to be dried when the day shift staff start their shift. Staff #89 was reminded that laundry has to be handled promptly and should not sit overnight as it can facilitate the growth of bacteria. Staff #89 was asked when was the dryer lint trap cleaned last and they provided the lint trap cleaning log which noted that the 2 dryer lint traps were last cleaned on 06/15/2017 at 11:15 PM by night shift staff. The next scheduled lint trap cleaning was for 9:30 AM that day. The facility failed to implement hand hygiene practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination; and properly store, handle, and process linens to minimize contamination.",2020-09-01
567,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2019-06-24,637,D,0,1,YZYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR) and interview, the facility failed to comprehensively assess and complete a significant change assessment within 14 days of determining the status change was significant for one of one sampled resident (Resident (R) 81) selected for review. Findings Include: On 06/24/19 at 09:41 AM, RR showed R81 had fallen on two separate occasions. R81's progress note dated 09/23/18 at 09:00 showed Certified Nurse's Aide (CNA) called staff in to assist R81 who had fallen to the floor in her room. According to the CNA, R81 was sitting on the edge of her bed and was assisted to standing position, hands on the walker. R81 lost balance and fell to the floor landing on right knee first. Initially, R81 was noted to have redness to the right side of the cheek which subsequently subsided. Bruise noted to right knee with redness to right palm base of index finger and dark bruise to 3rd finger. Later, x-ray showed mildly displaced comminuted fracture through the 2nd proximal phalanx. Progress note dated 11/05/18 at 9:55, another fall where staff heard thud and R81 was found lying supine and arms on side, legs extended on carpeted floor in hallway near nurse's station. R81 stated I fell down. R81 complained of pain (Pain scale 10/10) to left wrist. Later, x-ray showed distal radial intra-articular fracture and probable non-displaced ulnar styloid fracture. Documentation reflects R81's physician and family are aware of the falls. On 06/24/19 at 11:13 AM, interview with Minimum Data Set (MDS) Coordinators1 and 2 (MDS-C1 and C-2) who stated they missed the significant change status when R81 fell on [DATE] and 11/05/18. Both falls were with injuries. MDS-C2 stated they were not aware of R81's injuries at the time of the falls. Therefore, a significant change in status was not implemented in the MDS, no significant change in status MDS was submitted for R81 related to the falls with injuries to CMS. MDS-C2 stated they are working on improving the communication process between the nursing units and the MDS Department so resident's significant change in status MDS would not be missed in the future.",2020-09-01
568,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2019-06-24,657,D,0,1,YZYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure for one of five residents (Resident (R) 126) selected for review for limited range of motion (ROM) services, that the resident's comprehensive care plan was revised by the interdisciplinary team after the (MONTH) quarterly assessment and after the (MONTH) 2019 significant change assessment was done. Findings Include: On 06/19/19 at 10:19 AM and on 06/21/19 at 08:30 AM, observations and interview with R126 noted she had stiffness to her bilateral lower extremities (BLE), and to her bilateral upper extremities (BUE). During an interview with registered nurse (RN)1, she said the resident has passive range of motion (PROM) done with restorative nursing three to five times a week. When RN1 was asked how she knew the PROM was being done for this resident, RN1 stated she would have to check on this. Random observations of R126 found no PROM being done for the resident. Although R126 expressed the staff were very careful during her bed transfers because of her stiffness, she was uncertain about any exercise program that staff provided. A concurrent record review with RN1 found R126 had an active care plan for, Restorative Range of Motion: Passive. Resident has contractures r/t (related to) [MEDICAL CONDITION] Arthritis. The interventions were for R126's BUE contracture management which was to be performed 3-5x (times) a week as tolerated. On 06/21/19 at 08:38 AM, during an interview with RN2, she stated the resident could make her own needs known, and would either agree or refuse services. RN1 further stated for R126, Currently, I don't have her working with RNA (restorative nurse aide). However, during the record review, RN1 found a 03/03/19 order to discontinue the resident's PROM. RN1 confirmed the care plan thus should have been revised/updated to reflect the discontinuation of services and affirmed that R126 was not receiving services. Further, RN1 stated on 01/23/19, as R126 had been doing her own exercises, the interdisciplinary team (IDT) decided to discontinue the PROM to her BUE. RN1 said for R126's BLE, I know she has [MEDICAL CONDITION] arthritis and has been that way since she came to us. RN1 said R126 had refused to see the rheumatologist and had previously received PROM to her BLE. During an interview with MDS-C3, she stated the last MDS assessment was done on 04/22/19 for a significant change in status assessment (SCSA). She verified the care plan which RN1 identified for the restorative ROM had not been revised, and further, it should have been effectively discontinued on 01/23/19 when her prior quarterly MDS assessment was done. MDS-C3 also said with the SCSA done in April, she overlooked the care plan for this area. MDS-C3 said she just discontinued this active care plan for the restorative ROM on 06/21/19. Per MDS-C2, she verified that 01/23/19 was the actual date to discontinue R126's restorative services. MDS-C2 verified the care plan should have been revised to reflect this. MDS-C2 said it may have been miscommunication with nursing, who saw the discontinuation date as 03/03/19, but also did not revise the care plan at that time.",2020-09-01
569,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2019-06-24,676,D,0,1,YZYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 1 (Resident 102) of 7 residents in the active case sample received care and services to ensure that a resident's abilities in activities of daily living (ADL) do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Findings Include: Resident (R)102 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. On 06/19/19 at 11:36 AM a record review found a significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 04/15/19. In comparison with a quarterly MDS with an ARD of 04/15/19, R102 was found to have a decline in her ADLs. R102 went from requiring limited assistance to extensive assistance in the following areas: bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed); transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position); walking in room and corridor; toilet use (how resident uses the toilet room commode, bedpan or urinal, transfers on/off toilet, cleanses self after elimination); and personal hygiene (how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands). R102 also went from extensive assist to total dependence for bathing. The progress note dated 04/16/19 documents R102 was identified with a significant change in ADL functioning. A review of R102's care plan found a goal, resident will continue to participate as able with daily ADLs with assistance of staff through next review which was revised on 04/23/19 with a target date of 07/14/19; however, there is no update to the interventions. Under the heading of interventions/tasks, R102 is noted to require limited assistance by one staff with showering, able to reposition in bed, and toilet self. These interventions were initiated/revised on 10/24/18. The interventions were not revised following the identification of an ADL decline. On 06/21/19 at 07:57 AM an interview with the MDS Coordinator (MDS-C)1 confirmed R102 had a decline in ADLs. Inquired why the resident had an ADL decline. The coordinator responded, it was due to the progression of dementia. There is no documentation regarding the progression of dementia contributing to R102's decline in ADLs. On 06/21/19 at 08:09 AM an interview and concurrent record review was done with the Director of Nursing (DON). The DON was asked why R102 had a decline in ADLs. The DON reviewed R102's record and stated that R102 may not have had a decline in ADLs. The DON reported R102 was moved from the dementia unit to her current unit in (MONTH) and it may be that the staff are providing more assistance then necessary during the look behind period; therefore, this is an inaccurate representation of R102.",2020-09-01
570,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2019-06-24,692,D,0,1,YZYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff members, the facility failed to ensure 1 (Resident 102) of 10 residents sampled for weight loss received the care to maintain acceptable parameters of nutrition. A resident with an unavoidable weight loss has regained any weight since the loss. The facility did not assess causal factors that may be contributing to the resident's inability to return to her usual body weight. Findings Include: Resident (R)102 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. On 06/18/19, R102 was observed in her room having lunch. R102 was seated at the side of her bed with bedside table over her lap. R102's meal consisted of chicken, salad, rice, cake, coffee and juice. R102 was able to feed herself using regular utensils. R102 was not eating and had consumed approximately 25% of her meal. R102 was asked if she was done, she shook her head, Yes. On 06/20/19 at lunch, R102 was observed sitting up and feeding herself. The meal consisted of laulau (pork wrapped with luau leaves), rice, lomi salmon and poi. The resident was observed to actively feed herself and had consumed approximately 50% of her laulau. On the morning of 06/19/19 at 10:58 AM a record review was done. On 06/03/19, R102 weighed 90 lbs. On 03/01/19 the resident weighed 107 lbs., which reflects a 16% weight loss in three months. A comparison of weights from 03/01/19 at 107 lbs. and 04/01/19 at 94 lbs. shows a weight loss of 12% in one month. A progress note dated 04/03/19 notes R102 with significant weight loss and the resident was started on supplement (2 Cal HN, 50 ml, three times a day). A review of the Minimum Data Set with assessment reference date (ARD) of 04/15/19 for a significant change notes in Section K. Swallowing/Nutritional Status, R102 had a significant weight loss and was not on a physician-prescribed weight loss regimen. A progress note dated 04/16/19 documents R102 was identified for significant change in activities of daily living functioning, bladder status, behavior changes and weight loss. The resident was also noted with poor PO intake of solid foods. The resident also reportedly refused weekly weight. The resident's care plan indicates a goal for the resident to consume at least 50% of most meals and will not experience further significant weight loss through next review date. The revised interventions include the following: encourage po intake of meals, snacks, supplements and fluids; honor meal preferences, enjoys snacks from family, likes prune juice, coffee and papaya; and provide diet and supplements as ordered. A review of the Registered Dietitian (RD) Nutrition Data Collection/assessment dated [DATE] documents the resident's current weight as 92 lbs. The usual body weight was 103 to 108 lbs. and ideal body weight of 83 to 102 lbs. The RD notes, R102's intake has decreased, consuming 0-25% of meals. The RD also notes R102 had an acute illness in March. The progress note dated 05/02/19 documents R102 was discussed by IDT due to recent weight loss. The PO intake documents 0 to 50% consumption at meals and the resident was drinking supplements (2 Cal HN). The resident also weighted 98 lbs. on 05/01/19. Subsequent note of 05/13/19 documents R102 was discussed in grand rounds for decreased PO intake. The resident had a trial of Ensure Clear which was effective and there was an increase of 2 Cal HN (60 ml) to three times a day. On 06/21/19 at 07:57 AM an interview was conducted with Minimum Data Set Coordinator (MDS-C)1. Inquired what were the identified causal factors contributing to R102's weight loss? MDS-C1 responded the loss was due to progression of R102's dementia. R102 was discussed with the interdisciplinary team (IDT) and supplements and snacks were added. Inquired whether IDT documented R102's significant weight loss is contributed to the progression of dementia and that she is entering advance stage of the disease. The coordinator reported the resident was identified with weight loss and interventions were implemented. On 06/21/19 at 08:09 AM an interview and concurrent record review was done with the Director of Nursing (DON). The DON reported R102 had influenza A in March, she was treated with [MEDICATION NAME] (five-day course, starting 03/29/19). The DON also identified R102 was moved from the dementia locked unit to her current unit, which was another change that may have attributed to the resident's weight loss. The physician's summary dated 06/03/19 documents R102 was treated for [REDACTED]. A review of the weights found R102 had a spike in weight on 05/01/19 (98 lbs.). The DON noted an entry for 04/02/19 which documents R102 with recent illness, elevated temperature and positive for influenza with noted decrease in meal intake since illness. R102 also noted with an unwitnessed fall on 04/01/19. Also noted is R102 with constipation. R102 is prescribed with [MEDICATION NAME] 8.6 mg. if no bowel movement after second day and [MEDICATION NAME] suppository 10 mg. if no bowel movement after third day. A review of the MAR found [MEDICATION NAME] suppository was required due to ineffective results of the [MEDICATION NAME] in (MONTH) and (MONTH) 2019. The DON reported constipation is probably related to use of [MEDICATION NAME] to manage the resident's pain. Further queried whether constipation would affect the resident's meal intake and whether R102 ate in the dining area while on the dementia unit or prefers to eat alone as she takes meals in her room. The DON was not sure whether it is R102's preference to eat alone. The DON reported in response to the resident's weight loss, the team has increased the resident's supplements from 2 Cal, 120 ml every morning to 2 Cal HN, 80 ml three times a day at med pass (04/16/19). R102 is documented to drink 25 to 100% of supplement. The Ensure Plus was discontinued on 06/06/19 as resident did not like it, too sweet. On 06/21/19 at 09:23 AM an interview was conducted with the RD. The RD reported R102's weight loss was unavoidable as she had an acute illness. The RD also reported R102 is within her ideal body weight. Further queried why does the resident have a decrease in PO intake, consuming 0-25% of meals of her meals and has not been able to regain weight. The RD responded the facility has identified food preference and the family also brings R102 food from outside. Inquired whether the facility knows when the family brings food and how much of the outside food is consumed. The RD did not confirm the facility monitors outside food consumption. The RD stated she speculates this may be the resident's new baseline weight.",2020-09-01
571,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2019-06-24,725,D,0,1,YZYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with family member and record review, the facility did not ensure provision of sufficient numbers of nurse staffing to provide care to all residents to maintain their highest physical well-being for a resident (Resident 5) experiencing insidious weight loss. Findings Include: Resident (R)5 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 06/18/19 at 12:00 PM, lunch observation found R5 in bed with her mother visiting. Mother reported R5 had returned from [MEDICAL TREATMENT]. Upon query, Mother reported R5 has had a weight loss. Further inquired what is the facility doing about the weight loss, Mother replied she is not sure what is being done. However, Mother reported R5 is on a renal/diabetic diet which is controlling R5's diabetes. R5's lunch tray was on the bedside table. The plate was uncovered, the resident had pureed food. The brown pureed item formed a crust and appeared dry. Mother also reported R5 does not want to be fed by her and prefers to be fed by staff member. At 12:26 PM, R5 was still waiting to receive assistance with her meal. On 06/19/19, R5's mother reported concern that R5 has to wait to receive assistance for her meal. R5's mother reported the staff are working hard; however, there isn't enough staff members to assist residents with their meals. On 06/20/19 at 11:34 AM observed mother visiting R5. R5's lunch tray was on the bedside table, there was no staff member assisting R5 with her meal. Second observation at 11:47 AM, R5 was still waiting for assistance. The observation at noon found a staff member assisting R5 with her lunch. On 06/21/19 at 09:10 AM, R5 was receiving assistance from the Speech-Language Therapist (SLP)1 during breakfast. A brief interview was conducted, SLP1 reported R5 is being assessed for graduation from pureed food. On 06/18/19 at 12:31 PM a record review found R5 had a 5% weight loss in three months. On 03/02/19 R5 weighed 129 lbs. and on 06/10/19 weighed 122 pounds. A review of R5's Minimum Data Set with an assessment reference date (ARD) of 03/03/19 for significant change notes in Section [NAME] Functional Status R5 is totally dependent with one-person physical assist for eating. The previous comprehensive assessment with an ARD of 01/18/19 notes R5 required limited assistance with one-person physical assist for eating. On 06/20/19 at 05:10 PM interview with Unit Manager (UM)2 found the ratio of Certified Nurse Aides (CNAs) is one to eight residents. On 06/20/19 at 05:40 PM an interview was conducted with the Registered Nurse (RN)1. The RN reported during dinner there is usually three to four CNAs and two charge nurses. The nurses reportedly will assist residents with meals, for a total of five to six staff members available for meal assistance. RN1 reported there are nine residents on the unit that require total assistance during meal time.",2020-09-01
572,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2019-06-24,842,D,0,1,YZYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to ensure documentation of side effects related to the use of antidepressant, anti-anxiety, and antipsychotic medication was systematically consistent and accurate. Findings Include: Resident (R)114 was admitted to the facility on [DATE]. R114's [DIAGNOSES REDACTED]. A record review was done on 06/20/19 at 10:40 AM. A review of the physician orders [REDACTED]. in the evening related to [MEDICAL CONDITION], recurrent, severe, with psychotic symptoms; [MEDICATION NAME] 100 mg. two times a day related to mood disorder due to known physiological condition with depressive features; and [MEDICATION NAME] 1 mg. orally four times a day related to adjustment disorder with mixed anxiety and depressed mood, generalized anxiety disorder panic attacks. The order also included to monitor for the side effects of antipsychotic ([MEDICATION NAME]), antianxiety ([MEDICATION NAME]) and antidepressant ([MEDICATION NAME]). The order includes to monitor every shift and document (+) if side effects are present and write a progress note and document (-) if no side effects are present. A review of the Medication Administration Record [REDACTED]. On 06/20/19 at 11:20 AM an interview and concurrent record review was done with Unit Manager (UM)2. The UM explained the (+) indicates a side effect was present and the nurse will make a corresponding entry in the residents' progress note. UM2 further explained if a (-) is documented, that would indicate no side effects were present. The UM was asked what does the (X) coding indicate as there were entries with an (X) for antipsychotic medications during the day shift for 06/0719, 06/08/19, 06/09/19, 06/10/19; the evening shift for 06/01/19 through 06/09/19, 06/11/19 through 06/14/19, and 06/18/19 and 06/19/19; the night shift for 06/0/19, 06/08/19 and 06/09/19. Concurrent record review with UM2 found documentation in the MAR for side effects related to the use of antianxiety and antidepressant medications. A review of the (MONTH) 2019 documentation also found the use of (X) coding. The UM confirmed the MAR for the side effects of these medications has documentation of (X). UM2 was unable to identify what the (X) coding indicates in the MAR indicated [REDACTED]. A request was made for the facility's policy and procedures for coding side effects in the MAR. UM2 responded she would follow up with the software instructions for coding. Upon exit, no further documentation or information was provided.",2020-09-01
573,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2019-06-24,880,D,0,1,YZYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to post notification signage of Contact Precautions at the entrance doorway of Resident (R) 145's room. This deficient practice put anyone at risk of being exposed to R145's known condition of [MEDICAL CONDITION] (Shingles). Findings Include: During an observation of R145's room, on 06/18/19 at 10:50 AM, there was no posted signage at the entrance doorway which would have identified R145 as being on Contact Precautions. Thus, anyone could have entered the room not knowing that Contact Precautions were indicated. On 06/18/19 at 11:00 AM, Certified Nursing Assistant (CNA) 2 was queried about the Contact Precautions for R145. CNA2 stated that Contact Precautions were in place, but did not know why there was no posted signage at the entrance doorway at that time. CNA2 also said that other residents may have removed the sign. During an interview with Unit Manager (UM) 1 on 06/18/19 at 11:05 AM, UM1 acknowledged that a sign should have been posted at the doorway entrance of R145's room. UM1 further assured that the proper signage would be posted accordingly. During review of facility policy titled Transmission-based Precautions and Isolation Procedures, it stated the following: Transmission-based precautions are implemented based upon the means of transmission of an infection (contact .) in addition to standard precautions in order to prevent or control infection . When a resident is placed on transmission-based precautions, the staff should implement the following: Clearly identify the type of precautions and the appropriate PPE to be used, place signage in a conspicuous place outside the resident's room such as the door or on the wall next to the doorway identifying the CDC category of transmission-based precautions (e.g. contact, droplet, or airborne), instructions for use of PPE, and/or instructions to see the nurse before entering. Ensure signage also complies with residents' rights to confidentiality and privacy .",2020-09-01
574,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2018-09-27,550,D,1,1,75F211,"> Based on observation and staff interview, the facility failed to ensure residents were assisted to eat in a dignified manner for two residents (R ) R53 and R177 during a lunch observation. This deficient practice affected two of 45 residents residing on the South 3 nursing floor. Findings Include: On 09/24/18 at 12:23 PM, a certified nurse aide (CNA) 1 was observed feeding R53 at her bedside. R53 requires feeding assistance. CNA1 however, stood over the resident to feed her. Each time CNA1 put a spoonful of food into R53's mouth, any excess pureed food or thickened liquid that came out of R53's mouth was swiped up. CNA1 used the spoon to quickly swipe up the excess food around the lower lip of the resident's face, and then re-inserted this excess food into the resident's mouth. At 09/24/18 at 12:24 PM, CNA1 also said, I'm supposed to sit down, right? and proceeded to sit on the right edge of the bed. After sitting on the bed, CNA1 began talking to the resident, saying short words to her such as, We're almost done, juice, and okay, here. The resident was not able to reply. She was observed to utter illegible sounds. CNA1 repeatedly swiped around and re-inserted the food into R53's mouth until the resident no longer wanted to eat. On 09/24/18 at 12:31 PM, CNA2 was observed feeding another resident who required feeding assistance. CNA2 was standing to the right side of R177 to feed the resident her lunch. CNA2 engaged and talked with the resident during the meal, but did not sit down while she assisted R177 to eat. Yet, the nurse unit manager who was assisting R177's roommate to eat, sat on a chair next to her resident to feed her. During an interview with the Director of Nursing (DON) on 09/26/18 at 11:12 AM, she stated she preferred that her staff sat on chairs to feed residents who needed assistance to eat. The DON said she also wanted to see her staff engage their residents by talking to them, Because they can hear. The DON said for any excess food coming out of a resident's mouth, We wipe it with the napkin. She affirmed it should not be done by swiping excess food off of the resident's face and re-inserting it into their mouth for consumption. The DON acknowledged it was not a dignified way to feed any resident.",2020-09-01
575,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2018-09-27,578,E,1,1,75F211,"> Based on staff interview and review of the facility policy, the facility failed to establish sufficient policies and procedures that delineates the resident's right to formulate an advanced directive. This deficient practice had the potential to affect the 39 residents without a documented advance directive such that the residents may not be afforded the right to formulate an advance directive and/or the right to request, refuse, discontinue treatment, participate in or refuse to participate in experimental research. Findings Include: During a review of facility policy on Advance Directives (AD), the policy read, The resident has a right to execute or refuse to execute an advance directive, which stipulates how decisions regarding his or her medical care are made. Residents have the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including withholding or withdrawing life sustaining treatment. An advance directive is defined as a written instruction regarding care and treatment, such as a living will (a document that specifies a resident's preferences about measures used to sustain life) or a durable power of attorney for health care, recognized under state law in relation to the provision of such care when the resident is incapacitated. Community education and awareness efforts on the Patient Self-determination Act and state-specific laws on advance directives will be coordinated by the Social Services Director, using brochures in the facility lobby, public speaking, the Family Council, and health fairs. However, the policy did not mention any specific steps to assess, promote, implement, or evaluate the resident's right to formulate an AD. During an interview with the Social Services Director (SSD) 2, on 09/26/18 at 1:05 PM, SSD2 explained their current process for determining whether residents have ADs. SSD2 also explained how the facility provides education, material, and assistance with formulating an AD. The SSD2 said that ADs were also discussed during each resident's interdisciplinary group meeting. Although SSD2 was able to state what their current process was, it was not described in their current facility AD policy, and failed to include specific steps such as determining on admission whether a resident has an AD, identifying a primary decision-maker, and/or follow up procedures for residents who may have been incapacitated at the time of admission.",2020-09-01
576,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2018-09-27,689,D,1,1,75F211,"> Based on observation and staff interview, the facility failed to secure the soiled utility room located on the second floor. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public, at risk for accident hazards. Findings Include: During an observation of the soiled utility room located on the second floor, north unit, on 09/24/18 at 10:46 AM, it was noted that the door, which had a number pad lock mechanism to enter the room, was not locked. As a result, anyone could have entered freely. No staff were observed in the immediate vicinity to prevent anyone from entering the room. There were no residents in the area at the time as well. The room had one large cart for soiled material, a covered bin, another open bin for trash, a soiled utility sink, and chemicals for housekeeping/cleaning. On 09/24/18 at 10:54 AM, interviews with the Housekeeper (Hskpr 1) and the Manager (Mgr 5) were done. Hskpr1 and Mgr5 stated that the door to the soiled utility room should have been locked and secured. They acknowledged that the contents of the room had the potential to affect the safety of the residents, as well as the public, and further acknowledged the risk for accident hazards if it had been accessed. They then locked the soiled utility room.",2020-09-01
577,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2018-09-27,813,F,1,1,75F211,"> Based on interview and review of the facility's policy, the facility failed to have a current policy which addressed ensuring facility staff assists the resident in accessing and consuming the food, if the resident is not able to do so on his or her own, safe food handling practices, and storage of foods brought into the facility by family or visitors. This deficient practice had the potential to affect 223 residents residing in the facility. Findings Include: Review of the facility's policy titled, Food Bought into Facility, dated 01/01/07, indicated, Policy-The policy of this facility is to meet or exceed the safety and sanitation requirements for the residents, as set forth by the facility as well as the local, federal and state regulations. Guidelines-The Food and Nutrition Services department does not handle food that has not been purchased from approved sources. This includes storing, preparing and/or reheating food that was not purchased or prepared by the facility. Perishable food brought in by a resident, relative and/or friend should be eaten immediately or at the next meal. Any potentially hazardous food not eaten with four hours should be discarded. Space permitting, food requiring refrigeration may be held in the refrigerators designed for nourishment storage per facility guidelines. Any visitor desiring to bring in food to a resident should be informed of the facility guidelines regarding diet and storage of food. The facility's policy did not include how staff would assist the resident in accessing and consuming the food, if the resident was not able to do so, did not address specifically how they would store and label food brought in from outside, did not address how the facility would help family and visitors understand safe food handling practices, and did not address how or if staff would assist family or visitors with reheating or other preparation activities, following safe food handling practices. On 09/27/18 at 4:30 PM, the facility Registered Dietitian (RD) was asked if there was a more current policy for food brought into the facility for residents by family or friends. She stated let me ask the Administrator. She returned and stated, This is all we have.",2020-09-01
578,LIFE CARE CENTER OF HILO,125040,944 WEST KAWAILANI STREET,HILO,HI,96720,2019-11-14,689,D,1,0,908U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review (RR), observations, demonstration and interviews, the facility failed to provide adequate supervision to prevent a fall for one resident (R)1. The fall occurred during a transfer with a mechanical lift from the bed to wheelchair (w/c) that resulted in R1 striking her head and received swelling to the right side of the head and small laceration to her right ear. This deficient practice has the potential to affect any resident that requires the use of a mechanical lift. dings include: 1. Medical record revealed R1 was admitted to facility 05/10/14 with a [DIAGNOSES REDACTED]. R1 requires two person total assistance with bathing, bed mobility, dressing, and personal hygiene. R1 requires a mechanical lift with two persons staff assistance for transfers. 2. The Office of Healthcare Assurance ([NAME]HA) event report stated, On 09/04/19 at approximately 11:15 AM Certified Nurses Assistant (CNA1) proceeded to get R1 ready to get up. CNA1 provided incontinent care, dressed resident and placed sling (of mechanical lift) under resident. CNA applied the black colored straps onto the lift hooks. CNA lifted the resident and pulled the mechanical lift back two feet and resident slipped out of the sling . resident was noted to with a lump 5.0 centimeters (cm) x 5 cm to left parietal (area of head), reddened area to left posterior ear and superficial laceration 0.4 cm x 0.4 cm to left pinna (external part of ear). Upon reenactment of event it appears resident hit the foot board of the bed when she slipped out of the sling .Conclusion: It appears resident had an involuntary chorea (jerky involuntary movements) form like movement episodes while in the mechanical lift and dislodged self through bottom of sling. CNA did not follow care plan and transferred resident by self. 3. Review of the facility policy titled, Mechanical Lift Use general guidelines stated: Two persons are required to perform this procedure, and to review the resident's care plan to assess for any special needs of the resident. 4. Review of R1's active care plan (CP), revealed that R1 requires assist with ADL (activities of daily living) self-care performance/function and mobility. The CP stated R1 experiences involuntary movements to bilateral upper extremities and bilateral lower extremities from mild to severe, and states, The resident requires Mechanical Lift (Hoyer) with two person staff assistance for transfers. 5. Review of Facility Interview documents, revealed CNA2 said the process when R1 is transferred with a mechanical lift is to use a two man assist. 6. CNA1's Human Resource record (suspension pending investigation form) included the statement, 09/24/19 . Associate (CNA1) transferred to dietary department. Associate made poor decision in not following company policy for mechanical lift use. 7. On 11/13/19 at 01:28 PM during an interview with Director of Nursing (DON), she said she met with CNA1, and interviewed all staff involved after the incident. She stated, I started education that day before the day shift left. We went around and identified all residents that use a mechanical lift and checked if they had the right size sling. Queried if R1 had the right size sling, and DON stated, She was very tall and was using a large because it fit her lengthwise. After the incident we changed to a medium. DON said R1 has movements almost like a contortionist, and described and demonstrated how she had seen R1 curled up. CNA1 said, she just slipped out. Asked if CNA1 was still at the facility, and DON said, He is no longer doing patient care. He is now working in Dietary with no direct contact with residents. When asked what they determined the root cause of the fall to be, the DON, stated, CNA1 has been here [AGE] years and loves his patients, but the fact is, he didn't follow the care plan, and attempted to do the transfer alone. 8. On 11/14/19 at 08:40 AM, observed a demonstration by two CNA's of a transfer from bed to w/c using a mechanical lift. Another staff role played the resident. One of the CNA's role is to support the legs once the sling is secured in place and help guide the resident smoothly as they are moved to the chair or bed. If a second person had been present at the time of the incident, the fall potentially could have been prevented.",2020-09-01
579,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2017-04-21,272,E,0,1,3VM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to complete comprehensive assessments for the use of horizontal metal bar side-rails (SRs) as an assistive device for bed transfers and safety for 3 of 6 residents (R) (#17, #68 & #138) who were observed with metal horizontal bar side-rails in Stage 1 of the survey, and on the Stage 2 resident sample list of 28 residents. Findings include: Cross to F323 Accidents On 04/18/2017 during Stage 1 of the survey, observed R#138, R#17, R#68 lying in bed with bilateral horizontal metal bar SRs with space between the SRs and mattress for limb entrapment. On 04/19/2017 at 1:29 PM interviewed Staff#1 and went with her to the bedsides of R#138, R#17 and R#68 to demonstate that the SRs were loose and shaky when shook and that the resident's limbs could fit through the bars and between the mattress and SRs. The SR safety issue was discussed with both Staff#1 and #2, and both were not aware of accident risk with horizontal metal bar SRs. Both Staff#1 & #2 were not aware that horizontal metal bar SRs were considered accident risk and just considered restraint issue. The online Food and Drug Administration (FD[NAME]gov) guidance, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, was shared with Staff#1 & #2. On 04/19/2017 at 2:00 PM, R#138's MRR noted that the care plan (CP) Unsafe behaviors: At risk for injury including: Potential for falls related to : Cognitive loss resulting from [MEDICAL CONDITION] with behavior disturbances; limited ROM to upper and lower extremities resulting from atrophy of muscles mulitple sites; order of antianxiety; .as evidenced by: 15 points on fall risk assessment; episode of placing (dangling) both legs off edge of bed. (1/17/17). The interventions included that R#138 will use bilateral half rails up for safety and to assist with bed mobility. The facility interventions included: to reassess the appropriateness of SRs use every 3 months or as needed and offer total reduction when appropriate; provide/assist needs as appropriate; staff to make sure resident is in the middle of the bed to prevent rolling off the bed; turn and reposition every 2 hrs for comfort; and low bed for safety (1/17/17). The CP was last reviewed on 04/12/17. The Physician order [REDACTED]. The nursing assessment on 12/31/16 when R#138 was admitted from an acute hospital, described the resident's function in extremities as, Able to move both upper and lower extremities; both hands closed/clenched most of the time. The Restraint/Positioning Device Assessment form dated 12/31/16 documented, Restraints: both 1/2 Side Rails up; Bedrails Yes checked; Assist in transfer yes checked. On 04/20/2017 at 2:14 PM reviewed R#138's Hospice MRR and the CP dated 3/30/17 Problem Falls due to unsafe behavior as evidenced by her dangling both legs on edge of bed; with the goal that the resident would be without falls; and interventions included: Assess environment for adequate safety; Asssess need for DME/Assistive; Ensure bil half rails up for safety and to assist with bed mobility. On 04/20/2017 at 7:39 AM the MRR on R#17 noted that the CP, Unsafe behaviors: At risk for injury including potential for falls r/t Cognitive loss secondary to old cerebral infarction and mixed dementia with behavioral disturbance; limited mobility as a result of old cerebral infarction, right sided [MEDICAL CONDITION]; use of atidepressant as evidenced by: 12 pooints on fall risk assessment; fluctuating alertness; hx of leaning on one side when up in her chair; trunk control issues, was last reviewed on 03/25/17. The interventions included: Provide 2 person assist in transfer; Allow her to sit on by the edge of the bed for at least 60 seconds to prevent dizziness; Use Gait belt at all times for safety; Res will use bilateral half rails up for safety and to assist her with bed mobility and transfer; Will reassess appropriateness of SRS use every 3 months or as needed and offer total reduction when appropriate. The PO dated 9/25/15 for R#17 documented, (MONTH) use both 1/2 upper SR up while in bed for safety and mobility. The Restraint/Positioning Device assessment dated [DATE] documented, Restraints: Bilateral half SR up; Benefits: Enable bed mobility; Risks: Restrict circulation, pressure ulcer, B/B incont, anger. The evaluation summary noted, Resident is to continue using bilateral half rails up to assist her with bed mobility and safety. She has hx [MEDICAL CONDITIONS] and her trunk balance is poor. She is not restless or attempting to get OOB therefore its not a restraint. No A/R (adverse reaction) from SR use so far. On 04/20/2017 at 1:41 PM, queried Staff#6 on R#17's ability to move. Staff#6 stated that R#17 had periods of restlessness and able to move upper body and sometimes oberved with head leaning towards edge of bed. On 04/20/2017 11:02 AM, R#68's MRR documented on the PO dated 3/23/17, (MONTH) transfer to low bed w/2 1/2 upper SR up for safety/mobility. On 04/20/2017 at 2:19 PM, Staff#3 provided R#68's Restraint/Positioning Device Assessment, dated 3/23/17, that noted, Restraints: Side Rail 1/2 SR; Benefits: Enable bed mobility; prevent rolling/falling out of bed; prevent elopement/fall; comfort/security; Risks: agitation/hositle behavior like kicking, biting; Assessment done: Bedrails yes Fall incident: No. Interviewed Staff#3 regarding the use of SRs for R#68 and whether assessment on safety with use of horizontal metal bar SRs were done. According to Staff#3, R#68 was placed on an ajustable bed that could be lowered and the SRs provided the R#68 bed mobility, sanitary reasons, (kept pillows on bed), and able to hang bed alarm from SR. Queried Staff#3 for SR CP and she could not provide it. The facility failed to do comprehensive assessments on residents that were provided horizontal metal bar SRs for safety and bed mobility. All three residents had the capability of moving and becoming entrapped between the metal bars and mattress.",2020-09-01
580,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2017-04-21,280,D,0,1,3VM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews (MRR) and staff interviews the facility failed to evaluate and revise the care plan (CP) for 1 of 28 residents (R#63), as the resident's condition changed. Findings include: On 04/21/2017 at 8:41AM the MRR on R# 63 noted on the Physician order [REDACTED]. On the same date the physician also wrote to discontinue [MEDICATION NAME] 1 mg. The resident's CP for the problem of manifesting mood and behavior issues related to [MEDICAL CONDITION] as evidenced by: restlessness - gets OOB w/o calling for assistance; verbalization of feeling down , depressed, or hopeless, trouble falling or staying asleep, feeling tired and trouble concentrating, included the intervention of 10. Administer [MEDICATION NAME] as ordered for [MEDICAL CONDITION]. On 04/21/2017 at 10:03 AM reviewed R#63's Medication Administration Record [REDACTED]. The facility staff failed to revise the CP interventions for the use of [MEDICATION NAME] when R#63 manifested mood and behavior issues such as anxiety.",2020-09-01
581,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2017-04-21,323,G,0,1,3VM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Based on observations, medical record review and staff interviews, the facility failed to provide adequate supervision for Resident #90 (R#90). The facility must ensure that the resident's environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. Findings include: A review of a self-reported incident report (IR) submitted to the State Agency (SA) was investigated through record review and staff interviews during the recertification survey. 04/20/2017 11:09 [NAME]M. Record review revealed Resident #90 (R#90) was admitted to the facility on [DATE] with Alzheimer's dementia without behavior disturbance, failure to thrive, anorexia, cachexia. dysphagia and hospice. R#90 has a frail physique and very poor trunk control. Per the facility, R#90 has a tendency to bend over when sitting in a wheelchair and is kyphotic. R#90 has a history of falls and due to this is already a high fall risk. On 1/12/17 at 12:45, R#90 fell forward out of her wheelchair, hit her head on the floor and suffered an intracranial hemorrhage, subdural hematoma, laceration to the left eyebrow, bilateral peri-orbital contusions, contusion to upper lip, base of nose and abrasion to left eyelid. A staff member was putting R#90 back into bed. R#90 was placed next to the bed. The staff member stepped away from the wheelchair to draw the curtain closed. R#90 fell out of the wheelchair when the staff member drew the curtain. R#90 was sent to the emergency room by ambulance. On 4/20/2017 at 10:34 [NAME]M. interview was done with staff #1. When R#90 came back, we provided a 1:1 sitter for close monitoring and until the daughter felt that her mom was stable. Staff #1 stated The CNA stated that R#90 was not restless at the time and this could have been prevented if the staff had placed the wheelchair in front of her and not stepped to the side. It was an attended fall. The daughter was really upset. On 04/21/2017 at 11:34 [NAME]M. Interview with Staff #3 R#90 moved to the facility in (YEAR) because of a hip fracture and was hospice care for over a year. R#90 fell at home and suffered an intratrochanteric fracture and came here. She was cachectic. She requires extensive assist and one to two person assist with transfers. R#90 was able to use wheelchair but most of the time stays in her bed for comfort. She was careplanned for 1-2 person assist with transfers. Staff #3 was asked regarding R#90 that after the fall, they careplanned to make sure bed was in low position, staff will always stand in front of the wheelchair and hold the resident with one hand while pulling the curtain. Staff #3 was asked when R#90 came in presenting with kphyosis and poor trunk control, was safety measures care planned for wheelchair activity and safety, geri-chair or safety belt? Staff #3 answered no, we did not think of that and we felt that a belt would be a restraint. The facility failed to fully assess the resident's known predisposition to falls concomitant to her clinical condition and presentation on admission. This failure may have contributed to the resident's subsequent fall and injuries on 01/12/17. 2) Based on observations, staff interviews and medical record reviews the facility failed to evaluate and analyze hazards and risks in implementing the use of horizontal metal bar side rails (SRs) to promote the resident's function and/or safety for 3 of 6 residents ( R#17, #68 & #138) observed in Stage 1 of the survey, and of 28 residents sampled in Stage 2. Findings include: Cross to F272 Comprehensive Assessments On 04/18/2017 during Stage 1 of the survey, observed R#138, R#17, R#68 lying in bed with bilateral horizontal metal bar SRs with space between the SRs and mattress. On 04/19/2017 at 1:29 PM interviewed Staff#1 and went with her to the bedsides of R#138, R#17 and R#68 to demonstrate that the SRs were loose and shaky when shook and that the resident's limbs could fit through the bars and between the mattress and SRs. The SR safety issue was discussed with both Staff#1 and #2, and both were not aware of accident risk with horizontal metal bar SRs. Both Staff#1 & #2 were not aware that horizontal metal bar SRs were considered accident risk and just considered restraint issue. The online Food and Drug Administration (FD[NAME]gov) guidance, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, was shared with Staff#1 & #2. On 04/19/2017 at 2:00 PM, R#138's MRR noted that the care plan (CP) Unsafe behaviors: At risk for injury including: Potential for falls related to : Cognitive loss resulting from vascular dementia with behavior disturbances; limited ROM to upper and lower extremities resulting from atrophy of muscles multiple sites; order of antianxiety; .as evidenced by: 15 points on fall risk assessment; episode of placing (dangling) both legs off edge of bed. (1/17/17). The interventions included that R#138 will use bilateral half rails up for safety and to assist with bed mobility. The facility interventions included: to reassess the appropriateness of SRs use every 3 months or as needed and offer total reduction when appropriate; provide/assist needs as appropriate; staff to make sure resident is in the middle of the bed to prevent rolling off the bed; turn and reposition every 2 hrs for comfort; and low bed for safety (1/17/17). The CP was last reviewed on 04/12/17. The Physician order [REDACTED]. The nursing assessment on 12/31/16 when R#138 was admitted from an acute hospital, described the resident's function in extremities as, Able to move both upper and lower extremities; both hands closed/clenched most of the time. The Restraint/Positioning Device Assessment form dated 12/31/16 documented, Restraints: both 1/2 Side Rails up; Bedrails Yes checked; Assist in transfer yes checked. On 04/20/2017 at 2:14 PM reviewed R#138's Hospice MRR and the CP dated 3/30/17 Problem Falls due to unsafe behavior as evidenced by her dangling both legs on edge of bed; with the goal that the resident would be without falls; and interventions included: Assess environment for adequate safety; Assesses need for DAME/Assistive; Ensure bilateral half rails up for safety and to assist with bed mobility. On 04/20/2017 at 7:39 AM the MRR on R#17 noted that the CP, Unsafe behaviors: At risk for injury including potential for falls r/t Cognitive loss secondary to old cerebral infarction and mixed dementia with behavioral disturbance; limited mobility as a result of old cerebral infarction, right sided hemiparesis; use of atidepressant as evidenced by: 12 points on fall risk assessment; fluctuating alertness; history of leaning on one side when up in her chair; trunk control issues, was last reviewed on 03/25/17. The interventions included: Provide 2 person assist in transfer; Allow her to sit on by the edge of the bed for at least 60 seconds to prevent dizziness; Use Gait belt at all times for safety; Res will use bilateral half rails up for safety and to assist her with bed mobility and transfer; Will reassess appropriateness of SRS use every 3 months or as needed and offer total reduction when appropriate. The PO dated 9/25/15 for R#17 documented, (MONTH) use both 1/2 upper SR up while in bed for safety and mobility. The Restraint/Positioning Device assessment dated [DATE] documented, Restraints: Bilateral half SR up; Benefits: Enable bed mobility; Risks: Restrict circulation, pressure ulcer, B/B incontinent, anger. The evaluation summary noted, Resident is to continue using bilateral half rails up to assist her with bed mobility and safety. She has history of CVA with hemiparesis and her trunk balance is poor. She is not restless or attempting to get OOB therefore its not a restraint. No A/R (adverse reaction) from SR use so far. On 04/20/2017 at 1:41 PM, queried Staff#6 on R#17's ability to move. Staff#6 stated that R#17 had periods of restlessness and able to move upper body and sometimes observed with head leaning towards edge of bed. On 04/20/2017 11:02 AM, R#68's MRR documented on the PO dated 3/23/17, (MONTH) transfer to low bed with/2 1/2 upper SR up for safety/mobility. On 04/20/2017 at 2:19 PM, Staff#3 provided R#68's Restraint/Positioning Device Assessment, dated 3/23/17, that noted, Restraints: Side Rail 1/2 SR; Benefits: Enable bed mobility; prevent rolling/falling out of bed; prevent elopement/fall; comfort/security; Risks: agitation/hostile behavior like kicking, biting; Assessment done: Bedrails yes Fall incident: No. Interviewed Staff#3 regarding the use of SRs for R#68 and whether assessment on safety with use of horizontal metal bar SRs were done. According to Staff#3, R#68 was placed on an adjustable bed that could be lowered and the SRs provided the R#68 bed mobility, sanitary reasons, (kept pillows on bed), and able to hang bed alarm from SR. Queried Staff#3 for SR CP and she could not provide it. The facility failed to evaluate and analyze hazards and risks with use of horizontal metal bar SRs and implement interventions to reduce hazards and risks for limb and head/neck entrapment between the loose SRs and mattress for R#138, #17 and #68.",2020-09-01
582,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2017-04-21,329,D,0,1,3VM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record (MR), electronic medical record reviews (EMR) and staff interviews, the facility failed to ensure that 1 of 28 residents (R#63) on the Stage 2 resident sample list, received only those medications clinically indicated to treat the resident's assessed condition. Findings include: On 04/21/2017 at 8:41 AM, R#63's MRR was done as the resident was sampled for unnecessary medications. The Physician order [REDACTED]. Further documentation in R#63's EMR, noted that on 04/04/17 at 01:59 AM the resident had an episode of agitation and insisted on going home. The pharmacist was called and staff administered [MEDICATION NAME] 0.5 mg to R#63 on that date. On e physician 04/07/17 the resident refused walking therapy and a new order was made for a psyche consult. On 4/12/17 the physician prescribed [MEDICATION NAME] 25 mg by mouth every 8 hours as needed for distressing anxiety and discontinued the order for [MEDICATION NAME] 1mg. The CP for R#63 for the problem of manifesting mood and behavior issues related to [MEDICAL CONDITION] as evidenced by: restlessness - gets OOB w/o calling for assistance; verbalization of feeling down , depressed, or hopeless, trouble falling or staying asleep, feeling tired and trouble concentrating; included the interventions: 1 Determine reason for restlessness such as soiled brief, hungry, thirsty, feels hot/cold, in pain and etc. Address needs as appropriate. 9. Monitor for signs of depression such as decreased appetite, crying, or tearfulness, decreased energy, [MEDICAL CONDITION], withdrawal from actvities and etc. update MD as appropriate 10. Administer [MEDICATION NAME] as ordered for [MEDICAL CONDITION]. On 04/21/2017 at 10:03 AM reviewed the Medication Administration Record [REDACTED]. There were no corresponding documentation in R#63's EMR or MR on 04/15/17 for the need of [MEDICATION NAME]. Staff#7 looked at the 24 hr report book and on 04/14/17 the night nurse documented that R#63 was Ok, slept good, and the dayshift nurse on 04/15/17 documented that the resident had no c/o discomfort. Queried Staff#6 if nurses were required to document residents behaviors before and after providing antidepressants/antianxiety medications, and she responded that there should be documentation but could not provide information on R#63's behaviors/mood at midnight on 04/15/17. The facility staff did not document whether non-pharmacological interventions were considered and used when indicated, instead of, or in addition to medication to ensure the resident received [MEDICATION NAME] as clinically indicated.",2020-09-01
583,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2017-04-21,431,D,0,1,3VM911,Based on observation and staff interview the facility failed to ensure drugs and glucose test strips were labeled in accordance with currently accepted professional principles with the open and/or expiration date(s). Findings: 1) On 04/19/2017 at 1:26 PM while checking the medication cart used by day and evening shift licensed staff on the second floor it was observed that 8 eye drop containers where labeled with only the month and day date when opened and when to discard. The medication was missing the year for the open and discard by date. Interview of licensed staff #5 confirmed this and she was not able to state the year as it was not documented on the medication. 2) On 04/19/2017 at approximately 1:35 PM while checking the medication cart used by night shift licensed staff on the second floor with staff #5 a container of blood glucose test strips were found with no open date documented on the container. Interview of staff #5 confirmed that there was no date written on the container of blood glucose strips and it was apparent that test strips had been used as there were missing test strips from the container. The facility failed to ensure that drug and glucose test strips were labled completly with open and discard by date in accordance with currently accepted professional principles.,2020-09-01
584,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2019-08-23,578,E,0,1,VTI611,"Based on record review (RR) and interview, the facility failed to have a process in place to establish, maintain, and implement written policies and procedures regarding the resident's right to formulate an advance directive (AD) for 10 of 18 residents ((R) R16, R27, R37, R41, R42, R43, R55, R67, R68, and R79) selected for review. The facility's focus was to have a POLST( Provider Orders for Life Sustaining Treatment) rather than an AD. A POLST is a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency. A POLST form is not an AD. Findings include: 1. On 08/21/19 at 01:44 PM, RR for R37 reflected no AD on record for R37. On 08/21/19 at 09:40 AM, interview with Social Service Designee (SSD) who stated she is unaware of the need for residents to have an AD while at the facility. On 08/21/19 at 10:46 AM, interview with Facility Administrator (FA) who confirmed they do not have a process in place for residents to formulate an AD. FA said he will work with the staff to develop a process for AD's. 2. Additional RR revealed no AD or offer to formulate one for R42, and R79. 3. On 08/21/19 RR for R27 revealed a POLST in the medical record, but no AD or documentation of providing information regarding ADs. On 08/21/19 at 02:20 PM FA provided a document that listed all resident's indicating if they had a POLST or AD. R27 was listed as not having an AD. 4. On 08/20/19 RR for R41 revealed a POLST signed by R41's sister in the record, but no AD or documentation of providing information regarding ADs. On 08/21/19 at 02:20 PM FA provided a document that listed all resident's that indicated if they had a POLST or AD. R41 was listed as not having an AD. R41 is cognitively not able to comprehend a discussion about health care directives and family was unavailable for further discussion. 5. 08/21/19 RR for R43 revealed a POLST in the record, but no AD or documentation of providing information regarding ADs. On 08/21/19 at 02:20 PM FA provided a document that listed all resident's that indicated if they had a POLST or AD. R43 was listed as not having an AD. R43 was not available for further interview as she was transferred to an acute care hospital in the evening of 08/20/19 at 07:10 PM. 6. 08/21/19 02:14 PM RR for R68 revealed a POLST in the medical record, but no AD or documentation of providing information regarding ADs. On 08/21/19 at 02:20 PM FA provided a document that listed all resident's that indicated if they had a POLST or AD. R68 was marked as not having an AD. 7. Record reviews completed for R16, R67 and R55 found that they did not have an AD in their clinical records. 8. On 08/21/19 10:46 AM, the FA brought the facility's revised 04/01/19 Advance Directive (AD) Policy Statement. This policy stated: 5. The care plan team will review annually with the resident his or her advance directives to ensure that they are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). On 08/21/19 at 10:46 AM, interview with FA, who confirmed they do not have a process in place for residents to formulate an AD. FA said he will work with his staff to develop a process for ADs.",2020-09-01
585,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2019-08-23,640,D,0,1,VTI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR) and interview, the facility failed to complete the required Minimum Data Set (MDS) discharge assessment for one resident (R)1 after the resident was discharged from the facility. There is the potential that data for any other residents is not transmitted timely, which may affect information for payment and quality measure purposes. Findings include: On [DATE] RR revealed R1 was admitted to the facility for short term rehabilitation on [DATE] and discharged on [DATE]. There was no documentation that a MDS discharge assessment (discharge subset of items) had been completed and transmitted. On [DATE] at 09:54 AM during an interview with MDS Coordinator (MDSC), the medical record was reviewed and the MDSC validated R1's discharge date of [DATE], and that the required discharge assessment had not been completed. MDSC said nursing completes a form called Notice of discharged /Expired of Resident, and submits it to the MDS office to alert them a discharge assessment needs to be completed. The MDSC said We did not receive notification of R1's discharge, but I'll complete the assessment now.",2020-09-01
586,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2019-08-23,656,D,0,1,VTI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR) and interview, the facility failed to develop a comprehensive care plan (CP) to meet the needs of four of four residents (R)16, R33, R55, R68 sampled. The facility failed to include the use of a back brace in R68's CP, failed to CP activities/sensory stimulation for R33 and R55, and failed to CP a new skin tear for R16. As a result of this deficient practice there was potential that R16, R33, R55, and R68 would not have their needs met and not meet their highest practicable physical, mental and psychosocial well-being. Findings include: 1. R68 was a [AGE] year-old female admitted on [DATE]. She had history of limited mobility resulting from right hip surgery sustained in a fall, and subsequently diagnosed with [REDACTED]. R68's discharge summary from the acute care hospital read, the condition was likely to be a permanent disability. One of the discharge goals was to train upper body strength, and to use a [MEDICATION NAME] lumbar sacral orthosis (TLSO) brace when bearing weight. The TLSO brace is used to stabilize the spine for healing and decrease pain. RR revealed R68 received physical therapy (PT) from 07/06/19 to 07/26/19. The occupational therapy (OT) discharge summary included a short-term goal of Patient will tolerate sitting for 30 minutes upright in supported sitting with TLSO in place to complete ADL (activities of daily living) such as eating, grooming facilitating increased ADL tasks. It also included the goal that the patient will tolerate TLSO donned (put on) by educated caregivers. On 08/20/19 at 10:00 AM observed R68 lying on her back with the head of the bed (HOB) slightly elevated. R68 appeared comfortable and was visiting with family. She did not have a brace on. On 08/20/19 at 12:45 PM, observed staff member preparing R68 for lunch by raising the HOB in a sitting position to eat. R68 told staff to stop raising the bed when it became painful for her. The HOB was elevated less than 45 degrees. R68 did not have a TLSO brace on. Interviewed family member at that time who said R68's, not getting physical therapy (PT) anymore due to minimal progress. She said R68 could not tolerate sitting in a chair upright, and was now always in bed. On 08/21/19 at 10:43 AM, observed R68 sleeping in bed with TLSO brace on. HOB was slightly elevated. On 08/21/19 at 03:29 PM during an interview with Physical Therapist (PT)1, reviewed R68's chart and confirmed the recommendation that R68 was to have the brace (TLSO) applied by nursing staff for meals to help reduce pain and to tolerate the HOB up higher for meals and ADL's. PT1 explained, When a resident is discharged from PT, we make recommendations to nursing for maintenance. We have a restorative care program (RCP) and restorative nursing aides (RNA) to assist with the recommendations, and do the exercises. RR of the occupational therapy (OT) discharge summary for dates of service 07/06/10 to 07/26/19 signed on 07/30/19 included the following: a. Status: Patient and Caregiver Training: Instructed patient in safe task completion . specifically education to donn (put on) TLSO in bed to increase sitting tolerance, positioning .to facilitate improved performance during functional activities, increase safety and reduce the risk of further medical complications [REDACTED]. b. Discharge Recommendations: TLSO in bed to support when sitting for meals and activities as needed. Equipment recommended upon discharge: TLSO. Review of the facility's policy titled, Restorative Service Policy dated 01/04/19 states, Licensed rehabilitation (rehab) personnel will communicate to nursing staff in writing, all resident care like use of braces, splints, or mobility devices .to maintain progress of resident's rehabilitation, and once a resident has met his/her care plan goals, a licensed professional can either discontinue or initiate a maintenance program which either nursing or restorative aides will implement to assure that the resident maintains his/her functional and physical status. The policy also states, the rehabilitation goals and objectives are developed for each resident and are outlined in his/her plan of care relative to therapy services. RR of 68's comprehensive care plan included did not include applying the TLSO brace to increase sitting tolerance, reduce pain, or to help maintain ADL's. On 08/23/19 at 12:21 PM during an interview with Registered Nurse (RN)11, asked if she knew anything about R68's TLSO brace. RN11 said, I passed by R68's room one day while doing rounds and was called into the room. R68 had the brace on and one of the Occupational Therapists (OT) told me R68 might do better if the brace was used when sitting up in bed and might be able to tolerate sitting up longer. RN11 did not recall who the OT staff was. Inquired how OT usually communicates the RCP. RN said, When the resident is ending therapy, they give us a therapy communication form with directions .The RN's and RNA's sign off they are aware of the plan and have been educated. Then we add it to the Care Plan (CP), and the RNA task list. RN11 said they did not get a therapy communication form for R68. On 08/23/19 at 11:57 AM during an interview with Director of Nursing (DON) reviewed the OT discharge summary. The DON confirmed OT did not communicate to Nursing, and stated, They usually give us a form. That didn't happen. 2. Cross reference tag 676. The facility failed to provide R68 with the recommended therapy of applying the TLSO brace when elevated in bed for meals and performing ADL's. Nursing was to apply the brace to decrease pain and increase sitting tolerance so R68 could have increased participation in ADL's and improve quality of life. 3. Random observations of R33 during the survey found the resident in bed for the majority of the time with no activities observed for her. On 08/20/19 at 11:03 AM, R33 was seen in bed since the morning, and observed talking non-sensically to herself. On 08/21/19 at 03:41 PM, R33 was observed in bed mumbling softly and fidgeting with her hands over and over. The resident was not brought out by the staff to attend the daily group activities, but remained in her bed with no music or television on. RR found that R33 had [DIAGNOSES REDACTED]. One of R33's CP's for her cognitive deficit stated she was dependent on the staff for sensory stimulation related to her [MEDICAL CONDITION]. Other CP's included R33's self care deficit related to limited mobility resulting from atrophy of her muscles of multiple sites, behavioral disturbances, assistance in all of her ADLs, and the use of a wheelchair as her mobility device. There was also a CP for mood and behavior, but further review found no comprehensive CP for activity-related and/or sensory stimulation care. R33's clinical record noted visits by activity staff that daily one to one visits including verbal, tactile, and listening to music approaches were being provided to her. None of this however, was observed during random observations of the resident. On 08/22/19 at 02:04 PM, an interview with the Activities Coordinator (AC) was done. The AC said R33 could not tolerate coming out of her room because of her behaviors and dementia. The AC said she did, verbal, and 1:1 room visits. I spend about 5-10 minutes, because there are no responses. Any time I have time for them, that's when I do the tactile--breakfast time or lunch time. I have no specific time for them. When I come early in the morning, that's when I visit residents that are not coming out. When the AC was asked to provide the activity/sensory CP for R33, the AC only kept stating, R33's dependent on staff for sensory stimulation, but was unable to produce a resident-centered CP for the activities/sensory stimulation being provided to the resident. 4. Similarly, for R55, this resident observed on 08/20/19 at 11:16 AM, sitting up in bed, saying, come here, come here. R55 could state his name and understand some words spoken to him. He did not have any music or television on, but would call out to people who came into his room or saw them passing by in the hallway. Although the resident was receiving PT due to [MEDICAL CONDITION] affecting his right side and generalized muscle weakness, and with a stage 2 sacral pressure injury, the resident was observed sitting in his bed looking at people pass by in the hallway. On 08/22/19 at 08:53 AM, during an interview with certified nurse aide (CNA) 27, she said R55 does exercises while in bed but they did not want to get him up until the pressure injury healed (it was mostly healed). During an interview with AC, she stated she offered music, exercises, talking to him--he understands simple English. I offered him the radio, and acknowledged there was not much going on for him. The AC said, Whatever we do with him, we give to the MDS coordinator, we don't have a set one (CP for activities), it's all integrated with the cognition. The AC verified she had not developed a CP for R55 and said the reality orientation she did was the weather for the day. Yet during the AC's visit with R55 on 08/23/19 at 08:23 AM, she engaged the resident and had him do upper body exercises with simple commands and stated he likes to pray, read his bible and church members visit him. The AC acknowledged these approaches were being implemented, but there was no CP for it. On 08/22/19 at 03:11 PM, the Assistant Director of Nursing (ADON) stated the development of resident-centered CPs, Is open to everyone, not just for nursing. The ADON acknowledged the AC or others could have developed a CP for residents receiving sensory stimulation or other individualized activities based on resident preference. 5. On 08/20/19 at 10:41 AM, during the initial tour, R16 was on one-to-one monitoring with a nurse aide watching over him. R16 was found to have a skin tear on his right lower leg. R16, who is on hospice care, had been seen by the hospice nurse that morning who then assessed and dressed the skin tear. The hospice nurse stated he may have gotten the skin tear because he has an unsteady gait sometimes. On 08/22/19 at 09:56 AM, during an interview with the ADON, she said it would be an episodic or paper CP developed. Concurrent record review did not find a CP for this newly identified skin tear. On 08/22/19 at 10:15 AM, an interview was done with the hospice nurse who found and dressed R16's skin tear. She stated she did not get an order from the doctor, because it's a skin flap and it's better to keep the wound open to air and I know him to be impulsive. I only covered it with a dry dressing and put the flap in there, it will be easier to heal. The hospice nurse said her handwritten notes measured the skin tear to be 1.3 x 0.5 centimeters (cm) to R16's right shin, and noted the skin flap was placed back on with the use of normal saline to clean it and covered it with a dry dressing. The hospice nurse said she did not convey to the facility's nursing staff that she did a wound treatment/intervention on the day she found it on 08/20/19.",2020-09-01
587,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2019-08-23,676,D,0,1,VTI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review (RR) the facility failed to consistently provide a recommended therapy to one of one Resident (R)68 sampled. The staff did not apply a back brace that was recommended to decrease pain and provide support so R68 could maintain and improve participation in completing her activities of daily living (ADL's) with as little pain as possible. As a result of this deficient practice, there was the potential that R68 may not reach her fullest potential and may have a decline in functional condition. This could affect any other resident if recommended therapies are not communicated properly to all caregivers. Findings include: R68 was a [AGE] year-old female admitted on [DATE]. She had a history of [REDACTED]. R68's discharge summary from the acute care hospital read, the condition was likely to be a permanent disability. One of the discharge goals was to train upper body strength, and to use a [MEDICATION NAME] lumbar sacral orthosis (TLSO) brace when bearing weight. The TLSO brace is an externally applied corset type brace recommended to stabilize the spine for healing and decrease pain. On 08/20/19 at 10:00 AM observed R68 lying on her back with the head of the bed (HOB) slightly elevated. R68 appeared comfortable and was visiting with family. She did not have a brace on. On 08/20/19 at 12:45 PM, observed staff member preparing R68 for lunch by raising the HOB in a sitting position to eat. R68 told staff to stop raising the bed when it became painful for her. The HOB was elevated less than 30 degrees. R68 did not a TLSO brace on. Interviewed a family member at that time who said R68 was no longer getting physical therapy (PT) because she wasn't making progress. She said R68 had not been able to tolerate sitting in a chair, so was always in bed now. On 08/21/19 at 10:43 AM, observed R68 sleeping in bed with TLSO brace on. HOB elevation angle was at approximately 30 degrees. RR of R68's care plan (CP) did not include any reference to a TLSO brace. RR revealed a piece of paper in the front of R68's chart dated (MONTH) 21, 2019. The following was typed on the piece of paper: TLSO Clarification-Patient to wear TLSO when sitting or out of bed. Questions/Concerns please contact the Rehab (rehabilitation) department. The note was not timed or signed. RR of the occupational therapy (OT) discharge summary for dates of service 07/06/10 to 07/26/19 signed on 07/30/19 included the following: a. Status . Patient and Caregiver Training: Instructed patient in safe task completion. Task modification and compensatory strategies specifically education to donn (put on) TLSO in bed to increase sitting tolerance, positioning .to facilitate improved performance during functional activities, increase safety and reduce the risk of further medical complications [REDACTED]. b. Discharge Recommendations: TLSO in bed to support when sitting for meals and activities as needed. Equipment recommended upon discharge: TLSO. On 08/21/10 at 11:00 AM, during an interview with Registered Nurse (RN)11, asked what she knew about R68's TLSO brace. RN11 stated, she's supposed to have it on when she's sitting up in bed for meals. Asked if staff were expected to document when the brace was applied, she replied, Yes. Reviewed Nursing Progress notes that revealed staff did not consistently document the application of the TLSO brace. RN11 stated she thought, some staff may feel they shouldn't put it on if she's (R68) in pain. On 08/21/19 at 03:29 PM during an interview with Physical Therapist (PT)1, reviewed R68's chart and confirmed the recommendation that R68 was to have the brace applied by nursing staff for meals to help reduce pain and be able to tolerate the Head of Bed (HOB) up at a higher angle for meals and ADL's. PT1 explained, When a resident is discharged the rehab staff make recommendations to nursing for maintenance. We have a restorative care program (RCP) and restorative nursing aides (RNA) that assist with the recommendations and exercises. On 08/23/19 at 12:21 PM during an interview with RN11,asked if she knew anything about the unsigned typed piece of paper in R68's chart from the rehab department. RN11 said, I passed by R68's room one day while doing rounds and was called into the room. R68 had the brace on and one of the Occupational Therapist (OT) told me R68 might be able to tolerate sitting up longer if she had the brace on. RN11 did not recall who the OT staff was. Inquired how OT usually communicates the RCP. RN11 said, when the resident is ending therapy, they give us a therapy communication form with directions .The RN's and CNA's (Certified Nursing Assistant) sign off they are aware of the plan and have been educated. RN said they did not get one for R68. She stated, I was on vacation the week after her therapy ended and when I came back, I told them (rehab) I was given a verbal recommendation for the use of the brace but didn't get the form. That's when the typed note was put in the chart. RN11 said she asked why the therapist did not fill out the form and was told the therapist was not comfortable completing the specifics of a recommendation made by another therapist that was not available. Review of the facility's policy titled, Restorative Service Policy dated 01/04/19 states Licensed rehab personnel will communicate to nursing staff in writing, all resident care like use of braces, splints, or mobility devices .to maintain progress of resident's rehabilitation, and once a resident has met his/her care plan goals, a licensed professional can either discontinue or initiate a maintenance program which either nursing or restorative aides will implement to assure that the resident maintains his/her functional and physical status. The policy also states, the rehabilitation goals and objectives are developed for each resident and are outlined in his/her plan of care relative to therapy services.",2020-09-01
588,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2019-08-23,684,G,1,1,VTI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews and record review (RR), the facility failed to recognize and thoroughly address the physical needs of one of one Resident (R)27sampled. R27 had a [DIAGNOSES REDACTED]. Findings include: 1. R27 was a [AGE] year-old who had a complex medical history with multiple [DIAGNOSES REDACTED]. Due to the dysphasia, R27 was fed through a gastrointestinal tube ([DEVICE]) placed in her abdomen. She was first admitted to the facility on [DATE] after the stroke. 2. On 08/20/19 at 01:20 PM, observed R27 lying in bed sleeping. Brief interview conducted with a family member. On 08/21/19 noted R27's bed was empty and was informed R27 had been transferred to the hospital. 3. RR revealed R27 had several hospital admissions. The hospital discharge summaries contained the following: Discharge summary prior to facility admission, dated 03/16/19: [MEDICAL CONDITION] 03/12/19 Na (Sodium)152 (normal 133-145), 03/13/19 Na 156. Started on free water flushes (additional water via [DEVICE] to meet needs.) 03/14/19 Na 154. Recommendations: Ensure good hydration - can schedule free water flushes via [DEVICE] if needed. The treatment for [REDACTED]. 04/30/19 to 05/16/19 (First hospital admission): Facility found R27 to be lethargic (sleepy) and became unresponsive. Principal Diagnoses: [REDACTED]. Hospital Course: .CKD stage 4/ [MEDICAL CONDITION] .Now has [MEDICAL CONDITION] and undergoing free water flush. 05/17/19 to 06/07/19 (Second hospital admission): R27 admitted for respiratory distress . Principal Diagnoses: [REDACTED]. Secondary Diagnoses: [REDACTED]. After diuresis (loss of a great amount of water) developed [MEDICAL CONDITION] with Sodium peaking at 154. It was corrected with intravenous fluids and increased free water flushes. 07/03/19 to 07/08/19 (Third hospital admission): transferred to rule out gastrointestinal (GI) bleeding. Principal Diagnosis: [REDACTED]. Hospital course treatment for [REDACTED]. balance, levels of electrolytes like sodium and potassium, and how well the kidneys are working) IN 2-3 DAYS TO ENSURE NO(SIC) STABILIZATION OF SODIUM AND WOULD RECOMMEND TO CHECK SODIUM AT LEAST Q (every) WEEKLY (sic) Discharge notes: The pending discharge issues .PLEASE CHECK BMP (SODIUM) in two days AFTER DISCHARGE to ensure no worsening of [MEDICAL CONDITION] and adjust free water flushes as needed. 08/21/19 Transferred to hospital for fourth admission for [MEDICAL CONDITION]. 4. RR revealed R27's orders at the time of admission on 07/08/19 included: free water flushes (250 cc q 4 h) and lab tests (CBC,CMP (comprehensive metabolic panel) .). Laboratory (lab) results on 07/10/19 revealed abnormal GFR (Glomerular filtration rate-a measure of kidney function). Sodium 143 (normal 133-145) GFR 26 (normal >89) 5. RR of 07/13/19 Nursing Progress Note: Seen by MD1 this morning. Relayed . lab test result. Sodium Test within normal.order to discontinue weekly Na test . 07/13/19 Written order by MD1, Discontinue weekly Sodium (Na) test. 6. RR of Nursing Progress Notes: 08/19/19 05:37 PM .client appears more sleepy lately . 08/19/19 11:17 PM MD1 made aware regarding sleepiness. Order received to decrease [MEDICATION NAME] .for neuropathic pain 08/20/19 No nursing progress notes documented any of the three shifts. 08/21/19 09:48 AM still with sleepiness but easily arousable .MD1 made aware with order to Dc (discontinue) [MEDICATION NAME] ([MEDICATION NAME]), and lab work ordered. 08/21/19 03:00 PM entry: Resident frequently checked at bedside at 10:00 AM eyes closed, unable to respond to verbal and tactile stimuli. Not responding to even pain .As per daughter, wants to transfer resident to hospital for further treatment and evaluation. Called and notify MD1 at 10:30 AM with order to transfer .Called 911 .Transfer at 10:40 AM. 7. RR lab results drawn 08/21/19: Sodium 170 (normal 133-145), and GFR 8 (normal > 89). 8. On 08/23/19 at 02:32 PM during an interview with Director of Nursing (DON) discussed the 07/16/19 hospital discharge summary and recommendations made for monitoring and treating R27's [MEDICAL CONDITION] which included weekly sodium lab tests and then adjusting water flushes as needed based on the lab results. DON reviewed the chart and stated, On admission, the nurses take the recommendations off the discharge summary from the hospital and call the physician to get the orders. MD1 was her physician, and he bases his labs on symptoms. That's the only time he's going to order labs. Queried if the Medical Director gets involved if there are several readmissions. DON stated he does get involved if we bring it to his attention. Asked if R27's hospitalization s had been brought to the Medical Directors attention, and DON replied, No. Reviewed Nursing Progress notes, and discussed expectation for documentation of nursing assessments. DON said, They (Registered Nurses) should be documenting every shift for someone in her (R27's) condition. I don't know why they didn't document",2020-09-01
589,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2019-08-23,689,D,0,1,VTI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure that one of one resident (R)233 sampled was free from a potential accident related to smoking. The facility allowed smoking in an area that did not have a covered container of safe design to dispose of smoking products. This put R233 at risk of unintentional accident as well as any other resident that smokes. In addition, the area was not kept clean of the remains of smoking products. Findings include: R233 was a [AGE] year old who cannot complete all activities of daily living without assistance due to limited mobility and utilizes a wheel chair for mobility. R233's care plan indicated that she had a potential for falls. On 08/20/19 at 04:00 PM, during an interview with R233 she she goes out to have a cigarette about three times a day, but I always have someone supervising me. I'm not allowed to go out alone. 08/21/19 at 03:15 PM accompanied R233 and the Activity Coordinator (AC) out of the facility to smoke. The AC pushed R233, who was in a wheel chair out to the driveway by the exit of the basement parking lot. Observed the AC give R233 a lighter and R233 proceeded to light a cigarette. When R233 was done smoking, she returned the lighter to the AC and asked to be taken back to her unit. There was no ashtray in the area to extinguish a cigarette. The products of 19 cigarettes were observed on the driveway in the immediate and adjacent area. On 08/21/19 at 03:20 PM during an interview with the AC, asked if the driveway area was the designated smoking area. She replied, In the afternoon we come here because its too hot in the front. In the morning we go in front to the left on the sidewalk away from the facility. The AC said she accompanies R233 often when she goes out to smoke. When asked if she had ever seen a container to dispose of smoking products in either of the areas, she replied, No. On 8/22/19 at 03:15 PM during interview with Registered Nurse (RN)17, asked about the facility smoking policy. RN17 said there use to be a container in the utility room we took outside with us. RN17 did not recall when that practice was discontinued. 08/22/19 at 08:26 AM during an interview with the Director of Nursing (DON), she stated, The actual smoking area is out the back exit door. We have a table and smoking container out there. The problem is its really hard to open the exit door and is more convenient to take the patient out to the driveway or front. They hardly use the designated area because of the ramp and its hard to pull a wheel chair in and out. They took her out there today, but said it was hard. 08/22/19 at 09:01 AM Toured the designated smoking area located out the back exit door on the first floor with the AC. During a brief interview at that time, she said she did take R233 out to the area today, but it was hard to get her out the door. The AC demonstrated what she had to do to get R233 out the door and down the ramp to the designated smoking area. The exit door was heavy and there was a drop approximately 1/2 inch at the door exit that was a fall hazard for anyone in a wheel chair or walker. Review of facility policy titled No Smoking Policy dated 02/2018 states, Users of tobacco products must dispose of the remains (of smoking products) in proper containers to keep environment neat and clean.",2020-09-01
590,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2019-08-23,849,D,0,1,VTI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR) and interview, the facility failed to establish a communication process, including how the communication will be documented in a timely manner between the facility and the Hospice Provider to ensure the needs of the residents are addressed and met 24 hours a day, 7-days a week. The facility did not have adequate communication documented for one of one resident (R)60 selected for review. This deficient practice has the potential to prevent residents from attaining and/or maintaining his/her highest practicable level of physical, mental, and psychosocial well-being. Findings include: On 08/21/19 at 03:20 PM, RR for R60 showed R60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R60 started Hospice Care on 01/22/19. RR for R60 showed the last dated progress note by Hospice Nurse was on 07/22/19. On 08/21/19 at 03:30 PM, interview with Registered Nurse (RN)6 who stated the Hospice Nurse will verbally communicate any issues or concerns regarding the residents to them during their visits. Queried RN6 if R60 had a more recent progress note from Hospice Nurse because the last one on record was dated 07/22/19 and today is 08/21/19. RN6 checked R60's record and stated No. Asked RN6 how long it will take before the Hospice Nurse provides the facility documentation of their visits. RN6 stated she is not sure but this particular Hospice does not provide documentation till much later. On 08/21/19 at 03:45 PM, interview with Hospice Nurse (HN)1 who stated they usually provide the facility documentation of their visits two weeks later. Queried HN1 if that is the standard practice between her Hospice company and the facility. HN1 stated they had a meeting at the office, and it was her understanding that it was okay to provide the facility documentation of their visits two weeks later. On 08/21/19 at 04:15 PM, interview with DON regarding Hospice documentation of their visits. DON stated Hospice Nurses have the ability to print out their progress notes for the facility prior to leaving the facility. DON stated she reviewed the records of several residents and noted the progress notes by this particular Hospice is not up to date. DON said she has spoken to this Hospice in the past regarding prompt documentation of visits but the Hospice told her to inform the Hospice Nurses during their visits to document before leaving facility. DON stated she will call this Hospice and make sure they update their progress notes and document promptly during their visits for the residents in the facility.",2020-09-01
591,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2018-09-27,575,D,0,1,0HB911,"Based on observation and interview, the facility failed to ensure information regarding how to contact the State Survey Agency to file a complaint against the facility was available to the residents residing on the second floor and their representatives. This deficient practice had the potential to affect 38 of 78 residents of the facility and their representatives by hampering their ability to file a complaint against the facility with the State Survey Agency? Findings include: During the Resident Council meeting on 09/26/18 at 10:01 AM, the four residents in attendance, Resident (R)7, R21, R34, and R36, were asked if they knew how to contact the State Survey Agency to file a complaint. R36 responded, We had an Ombudsman - a go between, but we don't have one now. None of the four residents knew how to contact the State Survey Agency to file a complaint against the facility. Observation of the second-floor resident areas and of the nurses' station on 09/26/18 at 03:00 PM and on 09/27/18 at 12:17 PM, revealed no posted information that provided the residents and their representatives with directions and a phone number for contacting the State Survey Agency to file a complaint. During a tour of the second floor with the Director of Nursing (DON) on 09/27/18 at 12:17 PM, the DON stated that information on how to contact the State Survey Agency to file a complaint should have been in the area where an existing poster board affixed to the wall provided Ombudsman information. A review of the facility's policy titled, Filing Grievances/Complaints, with a review date of 08/29/08, revealed: Procedure . 7. Should the resident not be satisfied with the result of the investigation or recommended actions, he or she may file a written complaint to the ombudsman's office or to the state survey and certification agency.",2020-09-01
592,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2018-09-27,585,D,0,1,0HB911,"Based on observation, interview, and review of facility policy and other documents, the facility failed to provide a process and free access to materials for residents' and/or their representatives to submit an anonymous complaint or grievance to the facility. This deficient practice had the potential to affect all 78 residents of the facility by hampering the residents and/or their representatives right and ability to file a grievance/complaint with the facility anonymously and without fear of reprisal. Findings include: During the Resident Council meeting on 09/26/18 at 09:52 AM, the four residents in attendance, Resident (R)7, R21, R34, and R36, were asked how they would file an anonymous complaint to the facility. R36 responded by stating, Just don't say it. When asked if complaint or concern forms were available without asking for them, R34 stated, Not that I know of and R36 stated No. Observation of the resident areas and nurses' stations throughout the facility on 09/26/18 and 09/27/18, revealed no grievance or complaint forms were available to the residents or resident representatives. In an interview at 12:17 PM on 09/27/18, the Director of Nursing (DON) responded to the query of where grievance/complaint forms were located stating, They have to ask staff or me for one. The DON verified the residents had no free access to grievance/complaint forms. A review of the facility's policy titled, Filing Grievances/Complaints, with a review date of 08/29/08, indicated: Policy: Our facility will assist residents, their representatives, or family members in filing grievances or complaints when such requests are made. Procedure: 1. Any resident, his or her representative, family members or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of their residents, staff members, theft of property, etc. without fear or threat or reprisal in any form. 2. Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complain in behalf of the resident . A review of the facility's resident Admissions Packet, indicated on page 19 of 22, the facility's Grievance Procedure provided the residents and their representatives with the following information: (Facility name) maintains an open-door policy up to and including the Administrator. Residents and/or their representatives are also encouraged to share any concerns they may have with any employee or member of management at any time. Residents and/or their representatives may also file a verbal or written complaint with the facility Social Worker concerning treatment, abuse, neglect, harassment, medical care, behavior of other residents or staff members, theft of property, or any concern without fear of threat or reprisal in any form. Verbal - Please share any complaints or concerns with any staff member. If the staff member cannot resolve your concern, you are encouraged to bring your concern to the immediate attention of any of the following management staff: -Social Worker -Charge Nurse -Director of Nursing Written - You may file a written complaint. You may obtain a Grievance Form from the Nurses Station at the office of the Social Worker. On the form, please answer all applicable questions accurately, and be sure to sign and date the form. Please submit the completed form to the Social Worker. If the Social Worker is not available, the form may be given to the Director of Nursing or Charge Nurse.",2020-09-01
593,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2018-09-27,642,D,0,1,0HB911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a Minimum Data Set (MDS) Death in Facility Tracking Record for two of two residents reviewed for Resident Assessments, (Resident (R) 1 and R2), who expired in the facility. Findings include: 1. Review of a Nurse's Note in R1's electronic medical record (EMR) dated, [DATE] at 6:58 PM, indicated R1 expired at the facility on [DATE] at 6:45 PM. A review of R1's Minimum Data Set (MDS) assessments (an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning), indicated the last MDS submitted for R1 was an admission MDS with an Assessment Reference Date (ARD), the end-point of the assessment's evaluation period, of [DATE]. 2. Review of a Nurse's Note in R2's EMR, dated [DATE] at 3:35 AM, indicated the resident expired at the facility on [DATE] at 2:00 PM. A review of R2's MDS assessments indicated the last MDS submitted for R2 was an admission MDS with an ARD of [DATE]. In an interview on [DATE] at 10:23 AM, the Assistant Director of Nursing, also the facility's MDS Coordinator, stated, The MDS' submitted (for R1 and R2) were just the admissions, not (the) discharges. They (both) should have had a 'death' MDS done the day each one of them died . I did both of them yesterday. A review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.15 (MONTH) (YEAR), provided the following information under Chapter 2: Assessments for the Resident Assessment Instrument (RAI), section 2.5 Assessment Types and Definitions indicated: OBRA- (Omnibus Budget Reconciliation Act of 1987) Required Tracking Records and Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes . They include: Tracking records . Death in facility.",2020-09-01
594,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2018-09-27,692,G,0,1,0HB911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to maintain the necessary nutritional requirements for two residents (R38 and R19) who experienced significant weight loss resulting in actual harm for R38. Findings include: 1. Resident (R38) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation of R38 on the morning of 09/25/18 at 9:10 AM found his tube feeding formula hanging from an IV pole with approximately 250 cc left in the bag. R38 was not connected to the formula bag. The label on the bag noted the resident's name and physician's orders [REDACTED]. R38 was alert but unable to verbalize. An observation of R38 on the morning of 09/26/18 at 10:30 AM found him sitting up in bed watching a Filipino TV show. An observation of R38 on the afternoon of 09/26/18 at 02:30 PM found him sitting up in bed watching a Filipino TV show. An observation of R38 on the morning of 09/27/18 at 10:00 AM found him in a sitting position where he had just been connected to his tube feeding by a Treatment Nurse's Aide (TNA1). Licensed Nurse (LN13) was present observing TNA1. Interview of LN13 revealed he is not always present during TNA1's connection/disconnection of [DEVICE]. LN13 stated he will observe the TNA performing tube feeding connections if he's not busy. Otherwise the TNA is left to connect residents to their [DEVICE] feedings independently. An interview of the Director of Nursing (DON) on the morning of 09/26/18 at 08:41 AM when she noted R38 left the faciity on [DATE] to the hospital. R38 had been evaluated by a Speech Language Pathologist (SLP) who recommended oral feedings. The [DEVICE] he was admitted with in (MONTH) (YEAR) had been discontinued when he was upgraded to oral feedings. During his 03/24/18 hospitalization , another [DEVICE] was inserted. R38 returned from the hospital on [DATE] with the [DEVICE]. The DON reported TNAs did the tube feedings during day shifts. The DON utilizes four TNAs who received special training for tube feedings, simple dressings and treatments such as topical creams. The DON further noted the TNAs are responsible for documentation of tube feedings. When asked about assessing residents for tube feeding tolerance, the DON reported one nurse (LN1) assessed the residents who were stable for tube feeding tolerance on weekends (Saturday and Sunday). The unstable residents were assessed daily by the Charge Nurse on duty to look for signs and symptoms of aspiration. A review of the nurses notes dated (MONTH) (YEAR) through (MONTH) (YEAR) found day shift LNs rarely documented notes for R38. A few of the notes stated, [DEVICE] feeding tolerated per report. In reference to the tube feeding label without a date and time, the DON revealed the evening shift prepares the bags for next day use. She reported the staff usually label the bags to include the date/time. A concurrent medical record review and Registered Dietician (RD) interview on the morning of 09/26/18 at 11:48 AM found R38 was admitted to the facility in (MONTH) (YEAR) with a [DEVICE] and was later upgraded to oral feedings. The RD was unsure if the [DEVICE] was removed when R38 was on oral feedings. In (MONTH) (YEAR) R38 went to the hospital when he was on fine chopped solids and honey thick liquids. The RD noted she saw R38 in (MONTH) (YEAR) when he weighed 131 pounds. He was due for an update in (MONTH) (YEAR) but he went out to the hospital. The RD then saw R38 in (MONTH) (YEAR) when he weighed 120 pounds. The RD reassessed R38 on 07/25/18 when he had not been weighed since 05/23/18 at 121 pounds. The RD requested a weight since she didn't have a weight for (MONTH) (YEAR). On 07/26/18 R38 weighed 115 pounds (5% loss since last weight 05/23/18). The facility re-weighed R38 on 07/29/18 when he was 115 pounds. The RD noted the facility should weigh R38 at least monthly. The RD stated R38 had pneumonia in (MONTH) (YEAR) which may have contributed to his overall well being. On the morning of 09/26/18 at 12:00 PM a review of the RD's notes found one dated 07/25/18 stating R38 is dependent on [DEVICE] nutrition and hydration which he was tolerating without issues. She noted R38 experienced occasional constipation - 3 days without bowel movement despite generous fluids provided via [DEVICE]. She noted no recent weight recorded, new weight requested. And finally, Will continue with care plan. Another RD note dated 08/08/18 indicated R38 was 115 pounds, below his ideal body weight. The note stated R38's tube feeding was increased on 08/03/18. She again noted R38 was tolerating tube feedings without issues. He was noted with recent constipation but receiving generous fluids via [DEVICE]. A review of the nurses notes found an entry dated 07/26/18 when the Assistant Director of Nursing (ADON) noted R38 experienced significant weight loss and she would make a referral to the RD. The RD reported she was notified of R38's significant weight loss on 08/03/18. After being apprised of R38's weight loss, the RD increased the resident's feeding to [MEDICATION NAME] 1.2 300 ml 5 times per day (increased from 300 ml 4 times per day). On 08/08/18 the RD returned to assess R38 - weight was 115 pounds. A review of R38's resident assessment, Minimum Data Set (MDS), dated [DATE] noted the resident did not have a feeding tube at the time. It further noted a Brief Interview for Mental Status (BIMS) score of 6/15 indicating severely impaired cognitive function. Upon return to the facility, R38's MDS dated [DATE] indicated he had a feeding tube. R38's readmission assessment dated [DATE] noted a BIMS score of 05/15 or severely impaired cognitive function. The 07/24/18 assessment noted R38 required extensive assistance with one person assistance for bed mobility; limited assistance with one person assistance for transfer; Total dependence with one person assistance for eating; and total dependence with one person assistance for toileting. The 07/24/18 assessment noted R38 experienced a significant weight loss but not on a physician prescribed weight loss program. An interview of the ADON on 09/26/18 at 12:18 PM revealed she was the person who reviews all residents weights. She stated that if she finds a weight discrepancy the resident is re-weighed the next day. R38's weight loss was identified on 07/26/18 but he wasn't re-weighed until 07/29/18. The ADON reported she thought the scale may have been broken because R38 and some other other residents were experiencing weight discrepancies. The facility ordered a new scale. Despite her knowledge of R38's significant weight loss on 07/26/18, the ADON did not notify the RD for another 8 days - 08/03/18. An interview of the Charge Nurse, LN19, on the afternoon of 09/26/18 at 01:53 PM found two TNAs (TNA1 and TNA2) do the tube feedings. LN19 reported that the licensed nurses do not observe the TNAs when they administer tube feedings. LN19 stated her documentation notes [DEVICE] feeding tolerated per report, since she doesn't actually observe the TNAs connecting/disconnecting residents to their tube feedings. An interview of two licensed nurses (LN18 and LN19) and the ADON on the afternoon of 09/26/18 at 02:25 PM revealed they do not oversee the TNAs unless a resident is experiencing problems. The LNs do 24 hour reviews and the TNA tube feedings is not something reviewed at that time. If a feeding was not provided, the computer will flag them to let them know. A review of R38's Treatment Administration Record (TAR), the number 1 was listed under the initials of the person who administered the tube feeding. LN18 and LN19 stated they were unsure what the number 1 meant. An interview of the DON and ADON on the morning of 09/27/18 at 10:04 AM revealed residents' weights were reviewed weekly by the ADON. When a resident is identified with significant weight loss, the Charge Nurse communicates the information to the ADON via a written note. The ADON reviews the information from the Charge Nurse then she will request for the resident to be re-weighed. On the morning of 09/27/18 at 10:10 AM the ADON informed the Surveyor they found the missing (MONTH) (YEAR) weight for R38. The ADON reported the Administrator keeps residents' weights in his own log for his information. The Administrator's weight for R38 was dated 06/30/18 - 121 pounds. With this added information, it was noted that R38 lost 5% of his body weight in one month (06/30/18 to 07/26/18). Despite his significant weight loss and being on [DEVICE] feedings, the facility did not notify the physician/RD immediately. The ADON stated the facility's policy was to immediately notify the RD if a resident has a significant weight loss. The RD was notified of R38's significant weight loss eight days after (08/03/18) the ADON was aware (07/26/18) of the weight loss. On the afternoon of 09/27/18, a review of the facility's policy titled, Nutrition and Hydration Policy with revision date 10/11 noted, 9. Resident with weight changes will be referred accordingly for timely intervention. The facility's policy titled, Weight Assessment and Intervention dated 08/2016 noted, 3. Any weight change of greater than 5 pounds within 30 days will be retaken the next day for confirmation with licensed nurse confirming reweigh. If the weight is verified, nursing will immediately notify the dietary manager and refer to RD in writing. Attending physician will be notified of unplanned significant weight changes as described below. 2. Resident 19 (R19) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of R19 on the morning of 09/26/18 at 07:33 AM found him up in bed ready for breakfast. His meal had double portions of food and appeared pureed. There were 2 pieces of Vienna sausage (soft, pureed textured processed sausage) which LN19 sent back to the kitchen to puree because his texture was supposed to be pureed. The meal ticket for R19's diet order noted Moist minced. An interview of the Certified Nurses Aide (CNA28) at 08:12 AM revealed her understanding was that R19 was on a pureed diet and she confirmed that his breakfast tray contained pureed food. Observation of R19 during the lunch meal on 09/26/18 at 12:00 PM found his meal was double portions and pureed texture. CNA28 stated R19 eats 100% of his meals, snacks, and drinks all of his Ensure. A review of R19's medical record on the afternoon of 09/26/18 at 02:00 PM revealed a physician's orders [REDACTED]. On 07/06/18 a physician's orders [REDACTED]. On the afternoon of 09/26/18 at 12:26 PM, a concurrent medical record review and RD interview found R19's admission weight on 06/08/18 was 149 pounds. On 06/13/18 R19 was 140 pounds (9 pound loss or 6% in 5 days). The facility immediately notified the RD on 06/13/18 and the RD came to see him that same day. The RD noted the staff reported R19 had 3 to 4+ [MEDICAL CONDITION] on 06/11/18. On 06/13/18 R19 had mild swelling and on a diuretic every other day. The RD noted R19 was eating 100% of his meals to include Supercereal and Magic Cup ice cream. On 07/04/18 the RD returned to evaluate R19 - weight was 123 pounds (17% loss over one month). At that time, the RD added Ensure Plus, 1/2 cup three times daily. On 08/01/18 the RD followed up and he maintained at 123 pounds. The RD noted R19 needs to be 125 pounds to be stable. She reported R19 eats 100% of his meals, drinks all his Ensure. At that time (08/01/18) the RD added snacks three times daily between meals. On 8/15/18 the RD noted R19 eats all his meals, drinks all his Ensure, eats his snacks between meals and eats his Magic Cup and Supercereal. On 9/23/18 R19 weighed 132 pounds, an increase of 9 pounds since the previous month. The RD noted his current order is moist minced diet. The RD further noted the texture looks like oatmeal. The RD stated R19 eats 100% of his meals and all of his Ensure and snacks. She says no matter what interventions are in place, R19 continues to lose weight. She noted, however, that his weight stabilized over the past month. R19 experienced severe weight loss (17%) within the first month following admission to the facility on [DATE]. During survey, R19's diet order was moist minced solids but he was receiving pureed solids. Observations found R19 eating most and sometimes all of his pureed meals despite his upgraded diet texture of moist minced solids.",2020-09-01
595,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2018-09-27,758,E,0,1,0HB911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interviews for three of five sampled residents (Resident (R) 21, R31, and R80) reviewed for unnecessary medications and use of [MEDICAL CONDITION] medications, the facility failed to ensure the monitoring of target behaviors exhibited by R21, R31, and R80 were communicated to the licensed staff. Findings include: 1. Review of R21's Face Sheet identified [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS), an assessment of the resident conducted by the facility with an Assessment Reference Date, (the end date of the observation period) of 03/03/18, identified Section C: Cognitive Patterns, that R21 had a Brief Interview of Mental Status (BIMS), score 8 of 15 (moderate cognitive impairment), Section D: Mood, indicated no mood indicators were exhibited, Section E: Behaviors, documented the resident exhibited verbal behavioral symptoms directed to others on one to three days of the assessment's 7-day look-back period, and Section N: Medications, indicated the resident received antipsychotic and antidepressant medication on all seven days of the 7-day look-back period The quarterly MDS with an ARD of 07/04/18 identified Section C: Cognitive Patterns, and a BIMS score 9 of 15 (moderate cognitive impairment), Section D: Mood, no mood indicators exhibited, Section E: Behaviors, no behaviors exhibited, and Section N: Medications, antipsychotic and antidepressant medications were received on all seven days of the assessment's 7-day look-back period. The plan of care dated 01/10/18 and 07/10/18 identified, . short tempered, gets annoyed easily, aggressive behavior such as hitting and throwing things towards others and screaming towards staff during care. Interventions included, . Update the psychiatrist for worsening mood and behavior issues, administer dementia and depression medication regime as ordered. Review of the (MONTH) (YEAR) Mood/Behavior Monitoring P[NAME] document identified R21 had Little interest or pleasure in doing things on 03/10/18, 03/13/18, 03/22/18, 03/24/18, Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing) on 03/07/18, and Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others on 03/28/18. The (MONTH) (YEAR) Mood/Behavior Monitoring P[NAME] document identified R21 had Little interest or pleasure in doing things on 08/28/18 and 08/20/18. The P[NAME] failed to identify the specific behavior symptoms exhibited by R21. Review of the (MONTH) and (MONTH) (YEAR) Medication Administratrion Record (MAR) and the Nurse's Notes failed to reflect documentation of R21's mood and behaviors. Interview on 09/26/18 at 2:09 PM with Certified Nurse Aide (CNA) 33, assigned to provide care to R21, identified she documents mood and behaviors on the resident in the electronic record. CNA33 stated she thinks the nurse also documents behavior. CNA33 could not confirm that when a resident exhibited a mood or behavior, the nurse was notified. 2. Review of R31's Face Sheet identified [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The significant change MDS, with an ARD, of 07/16/18 identified under Section C: Cognitive Patterns, the resident had a BIMS, score 8 of 15 (moderate cognitive impairment), Section E: Behaviors, no behaviors exhibited, and Section N: Medications, indicated the resident received antipsychotic medication on all seven days of the assessment's 7-day look-back period. The plan of care dated 07/17/18 identified mood and behavior issues, . Sad facial, furrowed eyebrows, repetitive calling out, refusing meals, snacks, care and showers, easily agitated, argues with others, and aggression such as kicking, punching, slapping, and pushing-screaming towards others . Interventions include administer [MEDICAL CONDITION] medication, monitor side effects, and monitor target behaviors every shift. Review of the (MONTH) (YEAR) Mood/Behavior Monitoring P[NAME] document identified R31 Rejected evaluation of care that is necessary to achieve the resident's goals for health and well-being on 08/01/18, 08/03/18, 08/06/18, 08/07/18, 08/10/18, 08/13/18, 08/14/18, 08/15/18, 08/20/18, 08/27/18, and 08/31/18. The (MONTH) (YEAR) Mood/Behavior Monitoring P[NAME] document identified R31 Rejected evaluation of care that is necessary to achieve the resident's goals for health and well-being on 09/03/18, 09/05/18, 09/11/18, 09/12/18, 09/14/18, 09/18/18, 09/19/18, and 09/26/18. The P[NAME] failed to identify the specific care rejected by R31. Review of the (MONTH) and (MONTH) (YEAR) MAR and nurse's notes failed to reflect documentation R31 rejected care. Interview on 09/26/18 at 2:15 PM with Registered Nurse (RN) 7 (charge nurse) stated the nurse aides document resident behavior and mood in the electronic medical record point of care (P[NAME]). If the resident has a mood or behavior, the nurse aide is responsible to identify the behavior in the P[NAME]. RN7 stated, The nurse aide is responsible to notify the nurse if the resident has a behavior or mood and the nurse is responsible to document the specific behavior in the MAR, and the nurses' notes. 3. Review of the Face Sheet identified R80's [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The quarterly MDS, with an ARD of 06/06/18 and 09/06/18 identified under Section C: Cognitive Patterns, the resident had a BIMS score of 3 of 15 (severe cognitive impairment), under Section E: Behaviors, rejection of care occurred on one to three days of the assessment's 7-day look-back period, and Section N: Medications, indicated the resident received antipsychotic medication on all seven days of the assessment's 7-day look-back period. The plan of care, dated 06/07/18 and 09/07/18 identified potential for ill effects related to antipsychotic medication with use of [MEDICATION NAME] with interventions to monitor for side effects, quarterly and prn, review of medication for adjustment, note effectiveness of the medication, and monitor and record episodes of target behavior every shift. Review of the (MONTH) (YEAR) Mood/Behavior Monitoring P[NAME] document identified R80 had Other behavioral symptoms not directed towards others (e.g., scratching self, pacing, rummaging, etc.) on 07/19/18 and Wandering on 07/18/18. The (MONTH) (YEAR) Mood/Behavior Monitoring P[NAME] document identified R80 had Hallucinations (perceptual experiences in the absence of a real external sensory stimuli) on 08/09/18 and 08/16/18, Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, crying at others) on 08/16/18 and Rejected evaluation of care that is necessary to achieve the resident's goals for health and well-being on 08/30/18. The (MONTH) (YEAR) Mood/Behavior Monitoring P[NAME] document identified, Hallucinations (perceptual experiences in the absence of a real external sensory stimuli) on 09/13/18 and Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, crying at others) on 09/13/18. The P[NAME] failed to identify the specific behavior R80 exhibited and the July, August, and (MONTH) (YEAR) MAR and nurse's notes failed to reflect the behaviors. Interview on 09/26/18 at 1:56 PM with CNA5 (assigned to provide care to R80) revealed the CNA stated, Charting of mood and behaviors is done in the electronic record. We let the nurse know so the charting is the same. CNA5 stated, We document what it was, for example rejects care we write what care was rejected in a section in the electronic record. CNA5 stated, Sometimes you can forget to notify the nurse of what is documented in P[NAME]. In an interview on 09/27/18 at 11:30 AM, the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) stated, The licensed nurse should ask the CNA if the resident had any behaviors during the shift and the CNA should report to the nurse when they occur. The nurse charts the behavior in the MAR and nurses notes. The DON and ADON indicated it is the licensed nurse's responsibility to find out if any behaviors were displayed by the resident before documenting in the MAR. If behaviors are noted, the nurse should conduct an assessment. The DON stated, We know a lack of communication between nurse and aide is a problem. The DON did not confirm what action the facility had taken about the problem with communication. The DON and ADON verified the lack of documentation of the specific behavior on the MARs and the Nurses' Notes for R21, R31, and R80. Review of the facility Behavior Management policy revised (MONTH) 2011 identified, . If any behavior problems are identified, nursing staff will be informed immediately for them to be aware of what to observe and how to care for the particular resident . Every effort is made to ensure that a resident who uses the antidepressant receives the intended benefit of the medication and that the negative side effects will be minimized . l. When antidepressant therapy is initiated, the resident is monitored to determine the effectiveness of the medication .",2020-09-01
596,LILIHA HEALTHCARE CENTER,125041,1814 LILIHA STREET,HONOLULU,HI,96817,2018-09-27,880,C,0,1,0HB911,"Based on interview and record review, the facility failed to ensure a review of its Infection Control Policies and Procedures was conducted at least annually. This deficient practice had the potential to affect all 78 residents. Findings include: Review of the facility's Infection Control Policy indicated the title page of the three-ring binder stated, (Name of facility) Infection Control Manual (YEAR). The next page titled, Preface - Infection Control Manual had a copyright footer that read, (Vendor name) Health Services, Inc . Infection Control Manual (YEAR). In an interview on 09/27/18 at 12:36 PM, the Director of Nursing stated, (Vendor name) came from mainland in (YEAR) to do our infection control policies. They (the policies) were not reviewed last year but are due for review this year. Review of the facility's policy titled, Conformity with Laws, dated 02/2017, indicated, . 3. Our facility has developed written policies and procedures that govern day-to-day operations and such policies and procedures are reviewed for revisions/updating at least annually.",2020-09-01
597,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2017-10-06,225,D,0,1,3KOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and personnel file review, the facility failed to provide proof of a criminal background check for one staff member (Staff #103) prior to hiring her. Findings include: Cross reference to F241 On the morning of 10/5/17 at 8:30 [NAME]M., Staff #103 was observed treating 2 residents (Residents #16 and #130) in a rough manner warranting a review of her personnel file. On the morning of 10/6/17 at 10:00 [NAME]M. a review of Staff #103's personnel file revealed the facility did not obtain a criminal background check prior to hiring her on 5/7/01. On the morning of 10/6/17, the Administrator provided a criminal background check for Staff #103 which was dated 4/28/17. The Administrator explained the background check went back [AGE] years, taking it back to 2007. Surveyor asked for the background check before Staff #103's hire date of 5/7/01. The Administrator provided a list created by the facility (rather than a printed version from the agency providing the criminal background checks) of staff members who received a criminal background check on 5/2/07. The column which read, Date Record Check Completed, noted 5/2/17 with a line drawn down the rows of employees' names and stopped at the name right above the row for Staff #103, indicating it was not done. The facility failed to provide the necessary pre-employment criminal background check for Staff #103.",2020-09-01
598,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2017-10-06,241,D,0,1,3KOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, the facility failed to treat five residents (Residents #16, #130, #56, #58, and #21) with respect and dignity. Findings include: 1) While observing a staff member during medication administration on 10/5/17 at 8:30 [NAME]M., Surveyor observed another staff member (Staff #103) handling two residents (Resident #16 and #130) in a rough manner. After the breakfast meal, Resident #16 was seated in her wheelchair at the dining table with her head tilted forward. Staff #103 came along and without first speaking to the resident, she abruptly and in a rough manner pushed Resident #16's head upright. Resident #16 did not show a reaction to Staff #103's rough touch. In a rough and abrupt manner, Staff #103 then roughly placed Resident #16's left hand onto her lap followed by her right hand in the same rough and abrupt manner. Staff #103 then took a newspaper and roughly placed it onto Resident #16's stomach then grabbed the resident's left hand in a rough manner and placed the resident's hand onto the newspaper. Both of Resident #16's hands slipped off her lap and Staff #103 was again observed grabbing both hands in a rough manner and again abruptly and roughly putting the resident's hands on her lap. Resident #16 did not show a reaction to Staff #103's rough handling. During this time, Staff #103 appeared agitated: not smiling, appeared rushed and seemed annoyed at Resident #16 (Staff #103 appeared to be speaking to the resident during the rough handling but Surveyor couldn't hear from across the room). Staff #103 left Resident #16 in her wheelchair sitting sideways in relation to the table then tended to Resident #130. Again, Staff #103 was observed to abruptly and roughly grab onto Resident #130's left hand then right hand and roughly placed her hands onto the table while she pushed her wheelchair towards the table. Staff #103 went to the kitchenette area to get a paper placemat. She returned with the placemat and roughly placed the placemat onto the table in front of Resident #130. Staff #103 then got Resident #130's breakfast tray and roughly placed the dishes in front of the resident. During the interaction with Resident #130, Staff #103 appeared agitated - no smiling, no gentle talking, agitated look on her face. Staff #103 continuously looked over at the Surveyor and appeared to be aware that she was being observed. During all of these interactions, another staff member (Staff #121) was seated nearby feeding another resident. Staff #121 continuously looked over at the Surveyor while the Surveyor watched Staff #103. An interview of Resident #16 on the afternoon of 10/5/17 at 1:25 P.M. revealed she didn't feel afraid of Staff #103. Resident #16 was asked if Staff #103 treats her in a rough manner to which she replied, Yes, sometimes she's rough. On the morning of 10/6/17, a medical record review found Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #16's medical record, she was alert and oriented x 1 to 2. A review Resident #16's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/19/17 noted under Section G Functional Status, requires extensive assistance with one person physical assistance with: Transfer; Dressing; Toilet use; Personal hygiene. Resident #16 is totally dependent with one person physical assistance with: Locomotion on unit; Locomotion off the unit; and Bathing. Resident #130 was not interviewable. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the morning of 10/6/17, a review of Resident #130's medical record found an MDS with ARD of 8/29/17 which noted the resident had short and long term memory problems. Additionally, Resident #130 required: Extensive assistance with 2 person assistance for transfer; Totally dependent with one person physical assistance with locomotion on and off the unit, dressing, toileting, personal hygiene and bathing. An interview of Staff #121 on the afternoon of 10/5/17 at 1:00 P.M. was conducted to determine whether her observations of Staff #103 treating the residents roughly earlier in the day were typical of Staff #103. Staff #121 reported, Sometimes it's like that because maybe she had other residents to care for in the room. Staff #121 reported that it can sometimes feel like a lot of assignment for staff, particularly when they have several dependent residents. An interview of Staff #103 on the afternoon of 10/5/17 at 1:03 P.M. found her stating, I love my residents. Staff #103 reported she frequently received training on abuse/neglect - at least every month. Surveyor asked Staff #103 if she gets frustrated when working with residents who require extensive assistance with Activities of Daily Living (ADLs). Staff #103 answered, It's our job. Staff #103 stated that Resident #130 can sometimes do things for herself but cooperation is dependent on her mood. Staff #103 stated Resident #130 often drops her body and she therefore has to assist her with her posture. Staff #103 stated Resident #130 became more alert since lunch and was doing more for herself in comparison to the morning when she was totally dependent. Staff #103 reported that Resident #16's head sometimes goes all the way down and has to straighten her head. She noted that sometimes Resident #16 falls asleep and her head drops and Staff #103 then has to push her head up. An interview of the Nursing Supervisor on the afternoon of 10/5/17 at 1:23 P.M. revealed that as far as she knew, no one has ever complained about Staff #103. She added that she never had any concerns of abuse/neglect with Staff #103. However, the Nursing Supervisor was new to the facility, having been there only a few months prior to survey. An interview of Staff #54 on the afternoon of 10/5/17 at 1:36 P.M. revealed she had not been working in patient care over the past 2 years but when she did, she worked with Staff #103. When asked about her experience with Staff #103, Staff #54 recollected that Staff #103 had a complaint about her rough tone of voice. She recalls that the nursing supervisor previously had to verbally counsel her about her rough tone of voice. The Surveyor informed Staff #54 of her observations of Staff #103 on the morning of 10/5/17. Staff #54 responded that it sounded excessive and that she had never observed her being that rough with the residents. An interview of the Administrator on the morning of 10/6/17 at 7:10 [NAME]M. revealed she did not have concerns about Staff #103. She reported that in the past, Staff #103 only had to be reminded of speaking loudly in the hallway. Aside from that incident, the Administrator did not have any further concerns. A review of Staff #103's personnel file on the morning of 10/6/17 revealed she had been employed at the facility since 5/7/01. Staff #103's personnel file contained multiple incidents resulting in disciplinary action. The following incidents were of concern: 3/4/03 - Staff #103 was verbally warned: Staff #103 insisted a resident brush her teeth while seated on the toilet despite the resident's refusal. Staff #103 had the resident use a portable basin where she had the resident brush her teeth, rinse her mouth and spit. Staff #103 placed the resident's toothbrush on the floor of the sink then had the resident spread her legs while on the toilet and emptied the basin into the toilet. 6/29/04 - Staff #103 was suspended for 3 days: Staff #103 was assigned to showers when a resident's family members asked that the resident get showered and her hair washed before leaving on a family outing. Upon the family's arrival, Staff #103 was observed by several witnesses as being loud and argumentative with the resident's family members regarding their request. Staff #103 finally showered and washed the resident's hair. The resident reported that Staff #103 was verbally abusive during the entire bathing process. The resident was visibly upset and canceled her family outing. Along with being suspended, Staff #103 was required to attend a counseling session at the Employee Assistance Program (EAP). 7/9/04 - Staff #103 received her second written warning in a month regarding not staying for mandatory overtime. 1/2/09 - Staff #103 was verbally warned: Staff #103 and another staff member got into a verbal conflict in the hallway where they were both observed yelling at each other, calling each other names and sticking finger at each other. The Charge Nurse had to intervene to break up the altercation. 1/3/13 - Staff #103 was suspended for 5 days: During morning rounds on 12/3/12 the Director of Nursing (DON) found a resident sitting on a shower chair over the toilet with a gait belt around her abdomen/chest and the gait belt strap attached to the pipe over the toilet. The resident was calm and pleasant; nodding in response to the DON's questions but was unable to follow any directions. The DON found a Registered Nurse (RN) and another Certified Nurses Aide (CNA) to assist the resident while the DON searched for Staff #103. The resident had a bowel movement so she was cleaned, dressed and placed into her wheelchair by the other staff who was not assigned to the resident. The resident was smiling and pleasant during all interaction with her communication limited to nodding her head in response to questions. The resident had no visible reaction to the gait belt placement and was unaffected by her positioning. The DON finally located Staff #103 and the Charge Nurse on break in the staff lounge. Staff #103 acknowledged she placed the gait belt around the resident for her safety. Staff #103's primary concern was since the resident leans forward while on the toilet, she feared the resident would fall. Staff #103 reported that as she brought the resident to the toilet, another staff member came along to inform Staff #103 that her break time was switched and she'd have to take her break at that time. Staff #103 relented to the switch but said before she left the floor she informed the floor Charge Nurse she would go on break and that the resident was still on the toilet. However, the Charge Nurse understood from their verbal exchange only that the resident did not have a bowel movement. The Charge Nurse was unaware the resident was still on the toilet at the time, trying to make. The facility failed to treat two residents (Residents #16 and #130) with respect and dignity. Staff #103 had a history of [REDACTED]. Although both residents did not experience harm during the survey observations, Staff #103 appeared agitated and treated both residents in a rough manner. 2) During a staff interview on the morning of 10/3/17 at 9:07 [NAME]M., the Nursing Supervisor walked down the hall calling out to one of the Licensed Nurse's, (Staff Name) does (Resident #56) have a sore? She called out that question three times while trying to track the Licensed Nurse. Several residents were out in the hallway and several were in their rooms. The Nursing Supervisor called out loud enough for the residents and other staff to hear her. The facility failed to maintain Resident #56's dignity by loudly announcing information about her medical condition. 3) Resident #21 was admitted on [DATE] with MS, ([MEDICAL CONDITION]), Hypertension, [MEDICAL CONDITION], Kidney disease and Depression. During the resident interview on 10/02/17 at 9:15 AM, Resident #21 was observed with bilateral upper and lower extremity contractures which he stated confines him to his bed. At 11:00 AM Resident #21 was observed to be wheeled in his bed to the activity room wearing his hospital gown. On 10/04/17 at 1:30 PM Resident #21 was observed to be wearing his hospital gown while in his room. During an interview with the resident on 10/06/2017 10:47 AM in the activity room, Resident #21 stated that he was participating in another resident's birthday party, he was wearing a hospital gown. During an interview on 10/06/17 at 11:42 AM staff #64 stated that Resident #21 is very stiff which makes it difficult to put a t-shirt on. Staff #64 suggested getting a very large shirt or cut the shirt to make the back open may be easier. It would be better for the resident to wear a shirt instead of his hospital gown when he goes to activities. Review of the Out of the room activities plan on 10/05/17 states, Resident is to be taken out of the room in his bed daily except Sundays. Review of the MDS (Minimum Data Set) with and ARD (Assessment Reference Date) of 6/08/17 revealed as personal preferences that it is very important to choose what clothes to wear. Review of the quarterly resident care conference report dated 6/20/17, Resident #21 stated he would like the facility to buy a shirt instead of wearing a hospital gown. The facility failed to assist the resident to dress in clothes appropriate to the time of day and individual preferences enhancing his quality of life. 4) On 10/03/2017 at 8:55 AM during Stage 1 of the survey, went to R#58's room to complete observations and a sign was posted above the resident's side table, Does (Mrs. surname) have her teeth on? The resident was in a room with three other residents separated by privacy curtains and the sign could be viewed from the foot of the bed where staff and visitors passed through the room. On 10/06/2017 at 7:55 AM interviewed Staff#74 and she was shown the sign posted in R#58's room. According to Staff#74, R#58 often takes dentures off and places in napkin and lost dentures 3-4 months ago. Staff#74 was not sure whether staff or resident's daughter put sign up but would find out and educate staff and/or family about dignity issue. The facility did not protect the dignity of R#58 by posting confidential information at the bedside regarding denture use.",2020-09-01
599,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2017-10-06,247,D,0,1,3KOW11,"Based on resident and staff interviews and record review the facility failed to give written notice before the resident had a change in roomate for 2 of 14 residents ((R) #20 & R#55) on the Stage 1 census sample of the survey. Findings include: 1) On 10/02/17 at 11:58 AM Resident #20 stated that he had a roommate change and did not receive notice, adding that they usually bring a new roommate in without prior notice. 2) On 10/02/17 Resident #55 stated that he had a roommate change and did not receive notice prior to the new roommate being placed in the room. During an interview on 10/06/17 at 9:45 AM, staff # 50 stated that when a new roommate is brought into a room the CNA's introduce the new roommate to the resident. The residents get a verbal notice from the Nursing staff that a new roommate is coming into the room. There is nothing given to the resident in writing. During an interview on 10/06/2017 at 11:18 AM staff # 124 stated that when there is a roommate change the resident is given verbal notice they are receiving a new roommate by the CNA or the Nursing Supervisor. Notice is not given in writing. Per review of the Resident Handbook rights and responsibilities & services, page 17, #6. Transfers, The facility reserves the right to transfer any resident from one room to another, or from one bed to another, when it is deemed necessary or advisable by the Director of Nursing Services and/or the attending physician. The resident or his/her representative will be consulted and notified of such moves in advance and/or when roommates are being changed. The facility failed to give notice to the residents prior to receiving a new roommate.",2020-09-01
600,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2017-10-06,272,D,0,1,3KOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews and record review the facility failed to include a hearing deficit on the Resident Assessment Instrument (RAI) for one resident. (Resident #21). Cross reference F313 Findings: 1) On 10/02/17 at 10:01 AM during the resident interview Resident #21 had difficulty hearing the questions that were being asked. In order for the resident to hear the question. The surveyor moved close to the resident's right ear and spoke in a louder voice. Resident #21 stated that he started having trouble hearing in his right ear 2 months ago and was waiting for a hearing test. On 10/04/17 at 10:05 AM the television could be heard at a high volume from the hallway outside the resident's room. Upon entering the room, Resident #21 was laying in bed awake watching a television program. At 11:45 AM during personal care being given to the resident by the CNA, the CNA was observed to lean to the resident's right ear and speak louder to the resident in order for the resident to hear the questions asked by the CN[NAME] The resident stated to the CNA that he has been having a hard time hearing in the right ear, concurring with the resident's initial report to the surveyor on 10/02/17 about having a difficult time hearing in the right ear. Review of the medical records on 10/06/17 revealed a lack of documentation of hearing loss and/or follow up for a hearing evaluation. Review of the Minimum Data Set (MDS) quarterly review with Assessment Reference Date of 9/07/17 Section B hearing, speech, and vision, Hearing code is 0 indicating resident's hearing is adequate, no difficulty in normal conversation, social interaction, listening to TV. Review of the resident's Care Plan dated 6/15/17 does not include goals or interventions for hearing/communication. Review of the quarterly resident care conference report dated 6/20/17 revealed documentation that the resident is concerned about not being able to hear in the right ear. Review of the Physician note dated 9/20/17 states Persistent hearing loss. Assessment and plan: Hearing loss, audiology eval, cerumen impaction, [MEDICATION NAME]. Prior to the 9/20/17 Physician note there is no documentation about hearing loss for the resident. The progress notes from 8/26/17 to 9/30/17 were reviewed. A Social Services progress note dated 9/09/17 states resident is hard of hearing. No other documentation in the progress notes indicate Resident is having difficulty with hearing or that there is any follow up being done to obtain a radiological evaluation. Review of the Physician orders [REDACTED]. During an interview on 10/06/17 at 11:28 AM, staff #64 reported that the facility made an effort to schedule an audiology evaluation for Resident #21 and had not been able to find an Audiologist who can take the resident on a gurney, explaining that the resident can't go in a geri or wheelchair because of the inability to bend the lower extremities. Staff #64 added that the resident hasn't complained about the hearing loss in a few weeks so the Physician probably forgot about the referral for the audiology evaluation. Staff # 5 concurred with staff #64 that the facility looked for and was not able to find an Audiologist who can accommodate the resident on a gurney. The Facility failed to include a hearing assessment in the resident's comprehensive assessment.",2020-09-01
601,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2017-10-06,280,D,0,1,3KOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews (MRR), and staff interviews, the facility failed to review and revise the care plans (CP) in the use of side rails for 2 of 32 residents (R) #18 & R#34 on the Stage 2 Sample Resident List. Findings include: Cross reference to F323 1) On 10/02/2017 at 09:50 AM during Stage 1 of the survey, observed R#18's lying in bed with full bilateral metal type side rails (SRs) with padding attached in the middle sections. The resident's had the head of bed (HOB) up with the padded SRs at the waist level. On 10/05/2017 at 2:13 PM interviewed Staff#50 regarding the SR placement for R #18 and possibility of resident falling over SRs. According to Staff#50, R#18 only had history of petite mal [MEDICAL CONDITION] and not grand mal [MEDICAL CONDITION] so unlikely that resident wouldn fall off the bed. Additionally the resident came into the facility with her own bed and the SRs were already in place. The MRR on 10/05/2017 at 2:29 PM found that R#18 was seen by the medical doctor (MD) on 03/13/17 as the resident was observed shaking for approximately 2 seconds while lying in bed in the facility. The MD assessment/plan noted, This was [MEDICAL CONDITION]? Further noted was that R#18 had [MEDICAL CONDITION] disorder but didn't have [MEDICAL CONDITION] in a while. The MD ordered lab work to recheck reversible causes and that resident had constipation with slow transit. The MD plan was to continue the resident's same regimen, noted Arguable constipation can contribute to [MEDICAL CONDITION] either directly or indirectly so need to keep pt's BM regular. The residents CP#5 At risk for falls dated 08/19/17 included interventions of: Maintain a safe environment; ensure reduction of clutter in traffic/common areas; do not leave unattended in the bathroom; for res taking high-risk medication ([MEDICATION NAME]) remind to use call light and wait for assistance. The resident's CP#11 for [DIAGNOSES REDACTED]. reduce unnecessary light, noise, traffic and personnel; monitor lab vlaues - prn; administer meds as ordered - [MEDICATION NAME]; monitor side effects of meds. 2) On 10/02/2017 at 10:42 AM during Stage 1 of the survey, observed that R#34 had old metal type bilateral half SRs with space between the SRs and mattress for limb entrapment. On 10/05/2017 at 8:18 AM interviewed Staff#3 regarding how SR assessments are done at the facility along with concurrent observation of R#34's SRs. According to Staff#3 the SR assessments were done and only alert and oriented residents could have SRs. The SRs were color-coded as: Green coded SRs meant that resident can have their SR up all the time and were oriented & alert; Yellow coded SRs were for only when staff was assisting the resident the SRs were put up; and, Red coded SRs meant that the bed rails should be kept down at all times. Staff#85 came into R#34's room and Staff#3 asked her to clarify the resident's Green coded SRs. Staff #85 then stated that R#34 doesn't move anymore and no longer alert and oriented and didn't know why the SRs were still Green coded. Staff#3 stated that she didn't know that there was a change in R#34's cognition. On 10/05/2017 at 1:07 PM observed R#34 lying in bed with head of bed (HOB) up and SRs up with Red tape. Staff#77 came into resident's room and queried about SRs for R#34 with Red tape. Staff#77 stated, It was changed already and SRs are supposed to be down, as she placed SRs down. The facility failed to evaluate and revise the CPs as R#18 and R#34's status changed for use of SRs for safety and during care.",2020-09-01
602,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2017-10-06,313,D,0,1,3KOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews and record review the facility did not assist the resident with treatment and assistive devices to maintain hearing. (Resident #21). Cross reference F272 Findings include: 1) On 10/02/17 at 10:01 AM during the resident interview Resident #21 had difficulty hearing the questions that were being asked. In order for the resident to hear the question. The surveyor moved close to the resident's right ear and spoke in a louder voice. Resident #21 stated that he started having trouble hearing in his right ear 2 months ago and was waiting for a hearing test. On 10/04/17 at 10:05 AM the television could be heard at a high volume from the hallway outside the resident's room. Upon entering the room, Resident #21 was laying in bed awake watching a television program. At 11:45 AM during personal care being given to the resident by the CNA, the CNA was observed to lean to the resident's right ear and speak louder to the resident in order for the resident to hear the questions asked by the CN[NAME] The resident stated to the CNA that he has been having a hard time hearing in the right ear, concurring with the resident's initial report to the surveyor on 10/02/17 about having a difficult time hearing in the right ear. Review of the medical records on 10/06/17 revealed a lack of documentation of hearing loss and/or follow up for a hearing evaluation. Review of the Minimum Data Set (MDS) quarterly review with Assessment Reference Date of 9/07/17 Section B hearing, speech, and vision, Hearing code is 0 indicating resident's hearing is adequate, no difficulty in normal conversation, social interaction, listening to TV. Review of the resident's Care Plan dated 6/15/17 does not include goals or interventions for hearing/communication. Review of the quarterly resident care conference report dated 6/20/17 revealed documentation that the resident is concerned about not being able to hear in the right ear. Review of the Physician note dated 9/20/17 states Persistent hearing loss. Assessment and plan: Hearing loss, audiology eval, cerumen impaction, [MEDICATION NAME]. Prior to the 9/20/17 Physician note there is no documentation about hearing loss for the resident. The progress notes from 8/26/17 to 9/30/17 were reviewed. A Social Services progress note dated 9/09/17 states resident is hard of hearing. No other documentation in the progress notes indicate Resident is having difficulty with hearing or that there is any follow up being done to obtain a radiological evaluation. Review of the Physician orders [REDACTED]. During an interview on 10/06/17 at 11:28 AM, staff #64 reported that the facility made an effort to schedule an audiology evaluation for Resident #21 and had not been able to find an Audiologist who can take the resident on a gurney, explaining that the resident can't go in a geri or wheelchair because of the inability to bend the lower extremities. Staff #64 added that the resident hasn't complained about the hearing loss in a few weeks so the Physician probably forgot about the referral for the audiology evaluation. Staff # 5 concurred with staff #64 that the facility looked for and was not able to find an Audiologist who can accomodate the resident on a gurney. The Facility failed to assist the resident to receive proper treatment to maintain hearing.",2020-09-01
603,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2017-10-06,314,D,0,1,3KOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to have a systemic approach to the prevention and management of pressure ulcer development for three residents (Residents #56, #78 and #2). Findings include: 1) Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Upon admission, Resident #56 did not have a pressure ulcer. On 9/20/17 there was an order for [REDACTED]. revealed her understanding was the resident did not have a pressure ulcer. According to the nurse's notes, Resident #56 had an open area measuring 0.5 cm length x 0.5 cm width to her left buttock. The wound had opened according to the notes but the Nursing Supervisor reported it was not a pressure ulcer. When asked what type of wound it was, the Nursing Supervisor then reported, Maybe it's a stage 1. Staff #70 reported the wound is very superficial and like nothing. In addition to the confusion of the type of wound it was, the facility failed to complete a monthly skin assessment for Resident #56. 2) Resident #78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Upon admission, Resident #78 did not have a pressure ulcer. On 9/27/17, Resident was noted to have a Stage II pressure ulcer to his left buttock. The nurse's note did not indicate the onset date of the wound. Additionally, the wound assessment form did not have an onset date for the pressure ulcer. An interview of the Nursing Supervisor on the morning of 10/3/17 at 10:00 [NAME]M. revealed her confusion of the onset date for Resident #78's pressure ulcer. An interview of Staff #78 on 10/3/17 at 10:05 [NAME]M. revealed he discovered Resident #78's pressure ulcer. He admitted he did not document the identification of Resident #78's pressure ulcer in the nurse's notes. Additionally, he reported he did not note the onset date for Resident #78's pressure ulcer on the wound assessment form. 3) On 10/03/2017 at 12:43 PM review of the progress notes from 6/09/17 to 6/29/17 indicate Resident #2 was not admitted with a pressure ulcer and there is no documentation that a pressure ulcer developed until 6/29/17 when Resident #2 developed a stage 2 pressure ulcer to the mid upper back. On 10/04/2017 at 1:57 PM the admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/09/17 was reviewed. Section M0150 risk of pressure ulcers is coded 1 which indicates Resident #2 is at risk for developing a pressure ulcer. Review of the discharge MDS with ARD 7/01/17 M0300 indicates the resident developed a stage II pressure ulcer. During an interview on 10/05/2017 at 1:15 PM, staff #72 stated a stage I pressure ulcer is a non blanchable area of redness. During resident care the CNA's apply a protective barrier lotion (Aloe Vista) to the skin and examine the skin for changes. Because patient care is being checked every shift, a stage I pressure ulcer should be identified and reported before it turns into a stage II pressure ulcer. Any changes in skin condition should be identified and reported to the RN right away. The RN will call the Physician and obtain orders to apply a duoderm or other treatment. Once a stage I or greater pressure ulcer develops it is documented on the weekly wound sheet. During an interview at 1:30 PM staff # 64 stated that the wound care protocol follows the wound care policy for the prevention of pressure ulcers. The CNA's apply a skin barrier during daily resident care. The RN's do a weekly skin assessment. and document a skin change when a stage I pressure ulcer is identified. The Doctor will be notified if it is persistent and doesn't change, staff should be able to identify and document a stage I pressure ulcer before it becomes a stage II. During an interview at 1:33 PM staff #50 stated that the resident skin checks are done weekly during wound checks. Currently a wound care nurse is consulted for a resident who has a stage 3 or higher pressure injury. The wound nurse will start coming to the facility every month to provide in-service training to the nursing staff. The weekly wound sheet process and form policy dated 9/19/13 was reviewed. Procedure #1 states: Any size pressure wound will require a weekly wound sheet to be initiated. The facility failed to have a systemic approach to appropriately prevent and manage pressure ulcers for Residents #56, #78 and #2.",2020-09-01
604,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2017-10-06,315,D,0,1,3KOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and facility staff interview, the facility failed to provide the necessary treatment and services to achieve or maintain as much normal urinary function as possible for 1 of 2 residents (Resident #40) sampled for urinary catheter unjustified use. Findings include Resident #40 was re-admitted to the facility on [DATE] (initial admitted : 10/25/16) with [DIAGNOSES REDACTED]. Resident #40 was intermittently catheterized for [MEDICAL CONDITION]. A review of Resident #40's history and physical completed by his physician noted that since his latest stroke, Resident #40 will continue to experience [MEDICAL CONDITION] thereby making the Foley catheter a long term intervention. A review of Resident #40's physician's orders [REDACTED]. Another physician's orders [REDACTED]. Another physician's orders [REDACTED]. Resident #40 was sent for a Urology consult on 7/27/17 which found his catheter was in good position. The Urologist noted Resident #40's [DIAGNOSES REDACTED]. The recommendations included: Please change Foley once every 4 weeks; (MONTH) irrigate Foley as needed if occluded; and Follow up as needed in Urology clinic. Since Resident #40's consultation with the Urologist on 7/27/17, his Foley change dates were due on 8/24/17 and 9/21/17. On the morning of 10/5/17, a review of the nurses notes for Resident #40's found one dated 8/26/17 which stated: Indwelling Foley catheter clogged when attempted to flush. Removed and inserted new catheter aseptically. Draining well with yellow urine with minimal sediments, no foul odor. No bladder distention noted. Urine output over 8 hours - 475 cc. Resident #40's nurse's note dated 9/10/17 revealed: Indwelling Foley catheter intact but clogged. Urine leakage on diaper. Removed Foley catheter. Inserted a new Foley catheter. No resistance met upon insertion. On the morning of 10/5/17, a review of Resident #40's care plan found one titled, Indwelling Urinary Catheter with onset date of 5/6/17. The care plan noted the physician's orders [REDACTED]. The Care Plan, however, did not note the Urologist's recommendation to change the Foley every four weeks. An interview of the Nursing Supervisor on the morning of 10/6/17 at 2:10 P.M. revealed her lack of knowledge of the Urologist's recommendations for Resident #40. The Nursing Supervisor stated the staff was expected to document the specialist's recommendations in the care plan. The facility failed to provided the necessary treatment and services to promote the highest practicable urinary continence for Resident #40.",2020-09-01
605,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2017-10-06,318,D,0,1,3KOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review (MRR) and staff interviews the facility failed to ensure that 1 of 5 residents (R#35) observed with contractures and no splint device was provided appropriate treatment and services to prevent further decrease in range of motion. Findings include: On 10/03/2017 at 08:34 AM, R#35 was observed in the facility's activity/dining room and his bilateral hands were in a fist position on his lap. On 10/06/2017 at 8:01 AM observed R#35 being fed breakfast in the activity/dining room. Queried the CNA feeding him if the resident's hands were contracted and unable to hold a spoon. The CNA demonstrated that R#35 was able to open his hands but had tendency to contract fingers. The MRR on R#35 included care plan (CP))#2, Assistance required in performing ADLs r/t [MEDICAL CONDITION], and dementia dated 8/21/17. The interventions included: total assistance with eating; ambulation limited asst; device used FWW CGA with gait belt . The MRR also found that R#35 had an, Occupational Therapy Upper Extremity Splint Schedule, with directions to apply to the left hand splint while in bed from 10 PM - 7 AM. The CNA training was signed on 05/28/15. The form Resident's Care Planned Activity Level, updated 3/10/17, included under the special instructions box, 6. L hand splint on at night 10 PM - 7 AM. The residents annual minimum data set (MDS) 3.0 with assessment review date (ARD) of 08/02/2017 included that services for occupational therapy started on 12/02/2016 and ended on 01/05/2017. On 10/06/2017 at 8:29 AM asked the CNA in R#35's room to help locate the resident's splint. The CNA was unable to find any splints for the resident and stated that the left hand splint was discontinued to her knowledge. On 10/06/2017 at 8:49 AM interviewed Staff#49 and queried whether splint device for R#35 still being used or discontinued because in the MRR found splint device schedule and picture of how splint should be applied. Staff#49 was recently employed by the facility and had to ask CNA staff but they didn't know whether splint was discontinued and when the therapy staff were asked they didn't have old record on R#35's use of splint. The facility failed to provide adequate preventive care for further decrease in ROM for R#35.",2020-09-01
606,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2017-10-06,323,D,0,1,3KOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews (MRR), and staff interviews, the facility failed to identify, evaluate and analyze risks in the use of side rails for 2 of 32 residents (R) #18 & R#34 on the Stage 2 Sample Resident List. Findings include: 1) On 10/02/2017 at 09:50 AM during Stage 1 of the survey, observed R#18's lying in bed with full bilateral metal type side rails (SRs) with padding attached in the middle sections. The resident's had the head of bed (HOB) up with the padded SRs at the resident's waist level. The SRs were shook and it was apparent that they were loosely attached to the bed. On 10/05/2017 at 2:13 PM interviewed Staff#50 regarding the SR placement for R #18 and possibility of resident falling over SRs. According to Staff#50, R#18 only had history of petite mal seizures and not grand mal seizures so unlikely that resident would fall over the SRs. Additionally the resident came into the facility with her own bed and the SRs were already in place. The MRR on 10/05/2017 at 2:29 PM found that R#18 was seen by the medical doctor (MD) on 03/13/17 as the resident was observed shaking for approximately 2 seconds while lying in bed in the facility. The MD assessment/plan noted, This was seizure? Further noted was that R#18 had seizure disorder but didn't have seizures in a while. The MD ordered lab work to recheck reversible causes and that resident had constipation with slow transit. The MD plan was to continue the resident's same regimen, noted Arguable constipation can contribute to seizures either directly or indirectly so need to keep pt's BM regular. The residents CP#5 At risk for falls dated 08/19/17 included interventions of: Maintain a safe environment; ensure reduction of clutter in traffic/common areas; do not leave unattended in the bathroom; for res taking high-risk medication (Ativan) remind to use call light and wait for assistance. The resident's CP#11 for [DIAGNOSES REDACTED]. reduce unnecessary light, noise, traffic and personnel; monitor lab vlaues - prn; administer meds as ordered - gabapentin, ativan; monitor side effects of meds. 2) On 10/02/2017 at 10:42 AM during Stage 1 of the survey, observed that R#34 had old metal type bilateral half SRs with space between the SRs and mattress for limb entrapment. On 10/05/2017 at 8:18 AM interviewed Staff#3 regarding how SR assessments are done at the facility along with concurrent observation of R#34's SRs. According to Staff#3 the SR assessments were done and only alert and oriented residents could have SRs. The SRs were color-coded as: Green coded SRs meant that resident can have their SR up all the time and were oriented & alert; Yellow coded SRs were for only when staff was assisting the resident the SRs were put up; and, Red coded SRs meant that the bed rails should be kept down at all times. Staff#85 came into R#34's room and Staff#3 asked her to clarify the resident's Green coded SRs. Staff #85 then stated that R#34 doesn't move anymore and no longer alert and oriented and didn't know why the SRs were still Green coded. Staff#3 stated that she didn't know that there was a change in R#34's cognition. On 10/05/2017 at 1:07 PM observed R#34 lying in bed with head of bed (HOB) up and SRs up with Red tape. Staff#77 came into resident's room and queried about SRs for R#34 with Red tape. Staff#77 stated, It was changed already and SRs are supposed to be down, as she placed SRs down. The facility did not identify individual resident risk of an accident in the use of SRs that were loosely fitted to the bed with spaces for limb entrapment.",2020-09-01
607,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2017-10-06,329,D,0,1,3KOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview's the facility failed to ensure that the drug regimen was adequately monitored for one of five resident's (R#20) sampled for unnecessary drug use in Stage 2 of the survey. Findings include: Resident #20 was admitted with a [DIAGNOSES REDACTED]. On 10/04/17 at 10:43 AM the Care Plan for Resident #20 was reviewed. Problem #8 stated: Potential dehydration per use of Diuretics, monitor labs as ordered. At 11:02 the lab results for Resident #20 were reviewed, the resident's last Basic Metabolic Panel (BMP) was done on 7/20/16. Medical records were reviewed on 10/05/17. Review of the Pharmacy note dated 4/14/16 stated The resident was admitted to the facility on [MEDICATION NAME] 20 mg one time per day and [MEDICATION NAME] 25 mg twice per day for [MEDICAL CONDITION]. In view of occasional systolic blood pressure reading's The Medication Regimen Review (MRR) was reviewed. The medication review for Resident #20 was completed at regular monthly intervals although the Pharmacist did not recommend to the Physician to do a BMP on any of the reports. During an interview on 10/05/17 at 3:16 PM, the Pharmacy Consultant stated that the resident's Physician does not usually act on the pharmacist recommendations making his own decisions about the residents treatment plan. During a staff interview on 10/04/2017 at 11:23 AM staff #69 stated that the resident used to be on Hospice. The Doctor doesn't usually do labs for the residents who are on Hospice. When asked how often the Doctor orders a BMP for a resident on Diuretics staff #69 stated the physician usually orders labs every week on Thursday. During an interview at 11:39 AM staff #77 stated when a resident is on diuretic therapy the nurses monitor weights as ordered by the Physician and the Pharmacist may also recommend to the Physician to check the labs. The Facility failed to ensure the drug regimen for Resident #20 was adequately being monitored.",2020-09-01
608,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2018-10-12,578,D,0,1,RTL111,"Based on staff interview and record review, the facility failed to comply with the requirements specified to include provisions for future healthcare decisions. Findings include: 10/10/18 09:41 AM During record review for Resident (R)62, a POLST was identified in the chart. Advance Directives was not found in the record. Unit clerk (UC) on second floor was asked to check if there was an advanced directive in previous chart. UC on second floor reported that the resident did not have an advanced directive in the chart or previous charts.",2020-09-01
609,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2018-10-12,580,D,0,1,RTL111,"Based on record review and interview, the facility failed to immediately notify Resident (R)46's physician of a significant weight loss. The deficient practice affected R46 only. Findings include: Review of weight record on 10/10/18 at 10:46 AM reflected that on 09/01/18 R46's weight 127.8 pounds and on 09/02/18 R46's weight 120.4 pounds, a 5.7% weight loss in a day. Noted that R46 was care planned for nutrition, that significant weight loss was noted in the care plan as a problem on 06/20/18, and that risk factors were identified, and appropriate interventions included in the care plan. Reviewed dietary quality of care progress notes, interdisciplinary progress notes, physician's progress notes, and communication log to the physician for documentation that R46's significant weight loss was communicated to the physician and none were found to reflect communication of R46's significant weight loss to the physician on 09/02/18. Interview with Registered Dietician (RD)1 on 10/11/18 at 11:12 AM who referred to her 09/13/18 dietary quality of care progress note which does not reflect physician was informed of significant weight loss on 09/02/18. RD1 further explained that she viewed the weight record entry on 09/02/18 of 120.4 pounds as an error, and that fluctuations in the recorded weight are common because of differences in weighing protocol between each staff member, and discrepancies are followed up by a re-weighing of the resident. Reviewed R46's weight record with RD1 and asked if the weight record entry on 09/02/18 was marked as an error. RD1 replied it was not marked as an error. RD1 was asked if R46 was re-weighed on 09/02/18, and she replied that R46 was not re-weighed. RD1 was asked if she could find any documentation that physician was notified of the significant weight loss on 09/02/018 and she said there was none.",2020-09-01
610,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2018-10-12,623,E,0,1,RTL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, the facility failed to send a copy of the notice for reason of transfer or discharge to the representative of the Office of the State of Long-Term Care Ombudsman. Findings include: Record Review (RR) on 10/09/18 revealed that the Office of the State of Long-Term Care Ombudsman did not receive notice for three Residents (R), R10, R40 and R62 for discharge/transfer from the facility. 1) Resident (R)10 presented to the Emergency Department (ED) for complaint of abdominal pain on 08/10/18. He was in his usual health state when he complained of abdominal pain after eating breakfast. The pain started at the epigastric area and radiated to left upper quadrant (LUQ) and then the whole abdomen. In the ED, a total of 3 liters of normal saline bolus was given. One dose of [MEDICATION NAME] was also given. Patient needed to be admitted to Intensive care unit due to worsening [MEDICAL CONDITION]. 2) Continued RR for R40 revealed a hospitalization to an acute care facility on 07/11/18 for an upper [MEDICAL CONDITION] with acute blood loss, [MEDICAL CONDITION]. A scope of the gastroesophagus showed an [MEDICAL CONDITION] mass. 3) RR on 10/10/18 at 10:30 AM revealed R62 was hospitalized to an acute care facility on 08/31/18 for acute hypoxic [MEDICAL CONDITION], acute [MEDICAL CONDITION] and acute [MEDICAL CONDITION] and right upper arm [MEDICAL CONDITION]. 10/11/18 12:07 PM - Interview with Social worker (SW) - We did not send out any notices to the Ombudsmans regarding the admissions for the acute care facility.",2020-09-01
611,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2018-10-12,637,E,0,1,RTL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews (RR), the facility failed to identify within 14 days that there had been a significant change in the resident's physical or mental condition. Findings include: 1)Resident #40 was hospitalized to an acute care facility on 07/11/18 for an upper [MEDICAL CONDITION] with acute blood loss, [MEDICAL CONDITION]. A scope of the gastroesophagus showed an [MEDICAL CONDITION] mass. Past medical history - [AGE] year old brought to the hospital by her daughter on 7/11/18. Daughter noticed her mother's dementia had progressed in the last two months to the point of being nonverbal. Daughter further stated that her mother had stopped taking food by mouth and had a peg tube placed for feeding. R40 was admitted to the hospital for [MEDICAL CONDITION] that entailed a mass and required blood transfusion. On 10/11/18 at 02:01 PM a concurrent record review (RR) and interview was conducted with MDS (Minimum Data Set) coordinator who confirmed that a significant change was not done for R40's change in physical condition. 2) RR of R40's quarterly MDS with an an assessment reference date (ARD) of 05/11/18 showed no coding in Section M. skin conditions for a Stage 3 pressure ulcer (PU). However, on the MDS with the ARD of 08/10/18 section M was coded for skin conditions with a Stage 3 pressure ulcer (PU). There was no 14 day significant change documented in the MDS records. On 10/11/18 at 02:01 PM a concurrent record review and interview was conducted with MDS coordinator who confirmed that a significant change was not done in the MDS record for R40's change in physical condition for pressure ulcer. 3) On 10/10/18 at 10:09 AM record review (RR) of R63's last two Minimum Data Set (MDS) assessments dated 06/16/18 and 09/07/18 found R63 had a decline in two Activities of Daily Living (ADL) with bed mobility and transfer, going from a rating of three of extensive assistance, resident involved in activity, staff provided weight bearing support to a rating of four which is total dependence, full staff performance every time during entire seven-day period. On 10/11/18 at 03:19 PM interviewed Certified Nurse Aide (CNA)1 who confirmed R63 used to walk to the bathroom before but she cannot do that now and stated R63 is unable to turn herself in her bed, now staff have to turn her. Inquired if CNA1 knew why R63 could not walk anymore or turn herself and CNA1 stated that she did not know why R63 had the decline with her bed mobility and transfer. Inquired if R63 had fallen recently or had a stroke and CNA1 denied that R63 fallen recently and stated that she did not know if R63 had a stroke. On 10/11/18 at 03:23 PM interviewed Registered Nurse (RN)4 who confirmed that R63 has had a decline in her health and her ability to move herself in her bed and out of her bed. Inquired if R63 had a fall recently or a stroke and RN4 stated that R63 has not had any falls or illnesses that would cause the decline such as a stroke, RN4 believed the decline was related to worsening of R63's dementia. On 10/11/18 at 03:40 PM interviewed the MDS nurse1 and showed R63's decline in bed mobility and transfer from her last two MDS assessments. MDS nurse1 stated other nurses had completed these assessments and they had not identified the decline and did not notify her of the decline. MDS nurse1 stated she would look through R63's medical records to review R63's ADLS from (MONTH) (YEAR) to confirm the significant change and investigate if facility staff coded R63 ADLS incorrectly. On 10/12/18 met with MDS nurse1 at 10:12 AM who confirmed, according to R63's CNA flow sheet for her Bed Mobility and Transfer, found R63 was coded correctly on the last two MDS and the decline with R63 was not recognized and reported to MDS nurse1. MDS nurse1 confirmed that the decline in the two ADL areas is a significant change for R63 and the significant change should have been submitted to CMS within 14 days of it being identified but this had not been done.",2020-09-01
612,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2018-10-12,655,D,0,1,RTL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to provide a baseline care plan for Resident (R)278. The facility did not develop a care plan for hospice care and services. Findings include: 10/10/18 09:16 AM No plan of care for hospice in record noted. Resident (R)278 was admitted on [DATE]. No contract for hospice seen. Interview on 10/10/18 03:09 PM with Hospice nurse (HN)1 who stated that they have a new social worker and we haven't had time to bring it. She stated that she can bring it too.",2020-09-01
613,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2018-10-12,657,D,0,1,RTL111,"Based on observations, staff interview and record reviews, the facility failed to develop an ongoing activity program based on preferences stated in the comprehensive assessment for Resident (R)40. The care plan was not being followed or updated for R26 based on the comprehensive assessment. The deficiencies did not support the physical, mental, and psycho-social well being of R40 and R26. Findings include: 1) On 10/09/18 at 8:18 AM and 11:00 AM, 10/10/18 at 0730 AM AND 12:00 PM and 10/11/18 at 0720 AM, 10:45 am and 0200 PM, resident (R)40 was observed in bed for three days and not seen in activities. 10/11/18 at 10:22 AM. Record review (RR) revealed no careplan for activities. Minimum Data Set (MDS) with an Assessment reference date (ARD) of 08/11/18 was reviewed. Coding in section F, preferences were reviewed. Customary routine and activities noted that it is important for her to have music, hear the news and get fresh air. R40 was observed with no television, music or newspaper at her bedside. In addition, surveyor did not note any activity of one-to-one activity at bedside. Registered nurse (RN)2 spoke with resident as R40 received tube feeding. In addition, no orders were noted for activity. 10/11/18 12:00 PM - Interview with Activity aide (AA)1 who stated that there is no manager. On call staff work on weekends. AA1 stated there is no other activity person who can help with activities and go to the rooms and do one to one. 10/11/18 12:26 PM interview with MDS nurse 1 verified the MDS done on 8/11/18 and verified the preferences for activities. MDS nurse one 1 was informed that there is no careplan or doctors orders for activities. 2) During an observation on 10/09/18 at 02:02 PM R26 was lying in bed awake and staring at the ceiling. The television was off and the room was quiet, the other three residents were in the room sleeping. On 10/10/18 at 0845 AM and 10:37 AM, R26 was lying in bed awake and quiet. The other three residents were not in the room. Care plan reviewed, R26 requires assistance in performing activities of daily living (ADL) related to weakness. She is to get up to activities three to five times per week and have one to one at the bedside. The daily restorative program flow sheet was reviewed. R26 did not participate on the following dates: 09/04; 09/06; 09/08; 09/11, 09/12; 09/14; 09/18; 09/20; 09/21; 09/26; 09/28; due to pain. During an interview with RN3 on 10/11/18 at 03:16 PM, who stated she likes to watch the Korean dramas on the television (TV) but it doesn't work with the digital cable system. During an interview with NS2 on 10/11/18 at 04:08 PM who stated that when staff get R26 up to activities she wheel's herself back to her room. She likes to watch TV in her room but its not working with the new cable system. Currently we don't have a full time activity director. NS2 concurred that the activities listed on the care plan are not being followed and that R26 is not getting up to activities three to five times per week and having one to one as stated on the care plan.",2020-09-01
614,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2018-10-12,679,D,0,1,RTL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide R26 and R40 with an ongoing activity program, both individual and group based on her choice of activities and preferences that were stated in the comprehensive assessment and/or care plan. The deficiency did not support her physical, mental, and psycho-social well being. Findings include: 1) On 10/09/18 at 8:18 AM, 11:00 AM and 1:00 PM, observed Resident 40 (R40) in her room laying in her bed. No TV, music playing, lights off. On 10/10/18 at 07:30 AM, 12:00 PM, observed R40 laying in bed, lights off, no music or TV playing. 10/11/18 at 7:20 AM, 10:45 AM and 0200 PM observed R40 laying in bed, lights off, no music or TV playing. Did not observe resident involved in any activities or any visitors at bedside for dates noted above. 10/11/18 at 10:22 AM. Record review (RR) revealed no careplan for activities. Minimum Data Set (MDS) with a Assessment reference date (ARD) of 05/11/18 was reviewed. Coding in section F preferences for customary routine and activities stated it is important for her to have music, hear the news and get fresh air. R40 was observed with no television, music or newspaper at her bedside and lights off. In addition, surveyor did not note any activity of one-to-one activity at bedside. Registered nurse (RN)2 spoke with R40 while receiving tube feeding. In addition, no orders were noted for activity. (refer 657) 10/11/18 12:00 PM - Interview with Activity aide (AA)1 who stated that their is no manager. On call staff work on weekends. AA1 stated there is no other activity person who can help with activities and go to the rooms and do one to one. 10/11/18 12:26 PM interview with MDS nurse1 verified the MDS done on 8/11/18 verified the preferences for activities. MDS nurse1 was informed that there is no careplan or doctors orders for activities. 2)During an observation on 10/09/18 at 02:02 PM R26 was lying in bed awake and staring up at the ceiling. The television was off and the room was quiet, three other residents were in bed sleeping. On 10/10/18 at 0845 AM and 10:37 AM, R26 was lying in bed awake and staring at the ceiling. The other three residents were not in the room. At 02:04 PM R26 was lying in bed with her eyes closed. Per the annual activity assessment dated [DATE] R26 is oriented to Person and Place. Activity preferences are Music, spiritual, Buddhist, watching Korean dramas, and Hawaiian cultural programs. Review of the Minimum data set (MDS) annual assessment dated [DATE] confirmed the activities R26 prefers. The Activity participation record for month of (MONTH) (YEAR) was reviewed. R26 stayed in bed most of the time and actively participated in one newspaper, one entertainment and one pet visit. In (MONTH) and (MONTH) (YEAR), R26 had a similar outcome. The care plan was reviewed, R26 requires assistance in performing activities of daily living (ADL) related to weakness. She is to get up to activities three to five times per week and have one to one at the bedside. Daily restorative program flow sheet was reviewed. R26 did not participate on the following dates: 09/04; 09/06; 09/08; 09/11; 09/12; 09/14; 09/18; 09/20; 09/21; 09/26; 09/28; due to pain. During an interview with RN3 on 10/11/18 at 03:16 PM, who stated when staff attempt to get her up she refuses by yelling and kicking. If she has to go to the bathroom or when getting her shower she usually cooperates with the staff. She likes to watch the Korean dramas on the TV but it doesn't work with the digital cable system. During an interview with NS2 on 10/11/18 at 04:08 PM who stated that she was told when staff get R26 up to activities she wheel's herself back to her room. She likes to watch TV but its not working with the new cable system. We currently do not have a full time activity director. NS2 concurred that the activities listed on the care plan are not being followed and that R26 is not getting up to activities three to five times per week and having one to one as stated on the care plan.",2020-09-01
615,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2018-10-12,700,D,0,1,RTL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview and record review (RR) the facility failed to review the risks and benefits of bed rails and obtain informed consent with three residents (resident (R) 2, 27 and 30) prior to installation of bed rails on their beds. This deficient practice had the potential to put the residents at risk for harm who have not been told the risks of bed rail use and had the potential to affect all the residents at the facility who have bed rails. Findings Include 1) On 10/09/18 while doing initial observations and interviews with residents on the third floor unit noted that R2, 27 and 30 had bed rails on their beds. At 10:58 AM interviewed R27 and inquired if he signed an informed consent for his bed rails, if staff had told him the risks and benefits of bed rails and R27 stated staff did not talk to him about the bed rails and also stated that he might not remember if they did. On 10/10/18 at 03:05 PM inquired of Nursing Supervisor (NS)2 if facility has a process in place to inform residents of the risk and benefits of bed rails and if they obtain informed consent prior to residents having bed rails installed on their bed. NS2 stated that she would have to get back to me on this. Requested facility policy on this as well. On 10/10/18 at 03:09 PM met with unit clerk on third floor unit and requested R27's signed informed bed rail consent form. Unit clerk stated that the facility does not have a form for informed bed rail consent. 2) On 10/09/18 at 01:51 PM walked into R30's room and noted the resident had full bed rails up on her bed along with padding on the bed rails. On 10/10/18 at 02:18 PM interviewed RN5 and inquired about R30's padded full side rails. RN5 stated they usually get a doctor's order for the bed rails after they assess the resident and he stated this resident has a [MEDICAL CONDITION] disorder and the bed rails are used to protect the resident from falling out of her bed. RN5 looked through R30's medical record and was not able to find the informed consent form for bed rail use. On 10/10/18 at 02:23 PM requested a signed informed consent for bed rail use for R30 from NS2. NS2 stated that she would have to look for it and would get back to me on this. On 10/10/18 at 02:25 PM review of R30's medical chart found that she is coded, in her last Minimum Data Set ((MDS) dated [DATE], as having a [MEDICAL CONDITION] disorder. R30 has a care plan in place for at risk for falls and it mentioned bed rails that are padded to maintain resident safety. On 10/11/18 at 11:13 AM interviewed NS2 of who stated the facility does not have an informed consent for bed rail use form, they do if it is used as a restraint and this is based on the bed rail assessment. NS2 confirmed that residents 2, 27 and 30 do not have signed informed consents for bed rail use and that the facility does not have anything for this in place.",2020-09-01
616,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2018-10-12,758,D,0,1,RTL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR) and interview with staff members, the facility failed to manage and monitor drug/regimen to promote or maintain the highest practicable mental, physical and psychosocial well-being with the use of unnecessary drugs in 3 out of a sample of 30. Findings include: 1) Record review on 10/09/18 for R278 revealed an order for [REDACTED]. 2) Observation on 10/09/18 for R11 of Hospice nurse (HN) calling physician by telephone for whenever needed (PRN) medication for [MEDICATION NAME] 1mg. Give 1 mg by mouth sublingual every four hours whenever needed for anxiety, agitation x14 days. Observation/interview 10/09/18 at 8:18 AM R11's bedside. R11's power of attorney and friend at bedside. R11 is awake, pleasant and answering simple questions with friend. Observation 10/11/18 at 10:00 AM R11 is awake and watching TV. Observation on 10/12/18 R11 at 10:05 AM sleeping. Behavior/intervention monthly flow records for the month of (MONTH) and (MONTH) reviewed: Behaviors include: 1) Anxiety 2) Agitation 3) Inability to sleep. R11 did not demonstrate any behaviors of anxiety and agitation for the month of (MONTH) and October. The appropriateness and rationale for this PRN medication was not documented in the record. Interview on 10/12/18 at 01:19 with physician regarding Hospice R278 for order for [MEDICATION NAME] PRN which did not have a 14 day time limit and no agitation of the resident has been exhibited. Physician discontinued the mentioned order immediately. 3)Based on observation and record review the facility extended the as needed (PRN) [MEDICAL CONDITION] order for [MEDICATION NAME] beyond 14 days and did not document the rationale in the resident's medical record. The attending physician or prescribing practitioner did not evaluate the resident for the appropriateness of the PRN anti-anxiety medication. The deficient practice may have resulted in the oversedation of R62. Findings include. Medical record reviewed. Physician ordered the following: 09/13/18: [MEDICATION NAME] (anti-anxiety) 0.5 mg by mouth (PO) every (Q) 6 hours as needed (PRN) for 14 days. 09/28/18: [MEDICATION NAME] 0.5 mg PO Q 6 hours PRN (extended for 14 days). 10/11/18: [MEDICATION NAME] 0.5 mg PO Q 6 hours PRN (extended for 14 days). DX; Dementia with psychomotor agitation. Signed by Hospice consult. Reviewed Physician notes dated 9/07/18 to 10/05/18 and nursing notes from 09/28/18 to 10/11/18. No documentation found to justify why the [MEDICATION NAME] was extended. R62 also on the following daily [MEDICAL CONDITION]'s: 1. [MEDICATION NAME] (anti-psychotic) 0.5 mg tabs take 1 tab PO Q AM. 2. [MEDICATION NAME] (anti-depressant) 50 mg tabs take 1 tab PO at bedtime. 3. [MEDICATION NAME] (benzodiazapine) 0.5 mg tabs take 0.5 tab by mouth Q evening. for anxiety. Medication regimen review (MRR) dated 9/16/18: No documentation found to justify ordering/ extending the PRN [MEDICATION NAME]. No recommendations to decrease or discontinue the [MEDICATION NAME]. Care plan reviewed. Problem #10 [MEDICAL CONDITION] medications. 9/07/18 Goal: Resident will not have complication r/t [MEDICAL CONDITION]'s medication through the next review date. Behavior/ intervention monthly flow record reviewed for (MONTH) and (MONTH) (YEAR). Behaviors include: 1. Attempts of getting out of bed/ wheelchair unassisted. 2. Calling out. 3. Hallucinations. 4. Agitated yelling. In (MONTH) (YEAR) noted majority of R62 behaviors occurred on the night shift, with no behaviors occurring on day shift. Same for (MONTH) (YEAR). R62 has behaviors only on evening and night shift. Observation on 10/09/18 at 08:18 AM of R62 sleeping in her bed with a 1:1 nurses aide at her bedside. Staff stated that they switch out to watch R62 whenever they can. At 11:26 AM, R62 still sleeping in bed. No sitter at bedside. At 01:54 PM, R62 in bed sleepy but arousable. Observation on 10/10/18 at 08:30 AM, R62 up in dining/activities area but R62 noted to be sleeping most of the morning. Observation on 10/11/18 at 08:15 surveyor noted R62 in dining area and sleeping. Observation on 10/12 at 7:24 AM R62 in dining area with eyes closed. Registered nurse (RN)2 stated she is sleeping. At 08:00 AM, R62 went back to bed without eating because she was too sleepy to eat.",2020-09-01
617,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2018-10-12,761,E,0,1,RTL111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to label the opened on date for four containers of eye drops and one container of glucomter strips in two medication carts at the facility. This deficient practice had the potential to affect the residents receiving eye drops that may be expired and those having their blood sugar checks done with test strips that could be expired. Findings Include: 1) On [DATE] at 10:58 AM went through the medication cart on third floor with RN6 and found two opened containers of eye drops that did not have an opened on date for R76. The opened eye drops were Dorzolamide 2% opth soln instill 1 drop in both eyes twice daily Dx: [MEDICAL CONDITION] which was filled on [DATE] and [MEDICATION NAME] 0.01% sol instill 1 drip into both eyes at bedtime Dx: [MEDICAL CONDITION] which was filled on [DATE]. Also found a container of glucomter strips (Assure Platinum) that were also open and did not have an opened on date. On [DATE] at 11:02 AM the containers of opened eye drops and container of glucometer strips were shown to the NS on third floor unit who agreed all containers should have had open on dates on them. 2) On [DATE] at 11:06 AM went through medication cart on second floor with RN7 and found two container of eye drops that did not have the opened on date on them. One container of eye drops was for R10, Refresh tears 0.5% soln instill 1 drop in both eye every 4 hours as needed for dry eyes which was filled on [DATE] with a use date of [DATE] and second container of eye drops was for R18, Artificial tears 1.4% drops instill 2 drops in either eye every 4 hours as needed for dry or itchy eyes which was filled on [DATE] with a use by date of [DATE]. RN7 concurred that both bottles should have had the opened on dates on the opened containers of eye drops.",2020-09-01
618,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2019-10-28,550,D,0,1,TWBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR), and interview, the facility's Certified Nurse Aide (CNA) 1 failed to treat resident (R) 64 with dignity and respect by calling her a Feeder. Findings Include: On 10/22/19 at 12:03 PM, CNA1 was in R64's room (219C) and discussing the resident's gastrostomy tube ([DEVICE]) feeding with surveyor. It was during the course of the discussion when CNA1 referred to R64 as a Tube Feeder. There were other residents present in the room at the time. It was then discussed with CNA1 that calling a resident a Feeder may not be appropriate due to respect and dignity for the resident. CNA1 acknowledged she understood. On 10/22/19 at 12:18 PM, outside the dining/activity room by the nurse's station on the second floor, CNA1 was speaking with surveyor when she stated and gestured towards the dining room to surveyor stating she was going to assist with the Feeders. On 10/22/19 at 12:50 PM, interview with Nursing Supervisor (NS) 2 who stated she was unaware that calling residents who require assistance with their meals Feeders is inappropriate. NS2 queried surveyor what they should call these residents who require assistance with their meals. NS2 was informed one option maybe is to say residents who need assistance with their meals. On 10/23/19 at 01:45 PM, RR showed R64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RR showed R64 has a [DEVICE] through which she gets her medications and nutritional needs.",2020-09-01
619,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2019-10-28,578,D,0,1,TWBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR) and interview, the facility failed to document advance directive (AD) information was given, offered, and re-offered quarterly for two residents (R25 and R73) who did not have a copy of the AD in their records out of four residents selected for review. Findings Include: 1) On 10/23/19 at 01:30 PM, RR reflected no AD in R25's chart/record. On 10/23/19 at 01:48 PM, interview with Social Worker (SW) who stated R25 and family were provided with information regarding AD but no follow-up documentation that R25 and family were offered assistance to formulate an AD at a later date (preferably quarterly). SW stated they need to do more work on follow-up documentation regarding AD. 2) On 10/23/19 at 09:32 AM, a record review of R73's chart, did not contain documentation of an AD. R73 was admitted to the facility on [DATE]. On 10/23/19 at 02:17 PM, interviewed SW regarding the status of R73's AD and follow-up documentation. The SW responded that R73 does not have an advance care directive and the family was last offered information on AD in (MONTH) (YEAR). SW stated the facility should be offering AD information quarterly, but has not been following up and offering information to residents and/or families on a regular basis.",2020-09-01
620,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2019-10-28,656,D,0,1,TWBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff member, the facility failed to develop a comprehensive person-centered care plan for 1(Resident 31) of 18 residents in the sample. Resident 31 had an incomplete care plan to address his activities of daily living. Findings Include: Resident (R)31 was admitted to the facility on [DATE] for respite services. [DIAGNOSES REDACTED]. On 10/22/19 at 01:49 PM, R31 was observed in bed, he was unshaven and had a scruffy beard. A review of the quarterly Minimum Data Set with assessment reference date of 08/16/19 notes R31 is independent for decision making regarding tasks of daily life. The resident was also coded to reject care, one to three days during the assessment period. R31 requires limited assistance with one personal physical assistance for personal hygiene (how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands). A review of R31's care plan with an onset date of 05/09/19 notes the following goals for the resident's activities of daily living (ADL): resident's ADL needs will be met through next 90 days; promote resident's highest ADL functioning level in the next 90 days; and resident will show improvement with self-ADL performance in the next 90 days. The interventions for self-performance level and the support required for R31 to complete ADLs were incomplete. Further review found documentation in the resident's care plan for psychosocial well-being/mood/behavior an entry dated 06/13/19 that R31 is combative and resistive to hygiene care. R31 also refused showers most of the time but was agreeable to bed baths/wipe down. On 10/25/19 at 08:29 AM, concurrent review of the care plan and interview was done with Nursing Supervisor (NS)2. NS2 confirmed R31's care plan was incomplete. The level of self-performance and support were not indicated for the following areas: bed mobility; transfers; dressing; grooming/personal hygiene; locomotion; bathing; toilet use; and ambulation. The onset date of this care plan was documented as 05/09/19. Subsequent to review of the care plan with NS2, on 10/25/19 at 08:38 AM the NS provided a copy of R31's care plan with completion of the interventions identifying R31's need for support to complete all areas of ADLs.",2020-09-01
621,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2019-10-28,684,D,0,1,TWBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, the facility failed to ensure a resident with [MEDICAL CONDITION] receives treatment interventions as ordered by the physician and indicated on the comprehensive person-centered care plan. As a result of this deficient practice, R73 is at an increased risk for further complications. Findings Include: Cross reference with F842 An initial observation of R73 on 10/22/19 at 09:24 AM, noted R73 sitting in a wheelchair with redness and [MEDICAL CONDITION] to the right leg. resident (R)73 was admitted on [DATE], with a [DIAGNOSES REDACTED]. Observed R73 on fourteen (10/22/19 at 09:24 AM, 11:30 AM, 01:44 PM, 02:35 PM; 10/23/19 at 09:14 AM, 11:00 AM, 01:32 PM, 02:56 PM; 10/24/19 at 08:29 AM, 09:14 AM, 10:17 AM, 11:40 AM, 01:49 PM, 03:37 PM) occasion in which R73 was sitting upright in a wheelchair with no compression stocking applied to the right leg for [MEDICAL CONDITION]. On 10/23/19 at 01:49 PM, a record review R73's (MONTH) 2019 comprehensive care plan (initiated on 01/01/19) addresses R73's [MEDICAL CONDITION], secondary to [MEDICAL CONDITIONS], with an intervention to use a compression stockings/TED hose on the right leg. Additionally, R73 has a current physician order [REDACTED]. Further record review of the Treatment Administration Record (TAR), staff endorsed the application and removal of the compression stocking for R73. On 10/22/19, 10/23/19, 10/24/19, staff endorsed the application of the compression stocking on the TAR, the surveyor observation during these times found the resident without compression stocking. On 10/24/19 at 01:45 PM, interviewed Registered Nurse (RN)1 regarding the use and documentation of compression stockings for R73. RN1 stated R73 should have a compression stocking applied in the morning and removed it at night because R73 has [MEDICAL CONDITION] in the right leg. The treatment record was reviewed with RN1. RN1 confirmed that a check mark on the TAR indicates the compression stocking were applied and removed. The discrepancy between the observation and documentation was shared with RN1. Inquired with RN1, how does staff accurately report the use of the compression stocking to the physician. RN1 stated the TAR is used to communicate the use of the compression stocking and staff does not normally document the use of the compression stocking in the progress note. RN1 acknowledged the TAR documentation does not accurately portray the effectiveness of the compression stocking, R73 refusal to use the compression stocking, or the actual application of the compression stocking. A review of R73's annual history and physical conducted on 02/21/19 stated .still markedly swollen legs-despite TEDs (compression stocking) .- strongly consider diuretics= pt (patient) c (with) mult (multiple) comorbidities/ advanced age/ debility- patient's condition is very unstable and needs very close monitoring as very high risk outcomes esp (especially) [MEDICAL CONDITION] ([MEDICAL CONDITION]/ [MEDICAL CONDITIONS], hypo-hypertension/ [MEDICAL CONDITION]/ cardiovascular compromise.",2020-09-01
622,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2019-10-28,686,D,0,1,TWBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews with resident and staff members, the facility failed to ensure a resident with pressure injury receives necessary treatment to promote healing and prevent infections for 1 (Resident 71) of 3 residents sampled with pressure injuries. Resident 71 presents with three unavoidable pressure injuries with chronic infections. The facility has addressed positioning (providing education to resident regarding non-compliance) and nutritional values (protein supplements) to aid in the healing of the pressure injuries. However, the facility failed to perform root cause analysis to determine sources of the organisms presented; therefore, based on an assessment did not develop interventions for further prevention of infections to facilitate the resident's healing process to the most practicable level of well-being. Findings Include: Resident (R)71 was admitted to the facility on [DATE] from an acute care hospital. R71's [DIAGNOSES REDACTED]. R71 was admitted to the facility for hospice care. R71 was admitted to the facility with an unstageable pressure injury to the coccyx (2.5 x 3 cm) which has currently been assessed as a Stage 4. R71 also has a Stage 4 pressure injury to the right ischial tuberosity and a Stage 4 pressure injury to the left ischial tuberosity which was facility acquired. A record review was done on 10/23/19 at 01:31 PM. The Minimum Data Set with an assessment reference date of 10/03/19 found R71 yielded a score of 15 (cognitively intact) when the Brief Interview for Mental Status was administered. R71 is totally dependent on staff (two plus persons physical assist) for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and has functional limitation in range of motion bilaterally to the lower extremities. R71 is also noted to have three, Stage 4 facility acquired pressure injuries. On 10/22/19 at 09:40 AM an interview was conducted with R71. R71 reported that she was in pain due to the mattress, the resident reported initially an air mattress was provided but found that it was uncomfortable and requested a different mattress. R71 reported not participating in activities as she can only sit in the chair for one hour because of her wounds. On the morning of 10/24/19 another interview was conducted with R71. Inquired whether she is aware that the air mattress can help to heal her wounds, R71 responded she is aware but finds that the air mattress is not good for her body. R71 reported staff respond promptly to provide peri-care for bowel incontinence and also reported observing staff members washing their hands while providing care. R71 reported that sometimes she refuses dressing change. Further inquired what she needs to do to improve her wounds, she responded to turn every two hours; however, prefers to be on her back. R71 is aware that her wounds are infected. On the morning of 10/25/19 the facility provided the Pressure Ulcer Skin Assessment which documents the onset of the pressure injuries to the right gluteal fold and the left buttock on 12/04/17. The pressure injuries were assessed at Stage 1. The Treatment Record documents in 12/13/17 the injuries to the left and right buttock were now assessed as Stage 2. The pressure injury to the coccyx was assessed as a Stage 4. In (MONTH) (YEAR), the Registered Dietitian (RD) documents the pressure injuries to the left and right buttocks was assessed as Stage 3. A review of the Dietitian notes found documentation of resident's poor intake with some weight loss. Also noted are the supplements that were being provided to the resident to facilitate wound healing (multi-vitamins, glucerna, protein [MEDICATION NAME] liquids). The physician order [REDACTED]. A review of the Wound Specialist (WS) notes R71 has declined the use of an air mattress, bruising to wound related to resident's insistence of sitting in a shower chair, loose stools possibly related to use of antibiotics and an incident of leaking foley catheter. The WS documented on 10/17/19, R71 continues to decline the use of an air mattress and continues to request showers. The WS recommends a referral to an infectious disease physician due to recurrent infections. A wound culture was ordered on [DATE]. The Pharmacist's medication regimen review (MRR) found documentation of R71 on antibiotics due to wound infections, dating back to 05/15/18. R71 was noted to receive antibiotics in (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019. The cultures ranged from e. coli, morganella, staph aureus, [MEDICATION NAME], [MEDICAL CONDITION]. The MRR for (MONTH) 2019 found [MEDICATION NAME] and [MEDICATION NAME] was prescribed. The wound culture [MEDICAL CONDITION], pseudomonas and e. faecalis. A review of the facility's Quality Assurance Tool for assessing unavoidable pressure ulcers prepared by the Director of Nursing (DON) and signed by R71's physician notes the following, based on the measures identified, care planned and implemented, the interventions are sufficient and reasonable to prevent the formation of pressure ulcer; however, the measures were not successful in preventing the formation of pressure ulcers. Therefore, the formation of pressure ulcers were unavoidable. The document was signed on 09/02/19 by the Director of Nursing (DON) and the physician in (MONTH) (the signed date is illegible). On 10/24/19 at 08:32 AM an interview was done with the WS. The WS reported there are many components to the prevention and healing of R71's pressure injuries. The WS stated R71 refuses air mattress, continues to request showers (shower chair causes bruising and the resident requires use of Hoyer lift for transfers) and favors laying on her back. Further queried what causes the infections to the pressure injuries. WS acknowledged that the infections does not help with the wound healing; however, has observed good infection control techniques during wound care by facility staff. The WS stated maybe the bacteria is in the water or the resident's family brought it in while visiting. The WS could not identify the source of the bacteria. Further inquired whether the infection control consultant has been involved in R71's care, the WS responded not being aware if the facility has an infection control consultant/preventist. The WS reported the most important factor is for R71 to help them heal the wounds. The WS reported R71 will be referred to an infectious disease physician. On 10/24/19 at 01:30 PM an interview was conducted with Nursing Supervisor (NS)2. NS2 reported R71 graduated from hospice sometime in March/April 2019 after receiving hospice services for almost two years. Inquired whether causal factors contributing to R71's infections were assessed. NS2 responded maybe it is from the water or the food as the staff demonstrates good infection control techniques. The NS2 deferred to the DON. On 10/24/19 at 01:44 PM an interview was conducted with the DON. The DON reported infections are suspected when there is an odor or the wound healing is stalling. Although the resident does not present with a fever or pain, a wound culture is taken. Inquired whether the facility's infection control consultant was consulted. The DON replied the consultant is aware; however, has not said much. The DON also expressed concern whether the water source has been a contributory factor to the wound infections and would like to request evaluation of the facility's water. On the morning of 10/25/19, the DON report R71 has an appointment with the infectious disease physician. The DON also reported consideration of limiting the staff members to perform R71's dressing change to two nurses for consistency.",2020-09-01
623,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2019-10-28,689,D,0,1,TWBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policy, the facility failed to secure a treatment cart located on the third floor nursing unit. As a result of this deficient practice, the facility put the safety and well-being of the residents, as well as the public, at risk for accident hazards. Findings Include: During an observation of the treatment cart (located on the third floor) on 10/22/19 at 10:46 AM, it was noted that the cart latch/lock mechanism was not locked and anyone could have accessed the cart freely. At that time, resident (R)73, who self propelled his/her wheelchair was roaming the hallway and actually strolled past the cart. There was no staff in the immediate vicinity to prevent anyone from accessing the cart. The cart contained the following hazardous items: medical equipment (various scissors, several forceps, and numerous clamps) and medications (Cortisone cream, [MEDICATION NAME] cream, [MEDICATION NAME] ointment, [MEDICATION NAME] powder, [MEDICATION NAME] Propionate, Mupirocin, Halobetasol cream, Ammonium [MEDICATION NAME] lotion, and Dakins solution containing Sodium Hypochlorite or Bleach). A review of R73's record revealed the following Diagnoses: [REDACTED]. On 10/22/19 at 10:59 AM, the Nursing Supervisor (NS)3 was asked about the treatment cart not being secured. NS3 stated that the cart should have been locked and the cart secured. NS3 also revealed that the latch/lock mechanism had unlatched several times before. A review of facility's policy on Safety Program notes that the facility shall have an ongoing Safety Program designed to provide a safe environment for residents, personnel, and visitors and to monitor that environment. This was not followed.",2020-09-01
624,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2019-10-28,803,J,0,1,TWBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record review the facility failed to ensure resident (R)70 receives the correct physician's order for fluid consistency. As a result, R70 was observed coughing/choking during mealtime while consuming non-nectar thickened liquids. Findings Include: R70 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A speech therapist consultation on 07/31/18, identified R70 at risk for aspiration. However, the facility's kitchen staff, unit staff, dietary staff and NS1 were not aware R70 was not receiving a nectar thick fluid consistency as ordered since 07/18/19. On 10/22/19 at 11:47 AM, observed R70 in the 3rd floor dining area during lunch, drinking independently. R70 was seated at a table with one other resident which was being assisted with lunch by certified nurse's aide (CNA)2. The surveyor was positioned approximately 2 feet away from R70, with a clear view of the contents of R70's tray. R70 received a lunch tray that contained 3 separate cups of liquid. The cups contained different types of fluid. The fluid consistency appeared to be: a pre-filled thickened water; a cup of non-thickened water; and a brown mug filled with non-thickened coffee. Later confirmed in an interview with Registered Dietician (RD)1, the fluid on R70's tray consisted of 4 ounces(oz) of nectar thick fluid, 4 oz of regular (non-thickened) consistency that is to be mixed together for the appropriate consistency for R70 and confirmed R70 has not been receiving the ordered fluid consistency since 07/18/19. Observed R70 coughing/choking after drinking the clear fluid from the regular cup continuously throughout lunch. CNA2 was seated at the same table, did not inspect R70's food, drink or diet card and continued to assist another resident with lunch. While the surveyor observed R70 coughing/choking, the Nursing Supervisor (NS)1 entered the dining area and observed the surveyor monitoring R70. R70 started to cough/choke after drinking the non-thickened water. Later, observed NS1 removing the coffee and the diet card from R70. NS1 confirmed the consistency of the coffee was not thickened and should be thickened. Reviewed the diet card with NS1, the diet card stated, Fruit juice: 3 each Nectar thick water and 1/2C (cup) thin liquids by Nursing. However, a review of the (MONTH) 2019 Physician's Order sheet documented the fluid order as Nectar Thick Only. Further record review for R70 noted a nutrition assessment by RD2 which documented, .downgrade liquids to nectar thick liquids .Family also states kitchen is mincing meats, resident prefers meat mech (mechanical) soft as it states in diet order. Sent reminder to kitchen. On 07/18/19, RD2 completed a physician telephone order. The physician verified the telephone order as Nectar Thick Only fluid consistency. Additionally, R70's comprehensive care plan reflected the change to nectar thick consistency on 07/18/19. The Director of Nursing (DON) and NS1 both confirmed there was a discrepancy with the fluid consistency delivered to R70, the diet card (Fruit juice: 3 each Nectar thick water and 1/2C thin liquids) and the physician's order (nectar thick only). DON1, RD1, NS1, Unit Clerk (UC)1, Registered Nurse (RN)1 and Dietary Cook Supervisor (DCS)1 were unable to provide documentation of the change from nectar thick water and 1/2C thin liquids to nectar thick only fluid consistency for R70 on 07/18/19. DON1 and NS1 confirmed R70 has not received the changed fluid consistency since the order date of 07/18/19. The facility's failure to provide the correct fluid consistency and lack of staff awareness of what the resident should be receiving have contributed to R70's coughing/choking continuously during lunch on 10/22/19.",2020-09-01
625,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2019-10-28,842,D,0,1,TWBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to accurately document the use of compression stocking for Resident (R)73. As a result of this deficient practice, miscommunication between the use of the intervention between staff and the physician could subject R73 to the use of a diuretic and at greater risk for further health complications. Findings Include: Cross references with F684. R73 was observed with no compression stockings applied on fourteen occasions on 10/22/19, 10/23/19, and 10/24/19. Staff endorsed the treatment administration record (TAR), documenting the application and removal of the compression stockings for R73 as an intervention for [MEDICAL CONDITION] affecting the right leg. On 10/24/19 at 01:45 PM, conducted an interview with Registered Nurse (RN)1 in which the discrepancy between the surveyor observation and documentation was shared with RN1. RN1 acknowledged the TAR documentation does not accurately portray the effectiveness of the compression stocking, R73 refusal to use the compression stocking, or the actual application of the compression stocking.",2020-09-01
626,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2019-10-28,865,D,0,1,TWBN11,"Based on interview with staff members, the facility failed to ensure the Quality Assurance and Program Improvement (QAPI) committee corrected its own quality deficiencies. The QAPI committee did not ensure monitoring and improvement was achieved and sustained related to the formulation of advance directives. Findings Include: On 10/23/10 at 03:12 PM an interview was conducted with Assistant Administrator (AA) and Director of Nursing (DON). Inquired how the committee identifies quality deficiencies. The DON responded the facility identifies areas for improvement based on the results of the facility's previous recertification survey citations. Further queried regarding the citation for advance directives from the previous recertification survey as this is a repeat deficiency. The AA responded that there was some confusion regarding what was required for an advance directive, it appears that the chart auditing reflects whether residents had a POLST (Provider Orders for Life-Sustaining Treatment) not an advance directive. The AA stated based on the report/data presented to the QAPI committee the facility was almost a 100% for advance directives. Inquired what was the facility's goal to determine a successful project, the AA responded 100%. Further queried what happened, the AA responded she was not sure what happened. A review of the facility's Resident Census and Conditions of Residents provided on 10/22/19 at 12:45 PM found a total of 52 of 75 residents with advance directives.",2020-09-01
627,OAHU CARE FACILITY,125042,1808 SOUTH BERETANIA STREET,HONOLULU,HI,96826,2019-10-28,883,D,0,1,TWBN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of policy, the facility failed to offer and/or administer the pneumococcal immunization for one Resident (R)7, out of four residents selected for review. The schedule for the pneumococcal immunizations follows the current recommendation of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). As a result of this deficient practice, the facility put R7 at risk for acquiring, transmitting, or experiencing complications from pneumococcal disease. Findings Include: During a review of the current physician orders [REDACTED]. There was an actual physician order [REDACTED]. Thus, no evidence that R7 was either offered or received the pneumococcal vaccination. An inquiry was done with the Director of Nursing (DON) on 10/25/19 at 11:25 AM about the findings previously mentioned, the DON acknowledged that R7 had not received the pneumococcal vaccination. DON further stated that the overall pneumococcal immunization process for all residents is currently being reviewed, assuring that all the residents are up-to-date with their immunizations is still in progress. A review of facility's policy on Immunizations stated the following: Policy; It is the policy of this facility that all residents receive immunizations and vaccinations that aid in preventing infectious diseases unless medically contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director. Upon admission to the facility, permission must be obtained from the resident (or representative) to administer pneumococcal vaccine if there is no documented history of vaccination and influenza vaccine annually (in the Fall), unless contraindicated.",2020-09-01
628,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2019-01-14,578,E,0,1,EPJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review (RR), the facility failed to provide documentation that residents or their representatives were given opportunities to formulate an advance directive (AD) for residents (R)5, R49, R51, and R159 of 38 selected for review. Findings Include: 1) On 01/09/2019 at 08:59 AM, RR for R49 showed no AD and no Physician's Order for Life Sustaining Treatment (POLST). Interview with SW114 who stated she attempted to locate the AD and POLST but was unsuccessful. 2) R159 was recently admitted on [DATE] for long term care placement. R159's RR found she only had a general power of attorney for financial matters and a POLST. A 01/03/2018 progress note stated an admission care conference was held 12/27/2018 with the resident and her family members present. However, there was no AD or social services entry noting the status of whether the resident had a durable power of attorney for health decisions. On 01/10/2019 at 11:43 AM, during an interview with SW114, she was asked if during the admission process, whether the resident or resident's representatives were asked about an AD. SW114 stated, It has not been discussed with her (R159). SW114 confirmed that R159 does not have an AD. 3) On 01/09/2019 at 11:30 AM during a review of the R5's clinical record, it was revealed R5 had a POLST, and an order granting petition for the appointment of co-conservators and co-guardians. However, an AD was not found in her record. On 01/10/2019 at 11:41 AM, during an interview with SW114, she verified this resident did not have an AD in her chart. 4) On 01/09/2019 at 10:49 AM record review (RR) on R51 noted that the resident had a durable power of attorney (DPOA) for assets and a POLST form but no AD. On 01/10/2019 at 02:16 PM interviewed SW114 and she did RR on R51 and found that in the DPOA there is a paragraph that medical decisions can be made by the power of attorney as long as consistent with the living will. The RR found no living will and SW 114 went to investigate further. On 01/10/2019 at 03:17 PM SW114 reportedly spoke with hospice staff and the hospice file only had DPOA and POLST with no living will. The facility's policy and procedure, Resident Representation, (Rev. date: 10/25/99), stated at the section for AD: 1. Upon admission and during their residency at the facility, the social worker will discuss advance directives with the residents and their families or responsible representative and encourage them to execute these documents . 4. The Social worker ensures that the attending physician has a copy of the advance directives and a copy is placed in the resident's medical chart.",2020-09-01
629,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2019-01-14,584,E,0,1,EPJU11,"Based on observation, interviews and record review, the facility failed to ensure it maintained and provided comfortable, hot showers for residents for one of the shower rooms they used on the nursing units. This deficient practice had the potential to affect other residents who preferred showers on the nursing units. Findings Include: During the Resident Council (RC) interview conducted on 01/09/2018 at 10:15 AM, three residents stated sometimes when they showered, the hot water during their showers would become cooler and would be uncomfortable. One resident (R) 16 stated, I think the capacity of the water heater is not enough, when they turn on the shower, it's hot, then within 1 minute, it turns cold. R16 stated this happened again during his shower this morning. R16 resides on the second floor. R16 said he showers in both the A and B shower rooms, but that one of the shower rooms on their unit, gets cold. R16 said he did not have a preference for a particular shower room; he showered in whichever one was available to his certified nursing assistant (CNA) during his shower days. R22, who also resides on the second floor stated the hot water temperature was okay for her, and since she was on the same floor as R16, the difference was probably because she was on the other side of the second floor nursing unit from R16. R159, who resides on the third floor, stated for her hot showers, It starts off nice, but while showering, It really cools off. R9, who resides on the fourth floor, also said the hot water on their floor got cold during a shower. R9 said when another resident was simultaneously being showered in the other shower rooms, that was when the hot water became cold. On 01/10/2019 at 08:28 AM, a review of the water temperature logs taken for the shower rooms was done. During an interview with the environmental services (ES) staff 1, he stated he checked the water temperatures of the three shower rooms, A, B and C, daily, on all three nursing units. The facility's Daily Hot Water Temp Monitoring Log revealed that ES staff 1 was alternately checking the hot water temperatures for shower rooms B and C, but omitted checking the hot water temperatures for the shower room A on the three units. ES staff 1 affirmed he only checked the cold water temperatures for the three A shower rooms. ES staff 1 also said if he heard of any complaints about the hot showers being cold, he would check it right away and that he has checked shower room A for it. However, there was no documentation that this was done. The daily log showed for the three shower rooms on each nursing unit, a pattern existed whereby the A shower rooms were not checked for the hot water temperatures for (MONTH) through (MONTH) of (YEAR) and up to 01/10/2019. On 01/10/2019 at 08:52 AM, during an interview with the ES director, he verified ES staff 1 was supposed to check all shower rooms for the hot water temperatures and it was a random check. The ES director was unaware however, the A showers' hot water temperatures on the three units were not being checked as documented on the log, or that the hot water temperature became cooler during the showers. On 01/10/2019 at 09:21 AM, the ES director stated the CNAs will have to be re-trained to use a knob like a mixing valve during resident showers.",2020-09-01
630,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2019-01-14,655,E,0,1,EPJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan, in lieu of their baseline care plans, and provide a written summary of the comprehensive care plan to each resident and/or resident representative for three of 38 residents (Resident (R) 159, R111, and R109) selected for review. As a result of this deficient practice, there was a failure to ensure interim approaches/ interventions to address each resident's current needs were also implemented by staff within 48 hours of a resident's admission. Findings Include: A review was done for R159's, R111's, and R109's baseline care plans. An interview with Registered Nurse (RN) 122 on [DATE] at 10:44 AM revealed in lieu of developing baseline care plans required within 48 hours upon admission, the facility developed comprehensive care plans. For the three sampled residents, it was also found there were missing care plans based on the residents' admission diagnoses, and no written summaries were being provided as well. In addition, it was found the facility's policy and procedure on care plans had not been updated to include the current requirements for the development of either a baseline care plan and/or a comprehensive care plan if completed in lieu of the baseline care plan: 1) R159 was recently admitted to the facility on [DATE]. R159 was interviewed on [DATE] and [DATE], and found to be cognitively alert and oriented. On her Minimum Data Set (MDS) admission assessment, she scored 15 on her Brief Interview for Mental Status (BIMS). During the [DATE] interview, R159 stated she was here for long term and discussed her medical conditions and some of the medications she was receiving. However, she also stated she never received anything in writing about her care plans, although she attended a care plan meeting. R159's record noted her initial care plan conference was held on [DATE] and she and two other family members attended it. Record review (RR) also found R159's [DATE] admission orders [REDACTED]. There were six initial care plans developed, but none for the administration and use of the [MEDICATION NAME]mix and [MEDICATION NAME]. On [DATE] at 10:44 AM, during an interview of RN122, she stated R159's current care plans were comprehensive care plans that they developed upon the resident's [DATE] admission. RN122 verified the resident is also on a routine blood thinner, an insulin and a diuretic medication as per the admission orders [REDACTED]. RN122 further stated the admitting nurse was responsible for creating the baseline care plans. When RN122 was asked if these were the baseline care plans, she said, It's comprehensive, and affirmed they were not the baseline care plans, but comprehensive care plans developed in lieu of a baseline care plan. RN122 said an admission checklist to help develop baseline care plans still had not been implemented yet. RN122 was asked how a new or agency nurse would know how to develop a baseline care plan versus a comprehensive care plan. RN122 did not respond to the question but said for R159's admission, she thought it was an agency nurse (RN116) who should have developed the missing care plans. Another RN, (RN4) confirmed it should have been RN116. 2) A closed record review was done for R111's ,[DATE]-,[DATE] admission. The resident expired after being in the facility for six days with hospice care. R111's primary [DIAGNOSES REDACTED]. RR found the resident's initial five comprehensive care plans included care plans for her activities of daily living (ADLs), risk for fall, risk for skin breakdown, pain and discharge planning. However, based on a review of the resident's admission and stay, the facility failed to develop care plans for her [MEDICAL CONDITION] (swelling) to her lower legs, upper thighs, abdomen, and use of a diuretic, [MEDICATION NAME]. There also were no comprehensive care plans for how R111's magnesium oxide chewable tablets were to be given twice a day with fruit roll-ups. This was per R111's family member's request, and the record noted the family member was upset that it was not being given to R111 this way by the nurses. The nursing admission skin assessment also noted R111 was admitted with a portacath an ostomy bag, and swelling to both feet. R111 was also to continue her antibiotic use. Yet, there were no specific care plans to address the portacath, [MEDICAL CONDITION] bag and frequency of changes (i.e., every hour due to need and leakage) and/or the use of the antibiotic. 3) A closed RR for R109 was done. R109 was admitted to the facility on [DATE] post-surgery on her spine. She received and completed skilled rehabilitation services and was discharged to home on [DATE], with home health services to follow. A review of R109's comprehensive care plans revealed one for ADLs, falls, pain, skin, discharge planning, nutrition and interest/needs. R109 attended a [DATE] care conference, was able to make her needs known and was admitted for short term rehabilitation. However, there was no documentation in R109's clinical record that she had received a written summary of her care plans. On [DATE] at 12:12 PM, during an interview with RN122, she verified no written care plan summaries were given to their residents. She said they discuss the care plan with the resident during his/her care conference summary, but, no summary provided. UM121, also present during the interview, further stated the agency staff or newer nurses did not always formulate a care plan(s) and they have to do education for them. UM121 said it was based on nursing judgment. They both confirmed they currently do not have an orientation skills competency checklist for their new hire agency nurses but only a basic pamphlet about the things to learn (i.e., orientation topics) and phone numbers.",2020-09-01
631,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2019-01-14,656,D,0,1,EPJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review (RR), and review of the facility's policy and procedure, the facility failed to develop and implement a comprehensive care plan for four of 38 residents ((R) 33, R34, R35, and R77) selected for review. As a result of this deficient practice, there was a failure to ensure each resident's highest practicable physical, mental, and psychosocial well-being was provided. Findings Include: 1) R33 was observed on 01/09/2019 08:55 AM asleep in bed with no splint devices on. The resident triggered for limited range of motion (ROM) as part of her review. On 01/10/2019 at 07:14 AM, R33 was observed during a hoyer lift transfer out of bed to her wheelchair. The certified nurse aide (CNA) 56 stated R33 had bilateral knee splints applied when in bed, but clarified it was placed around 2:00 PM by the restorative nurse aide (RNA) 113 and taken off during evening shift. On 01/10/2019 at 09:18 AM, during an interview with RNA113, she verified she applied R33's bilateral knee splints from 01:00 to 02:00 PM, to help with her contraction. Reviewed a 06/18/2018 rehabilitation note to nursing for knee splinting and bed positioning with pictures with RNA113. RNA113 was asked how this was communicated and she said she provided on-the-spot training for new CNAs on how to apply R33's bilateral knee splints. On 01/10/2019 at 11:59 AM, during an interview with RN116, she produced R33's Restorative Care Flow Record for the month of (MONTH) 2019. The goal was to maintain the resident's current bilateral lower leg ROM, reduce the risk of both hip and knee flexion adduction contractures three to five times a week and to do stretching exercises slowly. RN116 confirmed the flow record was a treatment record and stated there was no comprehensive care plan developed specifically for R33's limited ROM for her bilateral lower extremity contractures with stated goals and interventions. 2) On 01/08/2019 at 12:45 PM, an interview with a family (F) 1 member for R35 was done. F1 said a yellow Velcro brace to R35's right arm had been discontinued. The F1 said it was to help R35 to be able to extend her arm out a little more, but due to the bruise she developed, the forearm splint was discontinued. The F1 said the resident is [AGE] years old with fragile skin. The F1 understood the reason for the splint application and was informed of the reason to discontinue it for now. RR found a 11/17/2018 order for 15 occupational therapy (OT) sessions in 90 days for contracture management, including therapeutic exercises, orthotic management and wheelchair positioning. R35's [DIAGNOSES REDACTED]. On 01/10/2019 at 09:14 AM, an interview of CNA40 was done. She stopped applying R35's right forearm splint around 01/03/2018 because of the bruise. CNA40 said she told the nurse about it, and the therapist also said not to use it anymore. The CNA40 was unsure of whether a care plan had been developed for it. On 01/10/2019 at 12:06 PM, during an interview with RN116, she said she was aware that R35's right arm splint was discontinued, but unsure of the date. On 01/10/2019 at 12:13 PM, during an interview with OT125, she stated for R35, due to her tightness and contractures in her right elbow, she was referred to OT. They were going to trial her with therapy for six hours and to transfer R35 to nursing to continue the therapy, but they noticed the bruising. OT125 said the CNA reported the bruise, it went to nursing and then rehab was told about it. OT125 said that was when the splint was, put on hold, right after we found out. There was an Occupational Therapy Upper Extremity Splint Schedule dated 01/03/2019. Per further interview with RN116 on 01/10/2019, she verified her 01/03/2019 progress note about R35's purple discoloration of 2 cm x 2 cm at the right inner elbow area with splint removal. RN116 said she did not care plan it because it it did not meet the facility's criteria, i.e., it was less than 2.5 cm in size. RN116 said this morning (01/10/2019), she received an endorsement by the night shift that R35's bruise was resolving but the bruise was noted at 14.0 cm x 10.0 cm as a green to yellowish and purplish bruise to R35's right arm and a purple bruise to the inner elbow site (antecubital) at 3 x 3 cm. RN116 stated the bruise was now larger (note: seven days after her 01/03/2019 entry). RN116 said she would start a care plan for it and verified she should have done so initially with the knowledge that the resident's right arm splint had been discontinued upon the discovery of the bruising. On 01/11/2019 at 12:57 PM, the Director of Nursing (DON) and Unit Manager (UM) 121 stated R35 had a comprehensive care plan developed for the resident's bruise. The State Agency (SA) told them that RN116 was going to develop it. The DON and UM then realized that R35's care plan #12 was just developed on 01/10/2019 after RN116 informed the SA there was no care plan. On 01/11/2019 at 01:16 PM, during an interview with the DON, she said it was an expectation that there would be a care plan for R35. She acknowledged the charting was not very clear based on RN116's 01/03/2019 nursing entry and there was no further documentation until the 01/10/2019 entry by the night shift RN. There also was no follow-up documentation as to R35's right arm status by other licensed staff and/or rehab services, including the DON and UM who were unaware of which staff and when the initial comprehensive care plan was finally developed. On 01/14/2019, during an interview with UM121, review of the facility's policy Comprehensive Care Plans, was done. Per the policy, it stated, B. Original Care Plans - 1. Initiate and complete an original care plan if standardized care plans do not accurately describe resident status or needs, e.g. if the majority of interventions do not apply, complete an original care plan. UM121 was asked how they identified the need for a care plans to be developed based on the lack of care plans found on the survey. UM121 acknowledged their policy was not up-to-date with the requirements. UM121 also replied if an agency nurse did not develop a needed care plan for a problem area, he would address it with the staff at the time, but overall, it was not something they were tracking to ensure assessments and appropriate care plans were being done. 3 ) On 01/09/2019 at 09:32 AM observed R34 in the activity/dining room with apparent neck contracture and head leaning to the left (L) with a towel on the L shoulder to catch drool from the resident's mouth. The record review (RR) on R34 found a comprehensive care plan (CP) dated 03/16/2018, for assistance required in performing activities of daily living (ADL) and interventions primarily for extensive to total assist in ADLs. On 01/14/2019 at 10:55 AM interviewed RN25 and inquired if R34 used a neck brace in the past. According to RN25, R34 was resistive to OT and neck brace was never worn because the resident was admitted for long-term care (LTC). The RR found on R34's admission form dated 07/29/2013, head tends to lean to the left, with admission [DIAGNOSES REDACTED]. The recent physician exam dated 01/03/2019 noted, under the Assessment and plan, . Dementia, Cont supportive care. No new behavioral issues. Plan of care: here for long term care. An OT note dated 07/30/2013 had written that R34 was observed as agitated at times and refused to assist with self care. The OT worked on therapy activity to increase neck range of motion (ROM), strength and proper positioning. The OT noted that R34 had fluctuating cooperation and to progress ADL retraining when R34 became cooperative. A PT progress and discharge summary form dated 07/07/2016 noted that R34 was discharged to SNF. Caregivers instructed in bed wheelchair transfers using bed bar and shoes. There was improvement in transfers, as a result of the skilled therapy services provided, and allowed R34 to require less caregiver support and reduced the risk of falls and injuries to the resident and caregivers. Inquired of UM121 if there was a CP for R34 for neck support and drooling onto L shoulder when sitting upright in activity/dining room and there was none. The UM121 stated that neck contracture CP could be started, but R34 had behaviors of swinging at staff, if asked to do something that didn't want to do. Inquired how agency or new staff would know what to do when R34 was transferred to the wheelchair and brought to activity/dining rm. The UM121 reviewed R34's CPs and agreed that there were no specific CP for the resident's neck leaning towards the L and need for drool pad on the L shoulder. Also, queried UM121 whether R34 would be more cooperative for neck ROM from OT 2013 assessment and UM121 didn't consider. The facility did not ensure that R34 had a comprehensive care plan to prevent further neck contracture to promote the resident's quality of life. 4 ) On 01/10/2019 at 11:25 AM observed RN29 do a dressing change on R77's bilateral ears. According to RN29 both ears were at Stage 4 due to ears have no muscle tissue or subcutaneous tissue just cartilage under skin. The R77 was lying on back and had a rolled towel at L side of head to position off of ear. Inquired of RN29 if pressure ulcer to ears happened due to R77 not turning every (q) two hrs, and RN29 stated that R77 was turned q 2 hrs but tends to turn head to the left. The comprehensive CP9 dated 12/17/2018, Resident receives stage-appropriate wound care, experiences pressure reduction and has controlled risk factors for prevention of additional ulcers within the next 14 days; 12/17/18 Resident will experience healing of pressure ulcers AEB decrease in size, in the next 14 days;12/17/18 Pressure ulcer noted on the L ear helix (St. IV) and to L ear mid section (St IV). The interventions included: Administer TX as ordered; turn res q 1-2 hrs. On 12/29/2018 CP#13 was developed for Pressure ulcer noted on the R ear mid section (St IV), and interventions were the same as for CP#9. On 01/11/2019 at 12:21 PM interviewed RN4 and reviewed R77 CPs with him. Inquired if R77's PU to the ears were avoidable or unavoidable and RN4 stated that PUs are avoidable because staff should turn resident q two hrs. Inquired whether PU started because of staff not turning R77. RN4 stated that staff turn resident, but R77 tends to turn towards the left (L) side which is the weak side, and pillow used to position head to off-load on ears. The CPs did not include interventions to position R77's head with a pillow to off-load on ears. On 01/11/2019 at 12:45 PM observed R77 with towel roll under the R shoulder area and inquired of CNA how towel roll, placed in shoulder area, kept R77's head from moving. The CNA did not have an answer and stated that when R77 was admitted she/he was unable to move head side to side but now able to and can now track with eyes. On 01/14/2019 at 11:11 AM interviewed UM121 and he stated that R77's PU on the ears were probably from the nasal cannula (NC) tubing. UM121 further stated that at admission R77 was flaccid and couldn't move and head rested on a soft pillow, with the only hard surface being the NC tubing around the ears. Queried whether a CP was developed to prevent PU's from developing with NC use, and UM121 stated that a PU CP9 was implemented, and subsequently a separate PU CP13 was developed for the R ear. Inquired what was done differently from CP9 to CP13, and UM121 stated that the wound specialist educated staff and CP should have been updated by treatment nurse after education. The facility failed to develop a comprehensive CP for PU to the L ear and subsequently R77 developed PU to the R ear. Also, R77 had skin wound on the L inner thigh close to where Foley tubing was secured, that was not yet diagnosed by the physician at time of survey.",2020-09-01
632,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2019-01-14,686,G,0,1,EPJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews (RR) and interviews the facility failed to promote the prevention of pressure ulcer (PU) development; and prevent development of additional PU for one of 38 residents (R) 77 on the survey sample. As a result of this deficient practice, R77 developed a Stage 4 PU to the left (L) ear six days after admission; and, Stage 4 PU to the right (R) ear 13 days after admission. Findings Include: On 01/10/2019 at 08:05 AM observed R77 lying in bed with adhesive bandage covering top of L ear . RR on R77 included admission orders [REDACTED]. Review of R77's physicians orders (PO) included a telephone PO dated 12/17/2018, Cleanse L ear helix with normal saline (NS), pat dry, apply [MEDICATION NAME] to open areas, and cover with absorbent dressing daily (QD) and as needed (PRN) until healed (Diagnosis: [REDACTED]. Additionally, a Wound Assessment Details Report, with date of 12/29/2018 noted a facility acquired pressure ulcer on the R ear at Stage 4. Description of the R ear wound included: tissue bright pink to red 50%; slough loosely adherent 40%; necrotic soft, adherent 10%; light serosanguineous exudates; maceration; and, measured 1.80 x 1.50 x unknown (LxWxD); area 2.70 cm2; no tunneling. On 01/10/2019 at 08:44 AM interviewed RN4 and inquired how R77's PU's on both ears started, and RN4 stated that R77 had L side weakness and tends to lie on L side. Reviewed R77's medical records with RN4 and on the 12/16/2018 [MEDICAL CONDITION] assessment, Stage 2 (0.2 x 0.8 cm); serosanguineous scant drainage; open edge pink/red; L ear tip (Helix) superior; and on 12/19/2018 Stage 4; 0.8 cm x 0.5 cm, written by RN29 (facility wound nurse). According to RN4, the unit manager (UM)121, corrected the wound from Stage 2 to Stage 4. On 01/10/2019 at 11:25 AM observed RN29 do dressing change for PU on R77's bilateral ears. According to RN29 both ears were at Stage 4 due to ears have no muscle tissue or subcutaneous tissue just cartilage. The RN29 cleansed PUs with NS, applied [MEDICATION NAME] and absorbent bandage to both ears. The R77 was observed lying on back and had rolled towel at L side of head to position off of ear. Inquired of RN29 if PU to ears happened due to R77 not turning q (every) 2 hours (hrs), and RN29 stated that R77 is turned q 2 hrs but tends to turn head to the left. The care plan problem list dated 12/11/2018 included a care plan (CP)9 At Risk for Skin Breakdown, that included interventions for staff to: assess skin daily during activity of daily living (ADL) care and report changes to charge nurse; reinforce importance of mobility, turning or ambulating; turn and reposition q 1-2 hrs and PRN; maintain proper body alignment; and, provide pressure relief interventions as needed based on skin assessments. On 12/17/2018 a comprehensive CP was developed for, Pressure Ulcer; Site: L ear helix. The CP goal was for resident to receive stage appropriate wound care, experience pressure reduction, and controlled risk factors for prevention of additional ulcers within the next 14 days. On 12/29/2018 a comprehensive CP13 was developed for pressure ulcer on the R ear midsection; Pressure ulcer noted on the R ear mid section (St. IV). On 01/11/2019 at 10:18 AM observed wound care assessment done by contracted wound specialist (WS) and RN26. The WS assessed, measured, applied treatment of [REDACTED]. The WS commented that the PU on the R ear was improving but the PU on the L ear was taking longer because R77's head leaned towards the [MI] The WS stated that R77 lying on ears caused PUs and when staff off-loaded the head from the L side, PU on the R ear started. On 01/11/2019 at 01:21 PM interviewed RN4 and inquired if R77's PU to ears were avoidable or unavoidable and RN4 stated that PU's were avoidable because staff should turn resident q two hours. Inquired whether PU started because staff did not reposition R77 off of ears, and RN4 stated R77 tends to turn towards the L side (weak side) even if staff reposition. Staff were supposed to position R77's head by using pillow to off-load on ears. On 01/14/2019 at 07:23 AM observed R77 lying on back and L ear open to air with gauze dressing underneath with scant serosanguineous drainage and towel roll to R of pillow. Inquired of RN4 if R77's PU on L ear now left open to air. RN4 stated that should be covered with foam dressing, then went to R77's bedside to close dressing shut as adhesive bandage didn't close properly. On 01/14/2019 at 11:11 AM interviewed UM121 and inquired about R77's PU to both ears. The UM121 stated that PU's probably from nasal cannula (NC) tubing because at admission R77 was flaccid and couldn't move. Staff positioned R77 to off-load on L ear and that's when PU on R ear started. The UM121 stated that facility staff didn't want to switch R77 to oxygen mask because there would be more pressure points from a mask. The UM121 further stated that R77 was referred to the wound consultant, provided PO for PU treatment, and PU CP implemented, with a separate PU CP for the R ear when it occurred. Inquired of UM121 what was done differently after PU on R ear was noted, and he stated that WS educated staff and the treatment nurse should have updated the CP after received education. Queried UM121 on his role in regards to pressure ulcer development and response was that he monitored whether wound consultant followed treatment plan, and discussed in weekly wound meetings. On 01/14/2019 at 12:14 PM interviewed agency RN131, who stated that it was her 3rd time to work at the facility as treatment nurse. RN131 finished treatment dressing to R77's L thigh wound and PU on both ears. RN131 described the PU to the R ear as drying, and PU on L ear still open The RN131 stated that R77's treatment plan was followed and found in the unit's treatment book. The RN131 further stated that R77 was weaned from oxygen yesterday and no longer using NC. The facility did not promote the prevention of pressure ulcer development and prevent development of additional pressure ulcers for R77.",2020-09-01
633,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2019-01-14,697,D,0,1,EPJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review (RR), the facility failed to adequately monitor R49's and R93's severe chronic pain of 38 sampled residents selected for review. This deficient practice prevented the resident from attaining or maintaining his or her highest practicable level of well-being and to prevent or manage pain. Findings Include: 1) On 01/08/2019 at 10:23 AM, Bedside observation and interview with R49 showed R49 had facial grimace and stated she has pain to her epigastric area. R49 stated she has severe pain on a daily basis. When queried by surveyor about pain medication and whether it helps, R49 did not respond. On 01/10/2019 at 08:29 AM, Interview with registered nurse (RN)10 who stated she was only able to locate pain monitoring flow sheet for (MONTH) (YEAR). RN10 stated there were no pain monitoring flow sheet for (MONTH) and (MONTH) (YEAR). RN10 stated there should be a pain monitoring flow sheet monthly. On 01/10/2019 at 08:45 AM, RR of R49's Medication Administration Record [REDACTED]. On the back of the MAR indicated [REDACTED]. As stated earlier, RN10 confirmed there were no pain monitoring flow sheets for November/December (YEAR). [MEDICATION NAME] 2.5mg by mouth every four hours as needed (prn) for pain was ordered on [DATE] and was given once on 12/30/2018 but nothing before or after was given to R49 by staff. 2) On 01/11/2019 at 09:27 AM, RR showed R93 has [MEDICATION NAME] ([MEDICATION NAME]) 5% patch 1 patch topically to lower back daily for pain, Tylenol 650mg by mouth four times a day (QID) not to exceed 3 grams per day, Tylenol 650mg by mouth every four hours prn for Temp greater or equal to 100F or pain on scale of 1-5 (not to exceed 3 grams per 24 hours), [MEDICATION NAME] 5/325mg by mouth every 6 hours prn for moderate pain (low back pain, hold for sedation). R93's pain monitoring flow sheet showed no consistent monitoring for (MONTH) 2019 (beginning of (MONTH) to survey date 01/11/2019) and on the back of the MAR's, no documentation of assessment of effectiveness of the pain medications given. On 01/11/2019 at 10:17 AM, Interview with unit manager (UM)115 who confirmed that pain monitoring for residents is not adequate. UM115 stated the facility is working on providing the staff in-service training on accurate assessment and documentation for pain monitoring of residents.",2020-09-01
634,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2019-01-14,725,H,1,1,EPJU11,"> Based on observations, record reviews, interviews and review of the facility's policies and procedures, the facility failed to ensure there was sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Cumulative findings included the development of facility acquired pressure ulcers for physical harm; resident reports of psychosocial distress due to delayed personal hygiene to change briefs; family report of need to come to facility during meal times because lack of staff to feed residents incapable of self-feeding; nurse comments of having to work double shifts; and the lack of development of resident-centered care plans. Findings Include: 1) On 01/11/2019 at 12:21 PM reviewed R77's pressure ulcer (PU) care plans (CP) with RN4 as he stated that PUs were avoidable because staff should turn resident q (every) two hours (hrs). RN4 stated that staff turned R77 q two hrs but resident tends to turn towards the left (L) side, and a pillow was used to position R77's head to off-load on ears. The RN4 couldn't find in R77's CP interventions that a pillow should be used to position R77's head to off-load on ears. On 01/11/2019 at 12:45 PM observed R77 with towel roll under the R shoulder area and inquired of CNA how towel roll, placed in shoulder area, kept R77's head from moving. The CNA did not have an answer and stated that when R77 was admitted she/he was unable to move head side to side but now able to and can now track with eyes. On 01/14/2019 at 11:11 AM interviewed UM121 and he stated that R77's PU on the ears were probably from the nasal cannula (NC) tubing for oxygen. UM121 further stated that at admission R77 was flaccid and couldn't move and head rested on a soft pillow, with the only hard surface being the NC tubing around the ears. Queried whether a CP was developed to prevent PU's from developing with NC use, and UM121 stated that a PU CP9 was implemented, and subsequently a separate PU CP13 was developed for the R ear. Inquired what was done differently from CP9 to CP13, and UM121 stated that the wound specialist educated staff and CP should have been updated by treatment nurse after education. On both CP9 and 13 there were no interventions to prevent PU on ear from NC. The facility failed to continually assess and develop comprehensive PU CPs for R77 and the resident acquired PUs to both ears after admission to the facility. Also, R77 had developed a skin wound on the L inner thigh close to where Foley tubing was secured, that was not yet diagnosed by the physician at time of survey. 2) Review of R159's, R111's and R109's baseline care plan status revealed licensed staff failed to develop and implement baseline care plans (comprehensive care plans were developed in lieu of them), yet not within 48 hours of admission, and failed to ensure written summaries were provided to the residents and/or their representatives (refer to F655). 3) Review of R33's and R35's comprehensive care plans revealed a failure to ensure each resident's highest practicable physical, mental, and psychosocial well-being was provided as resident-centered care plans were not developed for the R33's limited range of motion (ROM) and R35's bruise and limited ROM (refer to F656). A family (F) member 1 for R35 said the facility's staffing was different now with a lot of agency staff. F1 said if she did not come to feed R35, she was not assured the staff would be able to feed R35 timely because there were many residents who needed to be assisted with not enough staff. 4) During the Resident Council (RC) interview conducted on 01/09/2018 at 10:15 AM, two residents voiced concerns of the lack of staffing on their units. One resident confidentially shared on her fourth floor unit, they were often short of staff and staff did not come timely when she called for them. The resident stated it could take approximately 30 minutes for nursing staff to attend to her on the night shift, especially when she needed to be changed or cleaned. The resident said although she used her call light, one CNA often would not be able to attend to her because they were short of staff. Another resident also confidentially shared that on her third floor unit, during the day, there often was only one activity aide in the dining room. This resident said because the other CNAs are busy feeding and giving showers, so when you want to go, you have to wait and have no way of calling somebody. She said she has witnessed an old timer CNA tell a resident, You have to wait, and felt uncomfortable with how the resident was told this. This resident did not want to identify the old timer CNA, but stated she witnessed this upon her recent admission to the facility. 5) On 01/10/2019 at 06:30 AM, the resident on the fourth floor stated they had three CNAs for the night, and the response time was good. The resident verified it was when there were only two CNAs for the night shift that it took as long as 30 minutes for her needs to be met. The fourth floor nursing unit was identified as the more subacute unit with some residents who are ventilator dependent. 6) On 01/10/2019 at 06:59 AM, a confidential interview with three third floor night shift CNAs was done. They stated they are usually staffed with two CNAs at night with the exception to add an additional CNA if they have more restless residents to care for. The three CNAs said one resident likes to toilet herself and stands often and there were three other residents who were often restless at night. They said they were all in different rooms attending to them, and having an extra third CNA helped a lot. They said their fall rate was low because they took it upon themselves to literally run to get to a resident's bedside when they heard any slight noise, even like the rubbish can moving. Otherwise, they acknowledged it was harder to be staffed with only two CNAs at night with residents who were often restless. 7) On 01/10/2019 at 09:14 AM, per CNA40, she said for the third floor, the CNAs help one another. CNA40 confirmed this floor had a lot of residents requiring assistance with feeding, and said, I don't want to lie, hesitated, and continued on to say they help each other out and try their best to serve the residents. 8) A closed record review for R111 revealed a late 11/24/2018 nursing entry for a 11/23/2018 entry. The licensed nurse wrote a family member of R111 was so upset regarding what happened, . made her very anxious, pressed the call light and been waiting for someone to come but no one attended her for 30 minutes per resident. 9) On 01/14/2019 at 09:00 AM, an interview with the DON was done. She acknowledged they have had staffing concerns and worked with adding an additional agency to fill the shifts. The DON acknowledged the fourth floor nursing unit, because of subacute, our staffing is done differently there, but could not elaborate on how it is done differently to ensure the residents' care needs were being met on all shifts. In addition, the DON was vague in her response to various questions, such as what her process was to ensure the residents were being assessed and care plans were being developed and implemented. The DON said she has lost old timers, I have 100% change in my nursing leadership. The DON then referenced a process using a reference book for her new unit managers to use. However, she confirmed she has not done any training with her nursing staff for, this guide, that relates specifically to long term. The DON further said for their baseline care plans, it was a product she pushed forward, but other administrative staff did not agree with it so they were deadlocked over it. Hence, the baseline care plans nor their care plan policy had not been updated to reflect the new regulatory requirements and the DON affirmed she did not provide the long term care guidance to her new managers/nursing staff. 10) An anonymous complaint investigation was also reviewed during the survey related to the lack of sufficient staffing. Although the resident was not identified, based on the information provided by the complainant and the survey findings, the SA substantiates the allegation of the lack of staff which affects nursing's core ability to identify, assess, develop, implement and revise necessary care plans for their residents. 11) Interview on 01/08/2019 at 9:55 AM with Resident (R)96 stated I talked with the supervisor and told him but nobody is taking us seriously that it takes 2-3 hours to get my diaper changed. R96 goes on to say that last night, I wanted to get something to make me warm and she doubled the sheets to make me warm. Staff said oh there are no blankets. A couple of weeks ago, there was no socks. I had to tell my wife to go buy me socks because my feet was so cold. It's the nurses who say, I'll be back and they don't get back. I wait 2-3 hours. During the relicensing survey, complaint 5669 was investigated. An observation along with interview was conducted with R91's family (F) member (F2) on 01/09/2019 at 8:28 AM. F2 Stated that sometimes, the temperature is at 68 degrees but lately it's gotten better. F2 further states that a lot of nurses are working double time and they are tired. I am worried that they are so tired and the patients are being neglected. Something bad could happen, like a wrong medication administered. Interview and concommitant observation with Unit manager (UM)115 who stated that the air is at 72 degrees to accomodate the comfort of the residents and showed this surveyor the temperature reading. Temperature was confirmed at 72 degrees. Interview and observation on 01/10/2019 at 6:39 AM R96 stated I asked for a blanket last night and they gave me two sheets. I'm cold but it's too late. They said they had no blankets. This surveyor validated that the resident had double sheets. At 6:45 AM, CNAs were doing change of shift and this surveyor asked CNA if they had any blankets. Observed delivery of a cart from laundry department. No blankets were noted on the cart that was delivered. Checked the supply room where the CNAs stated that they stock their portable carts with blankets. Carts are located throughout the floor. There were no blankets in the supply room. Confirmed with Clinical Nurses Aide (CNA)52 who stated that they don't have any blankets on the 4th floor. CNA 52 stated I had to go to the 3rd floor to get a blanket. Interview on 01/10/2019 at 9:06 AM with Recreational Coordinator (RC)127 stated On the fourth floor, there is only me. There is only one staff because this is the rehab floor and there is less attendance. It's 8 hours a day and 7 days a week. All residents can participate in activities on any floor. We have a part-time position for sub-acute level to designate the ones that have difficulty coming out of bed, like the trachs. The position has been in place shortly after we started about 3-4 years ago. This is to accomodate more bedside visits, one to one. We set their bedside tables up. However, it's been vacant or six months. I've had students and some CNAs but haven't been able to find anyone. Activity Aide (AA)128 will dedicate part of her day where she will go one to one on the floor. She spends roughly 1-1/2 hours seeing residents on the floor. Interview with AA128 at 01/10/2019 at 9:17 AM - I go on the floor almost every day, like in the morning, I greet them, talk story. I give the newspaper, let them know the lunch and dinner. I go to every room. Since I start at 8:00 AM, I spend about one hour and 15 minutes because I have to come here before 9:15 AM. 01/11/2019 at 5:33 AM - Interview with Registered Nurse (RN)30 who wanted to remain anonymous because of retaliation. Queried RN30 regarding how often she has to work overtime, how much agency staff is being used, how are current staffing needs determined? RN30 stated Staffing has been bad since the last survey. Our sister facility transferred their vents here and admin didn't increase the staffing to accommodate the level of acuity. They don't see what our needs are . It's not safe when we have two CNAs and a lot of times we are short CNAs. When we are short CNAs, it is difficult. We just had a batch of new nurses in (MONTH) that are in training. A lot of times, we will train them and they stay for a year and they leave because they see how it is. I work at times 16 hours a day for a week and come in on my day off because if their short, the residents will suffer and there are too many newbies who cannot function as house manager. It seems that administration does not see how short we are, either nurses or CNAs or both. We want change. A lot of nurses want change. We are not a union. They will mandate us to stay and I have worked five days in a row of 16 hours at a time. It is getting better but I hope the new batch of nurses will stay. We have two agency nurses tonight and one RN on orientation. Our census is 33, capacity is 41. We need three CNAs. Interview on 01/11/2019 at 545 AM with RN130. I am an agency nurse and I've been here for three days. When I first started coming here, you get oriented to one side, 2nd and 3rd floor. Orientation on the 4th floor is five days and for the sub-acute, I took a respiratory class. Interview on 01/11/2019 at 5:55 AM with RN9 states I've been training since December. I will train a total of ten shifts for 4th floor A and B side. Two days on my own and three days for sub-acute. I also had a respiratory class. Interview on 01/11/2019 at 6:06 AM with RN129 states I haven't been here since (MONTH) but it was unsafe then. We were short for CNAs. As a nurse, when it is short, it pulls me away from the duties of the RN because we can't ignore lights. It was short staffed when I came in November. Tonight it's not too bad. Interview on 01/11/2019 at 6:21 AM with CNA99 states sometimes they mandate us to stay for day shift, either four hours or eight hours to help with vital signs, get residents up. Usually, we should have 3 CNAs but a lot of times we have two and evening stays back to help with vitals. A lot of CNAs work 16 hours. It happens a lot. Interview on 01/11/2019 at 6:30 AM with RN30 stated we usually have a treatment nurse but today we only have four with one orientee. The treatment nurse helps although they don't consider it a permanent position. Today we are short for treatment nurse and all week. We are short for a CNA today. Evening shift functions on four and pretty much short all week. On Monday, two evening shifts stayed back to for nights because we only had one CNA, so CNA was mandated to stay over. Interview on 01/11/2019 at 8:33 AM with Nursing Supervisor (NS)131 stated the treatment nurse is not an actual position. CNA level 2 can fill that position but it has to be a CNA2. If we have extra nurses, we try to fill it. Interview on 01/11/2019 at 9:02 AM with Director of Nursing (DON) stated the staffing is done differently on 4th floor because of the subcute and there would be 5 CNAs for 41. I inherited this grid. I have 16 vents, 12 on A and 12 on B. We have been advertising. I had six openings for RNs and filled one. I have six licensed practical nurse positions to fill but we have not been able to fill those. DON shared the various advertising and recruitment scenarios but says filling positions has been a challenge.",2020-09-01
635,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2019-01-14,726,H,1,1,EPJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations and interviews the facility failed to ensure that facility staff possess the competencies and skill sets necessary to provide nursing and related services to meet the resident's need safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Findings Included: 1) On 01/08/2019 at 12:28 PM interviewed the administrator (ADM) to investigate complaint (ACTS#6292), made to the state agency (SA) on 05/09/2018. The complainant reported that his mother (victim) was administered the wrong medications (meds) and sent to an acute hospital emergency department for treatment on 05/04/2018. According to the ADM, an agency nurse mistakenly administered meds that belonged to resident in bed (403C) to resident (victim) in bed (403B). On 05/04/2018 at 06:00 PM the resident (victim) was incorrectly administered: Atorvastatin 80 mg, [MEDICATION NAME] 300 mg, [MEDICATION NAME] 2 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 5 mg, Senna-S 8.6/50 mg, and [MEDICATION NAME] 5 mg. The resident was sent to an acute hospital emergency department (ED) by ambulance and arrived there at 08:39 PM. The ED progress notes documented that the resident (victim) was assessed, monitored and treated with 0.4 mg of [MEDICATION NAME]. The resident had no [MEDICAL CONDITION], no [MEDICAL CONDITION], no respiratory distress and vital signs remained stable. The resident (victim) was released from the ED on 05/05/2018 at 08:30 AM and brought back to the facility. The ADM stated that the resident was discharged on [DATE] to family with homecare services after completing her short-term rehab stay at the facility and had no other adverse events after the above incident. On 01/14/2019 at 02:49 PM interviewed the ADM and DON and inquired if the facility developed a new process for orienting agency nurses to the facility. The ADM stated that agency nurses follow seasoned nurses for one shift in general. The agency that the nurse (perpetrator) came from was more problematic with med errors. The facility still uses the agency but now use nurses that are known to them. The facility made med errors a quality assurance (QA) project and the med error rate decreased from a high of 65 in (YEAR) down to 5 in (YEAR). The med error went back up to 21 in (YEAR) on the fourth floor due to the resident status mix of subacute and short-term rehab. The resident (victim) was on the fourth floor. 2) On 01/10/2019 at 10:03 AM observed two CNAs transfer R77 from the shower gurney back to bed. The R77's Foley catheter container was lying flat on the shower gurney to the left side of R77. The Foley catheter container had urine in it and was was placed into the Hoyer-lift sling next to R77. As one CNA operated the Hoyer-lift to transfer R77 back to bed, the other CNA grabbed a towel to catch the urine that began to leak from the sling. Inquired of the CNA whether the Foley catheter container should be lower than R77 and the CNA stated, Yes, but we're transferring. Interviewed UM121 at the unit's nursing station and queried how Foley catheter system should be placed when transferring resident on shower gurney and Hoyer-lift. The UM121 stated that Foley catheter system should be hung to side of shower gurney and one CNA should be holding Foley catheter container when the resident is transferred in Hoyer -lift sling. Shared observations with UM121 and he stated that would talk to CNAs. 3) On 01/10/2019 at 12:50 PM observed RN4 administer insulin to R77. Observed that RN4 prepped the insulin 3 cc syringe for two units of insulin by pushing two units of air into the insulin bottle rubber stop and then pulling back two units of insulin. Followed RN4 to R77's bedside for insulin administration and RN4 removed the syringe cap and pushed out some insulin before administering to R77. Inquired of RN4 if that was the usual practice for insulin administration. RN4 stated that there was a small air bubble in the syringe and whether he injects subcutaneous (SQ) or intramuscularly need to ensure no air bubble in syringe. Inquired if R77 received the two units of insulin after RN4 pushed out some insulin with air bubble and he did not have an answer. The DON provided the policy and procedure for subcutaneous injections and there was no step in the procedures to remove air bubble from the syringe for SQ injections. 4) On 01/14/2019 at 09:00 AM, an interview with the DON was done. She acknowledged they have had staffing concerns and worked with adding an additional agency to fill the shifts. The DON acknowledged the fourth floor nursing unit, because of subacute, our staffing is done differently there, but could not elaborate on how it is done differently to ensure the residents' care needs were being met on all shifts. In addition, the DON was vague in her response to various questions, such as what her process was to ensure the residents were being assessed and care plans were being developed and implemented. The DON said she has lost old timers, I have 100% change in my nursing leadership. The DON then referenced a process using a reference book for her new unit managers to use. However, she confirmed she has not done any training with her nursing staff for, this guide, that relates specifically to long term. The DON further said for their baseline care plans, it was a product she pushed forward, but other administrative staff did not agree with it so they were deadlocked over it. Hence, the baseline care plans nor their care plan policy had not been updated to reflect the new regulatory requirements and the DON affirmed she did not provide the long term care guidance to her new managers/nursing staff. 5) The facility failed to provide no less than twelve hours of in-service education for every nurse aide employed by the facility. There were seven CNAs who did not meet this requirement. This included various topics, such as one for dementia care for the (MONTH) (YEAR). This topic was not completed by these seven CNAs (refer to F730). 6) Review of R159's, R111's and R109's baseline care plan status revealed licensed staff failed to develop and implement baseline care plans (comprehensive care plans were developed in lieu of them), yet not within 48 hours of admission, and failed to ensure written summaries were provided to the residents and/or their representatives (refer to F655). 7) Review of R33's and R35's comprehensive care plans revealed a failure to to ensure each resident's highest practicable physical, mental, and psychosocial well-being was provided as resident-centered care plans were not developed for the R33's limited range of motion (ROM) and R35's bruise and limited ROM (refer to F656). A family (F) member 1 for R35 said the facility's staffing was different now with a lot of agency staff. F1 said if she did not come to feed R35, she was not assured the staff would be able to feed R35 timely because there were many residents who needed to be assisted with not enough staff. F1 said with the change in staffing, this administration has been different, just different, about how concerns were addressed and with many different staff, F1 expressed uncertainty in whether the staff knew about the residents, including R35. 8) R20 was identified with recurrent urinary tract infections [MEDICAL CONDITION] and recently started on an antibiotics for eight weeks for a UTI. During an observation of perineal care for R20 done by CNA117 on 01/14/2019 at 10:43 AM, CNA117 stated this was the first time she was assigned to care for R20. CNA117 said she is an agency CNA and today was her first solo shift to care for residents on the third floor unit. CNA117 stated during the morning rounds and endorsement, she was told there was nothing to worry about for R20, including her skin condition. CNA117 was asked whether she knew that this resident was currently on antibiotics for a UTI and if she read R20's care plan. CNA117 said no, and said no other information or guidance was provided to her. CNA117 said she received two days of orientation, which was good enough for her, but nodded that it would be better to know more about the resident's condition in order to care for them. The facility failed to ensure agency staff were given adequate information to ensure for R20's highest practicable well- being, such as knowledge of R20's current underlying condition to assist CNA117 to provide for and track R20's hydration and intake/output status, report any potential side effects of antibiotic use, and/or provide timely perineal care for the resident.",2020-09-01
636,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2019-01-14,730,D,0,1,EPJU11,"Based on record review and interviews, the facility failed to provide no less than twelve hours of in-service education for every nurse aide employed by the facility. There were seven CNAs who did not meet this requirement. This deficient practice has the potential to affect the quality of care, treatment and services provided to their residents, as various topics, such as dementia care for (MONTH) (YEAR), was not completed by these seven CNAs. Findings Include: On 01/10/2019 at 02:51 PM, during an interview with the Director of Nursing (DON), she produced their Mandatory In-Services Record (YEAR). Review of the record revealed that several of the certified nursing assistants' (CNAs) in-service education/training was not done. These staff were not new hire CNAs and the record showed they did not meet the 12 hour in-service requirements. In addition, the DON stated her administrative assistant (AA) 126 tracked and documented each certified nursing assistants' in-service education/training. On 01/10/2019 at 03:02 PM, during a concurrent review of the in-service record with AA126, she said some of the CNAs who did not meet the 12 hours of in-service education either worked on the weekends, were not working or were on vacation. She verified however, they were all still employed at the facility. The administrative team stated that CNA124, as an example, missed five months, completed the (MONTH) inservice, and then left again on an extended trip without completing any further in-service education. It was also revealed that CNA85 came to assist in the evenings from 4:00 to 8:00 PM two to three times a week; CNA86 came to work one to two times a month; CNA81 worked two to three times a month on night shift; CNA123 worked three days a week as a part-time hire; CNA90 worked two to three times a month on night shift, and CNA87 has been out for a few months but had completed approximately 7 hours of in-service according to the record. AA126 said she tracked to see who completed their inservice, and if they miss it, I give them the handbook to complete that inservice for that month. Per the DON, she said she and the nursing home administrator (NHA) are the ones who should be tracking it as well. The DON acknowledged they were not in compliance with this.",2020-09-01
637,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2019-01-14,842,E,0,1,EPJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review (RR), the facility failed to accurately document as needed (prn) medications in the correct space provided in the Medication Administration Record [REDACTED]. This deficient practice has the potential to cause serious harm to residents as a result of medication errors. Findings Include: 1) On 01/10/2019 at 08:29 AM, Interview with Registered Nurse (RN)10 who stated R49 was given [MEDICATION NAME] 2.5 milligram (mg) by mouth as needed (prn) for pain on 12/30/2018 but in the MAR indicated [REDACTED]. When queried by surveyor, RN10 stated that's just the way they do. On 01/10/2019 at 08:40 AM, RR of R49's MAR indicated [REDACTED]. [MEDICATION NAME] (Tylenol) 325mg 2 tabs by mouth prn for pain was given on 01/05/2019 but was documented under 12/01-02/2018. 2) On 01/11/2019 at 09:27 AM, RR of R93's MAR indicated [REDACTED]. On 01/11/2019 at 10:17 AM, Interview with UM115 who stated they are working on giving the staff in-service on better documentation, more accuracy and consistency in monitoring for pain. On 01/11/2019 at 02:40 PM, Interview with Administrator who stated she has researched it with long time staff regarding medication documentation in the MAR's. Administrator stated the staff told her they was told to do it that way. Administrator was not able to say who told the staff to do that. Administrator said the staff stated when giving prn medications, they do not have enough room under the column of the date that the medication was given if the prn medication was given more than once. Administrator stated that's why the staff documented in the first open space farthest to the left. Administrator admitted that was not good practice but at least she understands why the staff did it that way. Administrator said she will work on getting the MAR's fixed as soon as possible.",2020-09-01
638,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,561,D,0,1,XRES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and record review, the facility failed to facilitate Resident (R)39's food preference as evidence by R39 not receiving mash potatoes for meals as requested and documented. As a result of this deficiency, R39 is at an increased risk for potential negative physical and psychosocial outcomes. Findings include: R39 was admitted to the facility on [DATE]. A review R39's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented admitting [DIAGNOSES REDACTED]. The MDS also documented R39 weighed 96 lbs (pounds) and had a weight loss of 5% or more in the last month of loss of 10% or more in the last 6 months and was not on a physician-prescribed weight-loss regime. A review of the dietician's progress notes documented R39 requested mash potatoes and gravy for meals. The dietician took appropriate action to comply with the resident's request. On 02/18/20 at 11:30 AM, R39 reported to this surveyor he/she does not receive mash potatoes and gravy for meals consistently. The resident confirmed the ticket, describes the contents of the meal, documents the resident should receive mash potatoes and gravy. R39 expressed feeling upset regarding the resident's food preferences and stated, it's the only thing I really feel like eating and I need to put on some weight. On 02/18/20 at 12:45 PM, observed R39's lunch which consisted of minced carrots, yakisoba, fruits, gravy, and fluids. R39 did not receive mash potato for lunch and stated, I never know if I will get mashed potatoes to eat. Sometimes I get it, sometimes I don't. What am I supposed to put the gravy on? Look at this other food, it doesn't look like it taste good. I don't want to eat it. The ticket which was delivered with lunch documented [ENTITY]ch/Bread: MASH POTATO WITH GRAVY. Food service staff (FSS)4, certified nurse aide (CNA)2, and Licensed Practical Nurse (LPN)[AGE] all confirmed the ticket which was on R39's tray documented the resident should have received mash potatoes for lunch, however, it was not on the lunch tray.",2020-09-01
639,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,684,G,0,1,XRES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record reviews, the facility failed to ensure staff applied Resident (R)41's right-hand resting splint according to the resident's person-centered care plan. As a result of this deficiency, R41 experienced contracture progression as evidence by R41's continued inability to wear current right-hand resting splint. Cross reference with F[AGE]2 Findings include: R41 is a [AGE] years old and was admitted to the facility on [DATE]. A review of R41's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/10/2019 documents R41's active [DIAGNOSES REDACTED]. R41 is totally dependent on staff for bed mobility, transferring, personal hygiene, always incontinent of bowel, and has an indwelling catheter. Additionally, R41 receives nutritional intake via tube feeding and has a tracheotomy. R41 is unable (rarely/never) to make needs/self understood and is unable (rarely/never) to understand others. Review of R41's Care Plan: Restorative Care Plan documented, Resident has actual contractures/impaired functional range of motion of: Bilateral Hands related to [CONDITION]I ([MEDICAL CONDITION]). The Care plan goals were: Resident will not experience contracture progression as evidenced by continued ability to wear current splints comfortably and without complication; Resident will not experience any complications related to wearing splint with a target date of 03/19/20. Interventions implemented for R41's Restorative Splinting Program includes applying resting hand splints to both hands: on for 6 hours; off 18 hours; apply at 09:00; remove at 15:00; and refer to therapy as needed. Reviewed R41's medical chart. Occupational Therapy Upper Extremity Splint Schedule includes directions of application/removal times (09:00 AM/ 03:00 PM) regarding splint usage. Throughout the survey (02/18- 24/20) multiple observations (02/18/20 at 10:57 AM, 01:45 PM, and 02:30 PM; 0[DATE] at 09:14 AM, 10:35 AM, and 02:45 PM; 02/20/20 at 10:58 AM and 01:15 PM; 0[DATE] at 10:07 AM and 02:15 PM; 02/24/20 at 09:00 AM) were made of R41 with no right-hand splint applied as indicated by the care plan. On 02/24/20 at 09:00 AM, Restorative Staff (RS)2 confirmed resting hand splint was not applied to R41's right hand, due to worsening of (R41's) contracture of the right hand and the splint not longer fits the resident. On 02/24/20 at 08:40 AM, inquired with Occupational Therapy staff (OT)1 regarding R41's bilateral resting hand splints. OT1 produced and reviewed R41's OT- Therapist Progress & Discharge Summary dated 05/24/19 and signed by OT2, which documented on, [ENTITY]t of Goal Status as of 02/15/2019, Tolerates BUE(bilateral upper extremity) resting hand splints for 4 hours; Prior level as of 05/03/2019, Tolerates B (bilateral) resting hand splints for 6 hours; End of Goal Status as of 02/24/2019, Tolerates B (bilateral) resting hand splint for 6 hours. OT1 confirmed facility staff's inability to apply the resting hand splint to R41's hand would indicate a contracture progression and staff should document and evaluate the progression of the contracture to assess for the resident's need for therapy services. OT1 also confirmed there was no record R41 had been referred for therapy services by the facility after R41's discharge from physical therapy on 09/17/19. Reviewed of R41's February 2020 Treatment Administration Record (TAR), initialed by the licensed nursing staff, and February 24, 2020 ADL (activity of daily living) Flowsheet, initialed by the restorative staff, with RS2. Facility staff documented on both, TAR and ADL Flowsheet, resting hand splints were applied to both hands, which contradicted observations made by this surveyor. RS2's confirmed the discrepancy between observations made by this surveyor and staff documentation of the right hand splint being applied by staff. RS2 stated R41 has not been able to wear the right-hand resting splint for a month or so and could not confirm a specific date or time staff stopped applying the splint. On 02/24/20 at 09:44 AM, inquired with the Director of Nursing (DON) regarding observations made by this surveyor, contracture progression for R41, and the accuracy of staff documentation. DON explained, residents who are on the RNA Program are visually and verbally reviewed monthly by multiple disciplines (DON, RNA, RN, and PT) for progress, status and the need for physical/occupational/speech therapy referrals. Reviewed Monthly RNA Meeting with DON held on 02/07/20. The monthly meetings report, documented R41's current treatment program PROM (passive range of movement) BLE (bilateral lower extremity) 4 times a week; B (bilateral) resting hand 5 times per week was reviewed and continued with no changes. DON could not recall if R41 wore the right-hand resting splint at the time of the monthly meeting and confirmed R41's contracture progression was not identified. DON further explained, if a change is identified residents are referred for rehab services. Also, DON confirmed staff should not document application of the splint if it was not applied. Accurate documentation is essential in the identification of contracture progression and the need for rehab referral to prevent contracture progression for R41.",2020-09-01
640,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,689,G,1,1,XRES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and record review (RR), the facility failed to prevent two residents (R) 68 and R[AGE] from avoidable falls that resulted in injuries to these residents of three sampled. This deficient practice has the potential to put all residents at high risk for harm, serious injuries, and/or death. Findings Include: 1) On [DATE], review of facility reported incident (FRI) dated 12/24/19, the facility reported R68 fell by the nurse's station on [DATE] at approximately 01:15 AM. According to the FRI, R68 was restless and unable to sleep so the Certified Nurse Aide (CNA) [AGE] brought R68 out to the nurse's station but subsequently went to answer a call light while leaving R68 by the nurse's station. Upon returning, CNA[AGE] found R68 sitting on the floor in front of her wheelchair. Initial assessment found no injuries at that time. The FRI stated CNA on the next shift (day shift) attempted to toilet R68 but noted resident was unable to bear weight on the left foot. Director of Nursing (DON) and Nursing Supervisor assessed R68 and notified the physician who ordered bilateral hip x-ray and pain medication for the resident. On 0[DATE] RR of R68's hip x-ray dated [DATE] showed an acute comminuted fracture present in the intertrochanteric proximal left femur. Impression: Acute comminuted fracture in the left intertrochanteric femur. On 02/20/20 RR showed R68 was admitted to facility on 03/14/19. R68 had sustained a fall at home resulting in a right [MEDICAL CONDITION] requiring hospitalization for surgery and subsequently transferred to this facility for rehabilitation services. Medical History for R68: 1) Closed fracture of right hip, surgically repaired 2) [MEDICAL CONDITION] 3) Vitamin D deficiency 4) Calorie malnutrition 5) Dementia with behavioral disturbances. R68's medications: [REDACTED]. Review of R68's care plan showed resident was already assessed and care planned for falls from time of admission. On 0[DATE] at 09:23 AM, interview with CNA[AGE] who stated on the night in question ([DATE]) R68 was restless and and unable to sleep. CNA[AGE] said she got R68 up in the wheelchair and took resident to the bathroom. CNA[AGE] stated after bathroom, she wheeled R68 to the nurse's station and gave resident a sandwich and coffee because resident likes coffee a lot. CNA[AGE] said she sat with R68 for awhile and noted R68 was falling asleep. CNA[AGE] stated she needed to do her rounds which was approximately 12-12:30 AM from rooms 201 to 204. CNA[AGE] said each time she came out of a room, she would check on R68 and noted resident to be asleep. CNA[AGE] stated when she came out of room [ROOM NUMBER] the last room she needed to finish, she saw her nurse with R68 by the nurse's station telling her that R68 had fallen. CNA[AGE] said she ran there to assists her nurse in assessing R68 and found no injuries at the time. CNA[AGE] said she knows that day shift had found R68 complaining of pain to the left hip area and later found [MEDICAL CONDITION] hip. CNA[AGE] said she has been working at this facility for almost [AGE] years but admitted she made an error in judgement for leaving R68 unattended that night by the nurse's station resulting in R68 fracturing her left hip. On 02/24/20 at 07:45 AM, interview with DON who stated the fall for R68 was definitely avoidable. DON stated she already started in-servicing all staff yesterday informing them they are to focus on what they are doing at all times and not to leave any residents especially high risk fall residents unattended. 2) On 02/18/20 at 08:50 AM, observed R[AGE] in the dining room sitting in wheelchair with gauze bandage noted to forehead above right eye. R[AGE] also had some bruising to her face around the eye area. Staff stated R[AGE]'s injuries were from a recent fall over the weekend. On 0[DATE] at 09:48 AM, interview with Registered Nurse (RN) 26 who stated R[AGE] fell over the weekend, Saturday (02/15/20) at approximately 02:30 PM. RN26 stated R[AGE] was in the activity/dining room for activities at the time of the fall. RN26 continued to say she was having problems that day with CNA25 in room [ROOM NUMBER]. RN26 stated CNA25 informed her she had back pain and needed help with the resident in room [ROOM NUMBER]. RN26 stated she wanted CNA25 to go home but CNA25 didn't want to. RN26 said she was unable to resolve the issue with CNA25 so she went to get another CNA to help the resident in room [ROOM NUMBER]. RN26 said she found CNA62 near the activity/dining room to help CNA25 in room [ROOM NUMBER]. When queried, RN26 denied knowing CNA62 was supposed to be watching the residents in the activity/dining room at the time. RN26 said she did not know CNA62 who was also training someone was asked by the Activity Aide (AA) 2 to watch the residents in the activity/dining room while AA2 left to take care of something. RN26 stated she did not think of asking CNA62 what she was doing at that time and denied she was informed by CNA62 that she was supposed to be watching residents in the activity/dining room because there were no staff there. RN26 admitted there should be staff watching the residents in the activity/dining room. On 02/20/20 RR reflected R[AGE] was admitted to facility on 08/11/16 with History of Dementia without Behavioral Disturbance, Hypertension, Chronic Systolic [MEDICAL CONDITIONS]. R[AGE] is on: [MEDICATION NAME] 7.5mg by mouth at bedtime, [MEDICATION NAME] 3mg by mouth at bedtime, [MED] 3.125mg by mouth twice a day hold for systolic blood pressure less than 120 or heart rate less than [AGE], [MEDICATION NAME] 20mg by mouth daily hold for systolic blood pressure less than 120. R[AGE]'s care plan showed appropriate goals and interventions for falls including a specific intervention dated 08/04/18 Do not leave resident in dining room unattended - Nursing. Documentation in Interdisciplinary Progress Notes dated 02/15/20 at 1520 noted R[AGE] found lying face down on floor with foot rest of wheelchair on back, blood on floor. Resident with laceration to right eyebrow with moderate amount of blood. Discoloration to right side of forehead and both knees. R[AGE]'s physician was called and orders given to cleanse laceration with normal saline, apply steri-strips, and monitor. On 0[DATE] at 08:23 AM, interview with CNA62 who confirmed she was training another CNA that day (Saturday 02/15/20). CNA62 stated she and the trainee were in the activity/dining room around 2:00 PM and she was showing the trainee how to document. CNA62 said she was asked by AA2 to watch the residents in the activity/dining room because AA2 had to leave the room to do something. CNA62 said she was fine with it because she was already in the room along with the trainee so no problem with watching the residents for AA2. CNA62 said RN26 came running up to her in a panic-look asking her to assists CNA25 in room [ROOM NUMBER]. CNA62 stated adamantly she told RN26 she was supposed to be watching the residents in the activity/dining room. CNA62 said she agreed to go to room [ROOM NUMBER] because she thought RN26 was staying behind to watch the residents in the activity/dining room. CNA62 said by the time she got to room [ROOM NUMBER], the resident in the room was already in the shower chair with help from other staff so she did not need to help. CNA62 said it was then she realized the trainee was following behind her and RN26 was also in room [ROOM NUMBER] with them. CNA62 said she did not know RN26 would leave the activity/dining room with no staff watching the residents. CNA62 said she then heard a staff calling out for help because someone had fallen in the activity/dining room. CNA62 said she headed back to the activity/dining room to find R[AGE] on the floor and staff trying to help. On 0[DATE] at 01:40 PM, interview with CNA25 who confirmed on day in question (02/15/20) she was in room [ROOM NUMBER] attempting to take the resident to shower. CNA25 said she had issues with her back, back pain and just deals with it. CNA25 stated adamantly she did not want to go home and wanted to finish what she was doing. CNA25 said RN26 kept insisting she fill out the blue paper (work injury form) and go home. Again CNA25 stated vehemently she did not want to go home and insisted she was able to finish what she was doing. CNA25 stated she and RN26 were in a heated discussion that should not have happened especially in front of residents. CNA25 admitted she feels badly R[AGE] fell and getting injured and is partly to blame. On 02/24/20 at 07:45 AM, interview with DON regarding R[AGE]'s fall on 02/15/20 and DON admitted the fall was avoidable. DON stated the staff are too comfortable at times and need to focus more on what they are doing. DON stated she already started meeting and in-servicing all staff telling them they are not to leave residents especially the ones with high risk for falls, unattended. On 02/24/20 at 10:15 AM, interview with CNA34 who stated R[AGE] fell on Saturday 02/15/20 at approximately 02:30 PM in the activity/dining room. CNA34 said he was assisting residents in room [ROOM NUMBER] when he heard a loud bang and a personal positioning alarm go off. CNA34 said he ran out of room [ROOM NUMBER] and across into the activity/dining room where he found R[AGE] face down on the floor with blood to forehead. CNA34 said R[AGE]'s wheelchair was partially tipped over with footrest on resident's back. CNA34 stated he called out to staff for help. CNA34 said he noted there were no staff in the activity/dining room at the time but they came shortly thereafter.",2020-09-01
641,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,692,E,0,1,XRES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review (RR), and policy review, the facility failed to provide documentation the Physician (MD) was notified when two of four Resident's (R) 20 and R13 sampled had a significant unplanned weight loss. In addition, the facility did not have a consistent and timely process to change residents with significant weight loss to weekly weights and refer them the Quality of Care Committee (QCC) for review and monitoring. As a result of this deficient practice, there is the potential that residents may show additional weight loss and nutritional needs may not be met. Findings include: 1. Review of the facility policy number 11A.5 titled, Weight Monitoring and Significant Weight Change Monitoring revised 12/01/2018 stated the purposes were To provide regular weight monitoring for all residents, To provide weekly monitoring for residents deemed at risk for weight loss, and To provide means of referral to Quality of Care Committee (QCC) for resident's at nutritional risk. The policy states, Significant weight loss will be addressed in a timely manner. The policy says a Significant weight loss or gain will be determined to be planned or unplanned, and The Physician will be notified if a resident experiences an unplanned weight change. The procedure directs staff to: (5). Monthly weights will begin on the 26th of the previous month and be completed by the 1st of the next month (8). If there is a weight change of 3 lbs or more, the nursing staff will notify the Registered Dietician (RD) .If there is a confirmed significant weight change, the RD may refer the resident to the Quality of Care Committee (QC) for evaluation. (9). Nursing will notify the MD of a confirmed significant weight change including current interventions and recommendations for MD's review in the Communication Book or by phone. (10). Residents with confirmed unplanned significant weight change will be monitored weekly until stable or determined by the QC (Quality of Care)Committee to be removed from weekly weight loss list. (11). Weight change is considered significant above or below 5% previously weight within 1 month. and weight is 10% above or below a previously recorded weight within 6 months. (15). If there is documented significant weight change, the resident will be referred to the Quality of Care Committee and placed on a schedule of weekly weight monitoring . There is a discrepancy in the policy of when the resident is referred to the Quality of Care Committee (QCC). 2. R20 was admitted to the facility on [DATE]. He had a history of [REDACTED]. A [DEVICE] ([MEDEQUIP] tube is a tube inserted through the abdomen to deliver nutrition directly into the stomach) was placed on 02/07/20 to maintain nutritional status. RR revealed R20's monthly weights (wt.) documented as: January 2020, 159 pounds, and February 2020, 147 pounds for a difference of 12 pounds, or a loss of -7.5%. The next documented wt was on the [DATE] weekly weight log when R20's wt. was 134 pounds. RR of the Nutrition Progress note dated 02/01/20 by RD, documented, Resident with significant weight loss., 12# (pounds) decrease / 7.5% / 1 month. Discussed with RNA ( Restorative Nurses Aide), res (resident) not eating well. Monitor wt. per protocol. 02/15/20 Comprehensive Nutrition Assessment by RD stated, .res with new GT (PEG) placement. Discussed at CP (Care Plan) meeting.being followed at QC (QCC) meeting until stable. Monitor wt. per protocol. On 0[DATE] at 01:00 PM, during an interview with RN26, reviewed R20's medical record. R26 was unable to provide documentation that MD1 had been notified of the significant weight loss. On 0[DATE] at 09:13 AM during a phone interview with the RD, reviewed R20's weight loss and discussed the facility policy which directed staff to do weekly weights after identification of unplanned significant weight loss with a referral to the QCC. RD said she did not refer R20 to the QCC because I expected him to do a slow increase in weight after starting the tube feeding. RD said, The practice is to start weekly weights once referred to the QCC. On 02/24/20 at 09:22 AM during an interview with the Registered Dietician (RD), she said weekly weights are done Monday's and the QCC meets on Wednesday and will discuss unplanned weight loss. The monthly weights start on the 26th of the month and takes a few days to complete. Once a significant weight loss is found, they reweigh and then report it to the RN (Registered Nurse) who notifies the Doctor. Usually they will call them. I am here two times a week, Tuesday and Thursday, and will make recommendations to start supplements. We give recommendations, but don't write orders. On 02/20/20 R20's significant weight loss was referred to the Quality of Care Committee. The weight loss was identified 0[DATE]. 3. R13 is [AGE] years who had a history of [REDACTED]. He had been able to self feed with supervision, but showed a slow decline and no longer able to feed himself. His weight had been stable until February. Review of Monthly Weights 2020 revealed R13's January wt. was 114 pounds. February wt. was 104 pounds for an unplanned wt. loss of ten pounds, or -8%. (February wt. taken on 0[DATE]) Weekly weights began on 02/10/20. Review of the MD1 Communication book and Nursing notes revealed no documentation that MD1 was notified of significant wt. loss identified on 0[DATE]. Review of R13's Care Plan (CP) documented: On [DATE] wt 104# (pounds) 10# /1 mo (month) / 8% (loss) On 02/10/20 wt 101# decrease 13# /11.4% / mo (loss) . secondary to poor variable intake. MD progress note dated 1/30/20 stated, Has lost 10 pounds this month. PO (oral intake) variable. Assessment and Plan was documented as: weight loss. Meds reviewed. Consult dietary for supplement . On 02/20/29 at 11:57 AM during an interview with RD, she stated. R13 had been on monthly weights and showed a significant wt. loss identified on 0[DATE]. We reviewed R13's status at the Quality of Care Meeting twice. On 0[DATE] at 10:14 AM, during an interview with the RD, asked her how MD1's communication book was utilized. She said to her knowledge it is for non-urgent, non critical communication. MD1 comes in twice a week, and when he comes, he checks the communication book. Asked if the communication book would be appropriate to communicate a significant weight loss to the MD, and she said, No. RD said, I assumed the nurse would call them. On 0[DATE] at 12:50 PM during an interview with the RN26 (Charge Nurse), she said, When a resident loses wt., it goes to the team. We follow RD's recommendation, and usually will update the doctor. RN26 was not able to provide documentation that MD1 was notified of R12's wt. loss. RN26 said the communication book is used for nutritional requests and recommendations from dieticians and sometimes we (nursing) use it. On 0[DATE] at 01:00 PM during an interview with RNA1, she said , I do the weights. If I find someone with a significant loss, I let the nurse know. Asked RNA1 if she ever wrote anything in the MD's communication books, and she said, No.",2020-09-01
642,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,700,E,0,1,XRES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR), and interviews, the facility did not consider grab bars (GB) to be siderails, so failed to have a process in place to educate resident/representatives of the risks of GB and obtain consent for use. Two residents (R) 416 and R20 of two sampled had GB installed and did not have consent or documentation of education prior to installation of the GB. This deficient practice affects all residents who had GB installed. Findings include: 1. R416 was admitted to the facility on [DATE] from an acute care hospital for short term rehabilitation. She is independent with self care and mobility in bed. On 0[DATE] at 09:02 AM, observed bilateral GB on R416's bed. RR revealed Bed Rail Entrapment Assessment form was completed on 01/25/20. There was no documentation in the medical record that R416 had been informed of the risks and benefit of the GB and there was no documentation of informed consent. 2. R20 is [AGE] years old and was admitted to the facility on [DATE]. He is non ambulatory and needs assistance with all activities of daily living. On 0[DATE] at 08:29 AM observed bilateral GB on R20's bed. RR revealed a Bed Rail Entrapment Risk Assessment form completed on 07/08/19. The form had the following notations on it: Note: Use 2 upper grab bar for, mobility and positioning. In use during bed mobility and repositioning only. The question on the assessment form, Has the decision to use or not use bedrails been discussed with the responsible party?, was checked No. R20's care plan (CP) included the problem, Resident uses 2 upper grab bars for bed mobility. The interventions included; release restraints every 2 hours during ., which did not apply to R20. The CP also include Obtain informed consent. There was no documentation of informed consent in the medical record. 3.On 02/20/20 at 08:28 AM during an interview with the Nursing Supervisor (NS)1 for the second and third floor, she said, We do not have consents for GB. We get consents for half and full rails, or lap belts. GB need doctors' orders to initiate and we do a nursing assessment for bed mobility and positioning in bed. Asked if education provided to the resident/representative of the risks and benefits of the GB is documented, she said no. The facility did not have an informed consent for the use of GB and does not review the risks of GB use with resident/representatives. 4. On 02/24/20 at 08:18 AM during an interview with the Director of Nursing (DON), asked what the current practice was for bedrails/GB. DON stated, We do an assessment on admission and determine with residents or families if they will be used. We recommend no siderails but sometimes they want them or need them for mobility. When asked if they consider a GB to be a side rail and document risks with consent, the DON said, Grab bars currently are not considered a siderail, so we don't get consent.",2020-09-01
643,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,711,D,0,1,XRES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review (RR), the facility failed to ensure that all orders were signed and dated by the physician (MD) 1. Two of eight residents (R) 20 and R416, sampled contained orders that were either not signed, or dated by the MD1. This deficient practice puts residents at risk for not having orders implemented accurately and timely. Findings include: 1. R20 is a [AGE] year old male admitted to the facility on [DATE]. Review of R20's medical records revealed the following telephone orders that were not dated by MD1: On 02/09/20 at 1700 a telephone order was taken from MD1 to discontinue (DC) [MEDICATION NAME] (for depression). The order appeared to be signed by MD1, but there is no date noted in the designated place to write the date. On [DATE], a telephone order was taken from MD1 to D/C speech therapy (ST). The order appeared to be signed, with an illegible mark, but there is no date noted. On 0[DATE] at 01:32 PM, during an interview with the Nursing Supervisor (NS), reviewed the orders and asked what the illegible mark in the signature of physician area was, and NS stated, It is MD1's signature. NS agreed there was no legible date documented when the orders were signed. 2. R416 was admitted to the facility for short term rehabilitation on 01/25/20. Review of R416's medical record revealed the admission orders [REDACTED]. One RN signature was for information verified with the physician, and the other indicating all information was checked in the Physician order [REDACTED]. The admission orders [REDACTED]. MD1 had been in the facility and signed other orders.",2020-09-01
644,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,755,D,0,1,XRES11,"Based on observations, staff interviews, and a review of facility policy's and procedures, the facility failed to ensure medications were properly destroying unused medications. As a result of this deficiency, staff and the community is at risk for accidental exposure to controlled medications. Findings include: On 02/20/20 at 09:30 AM, inquired with multiple staff registered nurse (RN)17, RN6, RN34 and Licensed Practical Nurse (LPN)4 who are responsible for administering medications, regarding the disposal of medications (included controlled medications). Interviewed staff reported medications are either crushed and placed down the sink or put into the sharp container as a means of disposal. Staff confirmed patches (of medication/nicotine) are disposed of by cutting the patches up into pieces and placing the pieces into the sharps container and if the medication is dissolvable, staff with crush the medication and wash it down the sink. Inquired with staff interviewed regarding the use of a product (e.g., Rx Destroyer) by the facility to safely dispose of the medication. Interviewed staff confirmed they do not use a product (e.g., Rx Destroyer) to dispose of medication. During an inspection of the medication storage room on the 4th floor, this surveyor along with nursing staff were unable to find/locate a chemical digestive agent. A review of the facility's policy's and procedure for medication disposal documents, A non-retrievable disposal method must be used.chemical digestion (for example, Rx Destroyer, Drug Dispose All, Drugbuster) or incineration. On 02/24/20, the Director of Nursing (DON) confirmed staff should be using a chemical agent to properly dispose of medications and did not produce a product to validate the use of a product.",2020-09-01
645,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,761,D,0,1,XRES11,"Based on observation, record review, staff interview, and policy review, the facility failed to monitor the temperature controls for the medication refrigerator located on the third-floor nursing unit. This deficient practice put the residents at risk for adverse reactions from possible improper storage of medications. Findings Include: On 02/20/20 at 08:17 AM, during an observation and review of temperature monitoring records for the third-floor medication refrigerator, temperatures were not recorded for nine days of the past six months reviewed. The nine days were the following: 08/16/19, 09/07/19, 09/12-13/19, 10/25-26/19, 11/26/19, 12/29/19, [DATE]. During staff interview with Registered Nurse (RN) 24, on 02/20/20 at 08:25 AM, RN24 stated that the temperatures for the refrigerator should have been monitored on a daily basis. During staff interview with Unit Manager (Mgr) 3 on 02/20/20 at 09:00 AM, Mgr3 acknowledged that the refrigerator temperatures were not recorded for the nine days as previously mentioned and should have been monitored each and every day. A review of facility policy on Medication Storage stated the following: Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 C (36 F) and 8 C (46 F) with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label . Medications that should be frozen should be stored in the freezer at 14 F (-4 C) to -20 F (-10 C). The facility should maintain a temperature log in the storage area to record temperatures at least once a day.",2020-09-01
646,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,812,E,0,1,XRES11,"Based on observations, staff interview, review of policy, and review of food storage guidelines, the facility failed to properly store the following frozen food items: Shrimp dumplings, Japanese style noodles, and an unmarked bag of seafood. As a result of this deficient practice, the facility put the residents at risk of being exposed to poor food quality and/or contaminated food. Findings Include: During an observation of the kitchen walk-in freezer on 02/18/20 at 08:07 AM, a bin that contained several packages of Shrimp dumplings, several packages of Japanese style noodles, and an unmarked bag of seafood were noted to be on the floor. On 02/18/20 at 08:07 AM, Food Service Staff (FS) 15, who accompanied the above observation was queried and acknowledged that the bin of food should not have been stored on the floor. A review of the facility policy on storing refrigerated/frozen/dry goods of produce stated the following: Policy, to maintain quality in our foods that will be kept safe to consume by residents and staff. Procedures, refrigerated/freezer items will follow United States Drug Administration (USDA) Food Safety fact sheet. Also, staff will follow Association of Nutrition and Foodservice Professionals (ANFP) food storage guidelines for fruits, vegetables, and dry goods. A review of the ANFP Standards of Practice, Food Storage Guidelines revealed that food should be stored off the floor, specifically at least six inches above the floor.",2020-09-01
647,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,842,E,0,1,XRES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, the facility failed to ensure the medical records were complete for 2 of 10 sampled resident, (R)41 and R66, and accurate documentation for 2 of 10 sampled residents, R113 and R41. Failure to have orders authenticated in a timely manner could potentially contribute to medical errors associated with communication and transcription of the actual content of the physician orders. Failure to accurately document administration of medication could potentially contribute to medication administration errors. Failure to accurately document the application of the use of a splint for R41 contributed to contracture progression as evidence by the facility not identifying and appropriately referring R41 to rehabilitation services when staff was unable to properly apply R41's right-hand resting splint. Findings include: A record review conducted on 0[DATE] and 0[DATE], multiple resident's medical records contained multiple red post-it like sticker indicating the Physician needed to sign the Telephone/Verbal order: 1) Resident (R)41's medical chart contained multiple orders not sign. Two examples of orders not signed were: [DATE] D/C Bactracin and 2/2/20, UTI- [MEDICATION NAME] (unledgeable number) mix with 2.1 ml lidocain daily. Dx: UTI. Additionally, the activity sheet which documents the activity the resident participated in, documented R41 watched television, daily, as an activity. Activity staff (AS) confirmed R41 listened to the radio and R41 did not have access to watch a television. 2) R66 order in the medical chart that were not signed included [DATE] Hold [MEDICATION NAME] N 2 Units SQ @ 0[AGE]0 today, Give [MEDICATION NAME] N 2 Units SQ @ 1[AGE]0 today. Additionally the January & February 2020 physician's orders [REDACTED]. 3) On 2/20/20 at 08:45 AM, observed R34 administer medications (Calcium/Vit D 500 mg/400 IU; [MED] 1100 mg; [MEDICATION NAME] 325 mg; and [MED] Chloride 500 mg) to R113. Reviewed the medication administration record (MAR) at at 10:25 AM, R34 did not sign the MAR, which indicates the medications were administered. 4) Cross reference with FTag 6[AGE] Review of R41's Care Plan: Restorative Care Plan documented, Resident has actual contractures/impaired functional range of motion of: Bilateral Hands related to [CONDITION]I ([MEDICAL CONDITION]). The Care plan goals were: Resident will not experience contracture progression as evidenced by continued ability to wear current splints comfortably and without complication; Resident will not experience any complications related to wearing splint with a target date of 03/19/20. Interventions implemented for R41's Restorative Splinting Program includes applying resting hand splints to both hands: on for 6 hours; off 18 hours; apply at 09:00; remove at 15:00; and refer to therapy as needed. Throughout the survey (02/18- 24/20) multiple observations (02/18/20 at 10:57 AM, 01:45 PM, and 02:30 PM; 0[DATE] at 09:14 AM, 10:35 AM, and 02:45 PM; 02/20/20 at 10:58 AM and 01:15 PM; 0[DATE] at 10:07 AM and 02:15 PM; 02/24/20 at 09:00 AM) were made of R41 with no right-hand splint applied as indicated by the care plan. On 02/24/20 at 09:00 AM, Restorative Staff (RS)2 confirmed resting hand splint was not applied to R41's right hand, due to worsening of (R41's) contracture of the right hand and the splint not longer fits the resident. Reviewed of R41's February 2020 Treatment Administration Record (TAR), initialed by the licensed nursing staff, and February 24, 2020 ADL (activity of daily living) Flowsheet, initialed by the restorative staff, with RS2. Facility staff documented on both, TAR and ADL Flowsheet, resting hand splints were applied to both hands, which contradicted observations made by this surveyor. RS2's confirmed the discrepancy between observations made by this surveyor and staff documentation of the right hand splint being applied by staff. RS2 stated R41 has not been able to wear the right-hand resting splint for a month or so and could not confirm a specific date or time staff stopped applying the splint. On 02/24/20 at 09:44 AM, inquired with the Director of Nursing (DON) regarding observations made by this surveyor, contracture progression for R41, and the accuracy of staff documentation. DON explained, residents who are on the RNA Program are visually and verbally reviewed monthly by multiple disciplines (DON, RNA, RN, and PT) for progress, status and the need for physical/occupational/speech therapy referrals. Reviewed Monthly RNA Meeting with DON held on 02/07/20. The monthly meetings report, documented R41's current treatment program PROM (passive range of movement) BLE (bilateral lower extremity) 4 times a week; B (bilateral) resting hand 5 times per week was reviewed and continued with no changes. DON could not recall if R41 wore the right-hand resting splint at the time of the monthly meeting and confirmed R41's contracture progression was not identified. DON further explained, if a change is identified residents are referred for rehab services. Also, DON confirmed staff should not document application of the splint if it was not applied. Accurate documentation is essential in the identification of contracture progression and the need for rehab referral to prevent contracture progression for R41.",2020-09-01
648,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,880,E,0,1,XRES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and a review of facility's policy's and procedures, the facility failed to ensure the implementation of infection control techniques that prevent the development and transmission of communicable disease and infections as evidence by staff not disinfecting/cleaning a reusable blood pressure cuff, not properly disinfecting a stethoscope, and handling medications without gloves. In addition, the designated person responsible for the infection prevention and control program was not familiar with the state reportable disease list and policy. As a result of this deficiency, residents are at an increased risk of exposure to communicable diseases and infections. Findings include: 1) Review of the Infection Control Plan stated, The infection preventionist or designee is ultimately responsible for the infection prevention program, and Responsibility is delegated to the Director of Nursing/ Infection Preventionist (DON/DON) to carry out the daily functions of the infection control program. Those functions are described in the DON job description. The DON/DON has knowledge of and interest in infection prevention. The plan also states, . the DON is responsible for .communicating with the health department on any reportable diseases. 2) Review of the DON job description provided revealed there is no specific job duties or functions listed related to infection Control. The position summary does not include the delegated responsibility for the Infection Prevention Program or Antibiotic Stewardship Program (ASP). 3) On 02/20/20 at 02:07 PM during an interview, asked the DON who was responsible to report communicable diseases to the Department of Health and to describe the process. The DON stated, I think the Administrator reports it. When asked the DON what required reporting, she was unable to verbalize the process and unaware the reportable diseases list was categorized by urgent and routine for reporting. DON said she had just started at the facility nine months ago and working to organzie the infection control stuff. 4) Review of the policy titled Reporting Communicable Diseases revealed the policy did not identify who was responsible for reporting to the Department of Health, or what that process was. 5) Cross Reference F[AGE]1 6) On 02/20/20 at 07:45 AM, observed registered nurse (RN)34 and licensed practical nurse (LPN) 4 administering medication to R17 via [DEVICE]. During the administration process, RN34 used a stethoscope given to him/her by LPN4 to auscultate placement of the [DEVICE] directly on R17 abdomen prior to administering medications. After using the stethoscope, RN34 returned it back to LPN4 who then placed the stethoscope back into his/her scrubs pocket and proceeded to provide care to another resident. RN34 confirmed he/she did not disinfect the stethoscope prior to using it directly on R17's skin and could not confirm the stethoscope had been disinfected prior to use. LPN4 confirmed he/she did not disinfect the stethoscope RN34 used prior to placing the stethoscope back into his/her pocket. A review of the facility's policy and procedure documents reusable items are cleaned and disinfected.between residents (e.g., stethoscopes, durable medical equipment. RN34 did not ensure the stethoscope was disinfect prior to use, in alignment with the facility's policy and procedure. Furthermore, LPN4 did not disinfect the stethoscope after use, before placing it back into his/her pocket. 7) On 02/20/20 at 08:00 AM, observed LPN4 unplug a blood pressure machine, with a reusable cuff, from the outlet in the hallway, take R[AGE]'s blood pressure, put the machine back in the hallway to be used again, and proceed to provide care to another resident. LPN4 confirmed the blood pressure cuff was not disinfect prior to or after obtaining R[AGE]'s blood pressure and placing it back into the hallway. A review of the facility's policy and procedure documents reusable items are cleaned and disinfected.between residents (e.g., stethoscopes, durable medical equipment. LPN4 did not clean and disinfect the blood pressure machine according to the facility's policy and procedure. 8) On 02/20/20 at 08:15 AM, observed RN34 preparing medication for R113. R113 has an order for [REDACTED]. RN34 confirmed medications should not be handled without gloves. A review of the facility's policy and procedure Specific Medication Administration Procedure: Oral Medication Administration, documents staff should avoid touching the tablet, unless staff dons gloves. 9) A review of Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/19 documented R66 was admitted to the facility on [DATE]. R66 has a [DIAGNOSES REDACTED]. On 0[DATE] at 11:44 AM, observed certified nurse aide (CNA)53 changing R66's [DEVICE] dressing. Observed CNA53 holding part of the dressing in his/her gloved left hand, pull out a scissors from his/her pocket and cut the tape (which was attached to the dressing) with his/her un-gloved right hand. CNA53 used his/her un-gloved hand to place the dressing around the [DEVICE] site. Observed CNA53's hand come into direct contact with R66's skin. A record review documented, on 01/30/20, R66 was ordered [MEDICATION NAME] 100 mg via [DEVICE] twice daily for two weeks die to a [DEVICE] site infection. The Director of Nursing (DON) confirmed CNA53 did not adhere to the facility's infection control policy's and procedures, CNA53 should don gloves while changing a [DEVICE] dressing. Furthermore, the DON stated staff should set up an area to for supplies as opposed to storing dressing supplies in his/her pocket. Also, staff should label(date and initial) the dressing prior to placing the dressing on the resident.",2020-09-01
649,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,881,F,0,1,XRES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review (RR), the facility failed to develop and implement protocols to optimize the treatment of [REDACTED]. As a result of this deficient practice, residents are at increased risk of adverse events, including the development of antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use. Findings include: 1. Review of the facility Policy titled Antibiotic Stewardship states one of the main components of the facility's antibiotic stewardship program includes the indication for prescribing antibiotics is documented in the medical record. The policy defines the Director of Nursing (DON) Role in the Antibiotic Stewardship Program (ASP) as follows: The DON/designee provide data analysis monitoring, and reporting of [MEDICAL CONDITION] . They review the antibiogram for any tread (sic) changes annually. The QAPI (quality assurance performance improvement) team also creates methodology and rules in the data-mining system (info from pharmacy) to capture information for data analysis. To measure the impact of the program, the policy states, Currently the QAPI team looks at process and outcome measures, but continually work to create better processes. The team starts by looking at specifically targeted antibiotics usage per quarter as a proxy for usage. 2. Review of the DON Job description did not include the any responsibilities related to the ASP. 3. On 02/20/20 at 02:07 PM during an interview with the Director of Nursing/Infection Preventionist (DON), asked what her role was as Infection Preventionist. The DON said she tracks who is put on antibiotics and follows up with the lab results. Inquired what was done for surveillance, and the DON said, The Supervisors report every morning at the standup meeting who has a potential infection. We use the Mcgeer criteria to identify possible infections, and complete a checklist. One copy of the checklist is placed in a binder on the unit and one is sent to me. If symptoms appear, they call the physician (MD). Often the MD will order an X-ray, or a urinalysis (U/A) for a possible urinary tract infection [MEDICAL CONDITION]. The DON said she keeps a copy of all the checklists in a binder, and reviews x-ray and lab reports to ensure the resident is on the correct medication. Inquired how the MD responds when informed of negative lab results, and the DON stated, Sometimes they will discontinue the medication. Asked the DON if she had any additional training to take on this new role, and she replied, No, I did have some experience in my previous job. Asked what quality measures were being monitored, and what kind of data was collected for the ASP. DON said they do not any process or outcome measures, and do not have targets. DON said, We try to be the lowest as possible.I only started at the facility nine months ago. The pharmacist tracks and calls the MD if there is a contraindication. The DON provided an antibiotic report titled Therapeutic type report, and the Monthly Infection Tracking Report that she provides to QAPI. Inquired if there was any other data collected that goes to QAPI, and she said the consultant provides a report. The DON was unable to verbalize details or summarize the consultant report. During the interview, reviewed the Therapeutic type report for antibiotic prescriptions during period of 11/26/19 to 12/31/19. That report revealed one resident (R) 21 of three sampled that did not have a checklist in the DON's antibiotic tracking binder. R21 had a diagnosis (dx) of UTI and prescribed 250 mg tablet of [MEDICATION NAME] tablets for a duration of seven days. The DON utilized the surveillance checklists to compile data for the Monthly Infection Tracking Report, and agreed the report for that period was incorrect because it did not include R21. 4. Review of the Monthly Infection Tracking Report 2019 prepared by the DON, revealed the report did not contain any information on antibiotic use. The report tracked the number of infections by category of: Respiratory , EENT (eye, ear, nose and throat), skin, UTI, and other. The report was broken down by unit and if the infection was facility acquired or not. 5. Review of the Infection Control Consultant agreement dated 01/10/05 included the following terms: Consultant shall be on island in January, April, July, and October. During the months that the consultant is off island business will be performed by email , 24 hours availability by phone, mail, fax, conference calls and/or video conferencing. The scope of services and obligations included, 2.2 on-going review and revision as needed to the infection control policies and procedures. 2.4 Attend quarterly Quality Improvement meetings and report on infection control for the quarter using graphs and charts as appropriate. Consultant will work with .to improve this data collection so the hospital will have a more accurate antibiotic stewardship program. One of the facility obligations was to: Provide on a monthly basis the total resident days in order to complete statistic report for the QI meeting. 6. Review of the 4th Quarter 2019 consultant report included a graph of Antibiotics Reported by Pharmacy and Number Facility Reported to Consultant 2019. The summary was; There were [AGE] antibiotics ordered during the 4th quarter. The facility provided eight surveillance forms. This is only 8% of the data needed. Data for this report was obtained by use of pharmacy report and culture data from the lab. The report did not utilize resident days for statistical report, and did not include process or outcome measures. The data from the DON Monthly Infection Tracking Report and the Consultant report was compared, which revealed the following: Consultant report for UTI infections for October 2019 was two; November 2019-two, December 2019-three. DON facility report for UTI's for October 2019 was three; November 2019- one, and December 2019-five. The data does not match and indicated that the surveillance process and reporting process lacks coordination between the facility and consultant. 7. Review of the facility Policy titled,Ordering of Antibiotics states, Physician /APRN (Advanced Practice Registered Nurse)/PA(Physician Assistant) shall provide a complete antibiotic order including .reason for order. There are no other policies or antibiotic use protocols. 8. The Therapeutic Type Report documents all antibiotics prescribed, dose, duration, patient, provider, location and reason for antibiotic. Review of the report of antibiotics dispensed during the period of 11/26/19 to 12/13/19 revealed the following documentation: R 66 Rx # 5 was prescribed [MEDICATION NAME] tab tab 250 mg for seven days. There is no documentation on the Therapeutic Type Report that is used for data collection and analysis of the Diagnosis (dx) or Reason for antibiotic. The DON later provided a copy of the paper order which included the dx: tracheitis, but was difficult to read. Review of the report antibiotics dispensed during the period of 12/31/19 to 01/30/19 revealed the following documentation: R110 Rx # 3 was prescribed Amoxicillen/K Clav tab 8[AGE]-125 tabs . There is no documentation of dx or reason for the antibiotic. R64 Rx# 3 was prescribed [MED]. There is no documentation of dx or reason for the antibiotic. R[AGE] Rx# 9 was prescribed [MEDICATION NAME] 1 GM IM. There is no documentation of dx or reason for the antibiotic R67 Rx 2 for [MEDICATION NAME] Tab 100 mg , There is no documentation of dx or reason for antibiotic. R24 Rx 6 for [MEDICATION NAME] tab 100 mg. There is no documentation of dx or reason for antibiotic There may have been additional information to support the reason for prescribing the antibiotics in the medical record, but this is the report the consultant used to collect and analyze data. On 02/24/20 at 01:30 PM during an interview with the Administrator (ADM), discussed the infection reports. At that time, the ADM said she had a consultant that provided reports for QAPI, but did have some concerns about the data.",2020-09-01
650,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,883,D,0,1,XRES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review (RR), the facility failed to assess one resident (R )20 of five sampled for administration of the pneumococcal vaccine to minimize the risk of acquiring, transmitting and experiencing complications from pneumococcal disease. As a result of this deficient practice, it put R20 at higher risk of acquiring pneumonia. Findings include: R20 is [AGE] year-old with hearing impairment, mild dementia, chronic [MEDICAL CONDITION], and malnutrition. He was admitted to the facility 08/14/18, and is at high risk for infection due his age and medical history. Review of facility policy procedure titled Pneumococcal Vaccine dated August 2016, revealed the policy statement was: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The policy states Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol, and Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. RR of R20's medical records, revealed no documentation that R20 had received a pneumococcal vaccine. On 02/24/20 at 01:14 PM, the Director of Nursing said she had called the physician's office and had obtained documentation that R20 had received a pneumococcal vaccine at an acute care hospital on [DATE]. Prior to this, there was no documented attempt to obtain R20's history of pneumococcal vaccination. On 02/24/20 at 02:00 PM, during an interview with the Administrator she agreed R20's medical record should have included his pneumococcal vaccination status and he should have had a documented assessment for revaccination according to CDC guidelines.",2020-09-01
651,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2020-02-24,921,D,0,1,XRES11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and reviews of facility records and policy's and procedures, the facility failed to provide a safe environment for Resident (R)108 as evidence by an [MEDICATION NAME] valve on the air conditioner breaking that caused water damage and ceiling tile to break in room [ROOM NUMBER]. As a result of this deficiency, the resident was at risk for potential serious harm and/or a negative outcome. Findings include: R108 was admitted on [DATE] with hospice services. At the time of the incident, R108 was in bed resting while on 2 Liters of oxygen via nasal cannula. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 01/28/20, documented R108 requires extensive assistance with 2+ person physical assist to transfer between surfaces including to or from: bed, chair, wheelchair, standing position and is totally dependent on staff to move throughout the unit. On 02/18/20 at 12:16 PM, observed a water soaked ceiling tile in room [ROOM NUMBER]. The tile bowed from the ceiling with a steadily medium flow of water dripping down into the room and splashing onto R108's oxygen machine. R108 was in bed approximately 2 feet away from the dripping water. An adjacent tile also had apparent signs of water damage. Staff relocated to another room right before the ceiling tile broke and approximately 1 to 2 gallons of water poured into a trash can maintenance staff supplied. When the tile broke, observed a pink plastic bin (used in patient care) fall from the ceiling (along with the ceiling tile and water). Staff confirmed if R108 had visitors at the time, the visitor would most likely be situated under the damaged ceiling tiles. Inquired with the Maintenance Supervisor ([CONDITION]) regarding the plastic bin that fell from the ceiling. [CONDITION] stated that the plastic bin had probably been placed in the ceiling to catch dripping water, which was most likely dripping from the AC [MEDICATION NAME] valve. [CONDITION] stated the plastic bin was probably used by the contracted AC repair staff, which the contracted AC repair company received from the facility, to which [CONDITION] denied knowledge that the plastic bin was being used in the ceiling to catch water. [CONDITION] stated the air conditioner (AC) in room [ROOM NUMBER] had been previously serviced, however, [CONDITION] was unable to recall when the AC any detail information. Requested a copy of the facility work order and documentation from company that previously serviced the AC. On 02/24/20 at 11:50 AM, [CONDITION] confirmed he did not have any documentation related to previous repair/services related to the AC in room [ROOM NUMBER]. On 02/18/20 at 01:45 PM, inquired with 4th floor unit clerk and staff regarding the process of work orders and review of previously requested work orders. A search of the work orders provided for 2020 and 2019 did not include a work order related to the AC unit located in room [ROOM NUMBER]. Unit staff confirmed the AC unit in room [ROOM NUMBER] had not been serviced in 2020 or 2019. On 0[DATE] at 08:00 AM, inquired with the Administrator regarding documentation of contracted and/or in-house service to the AC in room [ROOM NUMBER]. The Administrator provided the quarterly Air Conditioning Prevention Maintenance Form completed in January 2020 for room [ROOM NUMBER] which checks: operating conditions; check the pan; clean as needed; apply air to drain; place tabs into pan; change filter; and clean coil if needed. Administrator confirmed a visual inspection of the AC unit and various other components is required to complete the Air Conditioning Maintenance form. Inquired with [CONDITION] regarding the visual inspection of room [ROOM NUMBER] AC unit, the lack of discovering the plastic bin used to catch water, and the accuracy of the quarterly AC prevention checks. [CONDITION] was unable to provide a response to the inquiry or produce any other documentation of any services for the AC in room [ROOM NUMBER]. A review of the facility's policy's and procedure for maintenance Service Request documents the procedural steps for staff to follow regarding maintenance request. Per the facility's policy and procedure, staff is to fill out a request form with pertinent information, service request is then clipped on the maintenance clipboard at the nurse's station and notify the Environmental Service Coordinator if immediate attention is required, after the completion of the request the form will be signed and stored in the maintenance shop for future reference. [CONDITION] confirmed there was no documentation of the service request on the clipboard at the nurse's station or in the maintenance shop.",2020-09-01
652,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,550,E,0,1,782M11,"Based on resident interviews and interview with the resident council, the facility failed to ensure residents were treated with respect, dignity and care in a manner and an environment that enhances his or her quality of life. Findings include: 1) An anonymous resident interview was conducted on 12/20/17 at 12:45 P.M. The resident reported that staff members speak in the non-dominant language of the facility. The resident further reported that following the complaint, a staff member approached him/her and asked why this was reported. The resident reported feeling hurt and cried. However, the resident stated that following this incident, he/she does not feel afraid to make complaints. 2) A resident council meeting was done on 12/21/17 at 9:30 [NAME]M. The members of the council reported that staff members are found to speak in the non-dominant language of the facility. A resident reported that he/she is unsure whether the staff members are talking about them. The members also reported that staff members speak loudly while they are in the residents' rooms, especially when there are two or three of them in the room. A resident further reported that the staff members are also laughing which sometimes results in waking the residents. 3) During interview with Resident #362's spouse on 12/19/17 at 11:10 AM., who said that resident requested incontinence garment change because resident was incontinent of feces and wanted change prior to physical therapy session, the staff denied resident the garment change at that time, and two hours later when incontinence garment was checked, there was dried feces. During interview with staff #53 on 12/21/17 at 14:13 PM who said that resident should only need to wait for three minutes for staff to comply with a request, remembered this incident and claimed to have counseled staff about complying with residents' requests right away.",2020-09-01
653,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,561,D,0,1,782M11,"Based on resident interviews, interview with staff and review of documentation, the facility failed to ensure that residents' preferences and choices regarding bathing frequency were supported. Findings: (Cross-referenced to F725) 1) During interview with resident #1 on 12/19/17 01:51 PM who said she informed staff that she would like to bathe everyday was told by staff that there was insufficient staff to bathe more than twice a week. 2) During interview with resident #362's spouse on 12/19/17 11:06 AM who said that resident said, Feels dirty because only showers twice a week. Resident's spouse said that staff informed them that there is insufficient staff to bathe resident more than twice a week. 3) During interview with staff # 53 on 12/21/17 14:13 PM who said that residents are given a choice about how often they bathe, are asked on admission about preferences for bathing, and admitted that it was necessary to remind staff to honor bathing on request, especially for new residents. Staff #53 also gave surveyor a copy of the floor's bathing schedule. 4) Resident #1 has activity assessment that shows shower is the bathing preference, and extra is written on the form. The form itself does not ask how frequently the resident would like to bathe. 5) The bathing schedule provided by staff #53 supports residents' statements that they are only bathed two to three times per week, and the schedule does not indicate residents' preferences for bathing frequency have been supported.",2020-09-01
654,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,577,E,0,1,782M11,"Based on observation and interview with resident council members, the facility failed to ensure the results of the recent survey conducted by the State Surveyors with the plan of correction are posted and readily available for review. Findings include: A resident council interview was done on 12/21/17 at 9:30 [NAME]M. The council members were asked whether the results of the survey were available for viewing. The council members were not aware of the survey results posting. On 12/26/17 observation found the posting on the third floor was obscured by a hanging quilt. The posting on the second and fourth floor was found on the bulleting board by the elevators. However, resident council members were not aware the results of the surveys are posted for their review.",2020-09-01
655,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,582,D,0,1,782M11,"Based on record review and interview with staff member, the facility failed to provide 1 (Resident #165) of 3 randomly selected residents with notice of end of coverage. Findings include: On 12/22/17 at 2:54 P.M. Staff Member #2 provided copies of the issuance of Notice of Medicare Non-Coverage (NOMNC). The review of the issuance notices found Resident #166's last day of coverage was 11/13/17 and the notice was signed by the resident's representative on 11/11/17. A review of the notice for Resident #167 found the last day of coverage was 7/7/17 and the resident signed the NOMNC on 6/30/17. The review for Resident #165's NOMNC found the last day of services was 10/10/17. The signature of the resident's representative to acknowledge understanding of the notice was signed and dated 10/9/17. Staff Member #2 reported the resident's representative was informed of the discharge date and was only able to sign the NOMNC form on 10/9/17. A request was made for documentation of the notification to the resident's representative of the discontinuation of coverage. Staff Member #2 was agreeable to provide the documentation. On the morning of 12/23/17 further information was left in the conference room. A handwritten note was attached to communicate notes from physical and occupational therapist regarding caregiver training with family (spouse) for discharge on 10/10/17 from therapies. A review of the information that was provided, tabbed and highlighted found documentation PT - Therapist Progress and Updated Plan of Care dated 9/22/17 under patient/caregiver training, caregiver training with patient's spouse on care transfers and ongoing patient training on safe transfers and ambulation. Subsequent note dated 9/21/17 by the physical therapist documents care transfers training. A review of the occupational therapy note dated 10/6/17 highlights ongoing training with staff/family, particularly regarding bathroom activities of daily living and corresponding transfer was highlighted. The facility failed to provide documentation that Resident #165 or the resident's representative was informed of the last day of coverage two days prior to the discharge.",2020-09-01
656,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,584,D,0,1,782M11,"Based on resident interview, staff interview and review of facility policy the facility failed to provide reasonable care for the protection of resident (R) #40's property from loss. Findings include: On 12/19/17 at 11:49 AM during an interview with R#40 he stated he was missing plenty of items, reported that he was missing shirts and socks. R #40 acknowledged that these items were sent to laundry and never came back. R#40 stated that he reported the loss of items to staff #17 and the staff member told him that she could not find his personal items that were missing. R#40 stated that he reported the loss to staff #17 because she does the laundry. Review of resident's MDS 3.0 BIMS summary score on his quarterly report dated 10/14/2017 was 15. On 12/22/17 at 08:30 AM interviewed staff #182 who stated that R#40 did not report to her any lost items. Staff #182 was able to provide the facility policy Lost/ Damaged Article Investigations. On 12/22/17 at 08:34 AM interviewed staff #181 by phone. Staff was able to state the facility's process for laundering resident's laundry. Staff #181 stated that his department picks up the residents personal items, which are separated by the floor staff, and the laundry is washed separately, dried and delivered back to the floor after it is folded. The unit staff then return the clothes to the residents. Staff #181 denies that he was told of R#40's missing personal clothing items by staff #17. After hanging up with staff #181 interviewed staff #53 who denied being told of R#40's missing personal clothing items by resident or staff. On 12/26/17 at 11:29 AM interviewed staff #17 who reported that R#40 did report to her that he had missing clothing items, she had looked through the lost and found items and could not find these items. Staff #17 stated that she reported this to the nurse and pointed at staff #53. Review of the facility's policy Lost/ Damaged Article Investigations states Purpose: To ensure any incident of lost or damaged articles are investigated and compensated in a consistent manner. Also Procedure: 2. Upon reporting of a missing or damaged article, the staff should complete the Lost/Damage Report Form. 3. The investigation shall include the following. a. The reporter shall provide a clear and detailed description of the lost/damaged article(s). b. The reporter will identify the date and location when article was last seen. The facility failed to provide reasonable care for the protection of R #40's property from loss and failed to follow the facility policy in reporting and investigating of these lost items.",2020-09-01
657,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,585,E,0,1,782M11,"Based on interview with the resident council members, the facility failed to ensure residents are aware of the procedures for filing a grievance. Findings include: On 12/21/17 at 9:30 [NAME]M. a resident council interview was done. The residents were asked whether they are aware of how to file a grievance. None of the council members were aware of how to file a grievance and reported this right to file a grievance was not reviewed with them. On 12/22/17 at 10:20 [NAME]M. the facility provided a policy for the complaint/grievances process.",2020-09-01
658,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,641,D,0,1,782M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, record review and staff interview the facility failed to accurately assess three residents (residents R #80, R #89 and R #90 to reflect the resident's status. Findings include: 1) On 12/20/17 at 08:55 AM while observing R#80, who was in her room in bed, it was noted that resident had soft mittens on both her hands. Review of residents medical chart found that there was a doctor's order for Bilateral hand mitten ok for safety release every 2 hours for 15 minutes and may remove if family is present which was written on 10/02/2017 and renewed monthly on the physician order [REDACTED].#10 dated 10/3/2017 in place for use of bilateral hand mittens with interventions. Initial Restraint Assessment for R#80 was completed on 10/3/17 identifying Bilateral Hand Mittens as a restraint because resident cannot remove it. Condition identified that required the use of restraint was Resident attempted to [MEDICAL CONDITION], she was able to remove inner cannula.Review of R#80's Quarterly MDS dated [DATE] found that there was no coding for the use of restraint for this resident. Interview with staff #53 found that R#80 regained enough strength in her arms and she was trying to take out [MEDICAL CONDITION] 10/02/2017 and that is why there is an order for [REDACTED]. 2) On 12/19/17 at 02:02 PM reviewed R#90's MDS Quarterly assessment dated [DATE] and MDS Annual assessment dated [DATE] and noted that there was a decline in ADLs. Noted that R#90 had a decline documented in the MDS Annual Assessment on 11/28/17 in Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position from a one person physical assist to requiring Two+ persons physical assist. On 12/22/17 at 02:53 PM interviewed staff #53 regarding the decline in ADLs with R#90 and she stated that the coding on the MDS Annual assessment dated [DATE] was an error and that she would submit a modification form. Review of ADL sheet for R#90 confirmed coding error. 3) Cross reference to F 657 and F689. The facility failed to identify, analyze and evaluate the potential risk for accidents, wandering for R #89. Both the MDS admission and quarterly assessments were inaccurate to identify the potential accident and hazard risk-wandering for R #89.",2020-09-01
659,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,656,D,0,1,782M11,"Based on record review and interview with staff members, the facility failed to develop a comprehensive care plan for 1 (R #75) residents in the sample. Findings include: Cross Reference to F690. Resident #75 has history of urinary tract infections which were treated with antibiotics. A review of the resident's record found based on an assessment, the facility did not develop a care plan for the prevention of urinary tract infections. The annual Minimum Data Set with assessment reference date of 11/13/17 notes in active diagnosis, the resident had a urinary tract infection in the last 30 days. The Care Area Assessment also notes the fluid maintenance was triggered due to urinary tract infection.",2020-09-01
660,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,657,D,0,1,782M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with staff members, the facility failed to ensure four residents' (R #34, R #164, R #89 and R #362) care plans were reviewed and revised. Findings include: 1) Cross reference to F 641 and F689. The facility failed to identify, analyze and evaluate the potential risk for accidents, wandering for R #89. The facility failed to implement effective interventions to minimize the risk and monitor the effectiveness and modify the interventions for R #89. No care plan interventions were developed for R#89 wandering until 12/04/17 after he had a fall. The interventions were not effective as evidenced by the resident's monitoring monthly flow record (increase in the episodes of wandering). Findings include: 2 ) Cross Reference to F686. Resident #164 had a facility acquired Stage 2 pressure ulcer (identified 7/26/17) which progressed to a Stage 3 pressure ulcer (identified 10/6/17), the care plan was revised to reflect the change in treatment of [REDACTED]. 3 ) Cross Reference to F689. Resident #34 slipped out of the shower chair on 5/14/17 which resulted in a care plan; however, the interventions identified was not based on a root cause analysis. The facility failed to provide documentation an incident report was submitted to prompt a root cause analysis to prevent future falls in the shower. Subsequently, the Resident #34 slid out of the shower chair on 9/21/17 resulting in compression fractures and decline in ability to stand and bear weight. 4) Resident #362 had care plan for falls initiated on 12/7/17 and resident fell from bed on 12/8/17 at 2130 PM and sustained 0.5 cm abrasion to left great toe and care plan for falls was modified that same day. Resident fell a second time from wheelchair without injury on 12/9/17 at 1420 PM, no documentation that fall risks were re-evaluated, interventions were modified and no documentation that supervision needs were reassessed to prevent avoidable accidents after 2nd fall. Care plan for falls was modified on 12/13/17 after a 3rd assisted fall from wheelchair to bed.",2020-09-01
661,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,686,G,0,1,782M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff members, the facility failed to ensure one resident (R #164) of three sampled residents received the necessary treatment and services to promote the healing of a pressure ulcer. Findings include: Cross Reference to F657. Resident #164 was admitted to the facility on [DATE] with unspecified dementia without behavior; [MEDICAL CONDITION] stage 3 (moderate); anemic in [MEDICAL CONDITION]; muscle weakness; unspecified disorder of circulatory system; and vitamin D deficiency, unspecified. On 12/20/17 at 10:09 [NAME]M. a brief record review was done. The review found Resident #164 with two Stage 2 pressure ulcers to the coccyx. Further review found one of the Stage 2 ulcers progressed to Stage 3. A record review on 12/21/17 at 1:00 P.M. found a [MEDICAL CONDITION] Assessment form documenting Resident #164 was found to have an in-house acquired Stage 2 pressure ulcer, dated 7/26/17. The cause of the wound was due to incontinence of bowel and bladder. The size was 0.5 cm (length) x 1.7 cm (width) with The weekly assessments from 8/8/17 through 8/21/17 documented improvement. On 8/29/17 the ulcer was noted to deteriorate (an increase in size). Documentation was found that Resident #164's plan of care was updated on 8/29/17; however, a review of the plan of care did not find documentation of updated interventions. The wound measurements were 1.6 cm (length) x 0.6 cm (width) and On 9/11/17 the weekly assessment notes the ulcer deteriorated. The assessor noted that the care plan was update on 9/11/17; however, a review of the plan of care found there is no documentation of the updated intervention. The following week (9/19/17) there was noted improvement and no change on 9/26/17. On 10/6/17 the pressure ulcer was noted to be a Stage 3, measuring 1.5 cm (length) x 0.4 cm (width) with 0.1 cm in depth. Also noted there was slough (pinkish/yellow) in the wound bed. The assessment on 10/10/17 notes the ulcer deteriorated, the measurements include 1.5 cm (length) x 0.6 cm (width) with The weekly assessments dated 10/24/17 and 10/31/17 noted improvement. The assessment for 11/7/17 noted deterioration. The treatment was changed on 11/10/17 to cleanse abrasion above coccyx between upper buttocks with normal saline, pat dry, apply [MEDICATION NAME] and cover with [MEDICATION NAME] foam daily until healed. Due to continued deterioration of the ulcer, the treatment order was changed on 11/20/17. The physician's orders [REDACTED]. The documentation on 11/28/17 notes the Stage 3 ulcer deteriorated. The measurements were 2 cm (length) x 3 cm (width) and 0.1 cm in depth. The wound was noted to have a small amount of serous sanguineous drainage. On 12/4/17 the order for medi-honey was discontinued. The new order was to apply compound cream ([MEDICATION NAME] cream + zinc + [MEDICATION NAME]) to coccyx after cleaning with normal saline and cover with [MEDICATION NAME] foam twice a day. Subsequent note on 12/5/17 and 12/7/17 noted improvement with continued drainage. The last documented assessment is dated 12/19/17 which notes continued improvement in response to treatment. A review of the resident's quarterly Minimum Data Set (MDS) with assessment reference date of 9/20/17 noted in Section M. Skin Conditions, the resident had two Stage 2 pressure ulcers. The oldest ulcer was dated at 7/26/17. Further review found Resident #164 was coded as severely impaired for cognitive skills for daily decision making. In Section [NAME] Functional Status, Resident #164 was noted coded as totally dependent on staff with one person physical assist for bed mobility (how the resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture) and toilet use. The resident was coded as always incontinent of bowel and bladder. A review of the care plan for Stage 3 pressure ulcer (onset date of 10/6/17) included the following interventions that were continued from 7/26/17 for the Stage 2 pressure ulcer: assess specific risk factors for pressure ulcers; assess and stage pressure ulcer/s; measure the size of the ulcer and note the presence of undermining; describe the condition of the wound; assess for wound exudates, condition of wound edges and surrounding tissues, and pain levels; change resident's position frequently - bed-bound resident every 2 hours and chair bound every hour; and provide thorough perineal hygiene after each episode of incontinence. Further updates to the care plan after 10/6/17 reflected the changes in treatment on 10/11/17, 11/20/17 and 12/4/17. Observation on the morning of 12/20/17 found the resident was receiving morning care and treatment for [REDACTED].M. Resident #164 was observed up in the wheelchair and was taken to participate in activities. Subsequent observation at 12:34 P.M. (approximately two hours later) found the resident still in the wheelchair having lunch. On 12/22/16 at 8:48 [NAME]M. an interview was conducted with Staff Member #67. The staff member confirmed one of the Stage 2 ulcers (as noted in the MDS) healed. Inquired why Resident #164's pressure ulcer on the coccyx got worst and not healing. The staff member reported that the facility has changed the treatment orders and the resident is not meeting the fluid intake goals as well as decreased food intake; however, the staff member acknowledged that protein powder was added to the meals to promote healing. The staff member provided documentation of staff members repositioning the resident in bed. Further queried regarding the time the resident spends in the wheelchair. The staff member confirmed the care plan does not specify the amount of time the resident spends in the wheelchair. The staff member was unable to explain how the resident's position in the wheel chair would be changed every hour. The observation of the resident up in the wheelchair for approximately two hours was shared with Staff Member #67. The staff member acknowledged the care plan is not specific for the amount of time resident is up in the wheelchair to facilitate healing of the pressure ulcer and discussed the possibility that the resident may benefit from a gel cushion in the wheelchair. Concurrent observation with the staff member found the resident does not have a gel cushion in the wheelchair. On 12/26/17 at approximately 12:15 P.M. an interview was done with Staff Member #59. The staff member acknowledged that the resident's healing time is long and worsened, from a Stage 2 to a Stage 3. Inquired why did the pressure ulcer worsen. The staff member responded it is because the resident always has bowel movements so the order to stop taking senna was made by the physician. The staff member explained that the dressing does not ensure urine will not leak under the tape and when the resident has a bowel movement it is all over. Staff Member #59 confirmed that there was a change in the treatment for [REDACTED]. On 12/26/17 at 12:20 P.M. an interview was done with Staff Member #104. The staff member confirmed the resident is incontinent of bladder and bowel and confirmed the need to change the resident is important due to the pressure ulcer. The staff member reported the resident is checked in the morning and after breakfast for incontinence. Then the resident is checked before and after lunch too. Resident #164 had a facility acquired Stage 2 pressure ulcer to the coccyx which was identified on 7/26/17 which eventually progressed to a Stage 3 pressure ulcer on 10/6/17. There is documentation of changes in treatment and interventions on 8/3/17 (overlay mattress) and 8/7/17 (addition of protein powder). After the identification of the progression to the Stage 3 ulcer there was a change in the treatment order on 10/11/17 to cleanse with normal saline and apply medi-honey daily and prn. The treatment order was changed on 11/20/17 for the change of dressing every shift and prn. On 12/4/17 the treatment order was changed to discontinue the medi-honey and apply the compound cream ([MEDICATION NAME] cream + zinc + [MEDICATION NAME]). Although the treatments were changed, there was no care plan revision based on a root cause analysis (poor fluid and food intake) or lack of incontinence care or positioning/length of time spent in the wheelchair. Therefore, the development of the pressure ulcer and progression of the ulcer was avoidable if the facility had defined and implemented interventions that were consistent with the resident's need(s); monitored and evaluated the impact of the interventions; and revised the interventions as appropriate which resulted in actual harm, worsening of the Stage 2 pressure ulcer to a Stage 3 pressure ulcer and failure to progress towards healing.",2020-09-01
662,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,689,G,0,1,782M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide adequate supervision in order to eliminate and/ or reduce the risk of an accident and monitor the effectiveness of the interventions and modify the care plan in accordance with current professional standards of practice for three of five sampled residents (R #89, R #34 and R #362). Findings include: 1) Cross reference to F 641 and F657. R #89 was admitted to the facility from an Acute care hospital in (MONTH) (YEAR) after having a fall and serious head injury. The resident was living on the memory care unit of a community assisted living facility . On 12/19/17 at 10:00 AM R# 89 was observed to wheel himself into another female residents room (206). Staff #113 came into the room and told the resident this isn't your room, your room is in 201. Staff #113 removed the resident from the room. Staff #113 said R #89 often wheels himself into other residents room's and we have to keep an eye on him. On 12/20/17 at 08:36 AM Res #89 was observed to wheel himself into room [ROOM NUMBER], Staff #113 approached the resident saying wrong room, this is a ladies room and assisted R #89 to the dining/ activity room across the hall. During a review of the Medical Record on 12/20/17 at 10:19 AM the admission Minimum Data Set (MDS) with assessment reference date (ARD) of 9/01/17 and Quarterly MDS with ARD of 11/27/17 Section [NAME] 0900 wandering-presence & frequency was coded 0 on both assessments indicating wandering behavior not exhibited. Review of the resident's care plan noted an intervention for wandering was implemented on 12/04/17 after a fall. A progress note dated 12/04/17 stated that R#89 was found on the floor in front of another resident's room. He suffered with mild bleeding and an abrasion on the forehead. The Physician ordered a Physical Therapy (PT) evaluation on 12/04/17 for fall risk due to increased wandering. Review of the Progress notes dated 12/03/17 they day before the fall revealed that R #89 was found in another residents room [ROOM NUMBER] asleep at 21:45. On 12/21/17 the Behavior/ Intervention monthly flow record was reviewed, R #89 was being monitored for wandering beginning on 11/01/17 through 12/20/17. From 11/01/17 - 11/30/17 R #89 had episodes of wandering on 22 of the 30 days reviewed. Episodes ranged from 1 to 15 times per shift. Interventions used were redirection and offering fluids. The outcome was unchanged or worsened on 14 of the 30 days reviewed. From 12/01/17 - 12/20/17 R #89 had episodes of wandering on 14 of the 20 days reviewed. Episodes ranged from 1 to 20 times per shift. Interventions used were redirection, 1:1, and Return to room. The outcome was unchanged or worsened on 13 of the 20 days reviewed. The majority of the episodes documented on both of the flow sheets occurred on the evening and night shift. During an interview on 12/21/17 at 1:33 PM with Staff #54, R #89 was moved from the 4th floor in (MONTH) (YEAR) to the second floor. Staff #54 stated that when he came to the floor in (MONTH) it was noticed that he would often wheel himself around the unit and wander into other resident's rooms. We got the wander guard to monitor him so that if he gets close to the elevator or stairway to leave the floor an alarm will sound. When asked if 4th floor nursing staff reported to the 2nd floor nursing staff that R #89 wanders staff #87 stated that the progress notes only mentioned the Resident has [MEDICAL CONDITION]. During an interview on 12/22/17, Staff #2 stated that R #89 pedals around in his wheel chair. The Resident's care plan was shared with Staff #2 and Staff #54 informing them that an intervention for wandering was put on care plan on 12/04/17 the day of the fall. Also discussed that R #89 was transferred from the 4th floor on 10/23/17 and there was no documentation that R#89 wandered. Discussed the facility's lack of assessment, evaluation, and documentation of the resident's wandering and the potential risk for accidents (falls) and potential conflict with other residents. Discussed that documentation in the progress notes stated resident was reminded not to go into other's rooms. and that a progress note dated 12/03/17 stated R #89 was found sleeping in room [ROOM NUMBER] at 21:45. Discussed that resident had a fall on 12/04/17 and was wandering at the time. Discussed that R #89 was being monitored for wandering from 11/01/17 to 12/21/17 and that the interventions were not developed until 12/04/17 and the interventions were not effective as evidenced by the resident's monitoring monthly flow record (increase in the episodes of wandering). Staff #2 responded by saying that we're providing the least restrictive environment as possible for this resident, he is not violent has not shown any aggressive behaviors. However, the progress notes dated 11/05/19 documented that R #89 hit a CNA during a shower. The facility failed to do the following in order to keep the residents safe: Identify environmental hazards and individual resident risk of an accident, including the need for supervision; and evaluate/analyze the hazards and risks and eliminate them, if possible and, if not possible, reduce them as much as possible; Implement interventions, including adequate supervision, consistent with the resident's needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident; and monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current professional standards of practice. R #89 created a likelihood of potential serious harm and and potential harm can cause serious injury. R #89 was allowed to wander throughout the unit into other residents rooms where there was a potential for the resident to be injured through either conflict with another resident or during an accident such as a fall. In spite of the facility's efforts to monitor the resident, they failed to provide direct supervision for R #89 to ensure resident safety to all who are residing on the unit. 2 ) Cross Reference to F657. Resident #34 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 9/21/17 the facility submitted an Event Report to the State Agency to report an injury for Resident #34. On 9/20/17 at 8:45 [NAME]M. Resident #34 was receiving a shower and slid out of the shower chair and sat on the floor. The aide was unable to prevent the resident from sliding out of the chair. The resident complained of lower back pain on 9/21/17. Resident #34 was sent for imaging and found to have an age indeterminate L1, L4 and possibly L5 compression fractures. On 12/21/17 at 3:08 P.M. a record review was done for Resident #34. A review of the resident's care plan noted on 5/14/17 the resident slipped down to the floor while sitting in the shower chair. Subsequently on 9/20/17 there was further note documenting Resident #34 slid down to the floor while sitting down in chair inside of the shower room. A review of Resident #34's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 7/15/17 found in Section G0120. Bathing, the resident was totally dependent on staff with one person assistance for bathing. Subsequent quarterly assessment with an ARD of 10/10/17 (after the fall of 9/20/17) notes no change in the resident's bathing skills. Further review of the quarterly MDS with an ARD of 7/15/17 notes in Section G0300. Balance During Transitions and Walking, Resident #34 was coded 2 (not steady, only able to stabilize with staff assistance) for the following areas: moving from seated to standing position; moving on and off toilet; and surface-to-surface transfer (transfer between bed and chair or wheelchair). Subsequently, the quarterly MDS with an ARD of 10/10/17 documents the resident is now coded with 8 (activity did not occur) in the aforementioned areas. On 12/21/17 a request was made to Staff Member #51 to review the facility's incident report related to the fall on 5/14/17. Further record review with the assistance of Staff Member #5 found no documentation in the progress notes of the incident. A review of the Interdisciplinary Progress Notes (IPN) found an entry dated 9/20/17 at 1300 noting at approximately 0845 a loud noise was heard in the shower room. The writer went into the shower room and found the resident sitting on the floor with the aide behind the resident, holding up the resident's back. The resident was still wet and soapy. No injuries were noted, bruises were noted to the right upper buttock, redness to right buttock and upper left back. On 9/21/17 Resident #34 was seen by the physician for a follow up to a mechanical fall. The physician notes at baseline patient is able to assist with transfers and stand with assist .but today, patient was unable to transfer or stand with assist, as patient noted pain to lower back. A lower back x-ray was ordered which revealed an indeterminate L1-L4 compression fracture and possible L5. The physician also noted an MR of the spine without contrast done on 12/17/13 revealed mild spinal stenosis at L3-4 and L4-5. A review of the Plan of Care documents on 5/14/17 Resident #34 slipped down to the floor while sitting on shower chair. A care plan was developed which included the following interventions: assess level of care functioning; inform resident of actions or care to be done to be able to act upon cuing; remind CNA to call for assistance as needed when transferring, use arjo lift; organize shower needs prior to starting shower, place them within reach maintaining safety or resident; do not leave resident unattended in the bathroom; reassess risk for falls; and two person assist during transfer. Following the fall (slid down to the floor while sitting down in chair inside shower room) on 9/20/17, the resident's care plan was updated to include the following: make sure resident is well positioned while up on shower chair or shower gurney and use the shower chair with safety front lock. On 12/21/17 at 2:01 P.M. an interview was done with Staff Member #51. The staff member reported he/she was not at the facility in (MONTH) (YEAR) and could not locate the incident report related to the fall on 5/14/17. However, the staff member reported in (MONTH) the aide completed the shower, reached for a towel and the resident leaned forward, eventually landing on the floor. Queried the staff member whether the use of a front lock shower chair would have been indicated following the first fall in (MONTH) to prevent future falls in the shower room. The staff member responded he/she could not speculate whether the inclusion of a front lock shower chair after the fall in (MONTH) would have prevented the second fall. Upon further query, Staff Member #51 acknowledged that he/she would have updated the resident's care plan to add the use of the front lock shower chair for fall prevention. Interview was done with Staff Member #67 on 12/22/17 at 3:09 P.M. The staff member was queried regarding the use of bed and chair alarm as identified in the resident's care plan. The staff member reviewed the resident's care plan and reported these interventions were discontinued when the resident moved to their floor; however, the care plan was not revised to discontinue these devices. Staff Member #67 also confirmed the compression fracture was the result of the resident's fall on 9/20/17. On 12/22/17 at 10:20 [NAME]M. the facility's policy for Fall Prevention Program and Resident Incident Report was provided for review. The review of the fall prevention policy notes the following: 4. When a fall occurs, the licensed nurse will thoroughly complete the Incident Report Form to collect data for process improvement. a. The report shall be completed on the shift on which the event occurred and b. The completed reports shall be submitted to the Unit Supervisor to provide information on the incident to the IDT team, as well as completing a root cause analysis. A review of the incident report policy notes reportable events must be reported to Administration within 24 hours, reportable events include witnessed and un-witnessed resident falls/slips. The facility failed to revise the resident's care plan based on a root cause analysis following the resident's fall in the shower on 5/14/17. The facility was unable to provide the incident report related to the fall which occurred on 5/14/17 and a review of the resident's record found no documentation of the fall in the progress notes. The failure to provide interventions (i.e. use of the front lock shower chair) to prevent further falls in the shower room resulted in actual harm (compression fractures and decline in activities of daily living). 3) Resident #362 had care plan for falls initiated on 12/7/17 and resident fell from bed on 12/8/17 at 2130 PM and sustained 0.5 cm abrasion to left great toe and care plan for falls was modified that same day. Resident fell a second time from wheelchair without injury on 12/9/17 at 1420 PM, no documentation that fall risks were re-evaluated, interventions were modified and no documentation that supervision needs were reassessed to prevent avoidable accidents after 2nd fall. Care plan for falls was modified on 12/13/17 after a 3rd assisted fall from wheelchair to bed. 4) On 12/26/17 at 12:35 PM while talking with staff #17, on 4th floor, checked the janitor room door to make sure that it was locked and noted that it was left unlocked and the door opened. Asked staff #17 why the door was left unlocked and she stated for maintenance. Staff #9 was present and when asked why the janitor room would be left unlocked he turned and asked staff #17 How come? and staff #17 stated that she left it unlocked so that maintenance could get into the room if they needed to. Staff #17 and #9 confirmed that the janitor room door was to remain closed and locked to prevent residents from getting inside and having access to the cleaning chemicals.",2020-09-01
663,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,690,D,0,1,782M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure one (R #75) of four residents sampled received appropriate care and services to prevent urinary tract infections to the extent possible. Findings include: On 12/22/17 at 10:58 [NAME]M. a record review was done for R #75. A review of the physician's orders [REDACTED]. A subsequent order was made on 12/17/17 to discontinue Bactrim DS and administer ciproflaxin 250 mg. twice daily, seven days for [DIAGNOSES REDACTED].>100,000 cfu/ml of presumptive escherichia coli. The documentation on the lab report notes Resident #75 currently on [MEDICATION NAME] for [MEDICAL CONDITION] and Bactrim for UTI. However, the bacteria is Bactrim resistant; therefore, the antibiotic was changed to cipro. Further review found entries documenting resident with temperatures: 11/13/17 (101 degrees), 11/14/17 (100.4 degrees) and 11/15/17 (98.9 degrees). The resident was also noted with coughing and wheezing. A chest x-ray was done on 11/13/17 which was negative. On 11/17/17 the resident was started on [MEDICATION NAME], 100 mg. twice daily, seven days for [MEDICAL CONDITION]. Subsequent lab report dated 11/18/17 notes the result of urine culture was 3500 cfu/ml of morganella morganii. Handwritten note on the lab report notes the resident already on antibiotic, [MEDICATION NAME]. A review of the progress notes found documentation dated 10/29/17 that the resident had a temperature of 100.2 degrees and urine with foul odor. No hematuria or dysuria noted. On 10/30/17 Resident #75 noted with foul odor of the urine. The note for 10/31/17 documents the start of antibiotic, [MEDICATION NAME] 500 mg. three times a day for UTI. The lab report dated 10/31/17 found >100,000 cfu/ml with predominant growth of alpha [DIAGNOSES REDACTED] streptococci. A lab report dated 5/18/17 notes the result of the urine culture included, >100,000 cfu/ml of morganella morganii. A handwritten note on the lab report documents, 5/18/17 Bactrim DS twice a day for seven days for [DIAGNOSES REDACTED]. On the afternoon of 12/22/17 a review of the annual Minimum Data Set with an assessment reference date of 11/13/17 notes the resident is totally dependent on staff with one person physical assist for toilet use. The resident is also noted to be frequently incontinent of urine and bowel. Also noted in Section I. Active Diagnosis, R #75 was coded at . Urinary Tract Infection (last 30 days). A review of the comprehensive care plan found no documentation of a plan of care to prevent development of UTIs. There is a care plan for dehydration (potential and history of UTI). The interventions included the following: encourage po fluids and monitor food and fluid intake; encourage fluid intake by offering fluids regularly to cognitively impaired residents; provide preferred beverages i.e. juice if not contraindicated; and encourage family involvement in increasing fluid intake according to resident's fluid consistency. A review of the Care Area Assessment notes R #75 is frequently incontinent of bladder and bowel putting the resident at risk for skin impairment. Also noted, fluid maintenance triggered due to UTIs, putting her at risk for dehydration/fluid maintenance. Encourage 1000 to 1400 cc fluid daily. On 12/22/17 at 1:54 P.M. an interview and concurrent record review was done with Staff #67. Queried staff member regarding R #75's urine culture of morganella morganii, asked the staff member where does this organism come from, the staff member replied he/she could check. Further queried why the resident has frequent UTIs, the staff member reported the resident refuses to use the toilet and is dependent on staff to wipe after urination or bowel movement. Inquired whether a care plan was developed to prevent UTIs, Staff #67 confirmed there is no care plan for UTI prevention. The staff member reported, the resident's fluid goal is 1100 to 1400 ml; however, this does not take into account the resident has frequent UTIs. A review of the resident's fluid intake found the resident is being monitored for fluid intake as the resident is not attaining the fluid goal. The documentation of the fluid intake from 11/26/17 through 12/21/17 found the resident's fluid intake ranged from 136 ml to 1780 ml a day. Based on a thorough assessment to identify a thorough assessment to identify probable causal factors contributing to UTIs (abnormal post void residual, referral to urologist for assessment, etc.), the facility failed to develop a care plan for the prevention of UTIs.",2020-09-01
664,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,700,D,0,1,782M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, record review and staff interview the facility failed to provide a bedrail that did not pose an entrapment risk for two of the residents (R#40 and R#80). Findings include: 1) On 12/19/17 at 04:28 PM during resident (R) interview with R #40 noted that resident had a grab bar on the left side of his bed and on the right side of his bed he had a full length bed rail. Inquired with resident why his bed was set up like this and he stated he asked staff to put the bedrail on the right side of his bed so he can grab it and turn self and he reported that he had a history of [REDACTED]. R#40 stated that staff stand on the left side of his bed to provide care and that is why there is only a grab bar on that side. On 12/22/17 08:22 AM medical record review found that resident has a care plan in place for use of the bedrail on his right side and an Initial Restraint Assessment form was filled out for the bed rail use which shows that the resident requested to have his siderail up when he is in his bed for use of re-positioning self. After reviewing R#40's medical record interviewed staff #53 and discussed the width of openings within the bedrail perimeter and noted that it appeared large. Staff #53 brought a measuring tape and measured an open space within the bedrail perimeter and found it to be 7 3/4 inches. 2) On 12/20/17 at 08:55 AM while observing R #80 in her bed noted that resident had both bedrails up and resident had mittens on both hands. R #80 has the same type of bedrail that R#40 has on his bed. Review of R #80's MDS 3.0 dated 08/23/17 (Admission) and 11/18/17 (Quarterly Assessment) found that resident did not have a BIMS score because resident is mute and [DIAGNOSES REDACTED]. Interviewed staff #53 who confirmed that R #80 does have the same bedrails with the 7 3/4 inch openings within the bedrail perimeter. Staff #53 stated that R #80's family requested that staff use bedrails for resident when she is in bed for her safety and this was documented in the resident's Initial Restraint Assessment form and in her care plan. Staff #53 was reassured that bedrails can be used if they are safe and do not pose a risk for entrapment for the resident. Staff #53 was reminded that R #80 is cognitively impaired, does not have the use of her hands since she is wearing mittens and cannot use the call light if she could use it and is mute so cannot call out for help if she were to get entrapped by the bedrail that were on her bed. Staff #53 agreed with this. According to the FDA recommendations, made on page 16, in the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment they .recommend a measure of less than 120 mm (4 3/4 inches) as the dimensional limit for any open space within the perimeter of a rail. It was noted on page 15 of the Guidance for Industry . under the Data from the Retrospective Study that Adverse events identified as occurring within the rail were reported in bed models where open spaces within the rail were greater than 120 mm (4 3/4 inches). Manufacturers' measurements of bed models representative of those identified in these incidents had spacing within the rail of between 177 mm (6.97 inches) and 190 mm (7.48 inches). The data suggest that nearly all of these entrapment events may have been prevented if the spaces within the rails had been less than 120 mm (4 3/4 inches), representing head breadth as described above. The State Agency references the Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, (MONTH) 10, 2006, pp 15-16: Dimensional Limits for Identified Entrapment Zones 1-4 . Zone 1-- Within the Rail . Data from the Retrospective Study.",2020-09-01
665,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,725,E,0,1,782M11,"Based on observations, record review and interview with staff members, the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related serveds to assure resident safety and attain or maintain the highest practicable physical, mental, psychosocial well-being of each residident. Findings include: 1 ) On 12/ 21/17 at 9:30 [NAME]M. the resident council interview was conducted. The residents responded that staff does not respond to the call light in a timely manner. The residents reported the staff members are too busy. The residents reported calling for help to use the toilet or change their personal briefs. The residents stated waiting 10 to 30 minutes. One resident reported the call light is pressed to request for a change of personal brief (urinary incontinence) and the staff take so long that he/she urinates again. A staff member commented that the wait time is dependent on how busy the staff members are, reporting the aides are responsible for two rooms. The residents also reported the ratio is one aide for two rooms (a total of 8 residents), noting the need for more staff. 2) Cross reference to F686. The facility failed to ensure R #164 received the necessary treatment and services to promote the healing of a pressure ulcer. 3) Cross reference to F690. Based on record review and interview with staff members, the facility failed to ensure one resident (R #75) of four residents sampled received appropriate care and services to prevent urinary tract infections to the extent possible. 4) Cross reference to F689. The Facility failed to provide adequate supervision in order to eliminate and/ or reduce the risk of an accident and monitor the effectiveness of the interventions and modify the care plan in accordance with current professional standards of practice for three of five sampled residents (R # 89 wandering; R#34 and R#362 for falls). 5) Cross reference to F700. The facility failed to provide a bedrail that did not pose an entrapment risk for R#40 and R#80. 6) Cross reference to F561. The facility failed to ensure that residents' preferences and choices regarding bathing frequency were supported for R #362.",2020-09-01
666,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,880,E,0,1,782M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to maintain an infection prevention program designed to help prevent the development and transmission of communicable diseases and infections. Findings include: 1) On 12/26/17 at 09:10 AM met with staff #2 and staff #51 to discuss the facility's Infection Prevention and Control Program, Antibiotic Stewardship Program and infections that the residents at the facility had acquired. Staff #2 and #51 shared that their Infection Control Consultant (ICC), who compiled the facility's information on infections provides a report to the facility every quarter. The reports reviewed at this meeting were from the 1st quarter (Jan.-Mar. (YEAR)), 2nd quarter (April-June (YEAR)) and 3rd quarter (July - Sept. (YEAR)). Review of the reports found that the facility had the following infections by quarter: 1st Quarter Month UTI RTI Wound/Skin EENT GI Jan. 1 2 5 0 1 Feb. 2 3 2 0 0 March 1 9 1 0 0 Total 4 14 8 0 1 2nd Quarter Month UTI RTI Wound/Skin EENT GI April 2 4 1 3 0 May 2 2 0 0 0 June 0 1 1 1 0 Total 4 7 2 4 0 3rd Quarter Month UTI RTI Wound/Skin EENT GI July 8 10 5 0 0 Aug. 7 10 6 0 0 Sept. 5 3 4 0 0 Total 20 23 15 0 0 Review of this information provided found that the facility had a significant spike in Urinary Tract Infections [MEDICAL CONDITION], Respiratory Tract Infections (RTI) and Wound/ Skin infections in the 3rd quarter of (YEAR) (July - Sept.). When compared to the 1st and 2nd quarters the 3rd quarter had a 5 time increase in the number of UTIs going from only 4 in the 1st and 2nd quarter to 20 in the 3rd quarter. Notable increase in the 3rd quarter was the spike in RTIs going from 14 in the 1st quarter to 7 in the 2nd quarter and 23 in the 3rd quarter making that more than 1.5 times the number of RTIs from the first quarter and more than 3 times the number from the 2nd quarter. Another significant spike in infections was with Wound/Skin infections. There were 8 Wound/Skin infections in the first quarter, 2 in the second quarter and 15 in the 3rd quarter. This makes a more than 2 times the number of Wound/Skin infections in the 3rd quarter compared to the 1st quarter and a more than 7 times the number of Wound/Skin infections when comparing the 2nd and 3rd quarters. It was noted that all of the infections in the ICC's report were identified as facility acquired infections. Upon closer review of the 3rd quarter infections (UTI, RTI and Wound/Skin) report submitted to the facility by the ICC found that there were a high number of URIs and UTIs that occurred on the 4th floor. During interview with staffs #2 and #51 there was no mention of the spike in infections in the 3rd quarter, no mention of a high percentage of the URI and UTI infections occurring on unit 4 and no explanation of a root cause analysis being performed by the facility to find why this was occurring with their residents. During the interview with staff#2 and staff #51 they shared that there was training provided throughout the year with facility staff and provided the training schedule. It was noted that the facility provided Infection Control/Prevention training in (MONTH) (YEAR), Blood Borne Pathogens and Diseases training in (MONTH) (YEAR) and Personal Hygiene/Infection Prevention/Sanitation training in (MONTH) (YEAR). When asked about staff who might have missed this training staff #2 stated that those staff would go through the training binder before the end of the year to make up the training they missed. When asked if there was any monitoring of staff with hand hygiene and use of PPEs staff #51 stated that this was ongoing with various facility staff involved. When asked about the spike in infections from the 3rd quarter in (YEAR) and what was being done to bring down the numbers staff #51 stated that they are still in the planning phase of this part of their Infection Control Program. It was noted that staff #51 did show surveyors her documentation of tracking of the identified infections per unit with the antibiotics being used to treat the identified infections.",2020-09-01
667,PEARL CITY NURSING HOME,125043,919 LEHUA AVENUE,PEARL CITY,HI,96782,2017-12-26,921,D,0,1,782M11,"Based on observation and staff interview the facility failed to provide a sanitary environment for their residents, staff and the public. Findings include: 1) On 12/19/17 at 11:28 AM prior to observing R #90, who was resting in his bed, went to pull back privacy curtain to introduce self to the resident when it was noted that there were multiple large brown stains on the privacy curtain. Staff, who came to assist R#90, was asked what the facility's procedure is if the resident's privacy curtain is dirty and she was able to state that staff would notify maintenance to take the curtain down and have it cleaned. This staff member was shown the multiple large brown spots on the resident's privacy curtain and she stated that she would notify maintenance to take care of this. 2) On 12/26/17 at 11:29 AM interviewed staff #17 in shower room B on the 4th floor and quiered what was the black matter that was on the wall, floor and shower head and staff #17 stated that it was mildew and that she cleans the shower rooms after lunch with a green brush and A-456 II Disinfectant by Ecolab. Staff #17 stated that the staff do not use the shower head when bathing the residents, they use the hand held shower. Staff #17 stated that the mildew appears everyday. On 12/26/17 at 01:11 PM met and interviewed staff #9 on the 4th floor, as we walked and looked at shower rooms B and C. Quiered of staff #9 how does the housekeeping staff clean the blackened area between the floor and wall tiles and he stated that they use a grease cleanser and use a green scrub brush. When asked how he takes care of the orange areas below the door frames near the ground, such as the areas in shower room B, he stated that they dremel it and apply rust-oleum.",2020-09-01
668,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2019-02-04,584,D,0,1,JB5D11,"Based on observation and interview the facility failed to maintain comfortable sound levels for two Residents (R72 and R87) whose rooms were near a resident with poorly controlled behaviors: yelling loudly, crying and banging on the wall. Findings include: Cross reference to F740 1) During an initial tour of the unit on 01/28/19 at 12:43 PM a loud banging/ pounding sound could be heard at the end of the 400 room wing of the Wailani unit. The sound was coming from a residents room (R70), who was found in her room alone, lying on her bed that was pushed all the way up to the wall pounding on a large pad that was placed against the wall with her right fist. 2) During an observation on the unit on 01/29/19 at 02:30 PM loud yelling could be heard coming from the 500-600 room wing of the Wailani unit. The yelling lasted for 2 hours till 04:30 PM. After a brief inquiry, the loud yelling was found in R20's room. 3) During an interview with R72 on 01/30/19 at 10:17 AM (who's room is next door to R70), it is noisy at night and early in the morning, I can hear loud pounding on the wall, it sounds like they're banging on the walls or something. I'm not sure who it might be or what they're doing but its loud and hard to sleep. R72 is cognizant and alert to person, place and time. 4) During an interview with R87 (room on the other side of R70's room) on 02/01/19 at 09:30 AM she reported that she often hears loud banging on the wall throughout the night and day in the room next door to hers. It is hard to sleep at night because of the noise. I am also very worried about the lady next door, I hope she doesn't hurt herself or need help when banging on the wall. R87 is cognizant and alert to person, place and time. 5) On 01/30/19 at 09:30 AM, R20 was sitting in her wheelchair on the Wailani unit activity lounge restless, fidgeting, moving around in her chair, yelling out mommy! mommy!, crying, wheeling around in her wheelchair looking up at the nurse with tears on her cheeks, facial color red. There were several residents, visitors and staff sitting and standing in the activity lounge where R20 was agitated.",2020-09-01
669,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2019-02-04,656,D,0,1,JB5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for Resident (R) 41 related to problems with her teeth and breast. Findings include: 1) Interview on 01/30/19 with Resident (R)41 at 09:13 AM I have a tooth that is supposed to be taken care of. I went to the dentist because the back tooth is giving me trouble and you have to go to a special dentist for this particular tooth. I fell and all my teeth got turned and my teeth pushed in and broken. Interview on 01/31/19 at 01:20 PM with Staff (S)1 and a concurrent record review (RR) who stated, She saw a doctor in Waimea. This doctor is the only doctor who can see her in the wheelchair. The resident refused to see her the second time for the actual procedure. Resident refused to do the teeth extraction on (MONTH) 16, (YEAR). On (MONTH) 9, (YEAR), we got a consult to see another doctor. She had a nose bleed and she couldn't make the appointment. She also had dizziness, lightheadedness, nausea for a while and there is not visit to the second doctor. Follow-up interview on 02/01/19 at 08:52 AM with R41 who was asked by surveyor why she refused to see the first dentist again and verbalized I'd rather keep my tooth in than go to that person. I would never get taken care of in a place like that. When you sit outside to go in, they don't keep their people. Everybody seems to walk in there at one time. They must open one day a week. I couldn't figure that out. The dentist never showed me her face and stayed behind me. RR on 02/01/19 at 10:00 AM revealed no care plan for breast care for R41. 2) Interview on 01/30/19 at 09:45 PM with resident (R)41 My right breast has fallen to the side and it's hard. Resident shows this surveyor right breast. Right side of breast with different skin texture and some redness to area. R41 goes on to say that they told me that it is [MEDICAL CONDITION] and to go to my own physician. I don't have a physician. I went two different times, three different doctors. I would like it removed and it hurts. R41 offers me a copy of a report from a radiology service. Report states Our interpretation of your breast examination identified a finding that needs further evaluation. A full report has been forwarded to your physician. Interview on 01/30/19 at 10:18 with MD who stated, I didn't see that exact letter but we sent her to a surgeon and it was biopsied. The results came back as benign. We offered her to go to some surgeons here but she didn't want to. We offered her to go to Oahu but she didn't want to. We treated her with antibiotic. She shouldn't pick on it. Interview with S1 on 01/31/19 at 02:00 PM who was stated, there is no care plan or followup for her dental needs at this time.",2020-09-01
670,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2019-02-04,657,D,0,1,JB5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and staff interviews, the facility failed to review/revise care plans for two of 17 residents (R33 and R39) for nutrition and behaviors. Findings include: 1) Cross reference to F692 Cross reference to F740 Resident (R) 39 experienced a significant weight loss of 16% over a three month period between (MONTH) and (MONTH) (YEAR). The facility completed a significant change Minimum Data Set (MDS) assessment dated [DATE] which noted R39 had a significant weight loss and was not on a physician prescribed weight loss program. The 11/23/18 assessment also noted R39's Brief Interview for Mental Status (BIMS) score went down since her previous assessment from 15/15 to 9/15. The 11/23/18 assessment further noted R39's behaviors and mood had worsened since the 9/15/18 assessment. A review of R39's intake from (MONTH) (YEAR) through (MONTH) 2019 found she frequently refused lunch and dinner meals. Additionally, R39 often missed two or more meals in a day. On the morning of 02/01/19 a review of Interdisciplinary (IDT) notes found an entry dated 10/26/18 which noted R39's Weight change likely related to fluctuation in appetite with mood swings/shingles pain. Another IDT note dated 01/10/19 stated, Behavior interferes with meals. An interview of the Licensed Nurse (LN) 100 on the afternoon of 01/31/19 at 03:09 PM revealed R39's behaviors have interfered with meal consumption. An interview of the Registered Dietician (RD) on the morning of 02/01/19 at 08:51 AM revealed R39's mood/behaviors have affected her meal intake thus resulting in significant weight loss. A review of R39's care plans on the morning of 01/31/19 at 09:30 AM found one titled, Nutrition, with the onset date of 04/03/18. The problems listed did not include R39's frequent refusal of meals nor did it include approaches staff should use to address the resident's refusals. The care plan also did not discuss R39's mood/behaviors and its impact on her nutritional intake. 2) Record Review (RR) on 01/31/19 reveals R33 was an [AGE] year-old female, who has moderately impaired cognition r/t Dx of [MEDICAL CONDITION] and late effect [MEDICAL CONDITION](stroke). She requires extensive assist with activities of daily living. R33 is incontinent and at risk for skin breakdown. Brief Interview for Mental Status (BIMS) score is 11/15 (moderately impaired). RR of R33's comprehensive care plan initiated on 04/18/12 revealed the following Behavior Problem: a hx of being accusatory to staff and other residents. (e.g. saying hurtful things to caregivers and other residents), being verbally abusive and striking out at staff when she is angry or upset. Established goal was, R33 will be cooperative with care and not strike out at caregivers during caregiving tasks, and not be verbally abusive . Individualized interventions/approaches were implemented at that time to address R33's behavior. RR of R33's MDS for significant change dated 08/23/18 included: Verbal behavioral symptoms directed toward others, occurred 4 to 6 days Significant interference with the resident's care Put others at significant risk for physical injury Significantly disrupt care or living environment Residents behavior of rejection of care necessary to achieve goals for health and wellbeing occurred 4 to 6 days. The current behavior status, care rejection was marked Worse compared to prior MDS assessment dated [DATE]. RR of IDT Social Service (SS) notes dated 08/29/18, which stated, . Significant change related to resident poor meal intake and increased behavior refusing meals and refused medications r/t pain .Resident's Mood Interview score is 03 (minimal depression), however resident did express that she is depressed due to her health status. Resident was agreeable to consultation with Psychologist (P). During an interview with SS83 on 02/01/19 at 11:12 AM, discussed the IDT SS notes dated 08/29/18, and she stated, I attended the IDT meeting after the significant change and those are my notes. Asked SS83 if R33 attended, and she replied, Yes .her daughter was there also. Her daughter suggested her mother may benefit from a psychiatric consult. On 08/31/18 the care plan Psychosocial Well-Being problem was revised to include: Resident has a dx of Depression, her psychosocial well-being is at risk due to her declining health. When resident is not feeling well, resident often refuses to get out of bed. Approach was documented as follows, Observe need for psychological/psychiatric services. Provide for these services if agreed upon by resident/responsible party and ordered by physician. On 09/04/18 Registered Nurse (RN)41 documented in nurses notes she informed daughter R33 refused to see P. Entry was, POA (Power of attorney) updated regarding visit with Psychologist yesterday. On 09/10/18 Progress note by Dietitian 21 documented refused to talk to P. There was no additional documentation available regarding status of referral to P. On 11/21/18 Associate incident report form completed by Certified Nursing Assistant (CNA)36, documented R33 combative during shower, scratching and holding aid by the wrist-made verbal threats. On 11/23/18 R33's behavior care plan updated entry, R33 can be physically and verbally aggressive during shower time. Care Plan goal added was: R33 will not harm caregivers daily when taking a shower through the next review. This was the only revision to the behavioral care plan since it was initiated on 04/18/12. On 11/27/18 Associate incident report form completed by CNA26, documented, . she (R33) punched me. Resident hit my right chest with her right hand. Supervisor's (RN114) report dated 01/28/19 described incident as follows: CNA was providing care on R33 .when resident turned to L side, resident punched CNA to R chest area, without any reasons. Resident has hx of being physically aggressive to staff. During interview on 02/01/19 at 09:26 with CNA8, she stated, We try our best to make her (R33) comfortable, and always have two people when working with her. Asked if aware of the recent incidents and she replied, Yes, it happened to me too. I don't remember the date, but it was less than a year. While putting her in bed to change her diaper, I got struck in left side of chest. You cannot do it by yourself or someone will get hurt. I worry if she is soaked (diaper). Don't want her to get sores cause she refuses. I worry I won't be able to change her diaper when needed if she is upset. A care plan approach implemented 04/18/12 is: Do not try to reach out and touch her when she appears angry or verbally abusive during caregiving tasks. During interview on 02/01/19 at 09:43 AM with SS49, asked what follow up occurred after CNA incidents 11/23/18 and 11/27/18. I talked to R33 but did not document it. Asked if a significant change would be reflected in the care plan, and she stated, Yes, it should be. At the time I reviewed it and felt the care plan was still applicable. Reviewed R33's care plan with SS49, who validated the behavior problem was initiated 04/10/12 with one revision dated 11/23/18. On 02/01/19 at 10:17 AM during interview with MD, discussed R33's behavior. Inquired if notified, and she stated, No, I was not aware. Hitting behavior new to me. Usually they notify me, so not sure why that didn't happen. R33's behavioral care plan interventions were not effective. The facility failed to evaluate the effectiveness and revise R33's care plan after a significant change in her behavior and failed to investigate the underlying cause of R33's depression and aggressive behavior which led to three incidents of physical aggression toward CNAs, and ongoing rejection of medications and necessary care.",2020-09-01
671,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2019-02-04,684,D,0,1,JB5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the resident received the proper treatment and care in accordance with the comprehensive assessment of a Resident (R)42 with professional standards of practice. Findings include: Interview on 01/30/19 at 11:50 AM with R42 who voices, Just now, I had to put my fingers in my rectum to get the lumps out. I was ok for two months and when I turned 87, I started to have hard bowels. It's painful and I'm afraid I may hurt myself. I have to drink three orange juices and I drink them but I still have to do what I'm doing to move my bowels. When asked, he further states, that no one asks me about my constipation but I told them that they need to increase the meds. Record Review (RR) on 01/31/19 at 09:57 AM reveals doctors orders for [MEDICATION NAME] 100 mg by mouth twice a day for constipation. On 01/10/19, an order for [REDACTED]. The Resident also is receiving [MEDICATION NAME] extended relief 10 mg one tablet by mouth twice a day prn for moderate pain. Resident received this prn order on (MONTH) 5, 7, 12, 14 and 17th. In addition to this order, there is a regimented order for [MEDICATION NAME] extended relief by mouth twice a day and resident received this medication every day for the month of January. The resident also receives a [MEDICATION NAME] 75 mcg [MEDICATION NAME] every 72 hours for chronic knee pain. Side effects of [MEDICATION NAME] and [MEDICATION NAME] is constipation. Constipation care plan dated 11/24/18 states, R41 has a [DIAGNOSES REDACTED]. Administer bowel products as ordered (see Medication Administration Record [REDACTED]. Interview on 01/31/19 at 11:05 AM with Staff(S)121 who stated, R41 is independent and he prefers male nurses aides. I set up his bed. I supervise him when he goes to the bathroom. I take care of his urinal. I asked him when he had a bowel movement and he said he didn't. R41's constipation was discussed with S41 and that although the resident has medications to take if needed for constipation, he is not getting the medication he needs to move his bowels. S41 was not aware that he was constipated.",2020-09-01
672,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2019-02-04,692,G,0,1,JB5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and staff interview, the facility failed to maintain necessary nutritional support for one of seven residents (R) 39 which resulted in a significant weight loss of 16% over a three month period. Findings include: Cross reference to F657 Cross reference to F740 R39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Upon admission, R39 did not refuse meals and was not experiencing mood or behavior problems. An observation of R39 on the morning of 01/29/19 at 10:41 AM found her in bed with the curtains drawn as she was banging on the wall and yelling for help. She yelled, Help me. Help me. Don't leave me here. I need help. Surveyor went into her room to ask how she was doing. She said she wasn't feeling well. R39 appeared distressed and worried. She stated, My stomach hurts. I need Tylenol. Surveyor informed her she would notify the Licensed Nurse (LN) to assist her. She stated, Don't say that. You always say that. Don't say you're coming back. They always say that. Make sure you bring the nurse back or she won't come. Surveyor assured her she would make sure the nurse came in to assist her. Surveyor found LN43 to endorse R39's wishes. LN43 attended to R39 within five minutes. Observation of R39 on 01/29/19 at 11.20 AM found her asleep in bed. On 01/29/19 at 12:00 PM R39 was heard banging on the wall in her room and yelling for Staff 107 and Staff 37. R39 was yelling, (Staff 107, Staff 37) .You leave me here and don't come back .(Staff 107) don't leave me here .(Staff 37) come and get me. Don't leave me. At 12:04 PM the Registered Dietician (RD) walked into R39's room to assist her. R39 was upset and telling the RD she needs help. At 12:06 PM Staff 107 walked in and assisted R39 out of bed and into her wheelchair. Staff 107 wheeled R39 to the bathroom where he stopped to get her hairbrush and brushed her hair. R39 saw the surveyor standing in the hallway observing her. R39 appeared agitated and anxious with her brow furrowed. R39 stated, Don't you let that young (pause) woman wheel me. Staff 107 brought R39 to the dining room and placed her at a table. The lunch trays were passed out and she saw her meal of chopped pork and rice and yelled, I don't want to eat that. Take me back to my room. Staff 107 returned approximately two minutes later and wheeled her back to her room and placed her back to bed. An interview of Staff 107 on 01/29/19 at 12:30 PM revealed he placed R39 back to bed because she didn't like the way the pork was chopped. Staff 107 was asked whether she was offered a substitute for her meal which he didn't answer as he moved on to his next task. R39 did not have lunch on 01/29/19. An observation of R39 on 01/30/19 at 09:00 AM found her in bed asleep; At 12:00 PM she was in bed asleep. On 01/31/19 at 10:00 AM R39 was found in bed asleep. On 01/31/19 at 12:00 PM she was observed up in her wheelchair in the hallway waiting for lunch. She appeared worried and anxious with her brow furrowed and appearing restless as though she needed to go somewhere. At 12:02 PM, R39 began yelling for staff to return her to her room. A staff member returned her to her room. Again, R39 missed lunch. On the morning of 02/01/19 at 9:30 AM R39 was found in bed asleep. LN100 stated she was out earlier for breakfast then returned to bed. On 02/01/19 at 11:00 AM R39 was heard banging on her wall and yelling for staff to help her. A review of R39's intake log on the afternoon of 01/31/19 at 01:55 PM found she often refused her meals, particularly lunch and dinner. R39 almost never accepted the afternoon and bedtime snacks. In the month of (MONTH) (YEAR), R39 refused breakfast on 2 days; Refused lunch 9 days; and Refused dinner 7 days. For the month of (MONTH) (YEAR), R39 refused more than one meal per day: 10/1/18 refused lunch and dinner; 10/22/18 refused lunch and dinner; 10/24/18 refused lunch and dinner; 10/27/18 refused breakfast and dinner; 10/31/18 refused lunch and dinner. In the month of (MONTH) (YEAR), R39 refused breakfast 10 days; Refused lunch 10 days; and Refused dinner 10 days. For the month of (MONTH) (YEAR), R39 refused at least two meals on the following days: 11/02/18 refused breakfast and lunch; 11/03/18 refused breakfast and lunch; 11/09/18 refused lunch and dinner; 11/13/18 refused breakfast, lunch and dinner; 11/15/18 refused breakfast and dinner; 11/17/18 refused breakfast, lunch and dinner; 11/18/18 refused breakfast and dinner; 11/19/18 refused breakfast and lunch; 11/20/18 refused breakfast and dinner; and 11/22/18 refused breakfast, lunch and dinner. In the month of (MONTH) (YEAR), R39 refused breakfast 2 days; Refused lunch 2 days; and Refused dinner 6 days. In the month of (MONTH) 2019, R39 refused lunch 2 days and refused dinner 8 days. For the month of (MONTH) 2019, R39 refused lunch and dinner on 1/29/19. On the morning of 01/30/19, a review of R39's weights found she weighed 122 pounds on 9/17/18. On 10/15/18 R39 weighed 117 pounds, or 5% loss from 9/17/18 (one month). On 11/12/18 R39 weighed 106 pounds or 13% loss from 9/17/18 (two months). On 12/03/18 R39 weighed 102 pounds or 16% loss from 9/17/18 (three months). Her latest weight was 102 pounds on 01/14/19. On the afternoon of 01/3/19 at 3:00 PM, a review of R39's Resident At Risk (RAR) notes found an entry dated 10/25/18 which noted, appetite getting worse; continues to yell. Another entry dated 10/26/18 noted, Weight change likely related to fluctuation in appetite with mood swings/shingles pain. The 10/26/18 plan was to recommend 2Cal HN 60 ml three times daily with medpass. An entry dated 1/10/19 noted, Behavior interferes with meals. A review of R39's care plan titled Nutrition with onset date 04/03/18 did not discuss the fact that the resident frequently refused meals with the recommended approaches. On the morning of 02/01/19 at 08:30 AM, the physician's progress notes dated 06/19/18 to 12/31/18 were reviewed. On 10/18/18 the physician noted R39's appetite was satisfactory and had a 3 pound weight loss (117 pounds). However, from her baseline weight of 122 pounds, that was a 5% loss within one month (or significant). On 10/30/18, the physician noted R39's appetite was satisfactory with no significant weight change and that she was experiencing epigastric pain (10/29/18 weight 115 pounds or 6% loss in 1.5 months). The physician's plan for R39's epigastric pain noted it was [REDACATED] vs PUD ([MEDICAL CONDITION] Ulcer Disease) - Trial (PPI) Proton Pump Inhibitors daily to assess if this helps. On 10/31/18 the physician noted R39 had epigastric pain and she was constipated. An interview of LN100 on the afternoon of 01/31/19 at 03:09 PM revealed R39 had uncontrolled behaviors which the LN attributed to the resident's poor intake. LN100 stated R39 has outbursts, screams a lot, and refuses care on a daily basis. The LN noted R39's behaviors have interfered with her nutritional intake causing her to have a significant weight loss. LN100 stated R39 often refuses meals as a result of her labile behaviors. LN100 stated R39 receives 2Cal (nutritional supplement) three times daily with medication pass, which she takes. An interview of the Registered Dietician (RD) on the morning of 02/01/19 at 08:51 AM revealed R39's behaviors have progressively gotten worse. The RD noted, Sometimes her behavior affects her appetite. The RD stated she referred R39 for a swallow evaluation by a Speech Language Pathologist (SLP) on 04/09/18. She reported the SLP had difficulty completing her swallow evaluation because R39 did not like the SLP and she therefore had to stand at a distance during observations. The SLP recommended a regular, mechanical soft diet. The RD noted around (MONTH) or (MONTH) (YEAR) the facility did a significant change Minimum Data Set (MDS) because it seemed like her behavior started to affect her appetite. At that time, she was started on 2Cal (nutritional supplement) three times daily. The RD said it was her understanding that the physician was adjusting her medications and the RD wanted to see if it had any impact on her intake/weight. The RD was flipping through R39's medical record and mentioned, Oh it says here she had shingles. That may have gotten the ball rolling. The RD concluded that it's very likely her behaviors have affected her nutritional intake causing an avoidable significant weight loss.",2020-09-01
673,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2019-02-04,740,G,0,1,JB5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and staff interviews, the facility failed to maintain the highest practicable physical, mental and emotional well being for five of six residents (R) (R39, R33, R20, R41, R70) reviewed for behavior, with one resident (R39) who experienced actual harm from not receiving the necessary behavioral health care and services. Findings include: 1) Cross reference to F692 Cross reference to F676 Resident (R) 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation of R39 on the morning of 01/29/19 at 10:41 AM found she activated her call light and was banging on the wall in her room and screaming: Help me. Help me. I need help. Surveyor went into R39's room and asked how she was doing. She said her stomach hurt and she asked for Tylenol. Surveyor informed her she would return after she notified the nurse of the resident's needs. R39 yelled, Don't say that. Don't leave. You won't come back. Make sure you bring the nurse back or she won't come. She continued to scream that as the Surveyor went out to notify a Licensed Nurse (LN) of her request. LN43 said she would go in to help the resident and was observed going into the resident's room a few minutes later. At 11:30 AM the surveyor returned to follow up with R39 but she was asleep. On 01/29/19 at 12:00 PM R39 had again activated her call light and was banging on the wall, screaming the names of the Certified Nurses Aides (CNAs) who routinely care for her. She screamed, (CNA107) .(CNA37) .You leave me here and don't come back. Help! Various staff were present and continued with their tasks without checking on R39. At 12:04 PM the Registered Dietician (RD) walked into R39's room to assist her. The RD was seen talking with R39 while she lay in bed. R39 stated she was hungry and ready for lunch. CNA107 walked into R39's room at 12:06 PM and assisted her from the bed into her wheelchair. CNA107 wheeled R39 towards the door and stopped at the bathroom to brush the resident's hair. R39 could see the Surveyor standing in the hall observing. R39 was looking at the Surveyor and in an irritated voice she told CNA107, Don't let her wheel me. I don't want that young .(pause) .woman taking me anywhere. CNA107 assured R39 he would be the person wheeling her out of her room. R39 was brought to the dining room and placed at a table. The lunch trays were passed out and she saw the meal which consisted of chopped pork and rice. She yelled, I don't want to eat that. Take me back to my room. CNA107 brought R39 back to her room and placed her back in bed. An interview of CNA107 on 01/29/19 at 12:30 PM revealed he placed R39 back to bed because she didn't like the pork, particularly the (mechanical soft) texture. CNA107 was asked whether she was offered a substitute for her meal, which he didn't answer as he moved on to his next task. R39 did not have lunch on 01/29/19. On 01/30/19 at 10:30 AM R39 was heard yelling and banging on her wall from her room. While banging on the wall, she was screaming for a CNA, (CNA107) you come here now. I need help. She continued to scream until a staff member attended to her at 10:34 AM. When the staff member arrived, R39 told the staff to help her in an irritated tone of voice. On 01/31/19 at 12:00 PM R39 was up in her wheelchair, seated in the hallway with several other residents in preparation for the lunch meal. R39 began gettting restless and began raising her voice. She began yelling at the staff saying negative comments. She then yelled that she'd like to return to her room. A CNA returned R39 to her room and put back to bed. She did not have lunch that day. On 02/01/19 at 9:30 AM R39 was in bed asleep. An interview of LN75 on 02/01/19 at 9:30 AM revealed R39 came out of her room earlier for breakfast then returned to bed. A medical record review on the morning of 01/31/19 at 10:00 AM revealed multiple entries in the nurse's progress notes indicating R39 experiences distressed behaviors which included screaming, insulting staff/family members, physical aggression, banging on the wall and refusing to eat. A review of the nurses notes from 11/01/19 through 01/31/19 found R39 experiences distressful behaviors on a daily basis. According to the nurses notes, R39 would, on a daily basis, scream, bang on the wall, get restless, get agitated and insult staff and family members. In addition to these behaviors, R39 frequently refuses to eat. According to the nurses notes, the CNA staff would bring R39 out for meals where she would be among other residents. She would get agitated and ask to return to her room where she returns to bed. Occasionally R39's behaviors were inconsolable and the nurses would administer [MEDICATION NAME]. R39 was seen by a psychiatrist on 09/10/18. On the afternoon of 01/31/19 at 02:50 PM, a review of R39's visit with the psychiatrist noted the resident was fixated on one particular staff member whom she felt violent towards and had difficulty controlling her temper around. The psychiatrist diagnosed R39 with senile dementia with delusional features and [MEDICAL CONDITION] with delusions. He recommended a trial of [MEDICATION NAME] with slow increase. The psychiatrist suggested an alternative treatment using [MEDICATION NAME] (antidepressant) in combination with Aripiprazole (antipsychotic) instead of [MEDICATION NAME]. On the morning of 01/31/19 at 11:00 AM, a review of R39's intake from (MONTH) (YEAR) to (MONTH) 2019 found she ate breakfast on most mornings. However, she often refused meals particularly lunch and dinner. As noted above, observations during survey as well as nurses notes found she got agitated when placed among other residents in common areas. Observations and nurses notes found that R39 demands to return to bed within minutes of being placed among other residents. During the survey period, 1/29/19 to 2/4/19, R39 was often observed in bed asleep: 1/29/19, 11:30 AM; 1/29/19, 1:30 PM; 1/30/19 at 9:00 AM; 1/30/19 at 12:00 PM; 1/30/19, 2:30 PM; 1/31/19 at 10:00 AM; 1/31/19, 2:15 PM; 1/31/19, 4:00 PM; 2/1/19, 9:00 AM; 2/1/19 10:30 AM; and 2/4/19, 11:15 AM. On the afternoon of 01/31/19 at 1:30 PM a comparison of R39's last two Minimum Data Set (MDS), a resident assessment instrument, dated 11/23/18 (significant change) and 9/15/18 (quarterly assessment) found R39 experienced a significant change. The 11/23/18 MDS noted R39 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognitive patterns. The 09/15/18 MDS noted a BIMS score of 15 out of 15 indicating intact cognition. The 11/23/18 MDS noted an acute change in mental status from the resident's baseline. R39's mood score on the 11/23/18 MDS was 13 out of 27 as compared to 5 out of 27 on the 09/15/18 MDS, indicating increased symptoms of mood problems (feeling down, trouble sleeping or sleeping too much, poor appetite, restlessness). The 11/23/18 MDS noted R39 had verbal behavioral symptoms toward others 4 to 6 days as compared to 1 to 3 days on 09/15/18 MDS; and other behavioral symptoms (verbal/vocal symptoms like screaming) 1 to 3 days as compared to none on the 09/15/18 MDS. The 11/23/18 MDS noted the above named behaviors: Significantly interfered with the resident's care; Significantly interfered with the resident's participation in activities or social interaction; Significantly intruded on the privacy of others; and Significantly disrupted care or living environment. The 11/23/18 MDS noted R39 rejected care 4 to 6 days, but less than daily compared to 1 to 3 days on 9/18/18 MDS. The 11/23/18 MDS noted a worsening of R39's current behavior status, care rejection, or wandering compared to prior assessment. The 11/23/18 MDS noted R39 was frequently incontinent of bowel compared to always continent on 09/18/18 MDS. The 11/23/18 MDS noted R39 experienced a loss of 5% or more in the last month or 10% or more in the last six months but was not on a physician prescribed weight loss regimen. The 11/23/18 MDS noted R39 also experienced a decline in her functional status compared to the 9/18/18 MDS: Two person assist for bed mobility compared to one person assist; and One person assist compared with setup only for eating. On the afternoon of 01/30/19 at 02:30 PM a review of R39's physician's orders [REDACTED]. On the afternoon of 01/31/19 at 02:00 PM, a review of R39's behavior logs found one for use of [MEDICATION NAME]. Despite the many survey observations and review of nurse's note of R39's behaviors, the behavior log for the use of [MEDICATION NAME] only contained six entries between 11/01/18 to 01/31/19 (11/01/18, 11/09/18, 11/12/18, 12/01/18, 12/09/18, 01/31/19). Behaviors documented included verbal aggression, disruptive behaviors, calling names, yelling, wall pounding, and physical aggression. On the afternoon of 01/31/19 at 02:10 PM a review of the Medication Administration Records (MARs) for R39 found she received: 14 doses of [MEDICATION NAME] from 11/01/18 to 11/30/18; 3 doses from 12/01/18 to 12/31/18; and 8 doses from 01/01/19 to 01/30/19. The documentation on the behavior log for [MEDICATION NAME] did not match the MAR for use of [MEDICATION NAME] prn. On the afternoon of 01/03/19 at 02:30 PM, a review of the physician's notes dated 06/01/18 through 12/31/18 found the physician did not document R39's shingles outbreak in (MONTH) (YEAR). Additionally, the physician did not discuss R39's significant weight loss. The physician discussed R39's behaviors based on nurses' verbal reports. On the afternoon of 02/01/19 at 12:30 PM a review of the Interdisciplinary (IDT) notes for Residents At Risk (RAR) found a note dated 01/10/19 which noted, Behavior interferes with meals, with a corresponding plan stating, Increase breakfast/calories; Get order renewed for [MEDICATION NAME]. Another note dated 10/26/18 stated, Weight change likely related to fluctuation in appetite with mood swings/shingles pain. An interview of LN100 on the afternoon of 01/31/19 at 03:09 PM revealed the facility's approach to working with R39 is to use non-medication interventions. The LN stated R39's behaviors have gotten worse since her admission. LN100 stated R39 frequently says mean/hurtful things to her family and the staff. The LN noted R39 has clear preferences for staff and will vocalize her displeasure with persons. LN100 noted R39's behaviors are out of control and occur on a daily basis. She reports she bangs on the wall, is verbally aggressive, is very disruptive, and sometimes gets physically aggressive. The LN reported the nursing staff should be documenting R39's behaviors on the behavior log but acknowledges they haven't been. She validated the behavior log for [MEDICATION NAME] does not match the use of the medication (as it is documented on the MAR). LN100 noted the night shift nurses were responsible to review residents for an overall picture. She noted the information is inaccurate since the behavior logs were not being accurately done. LN100 stated R39's behaviors have interfered with her nutritional intake, resulting in a significant weight loss (16% in three months from (MONTH) to (MONTH) (YEAR)). The LN stated R39's significant weight loss could have been avoided if her behaviors were better managed. On the morning of 02/01/19 at 08:51 AM an interview of the Registered Dietician (RD) revealed her understanding that R39 experienced a significant weight loss which was not physician prescribed. The RD said, Sometimes (R39's) behavior affects her appetite. The RD noted a decline in R39's behavior. She reports R39 was initially pleasantly rude and has since gotten worse, noting her behavior is coming out more and has increasingly become more demanding. The RD referred R39 for a swallow evaluation which found she required a mechanical soft texture. The RD noted the staff discussed R39 at their weekly Resident At Risk (RAR) meetings where the Interdisciplinary Team (IDT) discussed residents with problems which include weight, behaviors, pain, falls, etc. The RD noted the IDT completed a significant change on the MDS as it seemed like R39's behaviors were affecting her dietary intake resulting in significant weight loss. The RD noted the physician was making revisions to her medications and the IDT was hopeful it would impact her intake/weight. The RD noted R39 had shingles in (MONTH) (YEAR) which may have started the ball rolling with her weight loss. The RD noted that R39's behaviors very likely contributed to her significant weight loss, which could have been avoided. An interview of R39's family member (FM) on the morning of 02/04/19 at 10:30 AM revealed that R39's behaviors have worsened. The FM noted R39 is always so angry. She understands she has dementia and noted it's turned her personality completely around. The FM stated R39 was hurtful to her husband as she told him she divorced him and married Staff 107. The FM stated R39's behaviors made her husband feel bad and for a while he didn't want to visit. An interview of R39's physician (facility's medical director) on the morning of 02/04/19 at 11:45 AM found R39 became more verbally aggressive with staff around (MONTH) (YEAR). The physician thought R39 was possibly depressed and she tried [MEDICATION NAME] (antidepressant) but she continued to exhibit behaviors. The physician referred R39 to a psychiatrist who found her to be paranoid and recommended an antipsychotic which was trialed. The resident's behaviors got worse so the physician tapered her off the antipsychotic. The physician noted R39 is very sensitive to medications. She stated she attempted [MEDICATION NAME] (dementia medication) as well as another antidepressant both of which worsened her behaviors. The physician tried her on prn [MEDICATION NAME] which she stated the family likes because it's not given daily. The physician stated the nursing staff are monitoring her sleep as R39 always wants to sleep. The physician noted the IDT could do better with managing her behaviors and will figure out a plan. The facility's failure to ensure the highest practicable physical, mental and psychosocial well being for R39's affected her nutritional intake, relationship with family, and her functional status. 2) Resident (R)41 is a [AGE] year old admitted to the facility on [DATE]. R41 has a history of asking for things and then refusing them per Staff (S)1. R41 has ongoing medical issues that have not been resolved because of her asking for treatment and then refusing. Record Review (RR) on 01/29/18, R41 has a care plan for Mood dated 09/13/17. Under goals, R41 mood and behaviors will be minimized with medication and interventions thru next review date with an onset date of 09/13/2017 and a target date of 03/08/2019. One of the approaches is to use alternate staff if acting out or refusing care. Come back later 10-15 minutes later. Interview on 01/29/19 at 10:50 AM with R41 who states, It's a lot of repetition. I don't go outside. I like watching TV and the news. I don't get out of bed. Interview on 01/29/19 at 11:00 AM with Staff (S)28 states, she gets up to shower. We have been encouraging her to get up but she refuses. Interview on 01/30/19 at 09:13 AM with R41 who states, I have a tooth that is supposed to be taken care of. However, R41 refused to do the teeth extraction on (MONTH) 16, (YEAR). (Reference F656). Interview on 01/30/19 at 09:45 AM with resident R41 My right breast has fallen to the side and it's hard. Resident shows this surveyor right breast. Right side of breast with different skin texture and some redness to area. R41 goes on to say that they told me that it is [MEDICAL CONDITION] and to go to my own physician. I don't have a physician. I went two different times, three different doctors. I would like it removed and it hurts. R41 offers me a copy of a report from a radiology service. Report states Our interpretation of your breast examination identified a finding that needs further evaluation. A full report has been forwarded to your physician. Interview on 01/30/19 at 10:18 AM with MD who stated that I didn't see that exact letter but we sent her to a surgeon and it was biopsied. The results came back as benign. We offered her to go to some surgeons here but she didn't want to. We offered her to go to Oahu but she didn't want to. We treated her with antibiotic. She shouldn't pick on it. (Reference F657). Record review (RR) on 02/01/2019 at 08:00 AM reveals the resident had a psychological examination on (MONTH) 17, (YEAR). At the time, R41 was diagnosed as having a Persistent [MEDICAL CONDITION]. Recommendations were 1) individual and family supportive counseling. 2) Follow-up regarding her concerns about her feet and walking. Confirmed by S41 that there were no other psych consults in record. On 02//01/19 at 09:05 AM, S66 stated there was a period that she was sitting in the wheel chair and sitting at the end of the bed and then she refused. (Reference F676). R41 refuses to get out of bed except to shower. Interview with S11 on 02/01/19 at 09:35 AM who stated she declined sitting at the edge of the bed. Behavior monitor form (BMF) was reviewed and showed that R41 is on [MEDICATION NAME] 25 mg for depression. Targeted behaviors for [MEDICATION NAME] was 1) calling out for help and 2) stating no one comes in to check on me. The targeted behavior for refusing care and treatment was identified on the care plan but not recorded on the behavior monitor form. 5) Record Review (RR) on 01/31/19 reveals R33 was an [AGE] year-old female, who has moderately impaired cognition r/t Dx of [MEDICAL CONDITION] and late effect of [MEDICAL CONDITION]. (stroke). There was a Minimum Data Set (MDS) for significant change for R33 dated 08/23/18 that included the following: Verbal behavioral symptoms directed toward others, occurred 4 to 6 days Significant interference with the resident's care Put others at significant risk for physical injury Significantly disrupt care or living environment Residents behavior of rejection of care necessary to achieve goals for health and wellbeing occurred 4 to 6 days. The current behavior status, care rejection was marked Worse compared to prior MDS assessment dated [DATE]. The MDS significant change assessment dated [DATE] and quarterly assessment dated [DATE] Section I, Active [DIAGNOSES REDACTED]. RR of R33's comprehensive care plan initiated on 04/18/12 revealed the following Behavior Problem: a hx of being accusatory to staff and other residents. (e.g. saying hurtful things to caregivers and other residents), being verbally abusive and striking out at staff when she is angry or upset. Established goal was, R33 will be cooperative with care and not strike out at caregivers during caregiving tasks, and not be verbally abusive . Individualized nonpharmaceutical interventions/approaches were implemented at that time to address R33's behavior The facility failed to evaluate the effectiveness and revise R33's care plan after a significant change in her behavior and failed to investigate the underlying cause of R33's depression and aggressive behavior which led to three incidents of physical aggression toward CNAs, and ongoing rejection of medications and necessary care. (refer to tag 657) RR of IDT Social Service (SS) notes dated 08/29/18, which stated, . resident did express that she is depressed due to her health status. Resident was agreeable to consultation with Psychologist (P). During an interview with SS83 on 02/01/19 at 11:12 AM, discussed the IDT SS notes dated 08/29/18, and she stated, I attended the IDT meeting after the significant change and those are my notes. Asked SS83 if R33 attended, and she replied, Yes .her daughter was there also. Her daughter suggested her mother may benefit from a psychiatric consult. On 08/31/18 the care plan Psychosocial Well-Being problem was revised to include: Resident has a dx of Depression, her psychosocial well-being is at risk due to her declining health. When resident is not feeling well, resident often refuses to get out of bed. Approach was documented as follows, Observe need for psychological/psychiatric services. Provide for these services if agreed upon by resident/responsible party and ordered by physician. On 09/04/18 Registered Nurse (RN)41 documented in nurses notes she informed daughter R33 refused to see P. Entry was, POA (Power of attorney) updated regarding visit with Psychologist yesterday. On 09/10/18 Progress note by Dietitian 21 documented refused to talk to P. There was no additional documentation available regarding status of referral to P. On 11/21/18 Associate incident report form completed by Certified Nursing Assistant (CNA)36, documented R33 combative during shower, scratching and holding aid by the wrist-made verbal threats. On 11/23/18 R33's behavior care plan updated entry, R33 can be physically and verbally aggressive during shower time. Care Plan goal added was: R33 will not harm caregivers daily when taking a shower through the next review. This was the only revision to the behavioral care plan since it was initiated on 04/18/12. On 11/27/18 Associate incident report form completed by CNA26, documented, .she (R33) punched me. Resident hit my right chest with her right hand. Supervisor's (RN114) report dated 01/28/19 described incident as follows: CNA was providing care on R33 .when resident turned to L side, resident punched CNA to R chest area, without any reasons. Resident has hx of being physically aggressive to staff. During interview on 02/01/19 at 09:43 AM with SS49, asked what follow up occurred after CNA incidents 11/23/18 and 11/27/18. I talked to R33 but did not document it. Asked if a significant change would be reflected in the care plan, and she stated, Yes, it should be. At the time I reviewed it and felt the care plan was still applicable. Reviewed R33's care plan with SS49, who validated the behavior problem was initiated 04/10/12 with one revision dated 11/23/18. On 02/01/19 at 10:17 AM during interview with MD1, discussed R33's aggressive behavior and incidents with CNA's. Inquired if she had been notified, and MD1 stated, No, I was not aware. Hitting behavior new to me. Usually they notify me, so not sure why that didn't happen. Asked if MD1 was open to psychiatrist referral and she replied, Yes, I am always open to referrals. There were no additional psychiatrist referrals documented or attempts for R33 to see a referral for accurate [DIAGNOSES REDACTED]. 3) During an initial tour of the Wailani unit on 01/29/19 at 11:43 AM a loud banging/ pounding sound could be heard in the 400's section. The loud sound was coming from R70's room. Upon entering the room, R70 was observed to by laying supine in the bed across the middle with her feet dangling off the mattress. Her hair was disheveled and she appeared to be hitting a pad that was attached to the wall with her right hand. She looked up and shouted, get out of here! During an interview with Certified Nurse Aide (CNA) 32 on 01/29/19 at 11:55 AM she stated that R70 is not very happy this morning. She won't let the janitor into her room to clean. I think it is the progression of the disease that's causing her to be this way, she didn't used to be like this. Shortly after the interview a loud crash was heard coming from R70's room and loud garbled yelling was heard coming out of the room. Breakfast food (eggs) and a plastic dish with silverware were on the floor near the bed. CNA32 stated, she threw her tray this morning. During an interview with Licensed Nurse (LN) 43 on 01/29/19 at 01:45 PM, surveyor asked about R70 and how her behavior was being managed. LN43 reported that we use [MEDICAL CONDITION] as a last resort and try to use other methods like comfort care, food or positioning first to address the agitated behaviors. Nursing note dated 01/28/19 at 04:36 PM was reviewed. Staff reported R70 having increased angry outbursts, increase in anxiety, increased episodes of throwing things on the floor, easily gets upset and very needy. She threw the melanine plate this AM in sun room. R70 has increased confusion, demands things. Review of the behavior monitoring forms dated 01/26/19 to 01/29/19 that revealed non-pharmacological interventions were implemented. Provided 1:1, active listening, positive distraction, help resident become more comfortable and validation, reassurance/safety, nursing assessment for physical needs. Documented outcomes were improved and no change. 4) During an observation on 01/30/19 at 09:30 AM, R20 was sitting in her wheelchair (W/C) in the activity room restless, fidgeting, moving around in her chair, yelling out mommy! mommy!, crying, wheeling around in her W/C looking up at the nurse with wide eyes, tears streaming down her cheeks, and facial color bright red. On 01/31/19 at 09:15 AM R20 yelling out, crying with tears streaming down her cheeks, her face bright red and her sweater tightly bunched up in her left hand and pulled up on her chest exposing her left bare breast. During an interview with RN100 on 01/31/19 at 09:20 AM she stated to the surveyor, we don't use [MEDICAL CONDITION] until its the last resort. Nursing notes dated 01/26/19 at 07:45 AM R20 woke up around 04:00 this AM. Continues on [MEDICATION NAME] 150 mg every night for [MEDICAL CONDITION]. R20 was yelling and screaming out loud towards end of this shift. As of this note, resident sitting up in W/C, intermittently talking out loud.",2020-09-01
674,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2019-02-04,758,D,0,1,JB5D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and staff interview, the facility failed to manage the use of [MEDICAL CONDITION] medications for one of five residents (R) 39 reviewed for unnecessary medications. Findings include: Cross reference to F740 R39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R39 was observed with behaviors which affected her nutritional intake resulting in significant weight loss. A review of the physician's orders [REDACTED]. On the afternoon of 01/31/19 at 02:30 PM a review of R39's behavior log for [MEDICATION NAME] 0.5 mg prn noted six entries from 11/01/18 through 01/31/19. A review of R39's Medication Administration Record [REDACTED]. In (MONTH) (YEAR), R39 received 14 doses of [MEDICATION NAME]. In (MONTH) (YEAR), R39 received 3 doses of [MEDICATION NAME]. In (MONTH) 2019, R39 received 8 doses of [MEDICATION NAME]. On the morning of 01/31/19 at 10:00 AM, a review of R39's Minimum Data Set (MDS) with assessment date of 11/23/18 found it was a significant change assessment. R39's previous MDS was dated 09/15/18 which was a quarterly assessment. The 11/23/18 MDS noted the following: Brief Interview for Mental Status (BIMS) score of 9 out of 15 compared with 15 out of 15 on the 09/15/18 assessment; An acute change in mental status with inattention present not previously noted on 09/15/18 assessment; Mood score of 13 out of 27 compared with 5 out of 27 on 9/15/18 assessment; Verbal behavioral symptoms directed toward others 4-6 days compared with 1-3 days on 9/15/18 assessment; Other behavioral symptoms (such as hitting, verbal screaming, disruptive sounds) 1-3 days compared to none on 09/15/18 assessment; Behavioral symptoms significantly interfered with the resident's care; Behavioral symptoms significantly interfered with the resident's participation in activities or social interaction; Behavioral symptoms significantly intrude on the privacy or activity of others/significantly disrupt care or living environment; R39 rejected care 4 to 6 days compared with 1 to 3 days on 9/15/18 assessment; and R39's current behavior status or care rejection worsened since the previous assessment. An interview of the Licensed Nurse (LN) 100 on the afternoon of 01/31/19 at 03:09 PM found the staff used non-pharmacological interventions with R39 before administering prn [MEDICATION NAME]. She noted the Behavior Monitoring Form should reflect the behaviors leading up to the administration of prn [MEDICATION NAME]. LN100 confirmed the Behavior Monitoring Form for R39 was not an accurate reflection of her behaviors. An interview of the physician on the morning of 02/04/19 at 11:45 AM revealed R39 did not have behaviors upon admission. The physician noted she became verbally aggressive with staff around (MONTH) (YEAR) which she attributed to the resident possibly being depressed. The physician prescribed [MEDICATION NAME] (antidepressant) but the resident continued to display behaviors. She later tried her on [MEDICATION NAME] (Alzheimer's medication) but the resident's behaviors did not improve. She noted R39 is very sensitive to medications which poses challenges for the interdisciplinary team. The physician noted they could do better with managing her behaviors.",2020-09-01
675,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2018-05-04,550,D,0,1,SMEY11,"Based on observation and staff interview the facility failed to promote a dignified existence for one of twenty nine residents Resident (R)70 sampled for investigation. Findings Include: On 05/02/18 at 08:19 AM R70 was observed in bed with a white towel draped on her left shoulder and under her chin. R70 was alone in her room and care was not being provided at this time by staff. R70 was also observed the day before (05/01/18) in mass service, sitting in the dining room with other residents, with one end of a white towel draped on her left shoulder and the other end under her chin. On 05/03/18 at 11:55 AM reviewed R70's Care Plan and found that there was nothing in her CP that stated that R70 had to have towel placed on her shoulder and under chin. Inquired with Staff (S) 7 why R70 had a towel on her shoulder and under her chin and S7 stated that it is placed there in case the resident drools. Based on the findings the facility did not promote a dignified existence for R70.",2020-09-01
676,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2018-05-04,582,D,0,1,SMEY11,"Based on review of Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review forms and staff interview the facility failed to provide one of three randomly selected residents Resident (R)27 with the SNF Advance Beneficiary Notice of Non-coverage (SNF ABN), Form CMS- , prior to Medicare Part A Service Termination/Discharge. Findings Include: In the afternoon, on 05/02/18, submitted three randomly selected resident names, from the Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, on the SNF Beneficiary Protection Notification Review forms to S139. On 05/03/18 at 03:42 PM, S139 submitted the completed SNF Beneficiary Protection Notification Review forms for the three residents selected and explained that R27 was not given a SNF ABN, Form CMS- . When inquired, S139 explained that she did not know why the form was not given to the resident. R27 was not discharged from the facility and at the time of survey was still at the facility. On 05/04/18 at 09:46 AM interviewed S85 who confirmed that R27 was inadvertently not given the form and concurred that she should have been given the SNF ABN, Form CMS- prior to Medicare Part A Service Termination/Discharge.",2020-09-01
677,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2018-05-04,684,D,0,1,SMEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that R#38 received treatment and care in accordance with professional standards of practice, comprehensive person-centered care plan and the resident's choices. Findings include: Resident (R) 38 has a [DIAGNOSES REDACTED]. She is severely impaired, never/rarely makes decisions and needs two person assistance for functional status according to the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/18. R38 on 05/02/18 at 10:52 AM was observed in activity room in front of television in wheelchair. There was lack of arm and shoulder support with R38's head rolling to left side in an awkward angle, right arm dangling to side and hyperflexion of the neck. At 11:00 AM, Staff (S)11 was walking by and noted R38's awkwardness, leaning to one side without support. S11 attempted to reposition R38 and place support. S11 solicited some help from S17, S128, S130 who came to the wheelchair in which R38 was sitting. They repositioned her and placed a support to her left side to keep her aligned. On 05/03/18 at 10:00 AM, the newspaper was noted to have been placed on resident's blanket near her knees. On 05/03/18 at 10:15 AM, observation was made during a transfer with the Golvo lift by the two staff members. R38's newspaper was still on her knees. At the time of the transfer, newspaper was placed on top of the side table. The bed was raised, a green sling was placed aside the resident. R38 was rolled and sling placed. Resident was not encouraged to assist with turning in bed. 05/03/18 at 0245 PM, R38 was turned to her right side, pillow behind left back. Newspaper is now placed in basket on upper shelf. Observation and concomitant interview on 05/04/18 at 0930 AM, R38 was on her right side but not aligned in bed. She was slumped and appeared to have difficulty breathing. Newspaper was placed on her chest and covering her lips. S79 was called to the room and asked if her position was okay. S79 stated, no, she needs to be positioned. Record Review (RR): R38 is careplanned for activities. According to careplan and care directives, staff is to encourage resident to assist with turning in bed by holding onto and using bilateral 1/8 side rail to turn on her left side. Keep right arm in neutral position to decrease risk of contractures. Position feet on 2 foot resting boards to obtain the neutral ankle range in motion. Put ankle contracture boot on when up on wheelchair during day shift and 2 hours during eve shift when in bed. Make sure the foot is in the boot properly and the heel is all the way back to obtain the neutral ankle range. R38 is careplanned for pressure ulcers for position with pillows to maintain proper body alignment prn. R38 is careplanned for falls which states position resident with pillows on each side of her and between knees to maintain proper body alignment. R38 is careplanned under cognition for anticipate resident's needs for positioning, discomfort, pain, incontinence, etc. R38's interests include: R38 reads daily newspaper. Interview with Staff (S)140 on 05/03/18 at 0912 AM stated R38's son orders her the newspaper. Usually , when the resident's son comes, he wants us to put the paper in the basket. S140 provided a copy of a plan approved by resident's son. It states R38's daily newspaper is to be placed in this box after she reads it. This box will be placed on her nightstand. If she reads the paper out on the units, return it to this box. Son will pick up their paper every evening. Reading the paper is partly the staff's responsibility. Record review (RR) of the Minimum data Set ((MDS) dated [DATE], section F reads How important is it to you to have books, newspapers and magazines to read? Answer was somewhat important. In conclusion, R38's position to maintain proper body alignment was not followed consistently and according to the facilities careplans. No observation was made of staff reading newspaper to resident before placing into basket and reading of the newspaper was not clearly care planned for. It was not observed by this surveyor encouragement of R38 to assist with turning in bed. In Summary, the facility failed to ensure that R38 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices.",2020-09-01
678,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2018-05-04,842,D,0,1,SMEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to accurately document resident (R) 70's Toileting Activities of Daily Living (ADL)- Self Performance and ADL-Support in seven occurrences in (MONTH) (YEAR) during the night shift. Findings Include: Observation of R70 on 05/02/18 at 08:19 AM found that she is unable to move on her own and requires staff assistance with all ADLS. On 05/02/18 at 08:48 AM review of R70's Electronic Medical Record (EMR) and Minimum Data Set (MDS) Quarterly assessment dated [DATE] found that R70 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. R70 is rated a 4 for total dependence for ADLs requiring full staff performance of activity and is rated a 2 or 3 for ADL support, requiring one to two person physical assist. Review of R70's facility ADL Monthly Flow Report for (MONTH) (YEAR) found that a staff documented that R70 is continent of urine and does not need physical assistance from staff with toileting. On 05/03/18 at 12:07 PM interviewed S7 who confirmed that R70 cannot move on her own and requires staff assistance with ADLs. Reviewed the (MONTH) (YEAR) Monthly Flow Report for R70 with S7 who confirmed that the documentation for Toileting of 1/1 and 1/0 for independent, no setup or physical help from staff and setup help only appeared to be documentation errors. 05/03/18 01:51 PM interviewed S132 and S59 who confirmed that the documentation for R70 appeared to have been an error and S59 was able to show that S122 had documentation training during orientation. S59 also stated that they meet monthly with CNAs to discuss topics such as documentation.",2020-09-01
679,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2018-05-04,880,E,0,1,SMEY11,"Based on observation, staff interview, and policy review, the facility failed to exchange suction equipment/cannisters for two different residents (Resident (R) 42, and R65). This deficient practice put the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: 1. During an observation of the suction equipment in R42's room, on 5/2/18 at 09:40 AM, the suction equipment cannister contained approximately 200cc of clear foamy liquid. This cannister was not dated and there was no way to determine when it was put in use. After an interview with Staff Member (SM) 17 and review of facility policy, the suction equipment/ cannister should have been dated when it was put in use and replaced in one week. Also, SM17 acknowledged that the clear foamy liquid should have been properly discarded. 2. During an observation of the suction equipment in R65's room, on 5/3/18 at 08:40 AM, the suction equipment cannister was dated 02/09/18 which would indicate that the suction equipment/cannister was put into use almost three months ago. Again, according to facility policy, the suction equipment/ cannister should be replaced every week, after it is put in use. During an interview with Staff Member 130, he/she acknowledged that the suction cannister was dated almost three months ago and should have been replaced as per facility policy.",2020-09-01
680,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2018-05-04,883,D,0,1,SMEY11,"Based on record review and staff interview the facility failed to document that resident (R40) or her representative was provided education regarding the benefits and potential side effects of influenza immunization prior to receiving vaccine. Findings Include: On 05/04/18 at 09:03 AM reviewed R40's hard copy medical chart for informed consent for influenza and pneumococcal vaccines and found that R40 had a signed influenza consent dated 10/10/16 and informed consent for pneumococcal vaccine dated 8/10/17 that were on one form, back to back. Inquired with S7 where R40's (YEAR) Informed Consent for Influenza Vaccine form was in resident's hard copy medical chart. S7 looked in R40's chart and stated that it was not there. S7 stated that the informed consents for influenza and pneumococcal vaccines are done every year on one form, back to back. S7 called S59, who administered the vaccine, to check if she had the consent form. S7 stated that S59 did not keep copies of the signed informed consent forms for the influenza and pneumococcal vaccines. Review of R40's Medication Administration Record [REDACTED]. On 05/04/18 at 09:41 AM interviewed S59 who confirmed that she did not have a copy of the influenza consent form for R40 and explained that the facility uses a new consent form each year for the influenza and pneumococcal vaccines and believes that the informed consent for pneumococcal vaccine was signed by accident for the flu vaccine given in (YEAR). Review of facility policy Influenza Vaccine,Pne umococcla (sic) Vaccine, and Flu Outbreak Management dated, last revised, 12/06/2007, states Procedure-Influenza Vaccine 1. Starting in (MONTH) (unless another month is recommended by the Department of Public Health) and extending to (MONTH) 31 (or check with local Health Department), residents are offered the influenza vaccine. Education is provided to the resident and/or representative regarding benefits and side effects or risks.",2020-09-01
681,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2016-12-09,329,E,0,1,JKWZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure each resident's drug regimen remain free from unnecessary drugs for 3 of 30 residents(Res #37, Res #63, and Res #177 in the Stage 2 sample. Findings include: 1. Resident (Res #63 triggered for medication review in Stage 2. He was a [AGE] year old resident, observed to be quiet and would slightly nod when greeted. The resident often had his eyes closed while sitting in his wheelchair. Medical [DIAGNOSES REDACTED].coli; muscle weakness; heart failure; [MEDICAL CONDITION]; etc Routine [MEDICATION NAME] 5 mg 1 tab daily for depression was ordered. Additionally, his [MEDICAL CONDITION] medication care plan stated the resident was taking the antidepressant for the [DIAGNOSES REDACTED]. During a review of his clinical record, no documentation was found to show the resident's mood/target behaviors were being monitored concomitant to the [MEDICATION NAME] use for his depression. On 12/08/2016 at 11:46 AM, during a concurrent record review with LN #1, she stated if the resident, is stable, if the behavior is stable, we discontinue the daily monitoring and we keep the monthly documentation. LN #1 verified there was no behavior monitoring or tracking of the resident's target behavior, such as crying, withdrawing, demonstrating or verbalizing sadness or wanting to die, etc. On 12/08/2016 at 4:21 PM, the Director of Nursing (DON) was asked how the resident's behavior related to his depression was being monitored, and what his target behavior/depressive features were. The DON said the resident has not had any negative behaviors and the Medical Director did not want to take him off the medication. The DON confirmed the consultant pharmacist performing the monthly drug regimen reviews last reviewed this resident's [MEDICATION NAME] use in (YEAR). The DON acknowledged a gradual dose reduction (GDR) has not been done and said, Minimally, should be annually. The DON validated they are not doing the daily tracking for the use of the antidepressant. Cross-reference to findings at F428 for Res #63. 2. Res #177 was recently admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. The resident was noted to frequently vocalize wanting to go home and/or to have staff call his family members. Res #177's clinical record review found he was prescribed [MEDICATION NAME] 7.5 mg daily for depression. A care plan for psychosocial well being due to depression was developed and noted the resident's significant family member passed away last year. The care plan also noted the resident to be hard of hearing and his current health status as contributing factors. Another care plan included the risk for complications related to the [DIAGNOSES REDACTED]. However, during an interview with the DON on 12/08/2016 at 4:37 PM, she validated that the behavior monitoring for this resident, including target behaviors related to his depression with the antidepressant use, was not being done. 3. Res #37 triggered for a medication review in Stage 2. Res #37 is on [MEDICATION NAME] 50 mg for [MEDICAL CONDITION]. Res #37 was able to answer all questions during an interview and participated in facilities activities and resident council. During a review of the clinical record, there was no documentation to show the resident's mood or target behaviors were being monitored concomitant to the [MEDICATION NAME] use for depression. On 12/8/16 at 4:17 PM, the DON was asked how the resident behavior related to depression was being monitored and what the target behavior/depressive features were. The DON acknowledged a GDR has not been done. DON validated they are not doing the daily tracking for the antidepressants and provided a psychoactive drug utilization summary report.",2020-09-01
682,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2016-12-09,371,D,0,1,JKWZ11,"Based on observation, policy and procedure review, and interviews, the facility did not distribute and serve food in accordance with professional standards for food service safety. Findings include: On 12/06/2016 at 12:15 PM, during observation of dining service, several staff members were serving trays without hand sanitization. First observation made was a staff who passed, prepped a tray, and then touched resident on shoulder gently before moving on. Staff then disposed covers from tray prep. This staff then grabbed another tray from cart and prepped tray for different resident and got shoyou for this resident. At no time did this staff member sanitize or wash hands. Second staff was passing fluids on a juice cart. Four residents sit at the table. As the staff with juice cart went around the table, staff was noted to touch residents and pass fluids without any hand sanitization. Third staff noted to enter dining area transported resident with a wheelchair (hands on wheelchair). After securing seat at the table for resident, the staff member went to obtain and deliver tray without hand sanitization. On 12/06/2016 at 12:30 PM, LN#1 was appraised of observed of lack of hand sanitization. LN#1 verbalized understanding. On 12/08/2016 at 12:15 PM, observation of dining area revealed staff members using hand sanitization or hand washing between passing of trays. Received facilities hand out regarding CDC Hand Hygiene & Guidelines on 12/09/2016. According to guidelines, indications for hand hygiene stated that hand hygiene should occur after contact with environmental surfaces in the immediate vicinity of patients.",2020-09-01
683,HALE ANUENUE RESTORATIVE CARE,125045,1333 WAIANUENUE AVENUE,HILO,HI,96720,2016-12-09,428,E,0,1,JKWZ11,"Based on record reviews and staff interview, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist to ensure irregularities, or that concerns were identified and reported, including: use of a medication without identifiable evidence of adequate indications; and use of medication without evidence of adequate monitoring for 2 of 30 residents (Res #63 and 37) in the Stage 2 sample. Findings include: 1. Cross-reference to findings at F329. For Res #63, the DON and consultant pharmacist validated the resident's last gradual dose reduction or GDR attempt for Lexapro (used for his depression) was last done in (MONTH) (YEAR). They acknowledged the GDR should have been done at least annually and it was not. In addition there was a failure to monitor the resident's response to any psychopharmacological medication, to evaluate whether there is a continued medical necessity. Often the only way to know whether a medication is needed indefinitely and whether the dose remains appropriate is to attempt a GDR and to monitor the resident for either an improvement, stabilization, or decline, which the facility failed to do. 2. Cross reference to findings in F329. For Res #37, the DON, consultant pharmacist, and a psychoactive drug utilization summary validated that Res #37's gradual dose reduction (GDR) attempt for Nortriptyline was not done since readmission on 2/21/2013. Res #37 was on Nortriptyline for a depressive disorder. They acknowledged the GDR should have been done at least annually and it was not. Policy and Procedures were provided by the facility on 12/18/2016. On page 12-51 under definitions, fourth paragraph, it states Gradual Dose Reduction (GDR) is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.",2020-09-01
684,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2020-01-22,880,F,0,1,77HP11,"Based on observation and interviews, the facility failed to ensure all food was prepared, distributed and served under sanitary conditions during two of three dining observations of the kitchen, the two dining areas and resident rooms. There were numerous flies in the building while the residents were having their meals or in their rooms. This deficient practice had the potential to cause the transmission of disease and/or infection and affect all residents residing in the facility. Findings include: On 01/14/20 at 12:00 PM, during the lunch observation in the Station 2 dining room, two flies were seen flying around in the dining room. One of the certified nurse aides (CNAs) was trying to shoo them away, but then many more flies were seen flying around the dining room. CNA1 and other staff were seen trying wave the flies off as they landed on the countertops of the kitchen service area and on the dining tables where the residents were sitting. On 01/14/20 at 12:10 PM, Resident (R) 38 had her meal delivered to her room and it was placed on her overbed table. R38 requested a sandwich instead of the pork adobo which was the lunch entree that day. R38 also had a red fly swatter at her bedside which she moved to another overbed table to the right of her bed area. On 01/17/20 at 11:13 AM, during an interview with R38, she said, sometimes flies come in because of the food, that is sorta of the vinegary taste, pork adobo. Also flies attracted from tuna and spaghetti. Yeah, the spaghetti. She said, I swatted one that day, and acknowledged it was on 01/14/19 when surveyor observed she had a red fly swatter at bedside. R38 said, the flies drives me crazy! R38 said her the red fly swatter was, my weapon. On 01/14/20 at 12:16 PM, observation of the Station 2 dining room saw R22's family member, who was sitting in a motorized scooter, trying to swat the flies around her and R22 while the resident ate. The family member was using a blue fly swatter and was seen smacking it down on the table several times. On 01/14/20 at 12:20 PM, CNA2 delivered an in-room lunch tray to R35. There was a fly at his bedside and the fly flew over to his roommate's side. On 01/14/20 at 12:31 PM, per interviews with CNA3 and CNA4, they said because of the rainy season, all the flies were coming out. On 01/15/20 at 12:09 PM, one fly landed on R40's hand while he began to eat his sandwich. R40 waved that fly away along with many other flies flying around him. R6, who was sitting near R40 was also trying to shoo away flies with one hand while trying to eat his lunch The kitchen staff server (KSS) said the flies come in because, sometimes they open the door in the back (of the kitchen). Then, at that time, the kitchen supervisor (KS) walked into the kitchen from that door, and the KSS said, like that. The KS said out loud that while he let one in, he also let one out (a fly). On 01/15/20 at 12:12 PM, R40 said to surveyor, Yeah, the flies, long time. R6 said, too many flies, and one fly then landed on his water cup, which a CNA removed. On 01/15/20 at 12:15 PM, R22 said, Irritating, the flies, not good for the food. My (relative), she hates flies. On 01/15/20 at 12:23 PM, many, many flies were flying around in the Station 2 dining room. Several of the flies were in and around R6's tea cup, with two more flies on the corner of his table and one fly on the table near him. R6 stated, It's sickening, it's sickening. At that time, the registered dietitian (RD) was nearby and was asked to see the numerous flies in R6's tea cup. The RD saw it, apologized to the resident and immediately removed the resident's tea cup away and the flies flew off into the dining room. R6 continued to say how sickening it was to see all these flies around him. On 01/15/20 at 12:36 PM, an interview of housekeeper (HK) 1 was done. He stated, never seen flies in the dining room when they eating. HK1 said, when I cleaning, no more food by then. HK1 said his supervisor was on vacation for two weeks and thus unavailable. On 01/15/20 at 12:58 PM, during an interview with the Director of Nursing (DON) and the Clinical Operations Specialist (COS), they stated they heard about the fly problems in the Station 2 dining room. They were also trying to figure it out and were trying the use of overhead fans in the lower dining room (Station 1, which had a lesser amount of flies than Station 2, but yet had flies per observations done by another surveyor during the kitchen/dining reviews there). The COS stated they considered the back door in the Station 2 kitchen as a probable factor since it was opened by the KS for quick access to the adjoining kitchen. This door had no blower air curtain and would open directly to the outside sidewalk, allowing flies to enter the kitchen. On 01/15/20 at 01:07 PM, an interview with the Infection Preventionist (IP) was done. The IP said she heard about the fly problem and the facility maintenance director (FMD) was in contact with their pest control vendor for additional spraying of the grounds. The IP also said they were going to re-assess their lighting. When she was queried as to the potential source of the flies, the IP said, I feel like it's more so, the rain and everything and indoors is more of an area they'd gravitate to. So we're doing more trap cleaning with the flies, making sure all of our exits are closed and fans in place to blow them out and (vendor) to do more spraying, repellant wise. When the IP was further queried as to the observed lack of response by staff to mitigate the fly problem, as the second dining observation revealed more flies, she said she was, kinda been educating the staff to get the food to the patients and if they're able to swat the flies. The IP acknowledged the need to respond faster to such a problem as the residents were being served food under unsanitary conditions. On 01/15/20 at 01:12 PM, an interview with the FMD was done. He was at the Station 1 dining room where another staff was replacing one of the blue light bulbs in the light trap. The FMD said the light was not working. The FMD said they had also checked Station 2 and replaced the blue trap boards in the lights yesterday. The FMD also said he was at the Station 2 dining room about an hour earlier and confirmed he saw the flies. The FMD said, I think what's happening is the door stays open too long, the ADA door stays open too long of a period and more chances of a flies to get in. The FMD said they have a problem with the flies off and on during the rainy season. He stated the vendor would do power sprays of the perimeter and grass where the flies tended to breed and within two days, the difference (less flies) could be seen. The FMD said their Administrator was aware of this current fly problem and the vendor was asked to come sooner than scheduled. The FMD said his future plan was to have more treatments with follow-up spraying. He understood the observed outcome was that food was being served in an unsanitary environment as a result of the numerous flies in both dining room and kitchens. On 01/15/20 at 02:35 PM, during a brief meeting with the Administrator, she stated their vendor, coming today and will work on putting up more barriers. She said it was their rainy season and that they are dealing with it now. The Administrator acknowledged and stated, we need to have more of an immediate response to this. On 01/16/20 at 05:24 PM, a third dining observation was done for the dinner meal. Observation in both dining rooms found only one fly flying around in the Station 2 dining room, and no flies in the hallways and/or the resident rooms on random observations. Cross-reference to findings at F925.",2020-09-01
685,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2020-01-22,925,F,0,1,77HP11,"Based on observation and interview the facility failed to eradicate and contain fly infestation in Station One's Main Kitchen and Station Two's Satellite Kitchen. This deficient practice has the potential to cause foodborne illnesses for residents who are already compromised given their various co-morbidities and health conditions. Findings Include: On 01/14/20 at 11:17 AM, during initial tour of the kitchen (Station One's Main Kitchen) with Cook1 and Kitchen Supervisor (KS) it was observed there were numerous large flies flying around the Main Kitchen. Kitchen staff present in the kitchen were observed not to be concerned or bothered by the flies. On 01/14/20 at 11:35 AM, upon entering Station Two's Satellite Kitchen with KS, immediately observed major fly infestation in the kitchen. Queried KS if the facility uses any devices that help eradicate the flies. KS stated yes, they use ECO Lab and proceeded to point towards the ceiling where a half dome was mounted on the wall below the ceiling. KS stated the flies go in and never come out. KS stated when they clean the dome, a lot of flies are inside the dome.",2020-09-01
686,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2018-10-19,550,G,0,1,0TZY11,"Based on observation, residents interview, staff interview, and review of policy, the facility failed to treat one out of eight residents (Resident (R) 63) selected in the initial pool for review with dignity and respect. The facility also failed to enhance the self-esteem and self-worth of R63 related to preferences and/or choices. As a result of this deficient practice, R63 showed signs of social withdrawal, anxiety toward staff, and resistance to care; such as not wanting to press the call light for assistance. This deficient practice had the potential to affect the remaining 76 residents at the facility if they were treated in a similar manner. Findings Include: During resident interview of R63 on 10/17/18 at 08:31 AM, R63 stated soon after being admitted , staff were mean and show no respect. R63 said after pressing the call light for assistance, staff would say loudly go to bed, go lay down, do you know how many residents are here - 100, I cannot help you right away, you have to wait. R63 said this had been happening since being admitted and stated it felt bad just to press the call light, I just lay down and no say anything, anymore. R63 could not identify any particular staff member or members and also wanted to remain anonymous at this point. During observation of R63 on 10/18/18 at 08:16 AM, R63 was in his/her room watching TV and preferred to stay in the room - away from the crowd and/or socializing. When asked the reason for staying in the room, the answer was I'd rather stay in the room, no reason, I can go outside later. At this point, it was observed that R63 did receive appropriate staff assistance with meals and the bed side commode. During record review on 10/18/18 at 10:10 AM, R63's Brief Interview for Mental Status (BIMS) score was fifteen which indicated that R63 was cognitively intact. This was consistent with previous interviews where R63 was answering questions appropriately and was oriented to person, place, and time. During an interview with R18 (the roommate of R63) on 10/18/18 at 12:09 PM, R18 witnessed hearing the above statements being said to R63 and further stating the staff are not nice, I could hear them grumbling. During an interview with R14 (the neighbor of R63) on 10/18/18 at 12:15 PM, R14 stated that staff have been treating me bad since day one. However, R14 also said it doesn't bother me because I treat them the same too. During a follow up interview with R63 on 10/19/18 at 04:15 PM, R63 agreed to no longer have anonymity and agreed to talk to facility staff about the concerns of not being treated with dignity and respect. It was at this time that R63 showed some signs of anxiety toward a staff member identifying him/her as the perpetrator. This information was immediately passed on to the facility Administrator and the Director of Nursing for further investigation.",2020-09-01
687,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2018-10-19,578,D,0,1,0TZY11,"Based on electronic medical record (EMR) review and staff interview the facility failed to periodically review the option of formulating an Advance Directive with one of 38 residents (Resident (R) 58) sampled for review. This deficient practice had the potential to affect the remaining 76 residents at the facility if they did not have an Advance Directive in place and did not have the opportunity to periodically review the option of formulating one. Findings Include: On 10/17/18 at 12:07 PM during EMR review found R58 is a full code. Noted there were no scanned documents such as an Advance Health Care Directive found in R58's EMR. On 10/18/18 at 08:10 AM met with Social Services Director and requested documentation of R58's Advance Health Care Directive or documentation that R58, his family, or responsible party was given information about Advance Health Care Directive. On 10/19/18 at 12:38 AM review of documents provided by Social Services Director found R58's wife signed the admission packet on 04/08/16 acknowledging that she received information on advance directives and the facility policy. It was noted Social Services Director met with R58 on 10/18/18 at 08:29 AM, explained what an advance directive was which he refused to fill out and documented in R58's EMR. This was done after the request was made for R58's Advance Health Care Directive documentation. There were no other documentation of review of advance health care directive with R58 or his wife and option to formulate one periodically during R58's two and a half year stay at the facility by facility staff. Upon interview Social Services Director stated the facility is working on putting this in place.",2020-09-01
688,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2018-10-19,655,D,0,1,0TZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and electronic medical record (EMR) reviews, the facility failed to ensure that a baseline care plan (CP) was developed within 48 hours for one of 38 residents (Resident (R) 321) sampled for review, included the instructions needed to provide effective and person-centered care that met professional standards of quality care for a blind resident. Findings Include: On 10/16/18 at 01:19 PM interviewed R321 who was admitted on [DATE] and the resident stated he was admitted to the facility because of being blind and had bilateral lower extremities amputated, (left below knee [MEDICAL CONDITION] (BKA) and right above knee [MEDICAL CONDITION] (AKA)). R321 stated he had constitutional rights to live freely and not be institutionalized, as he lived in institutions most of his life. The resident stated he wanted to do things for himself as much as possible and wanted to be independent. Queried R321 if he participated in admission and/or care plan goals, and R321 stated he was upset about being placed at the facility and had no choice in the decision-making. Further inquired how R321 ate at the facility and whether the food served was to his liking. The resident stated being blind he used his hands to eat, because he was unable to see food on the plate to poke with a fork, and the food would just slip off the plate. Inquired if R321 always ate with his hands and R321 stated at home he ate with a bowl and spoon because he knew how to scoop from the sides of the bowl. The resident further stated the food served at the facility was good but preferred dry food to eat with his hands as it would be difficult to eat wet, oily/gravy foods using his hands. Walked pass R321's room on 10/18/18 at 12:15 PM and overheard R321 yelling at the Certified Nurse Assistant (CNA) setting-up his lunch tray. The resident was very upset and used foul language so stopped to observe from the doorway. The CNA had just placed the lunch tray down and said, This is your lunch. The resident responded, You guys all stupid, how I supposed to know where the cup or plate, I blind, I cannot see. The CNA directed R321 to the cup of coffee and plate as he felt around the lunch tray with his fingers, continuing to verbally abuse the CNA with foul language. The CNA apologized to R321 and continued to direct him to the placement of the plate of food and coffee cup on the tray. On 10/18/18 at 04:00 PM interviewed the Director of Nursing (DON) and inquired about the 48 hour baseline CP for R321. DON found on R321's EMR that RN3 did the nursing admission evaluation on 10/15/18 at 03:45 PM, and documented the resident had impaired vision under the communication paragraph. Inquired of the DON if being blind is the same as having impaired vision. The DON stated that the nurse should have noted the resident as being blind because impaired vision can usually be corrected with prescription lenses. Inquired of the DON if facility staff considered how R321 ate, as the resident is blind, and shared observations of R321 being served lunch. DON stated he would investigate. The DON provided R321's baseline CP developed on 10/16/2018 that included, Nutrition Altered, with goal to achieve desired weight /nutrition; but, there was no baseline CP to indicate that R321 was blind and how activities of daily living such as eating would be performed. The DON stated R321 was to be transferred to the facility at an earlier date (10/10/18) but R321 delayed the process and was provided a State court appointed guardian for admission to the facility on [DATE]. The facility failed to complete and implement a baseline CP within 48 hours of R321's admission to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the blind resident, was informed of the initial plan for delivery of care and services by the facility.",2020-09-01
689,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2018-10-19,659,E,0,1,0TZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure staff were qualified to administer medications to two of 38 residents (Residents (R) 4, R19) sampled for review. The facility permitted unlicensed personnel to administer medications crushed and mixed in liquid or pudding. This is beyond the scope of practice for a Certified Nurse Assistant (CNA), is unsafe, and does not meet current standards of practice. This deficient practice had the potential to affect those residents at the facility who required their medications to be crushed and administered to them if they were given their medication(s) in a similar manner by unlicensed staff. Findings Include: 1) On 10/17/18 at 08:21 AM, observed the CNA as she prepped and set-up R4 for breakfast. R4 was bed bound due to her [DIAGNOSES REDACTED]. The CNA had to sit on the mattress to feed R4 and Licensed Practical Nurse (LPN) 1 walked into R4's room with a medicine cup of crushed medications, stood next to the mattress and asked the CNA where she wanted the crushed medications poured into as the CNA fed R4 breakfast. The CNA opened a chocolate pudding cup, LPN1 poured the crushed medications into the pudding cup and walked out of the room. Observed as the CNA mixed the crushed meds into the pudding cup and provided a spoonful of pudding to R4. Inquired of the CNA if R4 usually ate all of the pudding, and the CNA replied that chocolate pudding is R4's favorite, and rotated between spoonfuls of pureed breakfast meats and pudding. LPN1 continued with medication administration to other residents on the unit. Inquired of LPN1 if crushed medications administered to R4 were usually done as observed. LPN1 responded, It says give with food. The Director of Nursing (DON) was at R4's unit nursing station and shared observation of LPN1 pouring crushed medications into the pudding cup and that a CNA fed R4 the medications. The DON stated crushed medications should have been mixed with pudding in med cup and not poured into a pudding cup on the breakfast tray. Inquired if the facility allowed CNAs to administer prescribed medications and responsible for R4 to receive proper medication dose when crushed medications mixed with food. DON stated LPN1 should have administered the crushed medications and not the CN[NAME] On 10/19/18 at 08:36 AM interviewed LPN1 and she stated R4 was prescribed [MEDICATION NAME] 50 mg half tab, (25 mg), Tylenol 325 mg 2 tabs (650 mg), and [MEDICATION NAME] 15 mg tab (15 mg); these medications were crushed and combined in the medicine cup that was poured into the cup of pudding on 10/17/2018. According to LPN1, she went back to R4's room to ensure that all of the chocolate pudding was consumed. The facility did not ensure that prescribed medications were provided by individuals with proper licensure, skills and experience. 2) Review of R19's Medication Administration Record [REDACTED]. At 08:39 AM, the MAR indicated [REDACTED]. RN2 documented in the Clinical Note at 08:42 AM, CNA reported refused to drink her ensure where medication (aripiprazole and senna plus) were mixed. During an interview with Certified Nurse Assistant (CNA) 1 on 10/19/18 at 10:06 AM, she stated R19 only wants certain people to give the medicine and the CNAs are sometimes asked to give it. R19 only likes certain CNAs. CNA1 explained the medications are crushed and mixed with either orange juice or ensure. When asked if the ensure or orange juice with medications is ever left in the room, she replied yes. She stated, Sometimes we are asked by the Charge Nurse to give it. Sometimes we go alone. R29 can drink some by herself, and sometimes we assist. During an interview with Resident Care Manager (RCM) 2, on 10/19/18 at 10:06 AM, the RCM2 stated, The RN should be in the room and observe the medication is taken, and document that if it is refused. CNAs should not administer any medications. Interview with RN2 on 10/19/2018 at 10:39 AM stated Sometimes R19 wants this person to give it. We prepare it if R19 wants specific person, but I always give mine myself. R19's medications were prepared by the night shift and suppose to give. It was already clicked off that it was administered. The CNA picked up the breakfast tray and told me R19 didn't want to finish it. I went back in the record and changed to not administered and put refused. During facility policy review found the facility did not follow the process outlined in their policy titled Medication Administration General Guidelines. The process includes: 1. Medications are administered at the time they are prepared. 2. The person who prepares the dose for administration is the person who administers the dose. 3. Administer medication and remain with resident while medication is swallowed. Do not leave a medication in a resident's room without orders to do so along with documentation of self-administration, and 4. Chart medication administration on Medication Administration Record [REDACTED].",2020-09-01
690,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2018-10-19,689,D,0,1,0TZY11,"Based on observations, staff interview, and review of facility policy, the facility failed to recognize that one out of five sharps containers was full and overloaded with shaving razors protruding out of the opening. As a result of this deficient practice, the facility put the safety and well-being of the residents, employees, as well as the public at risk for accident hazards. Findings Include: During an observation on 10/16/18 at 08:52 AM of the sharps container located in room three, the container was noted to be full and overloaded with two shaving razors protruding out of the opening. There was also no staff in the immediate vicinity to prevent anyone from getting ahold of the shaving razors. On 10/16/18 at 09:18 AM, Registered Nurse (RN) 4 was queried about the overloaded sharps container. RN4 stated the housekeeping department was responsible to monitor and replace the containers and this one should have been changed. RN4 then notified the housekeeping department and the sharps container was eventually replaced. A review of the facility policy on Sharps Disposal revealed a section which stated Designated individuals will be responsible for sealing and replacing containers when they are below full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container. This was not followed.",2020-09-01
691,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2018-10-19,755,E,0,1,0TZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medication labels and staff interview the facility failed to ensure medication labels for three of 38 residents (Resident (R) 30, R58 and R65) from the sample list had legible discard dates. The deficient practice had the potential to affect the remaining 74 residents at the facility if their medications were delivered with medication labels that had illegible discard dates and the facility nurse did not identify those. Findings Include: An inspection of a medication cart on Unit one was completed on [DATE] at 11:54 AM. The contracted pharmacy's procedure was to hand write the discard date on the label of medication container/package. Illegible discard dates were found on five of the medication blister packages. Registered Nurse (RN) 2 was present during the inspection and was asked to review the medication label discard dates. RN2 agreed the dates were illegible and unable to determine if these medications were expired. The following labels were illegible for R30 (three blister packs of [MEDICATION NAME]), R58 (one blister pack of [MEDICATION NAME]), and R65 (one blister pack [MEDICATION NAME] 325 mg tab).",2020-09-01
692,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2018-10-19,842,D,0,1,0TZY11,"Based on observation, electronic medical record (EMR) review and staff interview the facility failed to document an identified skin tear resident (Resident (R) 61) acquired after it occurred on 10/10/18. This deficient practice had the potential to affect the remaining residents at the facility who are at risk for skin breakdown if they develop a skin tear and this is not accurately documented to reflect the resident's skin condition. Findings Include: On 10/18/18 at 12:11 PM observed dressing change to R61's right coccyx/buttock area which appeared to be a stage 2 pressure ulcer (PU). Inquired of Registered Nurse (RN) 4, who did dressing change, what R61's pressure ulcer was staged at and she stated the Resident Care Manger (RCM) 1 stated that it was a skin tear not a pressure ulcer. On 10/18/18 at 12:14 PM interviewed RCM1 who stated the area on R61's coccyx had a small skin tear with a flap. RCM1 explained the area with the flap healed and the open areas were from the skin tear. Noted upon observation R61 appeared to be placed more on his back in bed and inquired RCM1 about this and she stated R61 is on a turning cycle. RCM1 explained there are no set times but it is routine to turn R61 every two hours. RCM1 explained staff turn R61 from his side to his back and then to his other side. On 10/18/18 at 12:23 PM interviewed Certified Nurse Assistant (CNA) 2 and CNA3, who stated R61 is turned every two hours side to side and they used a wedge to keep R61 from going onto his back. Wedge appeared soft but firm enough to keep R61 in position and was placed under the sheet under R61's upper back and did not touch his right coccyx/buttock area. CNAs stated they keep R61 off of his back. The use of the wedge did not appear to cause any injury to R61. On 10/19/18 at 08:53 AM interviewed RCM1 and requested documentation of skin tear R61 acquired on 10/10/18. RCM1 stated she and the nurse practitioner (NP) went that day (10/10/18), after it was found, to see R61's wound and decided on the treatment. RCM1 did a review of R61's electronic medical record (EMR) and found the NP wrote a progress note on 09/26/18 but did not document a skin tear on 10/10/18. Inquired of RCM1 for a copy of any progress note documenting the skin tear that was discovered and reported and RCM1 stated she reviewed the progress notes but there was no documentation of the skin tear by the nurse assigned to work with R61 on 10/10/18, and no documentation by herself and the NP who observed the wound on 10/10/18. Further electronic medical record (EMR) review for R61 found there was no documentation of this wound under the Wounds tab. RCM1 checked the staffing schedule and explained the assigned nurse working with R61 on 10/10/18 was a new nurse who had just come off of orientation and also stated that she was not making excuses but trying to find why this occurred. When inquired RCM1 admitted she and NP did not document the skin tear which they should have. On 10/19/18 at 12:50 PM interviewed and did record review of R61's EMR with Director of Nursing (DON) who confirmed he could not find any progress notes that mentioned a skin tear on R61's right coccyx/buttock area from 10/10/18. Reviewed R61's progress notes and found there was no mention of a skin tear to R61's coccyx/buttock area till 10/19/18 with a late entry put into R61's EMR by RCM1. Noted the progress note stated the skin tear was on R61's left coccyx/buttock area. Escorted by DON to interview RCM1 regarding the late entry progress note she wrote in R61's EMR. Prior to meeting with RCM1 confirmed with RN4 dressing change observed on 10/18/18 was to R61's right coccyx/buttock area. Inquired of RCM1 which side the R61's skin tear occurred and she stated it was the left side and when told the dressing observation was for R61's right side RCM1 stated it was an error on her part, with the progress note she wrote and that she would fix it, that she was busy. On 10/19/18 at 01:06 PM RN corporate trainer showed surveyor the discovery of R61's skin tear was logged in the physician's communication book and was dated 10/10/18. Overall it was noted R61's right bottom/coccyx area appeared to have an old scar with very fragile skin that was healing from a reported skin tear which staff appear to be taking care of. The deficient practice did not accurately document the finding of the skin tear and did not accurately reflect R61's skin condition of healing open areas from the skin tear located on R61's right coccyx/buttock area.",2020-09-01
693,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2018-10-19,880,F,0,1,0TZY11,"Based on observations and staff interviews the facility failed to ensure that linens and laundry were handled and processed to produce hygienically clean laundry and prevent spread of infection to the extent possible. On 10/19/18 at 01:01 PM observed the facility's laundry room where the washer and dryer units were housed, with a large counter in the center of the room where laundry staffer was folding white sheets. Noted that the windows in the laundry room were open and the air conditioner (AC) units were not on. The window jalousies, screens and counter space below windows were covered in brownish dust-like particles. Used fingertips to wipe off particles and fingertips were covered in brownish substance. Interviewed the housekeeping/laundry director (H/L Dir) 2 who was present in the laundry room and inquired whether window jalousies were left open instead of using air conditioner. The H/L Dir2 stated the AC units were not used because there was no circulation for dryer exhaust and water heater venting if the jalousies were kept closed. There were clean linen and laundry stored on rolling laundry carts covered with a red mesh fabric in the laundry room. Dirty linens and laundry were stored and sorted outside of the laundry room on an open-air deck that had a curtain of thick vinyl panels hanging to separate the dirty laundry area from the residents smoking area. The hanging vinyl panels were not air-tight with space between each panel. The facility did not ensure cleanliness and protect clean linen from dust during loading, transport and unloading of clean linens; and, sorting and rinsing of contaminated laundry was done in an adjacent open resident care space.",2020-09-01
694,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2018-10-19,883,D,0,1,0TZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical record (EMR) review and interview, the facility failed to administer the pneumococcal immunization to one of five sampled residents (Resident (R) 2) who was eligible to receive the vaccine. This deficient practice placed R2 at risk for acquiring pneumonia. This deficient practice had the potential to affect the remaining 72 residents at the facility if they were not screened, offered and given the pneumococcal vaccine. Findings Include: A review of R2's EMR found there was no documentation a pneumococcal immunization had been given, declined or contraindicated. Review of R2's last quarterly Minimum Data Set ((MDS) dated [DATE] found R2 is a [AGE] year old female resident with a [DIAGNOSES REDACTED]. On 10/18/2018 at 02:35 PM, an interview was conducted with the Director of Nursing (DON), who stated R2's consent forms were marked 'No' from 2007-2013, indicating the pneumococcal immunization was declined. In 2014 the status of R2 was updated, and a legal representation was appointed through the Office of Public Guardianship (OPG). The OPG returned the Vaccine Consent/Declination form marked 'yes' consenting for R2 to receive the pneumococcal immunization. The DON provided a copy of the Vaccine Consent/declination form dated 3/03/18, and confirmed the vaccine had not been given. Reviewed the facility policy titled Immunizations: Pneumococcal Vaccination (PPV) of Residents/Guest and found the facility did not follow their facility guidelines. This policy stated The Advisory Committee on Immunization Practices (ACIP) recommends vaccinating persons at high risk for serious complications from pneumococcal pneumonia, including those [AGE] years and older and all resident/guests of nursing homes. Recognizing the major impact and mortality of pneumococcal disease on resident/guests of nursing homes and the effectiveness of vaccines in reducing healthcare costs and preventing illness, hospitalization and death, this community has adopted the following policy statements: [NAME] All resident/guests of our community should receive the pneumococcal vaccine if they are [AGE] years of age or older or younger than [AGE] years with underlying conditions .",2020-09-01
695,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2018-10-19,908,E,0,1,0TZY11,"Based on observation, staff interview, and review of facility policy, the facility failed to perform routine maintenance, based on manufacturer's recommendation, and failed to keep preventative maintenance records for six out of six oxygen concentrators reviewed. This deficient practice put the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: During an observation and staff interview, on 10/16/18 at 10:57 AM, with the Maintenance Manager (Maint Mgr) 1. Maint Mgr1 stated the cleaning of all Oxygen Concentrator Filters were supposed to be done on a weekly basis. Maint Mgr1 said prior to 10/03/18 the process to clean and maintain the filters were not in place and not being done. It was only on 10/03/18 when the facility began the process to properly clean and maintain the filters. A review of facility policy on Maintenance Service revealed a section which stated Maintenance personnel shall follow the manufacturer's recommended maintenance schedule. Another section stated The Maintenance Director or designee is responsible for maintaining the following records/reports . Maintenance schedules. This was not being followed. A review of the Service manual for the AirSep NewLife Intensity Oxygen Concentrator revealed a section (4.2) on Cleaning and Infection Control which stated Clean the air inlet gross particle filter with warm soapy water between each patient's use. Clean this filter at least once per week, depending on the environment, during normal operation. This also was not being followed. Another review of the Service Manual for the AirSep NewLife Elite Oxygen Concentrator revealed a section (3.2) on Cleaning the Air Intake Gross Particle Filter which stated the patient/facility must clean this filter weekly. The filter may require daily cleaning if the unit operated in a harsh environment . During an interview with the Maint Mgr 1, on 10/19/18 at 2:00 PM, Maint Mgr 1 presented a maintenance log that was created for various items which included the Oxygen Concentrators. Maint Mgr 1 also stated the process to properly clean and maintain the Oxygen Concentrators was currently in place and being followed.",2020-09-01
696,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2017-11-03,250,D,0,1,PG8K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview the facility failed to verify information that 1 resident of 31 residents (Resident #123), on the Stage 2 Resident Sample List, provided and placed on their Care Plan (CP), failing to maintain the highest practicable physical, mental and psychosocial well-being of resident. Findings include: On 11/01/2017 at 1:29 PM Resident (R) #123 electronic medical record (EMR) review found that R#123 was admitted on [DATE] at 12:55 PM with following Dx: Alcoholic hepatitis with ascites, paralysis of vocal cords and larynx, unspec., encounter for palliative care, dorsalgia unspec., bacterial infection unspec., enterocolitis due to clostridium difficle, benign prostatic hyperplasia without lower urinary tract symp, Bipolar disorder, unspec., Major Dep. Disorder, single episode, unspec. It was noted that resident was receiving Hospice services. During EMR review it was found that resident recently had made amends with his family, whom he had not been in contact with for many years due to his alcoholism. Noted on resident's CP problem has .Have family involved in care. with goal that resident .will have care provided to him according to his express preferences and interventions listed is Encourage his family to be involved in his care. Other problems listed throughout resident's CP are .feeling depressed and bad about himself, not sleeping at night, and having a poor appetite, .ETOH ascites with end of life Hospice care ., .dehydration risk d/t recent UTI . and . states he is sad due to the recent news of his father's death. On 11/01/2017 at 3:10 PM interviewed hospice nurse and social worker who were at the facility to work with R#123. Quiered how resident was handling the recent passing of his father the hospice staff were bewildered. Hospice nurse stated that she had spoken with resident's father that day to give him an update on the resident's health. Requested that staff #30 show R#123 CP to hospice staff to verify information on CP. After verifying the information that was on the CP, that R#123's father recently passed away, hospice nurse, hospice SW and surveyor went to talk with R#123. Hospice nurse reassured resident that she had spoken with his father that morning. Hospice nurse called resident's father on her cell phone and let him speak to his father on speaker phone. Resident looked relieved and was happy. Hospice nurse believes that resident may have had a nightmare, believed that his father had passed away and shared that information with staff who was around. On 11/01/2017 interviewed staff #30 to find out who had added the information to R#123's CP. This information was added to resident's CP on 10/30/2017 by staff #92. On 11/01/2017 at 3:47 PM interviewed staff #92 who stated that she had believed what the resident had told her, that his father had passed away and had not verified this with the resident's family. Staff #92 agreed that R#123's family is easy to contact, does want to be involved with resident's care and a phone call could have been made to verify that the information provided by this resident was accurate. Staff #92 was reminded that due to the resident's progressing terminal illness he may have periods of confusion. The facility failed to verify a death of a family member before placing this information on a resident's CP, failing to maintain the highest practicable physical, mental and psychosocial well-being of resident.",2020-09-01
697,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2017-11-03,272,E,0,1,PG8K11,"Based on observations, staff interviews and Electronic Medical Reviews (EMR), the facility failed to ensure that 3 of 31 residents, (R#13, 68, and 126) on the Stage 2 Resident Sample List, received comprehensive assessments for the use of bed side rails as an assistive device. Findings include: Cross reference to F323 1) On 10/31/17 at 11:26 AM, R#126 was observed sleeping in bed with metal bilateral upper quarter side rails (SR) up. The spaces between the metal SR bars were large enough to entrap the resident's limbs, head and neck. The SRs were also loosely fitted to the bed and shook easily. On 11/02/2017 at 12:36 PM interviewed Staff#30 and she was shown how loose the SRs were, the gaps between the metal bars and mattress that posed a safety hazard. Reviewed R#126's EMR and on the Bed Rail Assessment form dated 08/22/2017, noted Hx of Falls with FX r/t Left Femur FX, as explanation of need for use of bed rails; and, that the bed rails were utilized as an enabler for safety and mobility. The Resident Assessment Instrument (RAI), the Minimum Data Set (MDS) 3.0 completed during the admission period dated 08/29/2017, the resident had a BIMS summary score of 4 and needed extensive assistance with two + person physical assistance during bed mobility and transfer. 2) On 10/31/2017 at 11:59 AM, while doing resident observations for R# 13, noted that she had a loose fitting upper quarter side rail on her bed that was on the outside of her bed. Checked to see if the side rail fit the bed properly and noted that there was a gap between the mattress and side rail. While testing to see if the side rail fit the bed properly it was noted also that the side rail was loose and shaky. On 11/02/2017 at 12:36 PM interviewed and showed staff #30 R# 13's side rail while resident was in her bed. Staff #30 confirmed that rail was loose and that there was a gap between the mattress and the side rail which posed a safety hazard for R# 13. The Resident Assessment Instrument (RAI), the Minimum Data Set (MDS) 3.0 completed during the quarterly period dated 05/22/2017, had documented that the resident had a BIMS summary score of 3 and needed extensive assistance with 2+ persons physical assist for bed mobility and transfers. 3) On 10/31/2017 at 12:12 PM, while doing resident observations for R# 68, noted that he had loose fitting bilateral upper half side rails on his bed. It was noted that there was an approximate 1 inch gap between the mattress and side rail. The Resident Assessment Instrument (RAI), the Minimum Data Set (MDS) 3.0 completed during the quarterly period dated 09/23/2017, had documented that the resident had a BIMS summary score of 15 and needed extensive assistance with 2+ persons physical assist for bed mobility. Reviewed R# 68's EMR and on the Bed Rail Assessment form dated 01/11/2017, noted Resident informed the use of siderails, used as an assistive device as explanation of need for use of bed rails; and, that the bed rails were utilized as an enabler as staff documented used for assistance when repositioning in bed, resident verbalizes understanding of it's use. There were no other alternatives and less restrictive interventions/measures attempted and used documented on R#68's Bed Rail Assessment form dated 1/11/17. On 11/02/2017 at 12:32 PM walked with staff #30 around the unit to check R# 13 and 68's side rails. Surveyors forearm fit snugly in between mattress and side rail demonstrating potential for resident's arm to get trapped in between mattress and side rail. Staff #30 confirmed that these resident's side rails had a gap between the mattress and the side rails and that the rails were loose and shaky, posing a safety hazard for these residents. When asked why the bed rails were like this staff #30 stated that the facility has been working on changing out the old side rails and that these resident's side rails have not been changed out yet. The facility failed to conduct a comprehensive assessment as part of an ongoing process through which the facility could identify whether the resident's use of bed SRs were safe to use as an assistive device.",2020-09-01
698,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2017-11-03,318,D,0,1,PG8K11,"Based on observation, interviews and record reviews, the facility failed to provide range of motion and treatment services to increase range of motion and/or prevent further decrease in range of motion for 1 of 31 residents (Resident #94) on the Stage 2 Resident Sample list. Findings include: Interview with Resident #94 (R#94) on 11/01/17 at 1:00 P.M. who stated he does not receive any range of motion to his right hand. R#94 had a right hand splint on and stated he tries to move his hand on his own as he is able to lift his arm in the air. Interview on 11/01/17 with certified nurse aide, working with R#94, stated that she does not do range of motion with resident. Record Review on 11/01/17 revealed that the resident had a careplan that stated to Provide Range of Motion (ROM) prior to applying and after removing splint. Apply right hand splint daily for 6-8 hours as tolerated. Splint can be removed for bathing and ADL care. Check skin integrity before and after application and notify charge nurse (CN) for any problem. Interview with physical therapy found that they inserviced all the certified nurse aides on the floor regarding treatment. In service attendance records revealed the signatures of staff members from the floor who was inserviced. During interview with Staff #93 discussed the discrepancy of care not provided according to the careplan and Occupational Therapy Upper Extremity Splint Schedule recommendations of therapy for R#94. Staff #93 stated that they would look into this. The facility failed to provide ROM for R#94 to increase ROM and or prevent further decrease in ROM as stated in their care plan.",2020-09-01
699,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2017-11-03,323,E,0,1,PG8K11,"Based on observations, staff interviews and Electronic Medical Record (EMR) reviews. The facility failed to ensure that 3 of 31 residents (R#13, 68, and 126) on the Stage 2 Sample Resident List, were provided assistive devices that did not pose any hazards and/or risks. Findings include: Cross reference to F272 1) On 10/31/17 at 11:26 AM, R#126 was observed sleeping in bed with metal bilateral upper quarter side rails (SR) up. The spaces between the metal SR bars were large enough to entrap the resident's limbs, head and neck. The SRs were also loosely fitted to the bed and shook easily. On 11/02/2017 at 12:36 PM interviewed Staff#30 and she was shown how loose the SRs were, with gaps between the metal bars and mattress that posed a safety hazard. Reviewed R#126's EMR and on the Bed Rail Assessment form dated 08/22/2017, noted Hx of Falls with FX r/t Left Femur FX as explanation of need for use of bed rails; and, that the bed rails were utilized as an enabler for safety and mobility. The Resident Assessment Instrument (RAI), the Minimum Data Set (MDS) 3.0 completed during the admission period dated 08/29/2017, found the resident had a BIMS summary score of 4 and needed extensive assistance with two + person physical assistance during bed mobility and transfer. 2) On 10/31/2017 at 11:59 AM, while doing resident observations for R#13, noted that she had a loose fitting upper quarter side rail on her bed that was on the outside of her bed. Checked to see if the side rail fit the bed properly and noted that there was a gap between the mattress and side rail. While testing to see if the side rail fit the bed properly it was noted also that the side rail was loose and shaky. On 11/02/2017 at 12:36 PM interviewed and showed staff #30 R#13's side rail while resident was in her bed. Staff #30 confirmed that rail was loose and that there was a gap between the mattress and the side rail which posed a safety hazard for R# 13. The resident assessment instrument (RAI), the minimum data set (MDS) 3.0 completed during the quarterly period dated 05/22/2017, had documented that the resident had a BIMS summary score of 3 and needed extensive assistance with 2+ persons physical assist for bed mobility and transfers. 3) During an interview on 10/31/17 at 12:11 PM with R #68 the bed was observed to have metal side rails that did not fit snugly against the mattress. On 11/02/17 at 10:58 AM the resident's side rails were observed to slide straight up to locked position leaving approximately a one inch gap between the mattress and side rail on both sides of the bed. The surveyor could place the lower arm in between the mattress and side rail demonstrating the potential for an arm to get trapped. A warning sticker was found on the top of the left side rail stating that the side rail must fit snugly against the mattress to prevent injury. Review of the medical record on 11/02/17 at 2:30 PM revealed that a Bed Rail Assessment form dated 01/11/2017, noted Resident informed the use of siderails, used as an assistive device as explanation of need for use of bed rails; and, that the bed rails were utilized as an enabler as staff documented used for assistance when repositioning in bed, resident verbalizes understanding of it's use. There were no other alternatives and less restrictive interventions/measures attempted and used documented on R#68's Bed Rail Assessment form dated 1/11/17. The resident assessment instrument (RAI), the minimum data set (MDS) 3.0 completed during the quarterly period dated 09/23/2017, had documented that the resident had a BIMS summary score of 15 and needed extensive assistance with 2+ persons physical assist for bed mobility - to and from lying position, turns side to side, and positions body while in bed or alternative sleep furniture. R#68 is wheelchair dependent for mobility. During a resident interview on 11/03/17, R #68 stated that he has never been injured during a transfer from his bed to his wheelchair, although his arm has slipped in between the mattress and rail but he was able to free his arm. The facility did not evaluate and analyze hazards and risks in the use of old metal SRs for residents to prevent avoidable accidents.",2020-09-01
700,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2017-11-03,329,D,0,1,PG8K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and Electronic Medical Record (EMR) reviews, the facility failed to ensure that medication regimens for 2 of 31 residents (R#82, R#57) on the Stage 2 Sample Resident List, adequately monitored for behaviors as stated on their care plan and that these medications helped to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being. Findings include: 1) On 10/30/2017 at 10:11 AM observed R#82 lying naked in bed with a hand towel covering groin area with his/her bottom visible. The resident appeared incoherent and the privacy curtain was open. After leaving the resident's room heard a large thud against the wall and apparently R#82 threw an item against the wall. Informed staff that were available and Staff#14 went to attend to the resident. Interviewed Staff#14 after she provided care to R#82, and she stated that this resident does not like to wear clothes or briefs. When she attempted to assist R#82, she was told that he/she wanted to be left alone. The resident in the adjoining room, stated that R#82 was calling for the nurse but nobody came and when told to use the call-light, R#82 threw a plastic bottle against the wall. According to Staff#14, R#82 may be in pain because he/she does not want to be bothered and will inform the charge nurse. On 11/01/2017 at 1:56 PM reviewed R#82's EMR and noted on a psychiatry consult on 10/19/17 the resident had psychiatric history for [MEDICAL CONDITION] and a medical history that included diabetes mellitus, obesity, [MEDICAL CONDITION], and admitted to the facility status [REDACTED]. The physician orders [REDACTED]. On 11/02/2017 at 10:51 AM interviewed Staff#11, and she stated that R#82 has been refusing medications for about 1 week due to loose bowel movements. The resident was tested for [MEDICAL CONDITION] but results were negative. Queried Staff#11 on behavior monitoring for resident and she looked at R#82's EMR and noted that the resident had behavior monitoring for sadness with the use of [MEDICATION NAME] and hallucinations for the use of [MEDICATION NAME]. On 11/02/2017 at 11:18 AM interviewed R#82's psychiatrist and queried what the facility staff should be monitoring resident for. According to the psychiatrist, specific symptoms with the medications prescribed for R#82 are paranoia, hallucinations, and suicidal ideation with use of antidepressants. The psychiatrist preferred that staff provide non-pharmacological alternatives before using [MEDICAL CONDITION]'s ordered as needed. The resident's care plan states .is receiving antidepressant drugs on a regular basis, with the following included interventions of .record behavior on Behavior Tracking Record. Observe for changes in mood/behavior (sleep patterns, fatigue, appetite, ability to concentration, participation in activities, crying). On 11/02/2017 at 2:28 PM interviewed Staff#117 to verify behavior tracking form for R#82. Reviewed R#82's behavior tracking record with Staff#117. Noted on 10/23/2017, in the EMR, Progress Notes section, it was documented that the resident refused physical therapy, .was frustrated, slammed a fist to bed side table, raised his voice and kept insisting, they don't care about me, so why the f--- should I even do this but these behaviors were not on the behavior tracking record. Also, the CNA staff did not input any behavioral data for the month of 10/2017. 2) Resident #57 (R#57) admitting [DIAGNOSES REDACTED]. R#57's medication regimen include but not limited to Aripiprazole 15 mg for [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder one time daily. Also on [MEDICATION NAME] 100 mg tablet one time a day for depression. Record review on 11/01/2017 at 9:13 AM - Care Plan (CP): R#57 has a CP and is receiving antipsychotic drugs on a regular basis. The goals for the CP include R#57 will not cause harm or injury to self or others over next 90 days by 12/27/2017. The interventions on resident's CP are If behavior noted Remove from situation; allow time to calm down. Provide medication as ordered. Follow up Psych services as indicated . and Record behaviors on behavior tracking form. Monitor pattern of behavior (time of day, precipitating factors, specific staff or situations). Remind resident that BEHAVIOR is not appropriate. Resident #57 has multiple CP problems regarding her behavior of actually claiming abuse after asking staff to care for her in a certain way and then will claim abuse. R#57 has disruptive behavior, paranoia and accusations of belongings being stolen. Interview on 11/01/2017 at 10:31 AM with staff member #116 who stated R#57 is scheduled for her next visit with her psychiatrist. R#57 has pushed back at times with the meds and psychiatric treatment. We had the ombudsman out because she thought that she was blocked from her son from us. We dialed her son's number in front of her and the result was that it was blocked from his end and not from the facility. She thinks that there are special bingo cards. There are multiple things that we are working with her on. It will go for a while and then it will kind of escalate. She has paranoia that we are out to get her. She made a suggestion that the masked costume yesterday from Halloween was rigged against her. This is her paranoia. The staff try to counsel her during activities and she will be accusatory, i.e. like the dietician and diet is a big factor. She will ask for ten crackers and then she only gets nine and She will state that we are in conflict and bring her rights out and then things escalate. Behavior monitor sheets: Late entry for Friday 10/27/17. Friday.expressed many complaints to the staff which included: 1. Losing at bingo because staff is cheating 2. Giving her bad cards, not calling out her numbers on purpose 3. A staff member at bingo is making faces at her when no one is looking 4. Staff rigging the Halloween mask contest. 5. Upset that she lost her case manager because she is in the facility. Record review also revealed that on 10/18/17, during activities, a resident was coming into the dining area and was going to sit next to R#57. As another resident got closer to the table R#57 told the resident you cannot sit here. The other resident wheeled away. This writer was standing by R#57 and heard her tell the resident that . The writer told R#57 you cannot tell others where they cannot sit and you need to move your reacher and your big cup so we can make room for other's. R#57 just looked at this writer and said where do you want me to put my things. Staff member told her to move it closer on the other side of the table. R#57 moved her things. During bingo this writer was standing by a resident when the resident won 3 x in a row. R#57 told that resident who won you don't have bingo they did not call I42 this writer told R#57 that the caller did call that number and that the resident had bingo. Record review revealed that there was no monitoring for paranoia on the behavior monitor sheets. Interview with staff members #79 and #92 on 11/03/2017 at 10:57 AM regarding R#57 who stated: We have to continually remind her that no one is cheating . The pattern is when R#57 does not win at bingo, resident will get paranoid about bingo. R#57 will pick one person aside to complain and then we discuss them in the a.m. R#57 cycles and will be fine for a while. The behavior we describe is paranoia, not delusions or hallucinations. She is more manipulative than bullying. We have seen an improvement over the last year. Interview with Staff #93, on 11/03/2017 at 11:00 AM regarding R#57 The MD increased the [MEDICATION NAME] to 15 mg daily yesterday for [MEDICAL CONDITION] and paranoia behaviors. Staff #93 pointed out that Res#57 had all zeros for her log for [MEDICATION NAME] and to monitor for suicidal ideation. When asked where the behavior monitoring is for paranoia is because it is care planned for and meds are being adjusted for this behavior, Staff #93 agreed that there was no monitoring for the behavior of paranoia. The facility staff did not monitor 2 resident's medication regimen and behaviors adequately to maintain the resident's highest practicable psychosocial well-being.",2020-09-01
701,PU'UWAI 'O MAKAHA,125046,84-390 JADE STREET,WAIANAE,HI,96792,2017-11-03,431,D,0,1,PG8K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to label insulin in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 8 of 31 residents (R#5, 31, 47, 55, 70, 75, 84 and 89) on the Stage 2 Resident Sample List. Findings include: On [DATE] medication storage was done with Staff #37. Staff #37 stated that, once we opened the insulin it is good for 28 days. Upon further observation and inventory of the insulin kept in drug cart #1, there were seven insulin medications without expiration dates. These seven insulin orders were for Resident #31 (R#31), R#47, R#55, R#70, R#75, R#84 and R#89. Staff #37 stated that we calculate as we go. Upon further investigation, it was noted another staff member did include the expiration date; however, the 28 day count for three of their insulin orders were incorrect. On cart #1, R#5 date opened was [DATE] and the date on the bottle state: Expired [DATE]. Staff #37 stated that it was off by one day and that this medication is only given in the afternoon and was not given today, so it was not a med error. It is given by the night shift. On cart #2, staff #56 counted the 28 day for R#89's second insulin order which was incorrect. R#89's date opened on Lantus bottle was documented to be [DATE] and expiration date stated [DATE] which should have been [DATE]. Cart #2 also showed R#84 had an open date of [DATE] and expiration date of [DATE] which is incorrect by five days. Findings were shared with Staff #115 who agreed that practice was inconsistent and could lead to drug errors.",2020-09-01
702,HALE OLA KINO,125047,"1314 KALAKAUA AVENUE, 2ND FLOOR",HONOLULU,HI,96826,2019-04-12,756,D,0,1,COTT11,"Based on record reviews and interviews the facility failed to ensure that the pharmacist's medication regimen review (MRR) was acted upon by the medical doctor (MD) for one of five residents (R8) sampled for unnecessary medications. Findings Include: On 04/10/19 at 02:19 PM, interviewed the staff development manager (SDM) and requested R8's MRR sheets for the past six months. The SDM provided MRR's dated 10/18; 11/18; 12/18; and 01/19. The SDM needed to check with the director of nursing (DON) for the 02/19 and 03/19 MRRs . On 04/11/19 the SDM provided R8's pharmacist MRR done on 02/26/2019 and 03/19/2019 and both MRRs had pharmacist recommendations that were not acknowledged by R8's MD. On the 02/26/19 MRR, the pharmacist noted that R8 was receiving the combined use of more than one antidepressant and the physician should consider treating R8's depression with a single antidepressant. The MRR did not document a physician response or a signature. The 03/19/19 MRR noted that R8 was on an antidepressant whose dose should be evaluated and considered for gradual dose taper, and the form was not acknowledged by the MD nor signed by him. Interviewed the DON and she provided documentation that the MD was notified via phone of pharmacy recommendations on 03/19/19. The MD wanted the MRR placed in his communication binder at the facility and there were no new orders on that date. On 04/12/19 the DON provided the MD's acknowledgement on the 02/26/19 MRR, Pt stable on current psych meds . and on the 03/19/19 MRR, Keep same RX, with MD initials. The MD was in the facility and the DON requested that he acknowledge both MRRs on this date. The facility failed to ensure that R8's MD documented in the resident's medical record that the MRR was reviewed for any identified irregularities, and rationale if there is no change in the medication(s).",2020-09-01
703,HALE OLA KINO,125047,"1314 KALAKAUA AVENUE, 2ND FLOOR",HONOLULU,HI,96826,2019-04-12,812,F,0,1,COTT11,"Based on observation and interview, the facility failed to label pies and other food items in the freezer. This deficient practice had the potential to put residents at risk for serious complication from foodborne illness as a result of their compromised health status. Findings Include: On 04/08/19 at 08:06 AM the initial kitchen tour in the facility found several food items that were past the expiration date. In the cook prep refrigerator an opened bag of defrosted chicken thighs had a discard date of 4/7, and in the freezer section there was an opened bag of chicken patties with no expiration and/or open date, and other bags of frozen items with no expiration dates. In the walk-in produce refrig there was a tray of yogurt containers with expiration dates of 4/05 and a tray of stir fry vegetables with expiration date of 4/3. The reach-in freezer contained 12 sugar free pies with no use by and/or expiration dates. On 04/11/19 at 09:09 AM interviewed the Sous Chef and Food & Beverage Manager, and they provided the facility policy for food & beverage services to ensure that kitchen staff will label and discard food items appropriately. The Labeling and Discarding Food Items; Standard Operating Procedure - 19; Policy: Food and Beverage services will label and discard food items appropriately.",2020-09-01
704,HALE OLA KINO,125047,"1314 KALAKAUA AVENUE, 2ND FLOOR",HONOLULU,HI,96826,2019-04-12,842,D,0,1,COTT11,"Based on interviews and record reviews (RR) the facility failed to maintain medical records in accordance with accepted professional standards and practices for two of 23 residents (R15 & R8) sampled for survey. Findings Include: 1) On 04/08/19 at 10:22 AM, interviewed R15 who reported that a male residents wanders into her room and has occurred four to five times now. The R15 stated that the facility now uses a red tape across her doorway with Stop Do Not Enter signage printed on it. On 04/11/19 at 08:00 AM, RR on R15 did not find any documentation in nursing notes and/or care plan of the incident investigated and resolved. Interviewed the director of nursing (DON) and she couldn't provide any documentation but could verbalize about the incident and how it was resolved. The DON showed the red doorway tape Stop DO NOT ENTER signage that was ordered, and stated that R15 aware that it is near her doorway when needed. The staff are aware of this wandering resident and monitors his whereabouts when he is out and about in the hallways. 04/11/19 10:05 AM interviewed social services coordinator, and he had a grievance binder with R15's grievance regarding male resident entering her room; provided. According to the SSC grievances that are handled within 24 hrs are not documented in resident's medical records. The R15's care plan (CP) dated 03/23/18 to promote highest level of well-being; safety; independence; honor preference; resident centered care; with by date 6/19; . 10. Care related special instructions: -a resident who wheels self on hallway gets near residents door- resident is bothered with this resident's presence even near the door only - requested something to deter this resident to ensure this person does not enter residents room Resident (251) agreed to use a do not enter sign placed on her door (251) - will monitor effectiveness - will change CP as necessary. - sometimes resident also requests door to be completely closed - if it happens - staff regularly rounds resident for safety. This CP was the only documentation of R15's reported incident of a male resident wandering into her room. 2) On 04/10/19 at 02:19 PM, interviewed the staff development manager (SDM) and requested R8's MRR sheets for the past six months. The SDM provided MRR's dated 10/18; 11/18; 12/18; and 01/19. The SDM had to check with the director of nursing (DON) for the 02/19 and 03/19 MRRs . On 04/11/19 the SDM provided R8's pharmacist MRR done on 02/26/19 and 03/19/19. On the 02/26/19 MRR, the pharmacist noted that R8 was receiving the combined use of more than one antidepressant and the physician should consider treating R8's depression with a single antidepressant. The MRR did not document the medical doctors (MD) response or a signature. The 03/19/19 MRR noted that R8 was on an antidepressant whose dose should be evaluated and considered for gradual dose taper, and the form was not acknowledged nor signed by the MD. Interviewed the DON and she provided documentation that the MD was notified via phone of pharmacy recommendations on 03/19/19. The physician wanted it placed in his communication binder at the facility and there were no new orders on that date. On 04/12/19 the DON provided the MD's acknowledgement on the 02/26/19 MRR, Pt stable on current psych meds . and on the 03/19/2019 MRR, Keep same RX, with MD initials. The MD was in the facility, and the DON requested that he acknowledge both MRRs. The MD did not sign or date the MRRs acknowledgements. The facility failed to ensure that the medical records for R15 and R8 were completed and provided sufficient information for staff to respond to the changing status and needs of the residents; accurately documented with dates and times; and, systematically organized.",2020-09-01
705,HALE OLA KINO,125047,"1314 KALAKAUA AVENUE, 2ND FLOOR",HONOLULU,HI,96826,2017-05-05,247,D,0,1,WIHG11,"Based on medical record review, resident and staff interviews, the facility failed to give one resident, Resident #26, of eight residents interviewed stated she wasn't given notice prior to a roommate change. Findings include: During an interview with Resident #26 on the afternoon of 5/2/17 at approximately 1:00 P.M., she noted that she had a roommate change within the past 9 months. When asked whether the facility provided notice prior to the change in roommate, Resident #26 stated, No. An interview of Staff #8 on the morning of 5/4/17 at approximately 10:50 [NAME]M. revealed the staff documented their notification of change in room/roommate under the Social Services tab in the medical record. Staff #8 was unable to find documentation in that section for Resident #26. An interview of Staff #25 on the afternoon of 5/4/17 at approximately 1:15 P.M. revealed the Activities staff introduced new residents to their roommates. Staff #25 reported that the Activities staff does not document room/roommate changes in the medical record. In conclusion, the facility failed to document changes in rooms/roommates.",2020-09-01
706,HALE OLA KINO,125047,"1314 KALAKAUA AVENUE, 2ND FLOOR",HONOLULU,HI,96826,2017-05-05,309,D,0,1,WIHG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure services for a resident (Resident #12) who elected hospice services were coordinated in a plan of care. Findings include: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/14/16 Resident #12 was admitted to hospice services related to severe Alzheimer's dementia, many urinary tract infections, recent pneumonia and history of ulcers. A record review was done on 5/3/17 at 8:40 [NAME]M. The review found a Visit Log by the hospice staff members. The log has entries for the Registered Nurse (RN) and another staff member with notation of massage. A review of the hospice initial plan of care includes the following: durable medical equipment (oxygen, waffle mattress); physician to visit as medically necessary; skilled nurse (1x/week) and social worker (1x/month). A review of the facility's Resident Care Plan found the plan did not include information regarding who is responsible for performing respective functions that have been agreed upon and included in the plan of care. On 5/3/17 at 9:08 [NAME]M. an interview was conducted with Staff Member #2. Inquired how often does the hospice nurse come to visit the resident and what is the purpose of the nurse's visit, what services does the hospice nurse provide that the facility nurse does not provide. Also noted that there are entries for a hospice worker with the purpose of the visit listed as massage. Further queried how often does this person come to massage the resident. At 9:12 [NAME]M. Staff Member #43 provided assistance. Queried both staff members regarding what services the hospice nurse and aide provides for Resident #12. Also, requested for the documentation in the resident's care plan related to the services being provided by the hospice entity. The staff member reported the hospice is sending an aide and a massage therapist. Inquired how many times a week does the aide and massage therapist come and what services does the aide provide. Staff Member #43 reviewed the facility's care plan and commented the care plan is not specific regarding the delineation of services the facility and the hospice entity is providing. Staff Member #2 reported the aide usually comes to assist the resident at meal time. Staff Member #43 reported the facility will contact the hospice provider to obtain this information (who and how often Resident #12 will be visited by the nurse and aide as well as the services that will be provided by the hospice staff) to obtain this information. The staff member acknowledged the facility should have knowledge of this information. On 5/4/17 at 11:35 P.M. the hospice nurse provided the current orders for hospice services (frequency of visits and services to be provided). The orders included skilled nursing, once a week for 8 weeks; home aide, once a week for week 1 and subsequently twice a week for 7 weeks (every Tuesday and Thursday). The facility did not ensure services provided by the hospice entity were included in Resident #12's plan of care. The facility also failed to demonstrate ongoing communication and monitoring of the hospice services was being done.",2020-09-01
707,HALE OLA KINO,125047,"1314 KALAKAUA AVENUE, 2ND FLOOR",HONOLULU,HI,96826,2017-05-05,329,D,0,1,WIHG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review ad interview with staff members, the facility failed to monitor response to therapy and adverse consequences for 1 (Resident #35) of 5 residents sampled for drug regimen review. Findings include: Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/1/17 at 2:35 P.M., Resident #35 was observed in the activity room, looking at a magazine and dozing off. On 5/2/17 at 7:00 [NAME]M. Resident #35 was observed sitting in a wheelchair at a table in the nurses' station. Subsequent observation found the resident in activities during BINGO. Resident #35 was seated in a wheelchair and asleep, Staff Member #25 was observed to approach the resident, rubbing the resident's arm and speaking softly to engage the resident in the activity; however, the resident could not be roused. On 5/3/17 at 9:55 [NAME]M. Resident #35 was observed to be in the activity room asleep. Subsequent observation at 11:05 [NAME]M. found Resident #35 asleep at the table, the resident was holding her head in her hand. At 1:25 P.M. the resident was found in the activity room with her head resting on the table atop a neck pillow asleep. At 1:26 P.M. a staff member strolled the resident to the dining room and attempted to rouse her. Then another staff member, Staff Member #39 tried to wake the resident and determined the resident would be taken back to bed. In the resident's room, Staff Member #39 asked the resident if she wanted to go back to bed, the resident was agreeable but kept falling asleep while seated in the wheelchair. On the second attempt to transfer, the resident was able to move her body forward so a gait belt could be applied. Resident #35 was able to stand on the second attempt with the assistance of the staff member, took small steps toward her bed and was able to lower herself onto the bed. Observation at 2:30 P.M. and 2:55 P.M. found Resident #35 asleep in bed. On 5/4/17 at 7:00 [NAME]M. Resident #35 was observed at the nurses' station at the table with her head down (placed on a pillow). Staff Member #20 reported Resident #35 was at the nurses station from 6:00 [NAME]M. after the staff dressed her. The staff member further reported the resident cannot be left alone so the resident is brought to the nurses' station for supervision. At 7:10 [NAME]M. Resident #35 was placed back to bed. Observation at 7:27 [NAME]M. found the resident asleep in bed. Subsequent observation at 9:10 [NAME]M. found Resident #35 in the dining room at the table asleep. Staff Member #10 was assisting the resident with breakfast and reported it is hard to keep the resident awake. The staff member further reported sometimes Resident #35 is wide awake and sometimes she is sleepy during meals. Resident #35 had a shower and was observed in her room at 10:35 [NAME]M. with the nurse taking vitals. At approximately 11:15 [NAME]M. Resident #35 was observed to be alert and ambulating with a staff member on the unit in the hallway. Resident #35 had lunch in the dining room with assistance and was found asleep in the activity/living room from 2:30 to 2:40 P.M. On 5/1/17 at 11:15 [NAME]M. a record review found a physician order [REDACTED]. at hour of sleep (antipsychotic); [MEDICATION NAME] ([MEDICATION NAME]), 10 mg. daily (antidepressant); and [MEDICATION NAME] 3 mg. (2 tabs = 6 mg.) at bedtime for a [DIAGNOSES REDACTED]. The order also includes to monitor the resident for the following behaviors: refusal of care; physical restlessness; number of hours of sleep; and hitting. Resident #35 has a prescription for Ensure Plus (120 ml) after meals for nutritional deficiency, unspecified with a start date of 4/25/17. Further review found Resident #35's weight on 11/21/16 was 118 lbs. and the current weight taken on 5/1/17 was 109 lbs. Resident #35 had a 9 lb. (8.3%) weight loss from 180 days ago. Resident #35 also has a history of falls. A review of the progress notes found on 2/21/17 at approximately 8:20 [NAME]M. Resident #35 was found on the floor outside of the bathroom door on her right side. No injuries related to the fall. On 4/3/17 at approximately 8:00 P.M. a moan was heard and the resident was found in front of the wheelchair with the wheelchair resting on her. No injuries related to the fall. On 4/26/17 at noon, Resident #35 was found sitting on the foot rest of her wheelchair while seated in the living room. Resident #35 had a bump on the right temporal area and reddened area to the right flank. On the morning of 5/4/17, staff member and surveyors observed Resident #35 crawling on the floor toward the bathroom. A review of the Resident Change in Condition-MRR Request Form prepared by the Pharmacist, dated 2/25/17 notes there was a status change, a fall. The Pharmacist notes the possible contributing medication as [MEDICATION NAME] and [MEDICATION NAME]. The Pharmacist recommended a discontinuation attempt of [MEDICATION NAME] and consider decreasing [MEDICATION NAME] to 3 mg. by mouth once daily. The review on 2/27/17 noted no recommended changes to current medication regimen. A subsequent note by the Pharmacist was done on 4/7/17 related to an unwitnessed fall. The Pharmacist identified the use of [MEDICATION NAME] and [MEDICATION NAME] as possible contributing medications. The Pharmacist notes possible adverse medication consequences to [MEDICATION NAME] (lethargy and sedation) and [MEDICATION NAME] (lethargy, dizziness and drowsiness). The Pharmacist recommended decrease of [MEDICATION NAME] to 3 mg. at bedtime and decrease of [MEDICATION NAME] to 9.25 mg. by mouth once every other night x3 doses then discontinue. The review on 4/10/17 notes no changes to current medication regimen with handwritten notation of mild sundowning so will continue as resident has been stable. A review of the resident's care plan found a plan for Potential for Ill Effects of [MEDICAL CONDITION] Medications which lists [MEDICATION NAME] and [MEDICATION NAME]. The approaches include monitoring for ill effects of the medication which includes: stiff neck, tremors, tardive dyskinesia, dry mouth, blurred vision, constipation, [MEDICAL CONDITIONS], sedation/drowsiness, increased fall, headache, [MEDICAL CONDITION], rashes, etc. An interview was done with the Director of Nursing (DON) on 5/4/17 at 8:15 [NAME]M. The DON confirmed the Advanced Practice Registered Nurse (APRN) did the review of the Pharmacist's notes. The DON reported Resident #35's sleep pattern is difficult to predict, there are times when she wants to go to bed and when put into bed, she wants to get up again. The DON further reported it is hard to balance the resident's sleep as she may stay up at night and sleepy during the day. A review of the residents hours of sleep at night for (MONTH) and (MONTH) (YEAR) notes Resident #35 sleeps from one to eight hours at night. There was only one documented incident of one hour of sleep on 3/22/17. On 5/4/17 at 11:20 [NAME]M. an interview was conducted with the APRN. The APRN reported Resident #35 does not sleep at night and displays agitated behavior; however, the resident has been pretty stable on the current medication regimen so they are afraid to take the resident off the medication. During the APRN's visit, Resident #35 was alert and ambulating with staff in the hallway which the APRN reported is the resident's baseline. The APRN also reported Resident #35 may be up during some of the day as baseline then will dose off for a short nap. The observations of Resident #35 during the survey period were shared with the APRN. The APRN was informed Resident #35 was asleep for most of the day and difficult to rouse and only today (5/4/17) during the APRN's visit the resident was alert. The APRN also stated if the resident was experiencing weight loss, there would be consideration for a dose reduction or discontinuation of medication. Inquired whether the facility informed them of the times when the resident is not alert. On the afternoon of 5/4/17, the APRN reported Resident #35's medication will be reviewed with the physician and adjusted. The facility failed to monitor Resident #35 for adverse consequences while administering two medications ([MEDICATION NAME] and [MEDICATION NAME]) with identified adverse consequences of lethargy, sedation, dizziness and drowsiness. The resident also receives [MEDICATION NAME] (antidepressant) which also includes side effects of nausea, sleepiness, weakness, dizziness, feeling anxious and trouble sleeping. The observations of the resident during the survey found the resident asleep and difficult to rouse. The record review notes the resident had some weight loss and frequent falls which may be side effects of the medications.",2020-09-01
708,HALE OLA KINO,125047,"1314 KALAKAUA AVENUE, 2ND FLOOR",HONOLULU,HI,96826,2017-05-05,334,D,0,1,WIHG11,"Based on record review and interview with staff member, the facility failed to ensure 1 (Resident #14) of 5 residents or resident's representative receives education regarding the benefits and potential side effects of the pneumococcal immunization. Finding includes: On the morning of 5/2/17 a record review for Resident #14 was done. The review found a signed Informed Consent for pneumococcal vaccination with handwritten note that verbal consent was obtained from the resident's representative on 9/13/16 at 1600 and the representative will come to the facility to sign the consent. The box for acknowledging educational information on the pneumococcal vaccination was received and reviewed was not checked. On 5/2/17 at 3:00 P.M. an interview was conducted with Staff Member #2. The staff member reported the pneumococcal vaccine was administered on 9/13/16. The staff member confirmed there is no documentation that education was provided to the resident's representative before obtaining the consent and the administration of the vaccine. A review of the facility's policy and procedure entitled Immunization of Residents notes the following: The resident/family representative will receive education and be informed about the benefits and risks of immunizations before offering the vaccine. The facility failed to ensure a resident/resident's representative received education regarding the benefits and potential side effects of the pneumococcal immunization before administering the immunization.",2020-09-01
709,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2017-02-24,241,D,0,1,B8GN11,"Based on observation and staff interview, the facility failed to ensure 1 (Resident #85) of 26 residents in the Stage 2 sample received care in a manner that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. Findings include: On 2/23/17 at 8:00 [NAME]M. observed Resident #85 seated in the dining room eating breakfast with three other female residents at the table. Staff Member #59 brought the resident's medications to the table. While standing at the threshold to the dining room, Staff Member #59 was overheard saying this is your fiber so you don't get constipated. On 2/24/17 at 9:35 [NAME]M. interview was done with Staff Members #145 and #144. The staff members acknowledged Staff Member #59 discussing the resident's issue with constipation is not dignified or respectful.",2020-09-01
710,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2017-02-24,253,E,0,1,B8GN11,"Based on observation and staff interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. Findings include: 1) On 02/21/2017 at 08:03 AM during the Initial Tour on the Pikake unit, observed the Shower Room with dark gray grout throughout the tiled floor and near the wall. When leaving the Pikake unit, Shower Room surveyor stepped into the hallway and observed the wooden blinds in the alcove area that were disarrayed and very dusty. On 02/21/2017 at 8:48 AM while finishing up the Initial Tour on Maile unit it was observed that the Shower Room and Toilet Room both had dark gray patches of grout throughout the tiled floor. There was chipped tile in the Toilet Room tiled floor and baseboard. There was chipped paint on the metal poles that separated the toilet stalls in the Maile unit Toilet Room. There were orange colored drip marks on the tiles below one of the sinks. On 02/23/2017 at 1:19 PM while doing a walk through on the Pikake unit with Staff Member (SM) #33 he acknowledged the dark gray patches of grout on the tiled floor. When asked how long he has been working in his position he stated just under a year. SM #147 was present for this walk through and explained that the facility is in the process of remodeling the shower and toilet rooms but they are waiting for new bids to come in as the estimated cost for the changes had been underestimated last year. After leaving the Pikake Shower Room SM#33 acknowledged the dirty blinds, dirty jalousies and screens stating We're not doing what we need to do. We need to do better. Walk through continued over to the Ilima unit where SM #33 acknowledged the floor in the Ilima Shower Room was noted to have dark gray patches of grout as well. Walk through continued over to the Maile unit shower and toilet room. As SM #33 and surveyor walked into the Toilet Room he acknowledged the unused trash bags hanging from the wall mounted gloves rack. SM #33 acknowledged dark gray patches of grout in the tiled floor and broken tile and backboard in the Toilet Room. On 02/23/2017 at 2:06 PM did a walk through on the Maile unit with SM #41 and he acknowledged the railing in the hallway near the nurses station is missing paint that has peeled or chipped off. He was also able to show surveyor where tile in the Maile Toilet Room was chipped. The facility did not maintain sanitary toilet and shower rooms. 2) Observation on 2/21/17 at 9:28 [NAME]M. found a dead cockroach on the floor by the right side of Resident #59's bed. The cockroach was smashed and there was a black smattering of substance next to the dead cockroach on the floor. Subsequent observations at 9:28 [NAME]M. and 11:51 [NAME]M. found the dead cockroach still on the floor. Concurrent observation was done with Staff Member #121 at 2:11 P.M. The staff member confirmed the presence of the dead cockroach on the floor. Inquired when are the residents' rooms cleaned, the staff member replied the rooms are cleaned after the staff member completes the cleaning of the dining room after lunch. Observation of the dining room found no staff member present and the room was cleared of dishes, food and the tables were wiped. On 2/23/17 at 12:46 P.M. an interview was done with Staff Member #33. The staff member reported the shift for housekeeping staff begins at 11:00 [NAME]M. and ends at 7:30 P.M. The staff member further reported the housekeeping staff will start with room cleaning when they arrive on their shift. The staff member explained that a family member brought in a box and the facility staff were not aware of and believes the cockroach came in with the box. The staff member confirmed seeing the dead cockroach on the floor, commenting that somebody flattened the cockroach and it was not picked up. Upon query, Staff Member #33 was not sure what the black substance was next to the dead roach.",2020-09-01
711,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2017-02-24,278,D,0,1,B8GN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to accurately assess 1 (Resident #59) of 18 sampled residents of the 21 resident who were included in the Stage 2 review. Finding includes: On the morning of 2/23/17 a record review was done for Resident #59. Resident #59 was admitted to the facility on [DATE] from home. The admission [DIAGNOSES REDACTED]. Further review found a progress note for 10/22/16 documenting the resident had a witnessed fall in the dining room. The resident was at the threshold of the dining room when a resident ambulating in front of Resident #59 changed direction, turned and bumped Resident #59. Resident #59 fell to the floor. Subsequently, Resident #59 had a fall on 2/18/17, the resident was in the dining room, seated on a stool and fell while attempting to stand. A review of the resident's quarterly Resident Assessment Instrument (RAI) with assessment reference date (ARD) of 1/20/17 found at J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment, Resident #59 was coded as not having a fall since admission or the prior assessment. The prior quarterly RAI was completed on 10/20/16 (ARD). On 2/23/17 at 12:09 P.M. an interview and concurrent review of Resident #59's record was done with Staff Member #44. The staff member confirmed the resident had a fall on 10/22/16 and the quarterly assessment of 1/20/17 did not indicate the resident had a fall during this quarterly. The staff member confirmed the quarterly RAI with ARD of 1/20/17 should have been coded to reflect the fall of 10/22/16. The staff member stated the RAI will be modified.",2020-09-01
712,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2017-02-24,280,D,0,1,B8GN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview and facility policy review, the facility failed to provide appropriate services/interventions to treat pressure ulcers. Findings include: Cross reference to F314 for Resident #80. Resident #80 was admitted on [DATE] for hospice with [DIAGNOSES REDACTED]. In (MONTH) (YEAR), Resident #80 was taken off hospice for improvement in the pressure ulcer and weight gain. During the survey period, 2/21/17-2/24/17, Resident #80's stage 4 pressure ulcer was not yet healed. On the morning of 2/22/17, a review of Resident #80's care plans found one for Stage IV pressure ulcer. The goal stated, Pressure ulcers will begin to show signs of healing through next review (3/17). Interventions included: Treatment as ordered by wound rounds RN and MD; Air pressure mattress to bed; Extensive assistance with bed mobility; Pain medication; Treatment orders; and Wound specialist consultation. An interview with Staff #s 144 and 145 found that Resident #80's family and physician were noting she was on Comfort measures only. The care plan did not reflect Resident #80's current status and the interventions maintained the facility would work towards healing the wound rather than comfort measures. The facility failed to accurately reflect the current status and goals for Resident #80 in her pressure ulcer care plan.",2020-09-01
713,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2017-02-24,314,G,0,1,B8GN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview and facility policy review, the facility failed to provide the necessary services and interventions to treat pressure ulcers for 2 of 3 (Resident #s 80 & 19) residents reviewed. Findings include: 1) Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the survey period (2/21/17 - 2/24/17) it was noted that Resident #80's stage 4 pressure ulcer made very little progress and had not yet healed. Observation of Resident #80 on the morning of 2/21/17 at approximately 10:30 [NAME]M. found her in the hallway in a reclined Geri chair in front of a TV. Her eyes were closed and she was dressed in personal clothing and had blankets on her lap and chest. Resident #80 was sitting on a blue cushion which was placed on the seat of her Geri chair. At approximately 10:45 [NAME]M. a Certified Nurses Aide (CNA) moved Resident #80 from the hallway to the Activity Room. Observation of Resident #80 during the lunch hour on 2/22/17 at approximately 12:45 P.M. found her sitting on the blue cushion in her Geri chair in the dining room. The resident's daughter was feeding her lunch. The resident's daughter stated that Resident #80 does not eat very well and therefore she comes during lunch to assist her. Observation of Resident #80 on the morning of 2/23/17 at approximately 11:30 [NAME]M. found her in the Activity Room seated on the blue cushion in her Geri chair. Her eyes were closed. Observation of Resident #80 during the lunch hour of 2/23/17 found the resident's daughter with her in the dining room, feeding her. The resident was again sitting on the blue cushion on the Geri chair. Observation of Resident #80 on the afternoon of 2/23/17 at approximately 1:30 P.M. found her in the Activity Room seated on the blue cushion in her Geri chair. She had a lap blanket which she picked at, causing the blanket to bunch up in the center of her lap. During the observation period, the resident remained up in the Geri chair and did not get frequent, hourly repositioning. An interview of Staff #144 on the afternoon of 2/23/17 at approximately 2:00 P.M. revealed the blue cushion was brought in by the family for positioning of her upper body. Staff #144 stated that Resident #80 was supposed to sit on a pressure reducing cushion, which was under the blue cushion during the above observations. A medical record review for Resident #80 on the afternoon of 2/22/17 found she was admitted to the facility on hospice for a stage 4 pressure ulcer and adult failure to thrive on 1/5/15. In (MONTH) (YEAR), Resident #80 was taken off hospice for improvement of the pressure ulcer and she also gained weight. On 9/11/15, laboratory blood tests were conducted indicating: low [MEDICATION NAME]; low red blood cells; low hemoglobin and hematocrit; and high glucose. Since (MONTH) (YEAR) no further laboratory blood tests were conducted. An interview of Staff #145 on the afternoon of 2/23/17 at approximately 2:00 P.M. revealed no further blood tests were done because Resident #80 was on Comfort Care. Resident #80 was seen by her physician in (MONTH) (YEAR) when the physician noted, left a message for the wound nurse to discuss possible use of [MEDICATION NAME] for wound odor. The Nurse Practitioner, NP, was the provider who visited next on 4/10/16 when she noted that Resident #80's pressure ulcer was, Chronic with very poor healing and foul smell at times. The plan was to continue with local care and prevention [MEDICAL CONDITION]. The physician then followed up on 4/13/16 when she stated the pressure ulcer was, Stable and to continue wound care. A physician did not see the resident again until 10/24/16, when medical care was transferred to another physician due to change of insurance. On 10/24/16, the physician noted, Stage four to coccyx with red base. Wound care. Expect prolonged recovery. The next physician's visit was on 12/22/16 when he noted, Wound over coccyx area with beefy red base. Plan was topical wound care. The physician again visited on 1/9/17 when he noted, Sacral wound red. The plan was for pain management. A review of Resident #80's weekly wound assessments found minimal progress from the 2/7/16 to the 2/21/17 assessments. On 2/7/16, the assessment noted Resident #80's pressure ulcer treatment was: Clean with wound cleanser, lightly pack with calcium alginate, pack with wet to dry gauze, cover with foam dressing or abd pad & secure with tape every other day and as needed. The 2/7/16 assessment noted the wound measured 1.4 cm L x 3.8 cm W x 0.7 cm Depth. The 2/7/16 assessment noted undermining measuring: 2.3 cm @ 3 o'clock; 1.6 cm @ 7 o'clock; 2.4 cm @ 9 o'clock; and 3.2 cm @ 12 o'clock. The wound edges were macerated and fragile; Odorous; Painful; Heavy serosanguineous drainage; and the status did not change. The most current assessment dated [DATE] found the pressure ulcer treatment was: Clean with normal saline, pack with triple helix collagen, pack opening with normal saline gauze to maintain wound opening, cover with foam dressing, change every day and as needed. The 2/21/17 assessment noted the wound measured 2.0 cm (1.4 on 2/16) L x 0.5 cm (3.8 on 2/16) W x 0.8 cm (0.7 on 2/16) Depth. The 2/21/17 assessment noted undermining measuring: 0.5 cm @ 6 o'clock; 1.0 cm (3.2 on 2/16) @ 12 o'clock; 0.2 cm (2.3 on 2/16) @ 3 o'clock; 2.3 cm (2.4 on 2/16) @ 9 o'clock; 1.8 cm (1.6 on 2/16) @ 7 o'clock; and 2.6 cm @ 11 o'clock. The wound edges were white, rubbery, thick, macerated tissue with surrounding skin intact; Foul odor; No pain; A review of Resident #80's care plans found one for Stage IV pressure ulcer. The goal stated, Pressure ulcers will begin to show signs of healing through next review (3/17). Interventions included, 11/23/16 Wound specialist consultation. An interview of Staff #50 on the afternoon of 2/22/17 at approximately 2:00 P.M. revealed she worked with a Wound Consultant for oversight of wound care in the facility. Staff #50 noted that Resident #80 has made very little progress in the healing of the pressure ulcer. Staff #50 further noted the resident stayed up in her Geri chair most of the day per the family's request. Staff #50 stated that the Wound Consultant thinks that the tunneling and undermining of Resident #80's pressure ulcer is scarred. She stated that the scarring therefore inhibits the healing of the wound. Staff #50 stated that Resident #80 may benefit from debridement. She further noted the resident has not been referred for consultation/debridement of the wound. Staff #50 noted that Resident #80 does not feel pain when the pressure ulcer dressing is changed, possibly due to [MEDICAL CONDITION]. Currently, Staff #50 noted the opening of Resident #80's wound has decreased in size but the tunneling and undermining was still present. Staff #50 stated the treatment changed on 2/21/17 to include packing of the wound with wicking at the opening to avoid closure because of the continued presence of tunneling and undermining. Staff #50 was asked to provide notes from the Wound Consultant. Staff #50 stated the notes were not available in the electronic medical record and instead were kept in the emails of Staff #145. On the morning of 2/23/17 at approximately 8:30 [NAME]M., Staff #145 was asked to provide notes from the Wound Consultant. At approximately 10:30 [NAME]M., Staff #145 provided the consultant's Patient Order Sheets for 11/23/16, 12/19/16, 1/17/17, and 2/13/17. The Patient Order Sheet noted the wound characteristics (location, measurements) and the products used for dressing changes. It appeared like an invoice. One Wound Care Skin Integrity Evaluation form was included for 11/23/16 but was printed on the facility's stationary. On 2/23/17 at approximately 1:30 P.M. Staff #s 144 and 145 provided copies of the rest of the Wound Consultant's notes. The Wound Consultant's notes indicated the wound size, drainage, and recommended treatment. There was no mention of referral for debridement. On the afternoon of 2/23/17 at approximately 1:13 P.M. and 2:05 P.M., the Surveyor attempted to contact the facility's Wound Consultant and left a message for her. On the afternoon of 2/23/17 at approximately 2:30 P.M. Staff #144 informed the Surveyor that the Wound Consultant was fearful of speaking with the Surveyor. The Wound Consultant called the Surveyor back on 2/24/17 at approximately 8:23 [NAME]M. when she informed her that she was not a consultant for the facility. The Wound Consultant stated that she provided education and inservices to the facility. The Wound Consultant further noted that her company provided dressing supplies to the facility. The Wound Consultant noted that she didn't actually see Resident #80's wound and instead took the information documented by the facility staff and plugged that information in to order the necessary supplies. The role of the Wound Consultant stirred confusion. An interview of Staff #s 144 and 145 on the morning of 2/24/17 at approximately 8:00 [NAME]M. explained the goal for utilizing a Wound Consultant included having outside consultation for the wound care; determine resident's progress; and consider change in treatments. Staff #145 noted Resident #80's wound was slow healing and stated that the goal was not to totally heal the wound. Staff #145 then stated that Resident #80 was on Comfort Care and that the goals were pain management and keeping the wound clean. Staff #s 144 and 145 both stated that the family of Resident #80 wanted to keep her comfortable. On 2/24/17 at approximately 12:00 P.M., Staff #144 provided a copy of the facility's agreement with the Wound Consultant which confirmed her role to provide, wound care education, to include, but not limited to, wound care prevention, assessment, treatment plans, dressing change protocols and documentation pertaining to the wound care products (Consultant Agency) provides. During the survey period, 2/21/17-2/23/17, Resident #80 was observed on multiple occasions up in the Geri chair in the Activity room. An interview of Staff #116 on the afternoon of 2/23/17 at approximately 12:45 P.M. revealed Resident #80 was up in the Geri chair all day every day. She reported that the resident returned to her bed only when she felt tired. An interview of Staff #48 on the morning of 2/21/17 at approximately 10:45 [NAME]M. revealed Resident #80 was out in the Activity room all day per the family's preference. A review of the Interdisciplinary Team (IDT) meeting notes for Resident #80 on the morning of 2/24/17 revealed the resident's family did not attend any of the meetings over the past year. The IDT meeting on 12/15/16 noted, Per nursing, resident continues with Stage IV coccyx with new treatment added. Family did not attend the meeting. The IDT meeting on 9/28/16 noted, (Resident #80) continues with wound to sacrum, treatment applied daily as ordered. The family did not attend the meeting. The IDT meeting on 7/28/16 did not mention Resident #80's pressure ulcer. The family did not attend the meeting. The IDT meeting on 5/4/16 noted, Continues with stage IV pressure ulcer to sacrum. Treatment applies as ordered. (Resident) continues to utilize a Geri chair for comfort and to maintain her safety. The family did not attend the meeting. An IDT meeting for (MONTH) (YEAR) was not available at the time of survey. The facility was unable to provide documentation of discussions/meetings with Resident #80's family members which would demonstrate their desire to maintain the pressure ulcer by keeping it clean, free of infection and pain. Additionally, the facility was unable to provide documentation from the family indicating their preference for the resident to be out of bed all day in the Activity room. On the morning of 2/24/17, a review of the facility's policy titled, Pressure Ulcer Problem Identification and Treatment dated 7/22/05 noted, B. Clinicians can reasonably expect a clean pressure ulcer with adequate innervation and blood supply to show evidence of healing within 2 to 4 weeks. Failure to do so should prompt a re-evaluation of the plan of care, and evaluation of adherence to the plan, and a possible modification of the plan. For example, draw labs, check [MEDICATION NAME] level, suspect colonization of bacteria. The policy further noted, Sitting individuals should be repositioned at least every hour and should shift their weight every 15 minutes if possible. If hourly repositioning is not feasible, the individual should be returned to bed. An interview of Staff #149 on the afternoon of 2/23/17 revealed the care for Resident #80's pressure ulcer would depend on her overall condition. She stated that since the resident was older, it may not be feasible to do wound debridement. However, Staff #146 stated that her expectation was for staff to do routine, frequent repositioning. In summary, the facility failed to maintain the highest practicable well being for Resident #80's pressure ulcer based on her current condition with consideration and documentation of the facility's, resident's and/or family's goals and/or expectations. 2) Resident #19 was admitted to the facility on [DATE] from an acute hospital. A review of the resident's record on 2/21/17 at 2:00 P.M. found an admission note dated 11/9/16 with documentation of the following: right heel deep tissue injury 4 x 3 cm; left foot 2.5 x 3 cm; left foot base great toe 1 x 1 cm; Stage II healing ulcer; left center abdominal fold with 1 (one) cm skin tear; and coccyx area excoriation on left buttock 4 x 3 cm, center area with 1 (one) x 0.5 cm, right buttock 2 x 2 cm. A record review on the morning of 2/22/17 found a comprehensive Resident Assessment Instrument with an assessment reference date of 11/15/16 which documents in Section M. Skin Conditions, Resident #19 is noted to have two Stage 2 pressure ulcers which were present on admission. Further review found documentation of the facility's Weekly Skin Rounds. An assessment was done on 11/16/16 which notes a Stage II pressure ulcer to coccyx and a Stage II pressure ulcer to the left buttock. The ulcer to the coccyx measured 0.5 x 0.5 with no odor, pain or drainage. The ulcer to the left buttock measured 0.8 x 0.4 cm. with no odor, pain or drainage. On 2/22/17 at 1:30 P.M. an interview and concurrent record review was done with Staff Member #50. The staff member confirmed Resident #59 was admitted on [DATE] with two Stage II pressure ulcers, one to the coccyx and one to the left buttock. At the time of admission, the resident was a hospice recipient. A review of the physician's orders [REDACTED]. A review of the resident's care plan found an episodic care plan, created 11/10/16 with the goal to resolve the Stage II pressure ulcers over 21 days. The interventions included the following: apply sensi-care as ordered; turn resident Q1 hour to prevent further injury; update physician if unresolved; weekly skin assessment; and weekly wound rounds. Further review found a care plan to address no further pressure related skin breakdown through the next review. The interventions include: extensive assistance with bed mobility; hospice to provide air mattress; provide incontinent care, PRN; and weekly skin assessment by the CN. Further review with Staff Member #50 found no documentation of a skin assessment on admission (11/9/16), the first documentation was dated 11/16/16, a week after the resident's admission. There was no further documentation of subsequent weekly skin assessments to determine the status of the resident's pressure ulcers prior to discharge on 12/5/16. The staff member assisted in the review of Resident #59's treatment/medication administration of applying sensi-care three times a day; there is documentation the resident received sensi-care as ordered with a start date of 11/17/16. Interview with Staff Member #50 confirmed Resident #59 was admitted with two Stage II pressure ulcers without admission orders [REDACTED]. The staff member was queried whether the facility would provide treatment for [REDACTED]. The staff member replied for residents on hospice with pressure ulcers, treatment will be provided. A review of the facility's policy and procedure related to pressure ulcers was provided on 2/24/17 at 9:30 [NAME]M. The procedure for Pressure Reduction & Prevention Program includes the Pressure Ulcer Risk Assessment tool will be used upon admission . Although Resident #59's admission notes documented the presence of Stage II pressure ulcers, the facility failed to assess the resident's skin integrity upon admission; therefore, delaying treatment of [REDACTED].",2020-09-01
714,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2017-02-24,323,D,0,1,B8GN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff members, the facility failed to provide assistive devices to prevent accidents for 1 (Resident #59) of 2 residents sampled for accidents of 26 residents in the Stage 2 sample. Findings include: A record review was done on 2/23/17 at 7:35 [NAME]M. Resident #59 was admitted to the facility from home on 8/26/13 with the following Diagnoses: [REDACTED]. On 2/22/17 at 12:30 P.M. observed Resident #59 seated in a chair at a table eating his lunch in the dining room. There was no chair alarm attached to his chair. Subsequent observation at 2:30 P.M. found the resident sitting on a chair in the activity room holding a baby doll. No chair alarm was observed. On 2/23/17 at 7:50 [NAME]M. Resident #59 was observed in the dining room having breakfast. He was observed to attempt to stand, then Resident #59 stood up at the table, he walked to the middle of the room where he was met by Staff Member #59. The resident was redirected back to his seat. An alarm did not sound at this time and observation found no chair alarm was attached. Interview with Staff Member #73 was done on 2/21/17 at 11:35 [NAME]M., the staff member reported Resident #59 had a fall on 2/18/17. The resident was sitting on a stool and when he attempted to stand, fell on his buttocks. He reportedly had an abrasion to the right knee. Further record review on the morning of 2/23/17 found a progress note dated 2/18/17 regarding Resident #59's fall. The resident's fall was witnessed, the resident was in the dining room when a staff member observed the resident standing and while enroute to the resident, he lost his balance and fell to the floor, hitting his buttocks. On 2/23/17 at 7:35 [NAME]M. a record review found a progress note of 10/22/16 documenting Resident #59 had a witnessed fall in the dining room. Resident #59 ambulated to the dining room and while standing at the threshold a resident in front of him abruptly changed direction and bumped into Resident #59. Resident #59 stumbled backward and collapsed in a heap to the floor rather slowly. Further documentation notes the assigned Certified Nurse Aide (CNA) was assisting another resident and the other CNA was on dinner break. A review of the resident's care plan identified the goal for the resident to demonstrate the ability to ambulate/transfer without fall related injuries over the next 90 day period (revised 4/17). Interventions included: ambulate with extensive assist of 1-2 staff; footwear will fit properly and have non-skid soles; keep areas free of obstructions to reduce the risk of falls or injury; offer and assist with toileting routinely; use chair sensor alarm due to resident standing unassisted; assist resident to dining area first; and frequent visual observations. On 2/23/17 at 9:26 [NAME]M. Staff Member #81 was asked whether Resident #59 has a chair alarm, the staff member replied that he/she didn't think the resident has a chair alarm. Interview was done with Staff Member #121, the staff member checked the resident's care plan (kardex), concurrent review of the resident's record found the care plan specified a bed sensor alarm. At 9:29 [NAME]M. concurrent observation was done with Staff Member #81, the staff member placed her hands under the resident's sheets and replied the resident does not have a bed sensor alarm. On 2/23/17 at 12:56 P.M. an interview was done with Staff Member #59. The staff member reported that is is unclear why Resident #59 would have a care plan for a bed alarm as the resident stays in bed and has not fallen out of bed. The staff member further reported a chair alarm may be helpful; however, does not feel it is needed as staff members always keep the resident in the line of sight. The facility failed to ensure Resident #59's interventions identified in the plan of care (chair sensor alarm) was consistent with the information in the direct care staff's kardex (bed sensor alarm). The facility also failed to implement interventions for fall prevention, chair sensor alarm and/or bed sensor alarm.",2020-09-01
715,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2017-02-24,387,D,0,1,B8GN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to ensure a physician visited residents every 60 days for 1 of 26 residents, Resident #80, reviewed in the stage 2 sample. Findings include: A medical record review for Resident #80 on the morning of 2/23/17 revealed that Resident #80 was admitted to the facility on [DATE]. A review of physician's visits over the past year found she was seen by her physician on the following dates: 12/2015; 4/13/16; 10/24/16; 12/22/16 and 1/9/17. From 12/2015 she wasn't seen again until 4/13/16 (4 months span). From 4/13/16 she wasn't seen again until 10/24/16 (6 months span). The facility failed to ensure a physician saw Resident #80 at least every 60 days.",2020-09-01
716,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2017-02-24,441,F,0,1,B8GN11,"Based on observation and staff interview the facility failed to maintain an infection control program to control, to the extent possible, the onset and spread of infection within the facility by providing written standards, policies, and procedures to the Housekeeping and Rehab Unit to be followed to prevent spread of infections. Findings include: 1) On 02/24/2017 at 8:24 AM met with Staff Member (SM) #33. Surveyor asked SM #33 what the facility's policies are for infection prevention/control when laundering linens and he gave surveyor a binder of Infection Control policies that were dated from 1999. SM #33 was unable to tell surveyor where he would get the updated Infection Control policies for the facility. SM #33 was not able to explain the procedure to prevent the spread of infection while laundering facility linens. SM #33 denied knowing what the manufacturer's recommendations are for the use of the washer and dryer at the facility. 2) On 02/24/2017 at 08:52 AM met with SM #145 and when asked how everyone has access to the facility's Infection Control policies she stated that each department has their own binder with the Infection Control policies that are written by the facility's corporate office. The DON was not aware that housekeeping did not have an updated binder on Infection Control policies for the facility. 3) On 02/24/2017 at 9:39 AM Surveyor asked SM #148 if he would ever bring in a resident who was positive for C.diff into the rehab unit to work with the PT and he stated that he would. After he saw surveyor's expression he clarified that he would if staff cleared the resident. When asked where the binder with the infection control policies for the facility was kept in his department SM #148 looked on the shelf and then stated he did not know where it was and asked a co-worker, SM #149 and she handed him a binder that was labeled MSDS. Surveyor looked inside of binder with SM #148 and there were no facility policies on infection control in the binder. The facility failed to provide written standards, policies, and procedures to the Housekeeping and Rehab Units to be followed to prevent the spread of infections.",2020-09-01
717,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2017-02-24,458,D,0,1,B8GN11,"Based on interview with staff member, the facility failed to ensure a multiple resident bedroom has at least 80 square feet per resident and a single resident room has at least 100 square feet. Findings include: 1) Room #1 is a single resident room on the[NAME]Ho'Olu unit. Room #1 is currently occupied by one resident. This room does not meet the requirement for 100 square feet for a single resident room. Room #1 is measured at 78 square feet. 2) Room #3 on the[NAME]Ho'Olu unit is occupied by three residents. This room does not meet the required footage for three residents, 80 square feet per resident. On 2/21/17 at 8:07 [NAME]M. the entrance conference was conducted with Staff Member #146. At this time, the staff member confirmed that there has been no changes to Room #1 and Room #3 on the[NAME]Ho'Olu unit. On 2/21/17 at 8:55 [NAME]M., the facility provided a copy of waiver request dated 3/22/16 to the State Agency in regard to the non-compliance withe the requirements for the square footage for Room #1 (single occupancy) and Room #3 (multiple occupancy).",2020-09-01
718,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2019-03-08,554,D,0,1,KNI111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to act timely to allow one Resident (R)14 of one, to exercise the right to self-administer pain medication after the interdisciplinary team (IDT) determined it was clinically appropriate. As a result of this deficient practice, R14 did not have access to pain medication when off site attending school which put R14 at potential risk of unnecessary pain. This deficient practice has the potential to affect other clinically appropriate residents who may want to exercise their right to self-administer medication. Findings Include: 0n 03/06/19 at 04:57 PM, during an interview with R14, he stated, I have long days at school and want to take my PRN (as needed) pain medication with me so I can take it if I need it. The Doctor agreed and already approved it last month. They evaluated me and that I knew the name of the medication and everything. I met with the Director of Nursing (DON) in her office. Asked what the medication was and R14 stated, [MEDICATION NAME] (pain medication). They told me that the insurance wouldn't cover another 30 pills and it was too early. I'm not sure what the delay is but think it's something with the pharmacy. On 03/07/19 at 07:31 AM, during an interview with DON, she stated, There's been some setbacks with R14's request. We asked the pharmacy to send packets of one or two tabs (tablets of pain medication [MEDICATION NAME]), rather than a package of 30 (how the medication is usually packaged). We did an assessment with R14 already. What we have been doing is medicating him prior to going to school. I followed up with the pharmacy and they said there was a misunderstanding. Whoever read the request how to package it (the pain medication), read it wrong and they did not send it correctly. I educated R14 already about side effects and he can verbalize understanding. He would report back to us when he returned from school to document if he took the medication. I'm going to follow up with potential options. If he needs it, we need to make sure he's not in pain. Goal was to start it this month. Review of R14's medical records revealed the following: 1.Medication order for pain was, [MEDICATION NAME] 30 mg (60 mg) tablet Every Four Hours . 2. 01/14/19 Nursing note entry: Resident verbalizing that his pain medication is not effective through longer periods. Resident leaves facility Monday through Thursday for classes at local community college around 0800 until 1400. Resident concerned that by 1200 he is already starting to feel pain and achiness start to build up in his body. Resident requesting to be able to take his PRN (as needed) narcotic with him to school and self-administer at the time due (scheduled PRN Q (every) 4 hours). Resident on a long acting pain medication as well as PRN immediately before leaving for school in the morning. Resident states it still doesn't manage his pain though the school day and he needs to take another pill but doesn't have it available while in school. Unit CN (Charge Nurse) updated on resident statements and to follow up with MD. Resident adamant that he would only take it when time was due. Resident agreeable to wait for a physical assessment and 1:1 with MD (Medical Doctor). 3. 01/29/19 a Self-Administration of medications consent and assessment form was signed by R14 and the DON. The form includes: informed consent, assessment of R14's cognitive, physical, and visual ability to self-administer, and determination of R14's ability to self-medicate. The form indicated, The Interdisciplinary Team has determined that: The resident can safely self-medicate and should be allowed to exercise this right. 4. 03/07/19 Nursing note, MD in facility. Gave new order: okay to take [MEDICATION NAME] packet (30 pills or less) to school with him due to reordering issue with pharmacy. Order carried out. 5. Reviewed the facility Admission Agreement, which included the statement, The Resident has the right to self-administer medications. 6. Reviewed facility policy, Self-administration by Resident. Policy statement reads, Residents who desire to self-administer medications are permitted to do so with a prescribers order and if the nursing care center's interdisciplinary team has determined that the practice would be safe, and the medications are appropriate for self-administration. On 01/14/19 R14 made a request to the facility to exercise his right to self-administer pain medication while he was off site at school. On 01/29/19 R14 was assessed, and IDT determined he could safely administer the medication. At the time of survey 03/07/19, the facility had not provided R14 with pain medication to self-adminster if needed while he was at school.",2020-09-01
719,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2019-03-08,636,D,0,1,KNI111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Resident assessment for one Resident (R)2 is more than 120 days overdue. Findings Include: Medical record for R2 reviewed. The Quarterly assessment dated [DATE] was found in the minimum data set (MDS) of the electronic medical record (EMR). The annual assessment for R2 was due on 01/15/19. Social service notes in the EMR dated 01/01/19 to 03/08/19 were reviewed. No documentation found to indicate the annual assessment was completed for R2. During an interview with the Administrator on 03/08/19 at 12:47 PM validated that the annual assessment was not completed, stating the MDS coordinator said its not done.",2020-09-01
720,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2019-03-08,638,E,0,1,KNI111,"Based on interview and record review (RR), the facility failed to have a system in place to complete timely Quarterly assessments for three residents (Resident (R)1, R3, and R4). The deficient practice of not completing timely assessments, using the Standardized Quarterly Review assessment tool put R1, R3, and R4 at risk of not being tracked and monitored for gradual change in their health and functional status. This deficient practice had the potential to affect all residents who are due to have their Standardized Quarterly Review assessment. Findings Include: 1. Review of R1's Minimum Data Set (MDS) revealed the last quarterly review assessment was dated 10/20/18. 2. Review of R3's MDS revealed the last quarterly review assessment was dated 10/20/18. 3. Review of R4's MDS revealed the last quarterly review assessment was dated 10/27/18. 4. During an interview with the Administrator on 03/08/19 at 12:47 PM, it was validated the quarterly review assessments had not yet been completed for R1, R3, and R4, and that the assessments were over due. The Standardized Quarterly Review assessment tool was not completed timely for R1, R3, and R4. This put R1, R3, and R4 at risk that gradual changes in functional and health status could potentially be missed and that care plans would not be reviewed/ revised to address any potential needs.",2020-09-01
721,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2019-03-08,655,E,0,1,KNI111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR), and interviews, the facility failed to develop a comprehensive care plan or baseline care plan for one Resident (R)120, and failed to develop adequate baseline care plans for two Resident's (R67 and R68). The facility also failed to provide a written summary of the baseline care plans to R67 and R68 or their representatives that included medications and services to be provided. As a result of the deficient practices, the residents (R120, R67, and R68), or their representatives were not adequately informed of the initial plan for delivery. This deficient practice had the potential to affect the other 11 new admissions. Findings Include: 1.R120 was admitted on [DATE] to facility. RR on 03/08/19 revealed that R120 did not have a comprehensive or baseline care plan initiated within 48 hours of admission. Interview at 08:30AM on 03/08/19 with Staff (S)86 confirmed that there was no care plan for R120. The facility failed to develop a comprehensive or baseline careplan for R120 that includes the instructions needed to provide effective and person-centered care of the resident 2. R68 did not receive a written summary of her baseline care plan dated 02/13/19 that would include the initial goals, a summary of her medications and dietary instructions, and any services and treatments to be administered by the facility and personnel acting on behalf of the facility. During an initial observation and interview with R68 on 03/06/19 at 01:04 PM, stated she did not receive a written summary of her care plan after she was admitted to the facility on [DATE]. R68's baseline care plan dated 02/13/19 was reviewed and included the following interventions: Improve functional decline to prior status; achieve optimal continence; achieve discharge as planned; prevent/ heal pressure injuries; experience less pain, and resolve infection. The social services and nurses notes, dated 02/13/19 in the electronic medical record (EMR) were reviewed. No documentation was found to indicate a written summary of the baseline care plan was provided to R68. During an interview on 03/07/19 at 10:45 AM, the Social Worker (SW) stated the written summary of R68's baseline care plan was not provided to the resident or her family. During an interview on 03/07/19 at 04:45 PM, the Chief Nursing Officer validated that the family/ representative did not receive a written summary of the baseline care plan. 3. R67 was a [AGE] year-old admitted to the facility on [DATE] for short term rehabilitation due to deconditioning and weakness secondary to hospitalization for fall. R67 had a [DIAGNOSES REDACTED]. R67 had a hard-cervical neck collar in place 24/7 and had an order to wear a [MEDICATION NAME] brace while out of bed. R67 has a PEG tube (flexible feeding tube placed in the abdomen) for nutrition due to dysphasia (difficulty swallowing). R67 had MEDICATION ORDERS FOR [REDACTED] RR revealed a Baseline Care Plan for R67 dated 02/14/19. The following initial goals were established: Improve Functional decline to prior status, Achieve discharged as planned, Prevent/Heal pressure injuries, Activities as desired until discharged achieved, Psychosocial Well-being, No injuries/falls, and No complications to Feeding tube. There were no goals identified for Pain Management or Bowel. There were no interventions documented on this care plan for the goals related to Functional/ADL, Pressure injury/Skin at Risk, or Feeding tube. At the bottom of the Baseline Care Plan was a statement, Medication orders, treatment orders and Kardex are considered elements of this baseline care and are available upon request. On 03/07/19 at 03:58 PM conducted an interview and record review of R67's baseline care plan with Social Service (SS)1. Asked who provides the resident and/or representative with a written summary of the baseline care plan, and SS1 replied, Social Service gives them a copy when they give them the admission packet. Asked if SS provides a summary of medications and services/treatments to be recieved, and SS1 replied, No, but nursing might give that to them. Asked SS1 to provide documentation that a summary of the baseline care plan as given to R67, and she stated, We don't document specifically that we give it to them. We just do it as part of the admission process. On 03/08/19 at 11:00 AM during interview with DON, asked what the process was for baseline care plans. DON stated, Social Services said they did give the resident (R67) a copy of the baseline care plan. Asked if the nursing staff gave the resident and/or representative a copy of the medication orders, therapy orders and Kardex, and DON replied, No, we have not been doing that. We would provide them if requested. Asked if R67 had received a written summary of medications, services and treatments, and DON stated, No, we did not give that information to him. Reviewed Facility Policy titled Baseline Care Plans updated 02/15/18, which states, The baseline plan of care includes the .initial intake care plan additionally the medication profile, the treatment profile and the KARDEX are considered part of the baseline plan of care.The community will provide the resident/guest and their representative a written summary of the baseline care plan The baseline care plan will include at a minimum: a. Initial goals for the resident. b. Summary of resident's /guests medications c. Summary of resident/guests dietary instructions d. Services and treatments to be provided and personnel acting on behalf of community. The facility did not have evidence that a summary of the baseline care plan was provided to R67. The baseline care plan summary provided to R67 did not include current medications or services and treatments to be provided and did not identify interventions for all goals. The baseline care plan did not effectively ensure that R67 was informed of the initial plan for delivery of care, and ensure his immediate health care needs would be met.",2020-09-01
722,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2019-03-08,657,D,0,1,KNI111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to evaluate the effectiveness of one Resident's (R)32's comprehensive care plan and revise the plan of care (P[NAME]) as needed. As a result of this deficiency, R32 pulled out his gastrostomy tube (a gastrostomy tube (also called a [DEVICE]) is a tube inserted through the abdomen that delivers nutrition directly to the stomach) five times since (YEAR). This increased the risk for infection, and other complications related to [DEVICE]s and [DEVICE] dislodgement. Findings Include: 1. R32 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R32 had a [DEVICE] in place for all nutrition. R32 pulled out his [DEVICE] requiring transport to the hospital for replacement on 5 occasions (02/18, 05/18, 06/18, 07/18, and 03/06/19). 2. R32's P[NAME] goal for the [DEVICE] was to have no complication with [DEVICE] through next review. (05/19). The intervention in the P[NAME] was: Abdominal binder in place d/t hx (due to history) of pulling on [DEVICE]. The abdominal binder used to hold the [DEVICE] in place has been used since 2014. 3. The intervention of the abdominal binder alone, was not effective. There was lack of sufficient evidence that the interdiscipinary team (IDT) reviewed and revised the P[NAME] to meet R32's needs. There were no additional interventions added to the P[NAME] after any of the times R32 pulled the [DEVICE] out. 4. On 03/08/19 at 10:57AM during interview with Director of Nursing (DON), asked if she was able to provide documentation the facility reassessed R32's P[NAME] to prevent future dislodgement of the [DEVICE]. DON stated, I made a note in the record this morning. Plan is to contact the daughter and I tried to reach out to her today. We will reevaluate alternatives. 5. The facility was not able to produce the incident reports written for each event when R32 pulled out his [DEVICE], and confirmed they had not evaluated the specific details/circumstances of the events to be able to identify any specific trends or root cause of R32 pulling out his [DEVICE]. 6. Cross reference tag 693 (Tube feeding Management). The facility did not ensure that the appropriate treatment and services were provided to prevent complications related to R32's [DEVICE]. The facility did not take steps to look at alternatives / strategies to prevent R 32 from pulling out his [DEVICE] multiple times, which put him at risk for potential complications.",2020-09-01
723,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2019-03-08,693,D,0,1,KNI111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review (RR) the facility failed to provide the appropriate care and services to one Resident(R) 32 to prevent complications of a gastrostomy tube (a gastrostomy tube (also called a [DEVICE]) is a tube inserted through the abdomen that delivers nutrition directly to the stomach). As a result of this deficient practice, R32 pulled out his [DEVICE] multiple times which put him at increased risk for infection, and other complications related to [DEVICE]s and [DEVICE] dislodgement. Findings Include: R32 is a [AGE] year-old who was admitted to facility on 08/22/14. His [DIAGNOSES REDACTED]. The Minimal Data Set (MDS) assessment dated [DATE] indicates R32's cognitive skills are severely impaired, has memory problems and sometimes understands-responds to simple direct communication. R32 is fed and receives all nutrition through a [DEVICE]. Record review (RR) revealed the following: 1. R32 pulled out his [DEVICE] four times in (YEAR) (02/18, 05/18, 06/18, 07/18) and again on the evening of 03/06/19. 2. R32's Plan of Care (P[NAME]) goal for [DEVICE] was to have no complication with [DEVICE] through next review. (05/19). The only documented interventions related to [DEVICE] dislodgement was, Abdominal binder in place d/t hx (due to history) of pulling on [DEVICE], and Assess [DEVICE] site to ensure placement d/t hx of pulling [DEVICE] out. The abdominal binder had been used since 2014. R32's P[NAME] had not been revised to include any additional interventions to prevent future incidences of R32 pulling out the [DEVICE]. 3. 03/06/19 09:46 PM clinical notes entered: Resident (R32) being administered his PM (evening) feeding. CNA went into the room to check on resident and discovered that [DEVICE] had been removed by the resident. A dry dressing was placed over the abdominal opening. Abdominal binder was in place per order when resident was receiving feeding. order to send to hospital to have tube reinserted. R32 was transported to a hospital for replacement of the [DEVICE] and subsequently returned to the facility 03/07/18 at 01:30 AM. 4. 03/08/19 06:41AM clinical notes entered by Director of Nursing (DON): .Due to recent self removal of GT ([DEVICE]) and history, would like to revisit P[NAME] and explore if any other options available. Per previous conversations family's wishes to keep GT in place due to it serving as resident's primary route of nutrition. Abdominal binder provided by family and has been in use since 2014. Will monitor and attempt to set up formal care plan meeting as needed. Requested medical records for evidence that the facility and Interdisciplinary Team (IDT) addressed the issue of R32 pulling his [DEVICE] out. The following documents were provided by the facility: 1. Consent for restraint use, signed 08/22/14 for use of the abdominal binder. 2. Care conference summary dated 10/04/18. Summary noted, Restraint reasons/ benefits: Abdominal binder due to resident has behaviors of pulling [DEVICE] out. There was no documentation in the area provided for problems/comments identified by residents/staff/family and follow-up recommendations. 3. Care conference summary dated 01/10/19. Summary did not have any documentation related to strategies or discussion related to prevention of [DEVICE] dislodgement. On 03/07/19 at 02:15 PM requested to see how R32's [DEVICE] was secured. Observed velcro abdominal binder in place. Abdominal binder was released by RN to visualize and demonstrate how the [DEVICE] was held in place by a small velcro strap inside the binder. On 03/08/19 07:21 AM, RN73 informed surveyor, We won't be able to do R32's tube feeding and dressing change this morning. During his shower, it ([DEVICE]) was noted to be loose and coming out. We will be sending him out to have them look at it. Asked RN73 what the circumstances were and if R32 pulled the tube out. RN73 replied, No, it is probably something to do with the placement of the new tube yesterday. Asked RN73 if she has been present any of the times R32 pulled out his [DEVICE], and she replied, Once, but I haven't been here that long. Asked if there had been any discussions about how to prevent future events, RN73 stated, 'the binder (abdominal) was probably the least restrictive thing we can do. Confirmed with facility that internal incident reports should have been initiated each time an adverse event occurred with a [DEVICE]. Requested incident reports for the times R32 pulled out the [DEVICE]. Facility was unable to provide the incident reports at survey time for when R32 pulled out the [DEVICE] in (YEAR). On 03/08/19 at 10:57AM during interview with DON, asked if able to provide any additional documentation the facility reassessed P[NAME] to prevent future dislodgement of R32's [DEVICE]. DON stated, No. I made a note in the record this morning. Plan is to contact the daughter and I tried to reach out to her today. We will reevaluate alternatives. The facility did not provide evidence that the incident reports were reviewed when R32 pulled out his [DEVICE] in (YEAR) (02/18, 05/18, 06/18 and 07/18) to identify root cause, or that the IDT discussed risk reduction strategies to prevent future events. Dislodgement of [DEVICE]s is a serious event and could put R32 at risk for infection and other potential complications.",2020-09-01
724,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2019-03-08,842,D,0,1,KNI111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to accurately document R8's end of life wishes and code status. The Physicians order for life sustaining treatment (POLST) states Do not resuscitate although she is listed as a full code. Findings Include: On 03/05/19 at 10:30 AM during an observation, R8 was lying in bed awake with her eyes open and unresponsive to voice. On 03/05/19 at 10:38 AM during an interview with staff, (S)59 stated that R8 use to be better and was able to talk. Something happened to her and when she came back to the facility she was more unresponsive. On 03/05/19 at 04:00 PM during an interview with R8's husband (F1), he stated two weeks ago the nurse called me to come see my wife because she was not doing well. When I got to the facility the nurses said they were going to let her go because she is on hospice. I was very upset since I didn't know this, so I called an ambulance for her and she went to the hospital. I told the nurses to change her code status to full code and take her off hospice. Medical records revealed: 1. A physician's orders [REDACTED]. No artificial nutrition by tube. 2. Physician order [REDACTED]. During an interview with the social worker (SW) on 03/07/19 at 08:20 AM stated R8's POLST should have been changed back to full code when she came back into the facility on [DATE], after hospitalization . R8 previously made the decision to be hospice because she was being sent out of the facility for wound care every week and decided she did not want to go to the wound care clinic anymore. R8 was given information about hospice and she made the decision to be on hospice and changed her POLST to DNAR. R8 was also offered information about advanced health care directives and declined. Before the last hospitalization she could speak and understand. R8's Brief Interview for Mental Status (BIMS) was 15, she was self-responsible, alert, and could make her own decisions. On 02/11/19 she was declining with a very low blood pressure. We called F1 to come in. F1 came and was upset she was on hospice and that no heroic measures were being taken to save her, so he called 911. R8 was able to verbalize her wishes to go to the hospital and was taken there by ambulance. F1 changed her code status to full code and signed an order to revoke her hospice. When R8 came back to the facility, her BIMS score had declined to 10 and she was unresponsive, so the decision maker would be F1. During a meeting with the Administrator and Director of Nursing (DON) on 03/07/19 at 09:43 AM, validated that R8's POLST was not updated at the time she was readmitted to the facility. If R8's condition declines, the facility staff will refer to the medical record and treat her as a full code per the Physicians orders dated 02/22/19.",2020-09-01
725,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2018-05-15,600,E,0,1,YF4Y11,"Based on Facility Reported Incident (FRI), staff interview, and record review, the facility failed to protect Residents#48 (R48), #223(R223) and #224 (R224) from preventable episodes of sexual abuse by Resident #221(R221) on 07/12/17, 07/17/17 and 08/07/17 respectively. Findings include: Per record review, the facility was aware of R221 sexual behavior as of 6/20/17 because of a care plan initiated at that time for R221 for grabbing staff on butt. R221's care plan interventions included Speak with wife/daughter when behaviors happen. and Update MD as indicated. On 07/12/17, R221 was found sucking on R48's fingers. On 7/13/17 R221's care plan for sexual behaviors was updated with the intervention Keep resident away from Female residents at all times. On 07/17/17 R221 was found rubbing R223's stomach, and on 08/07/17, R221 was reported to be fondling R224's breast. For both incidents, per interview with DON, she verbalized that she could not produce the documentation that the intervention of keeping resident away from female residents at all times was maintained, and therefore was not confident that the intervention was maintained and that is why those incidents occurred. The facility was aware of R221's sexual behavior prior to the consecutive incidents of sexual abuse. The facility had care planned for the behavior, and there were interventions in place to prevent the behavior, and the DON validated that incidents occurred because the intervention to keep resident away from female residents at all times was not maintained.",2020-09-01
726,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2018-05-15,623,D,0,1,YF4Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to notify resident's (R67) Power of Attorney (POA) and representative of the Office of the State Long-Term Care Ombudsman of R67's transfer to an acute hospital and the reason for the move in writing. Findings Include: During interview with POA on 05/09/18 at 04:22 PM stated that they thought R67 was admitted to an acute hospital in (MONTH) or (MONTH) (YEAR) for possible flu. On 05/11/18 at 08:57 AM reviewed R67's Electronic Medical Record (EMR) and found that he was transferred to an acute hospital on [DATE]-2/6/18 to have his Gastric Tube (GT) replaced. Interviewed staff (S32) who confirmed that R67 was not sent to the hospital for the flu, he was sent to have his GT replaced. On 05/14/18 at 04:30 PM interviewed staff (S99) and asked if R67's POA and the state's Long-Term Care Ombudsman were notified in writing of R67's transfer to an acute hospital on [DATE]. S99 stated that she would look for this information and let me know. On 05/14/18 at 04:54 PM S99 called and stated that she was not able to find copies of the notifications sent to the R67's POA and the state's ombudsman at that time but would have staff (S100) look for it on 05/15/18. S100 did not show or provide copies of letters to R67's POA or representative of the Office of the State Long-Term Care Ombudsman for R67's transfer to an acute hospital from 2/4/18-2/6/18.",2020-09-01
727,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2018-05-15,656,D,0,1,YF4Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview the facility failed to develop a comprehensive person-centered care plan for resident (R10) who is diagnosed with [REDACTED]. The deficient practice is that the R10 might not be receiving all of the care that she needs to manage [MEDICAL CONDITION] maintain safe and healthy blood pressures, monitor her medications and their side effects that are being used to treat her HTN. Findings Include: On 05/09/18 at 12:06 PM during resident interview, R10 stated that she takes Blood Pressure (BP) medication. Review of R10's Minimum Data Set, admission assessment, dated 3/1/2018 has hypertension checked off as an active diagnosis. On 05/11/18 at 04:46 PM review of R10's EMR found that she was admitted to the facility with the following [DIAGNOSES REDACTED]. Review of R10's medications found that she was taking [MEDICATION NAME] 10 mg 1 tab one time daily, losartan 100 mg one time daily, and [MEDICATION NAME] 100 mg two times daily. These medications are used to treat HTN. Review of R10's EMR Care Plan did not include a problem [MEDICAL CONDITION] interventions such as medications mentioned to control R10's BP. On 05/11/18 at 05:10 PM interviewed S32 who reviewed R10's CP, which was dated 2/24/18. S32 confirmed that this res does not have a CP in place for HTN.",2020-09-01
728,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2018-05-15,657,D,0,1,YF4Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and staff interview, the facility failed to review/revise the care plan for two residents (R52 and R321). Findings include: 1) Observation of R52 on the morning of 5/10/18 at 9:52 [NAME]M. found her seated in the Day Room participating in Activities. The resident was observed over a period of one hour and found her continually getting up out of her chair to wander around the unit and into her room. R52 did not have a chair sensor and/or clip alarm. Observation of R52 on the afternoon of 5/11/18 at 2:00 P.M. found her getting up out of her chair in the Day Room to wander around the unit and into her room. Again, R52 did not have a chair sensor and/or clip alarm. A tour of R52's room found she had a bed alarm. Interview of Staff 86 on the afternoon of 5/11/18 at 2:30 P.M. revealed R52 did not use a chair sensor and/or clip alarm. Observation of R52 on the afternoon of 5/14/18 found her wandering about the unit, getting in and out of a chair in the Day Room. R52 did not have a chair sensor and/or clip alarm in place. A medical record review for R52 found she was at high risk for falls and had experienced falls in the facility without major injuries. The facility developed a care plan for R52 for falls prevention. One intervention stated, Chair clip alarm replaced with chair sensor due to resident able to remove and is an elopement risk. An interview of Licensed Nurse (LN40) on the morning of 5/15/18 at 9:00 [NAME]M. revealed R52 did not have a chair and/or clip alarm. The LN40 was shown R52's care plan for falls which noted she had a chair sensor. The LN40 stated the care plan needed to be revised since she no longer had alarms in place. 2) Interview with R321 on 05/0918 at 11:53 AM revealed R321 had just returned to the facility on [DATE] from an acute care hospital. R321 stated she was admitted to the hospital for urinary tract infection [MEDICAL CONDITION] and pneumonia. R321 said the hospitalization may have been avoided if the facility staff were more attentive to her care. R321 stated sometimes it takes facility staff as long as 30 minutes to come and change her soiled brief. R321 said she was hospitalized not long ago for the same thing. A record review on 05/11/18 showed R321 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R321's Minimum Data Set (MDS) with an assessment reference date of 10/08/17 revealed R321 is always incontinent of bowel/bladder, requiring extensive assistance with two persons physical assist for toileting. The History and Physical (H&P) and discharge summaries from the acute care hospital dated 12/20/17 and 04/27/18 showed R321 was admitted on both occasions for UTI and aspiration pneumonia. The most recent hospitalization [DATE], R321 was found to [MEDICAL CONDITION], probably from aspiration pneumonia/UTI (E. coli, quinolone resistant). On 05/15/18 at 1:20 PM an interview was conducted with RCM32 regarding R321's care plan for UTI/aspiration pneumonia prevention, intervention, and revision related to R321's hospitalization s within the past six months. RCM32 stated she was unable to locate and/or provide any revision to the resident's care plan related to UTI/aspiration pneumonia following the hospitalization s.",2020-09-01
729,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2018-05-15,684,D,0,1,YF4Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with resident and facility staff and record review, the facility failed to provide care and/or services to R321 to prevent re-hospitalization for urinary tract infection [MEDICAL CONDITION] and aspiration pneumonia. Findings include: R321 was admitted to the facility on [DATE] and has the following Diagnoses: [REDACTED]. On 05/09/18 at 11:53 AM R321 reported to surveyor she had just returned to this facility from being hospitalized (return date to facility 05/08/18). R321 stated she was hospitalized for [REDACTED]. R321 stated sometimes when she calls staff to change her soiled brief, the staff doesn't come till 30 minutes later. R321 stated there was no particular shift that this happens on. R321 said she was also hospitalized back in (MONTH) (YEAR) for the same thing (UTI/Pneumonia). A review of the copies of History & Physical (H&P) and discharge summaries from the acute care hospital provided by the facility for R321 dated 12/20/17 and 04/27/18 showed R321 was admitted to the acute care hospital on both occasions for aspiration pneumonia and UTI. The H&P hospitalization on [DATE] found R321 to [MEDICAL CONDITION] probably from aspiration pneumonia/UTI (ecoli, quinolone resistant). On 05/15/18 at 1:41 PM a review of R321's Quarterly Minimum Data Set (MDS) with an assessment reference date of 10/08/17 under Section H, Bladder and Bowel, Urinary/Bowel Continence, R321 showed a code of 3 which is always incontinent for bladder/bowel. Also noted in MDS is R321 requires extensive two person assist for toilet use. On 05/11/18 at 10:10 AM a review of R321's care plans dated 02/25/16 - present and 05/09/18 (Baseline Care Plan initiated day after R321's return to facility on 05/08/18 from hospitalization at acute care hospital) showed no care plan revision for prevention and intervention related to R321's UTI/aspiration pneumonia. The care plans do not reflect revision to the as stated above after R321's hospitalization on [DATE] and 04/27/18 for UTI/aspiration pneumonia. On 05/15/18 at 1:20 PM interviewed RCM32 about R321's care plans regarding UTI/aspiration pneumonia intervention and revision due to R321's two hospitalization for UTI/aspiration pneumonia within the past six months. RCM32 stated she is unable to locate and /or provide any revision related to intervention/prevention in the care plans related to UTI/aspiration pneumonia after each of R321's hospitalization s (12/20/17 and 04/27/18).",2020-09-01
730,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2018-05-15,761,D,0,1,YF4Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to monitor the temperature controls for two medication refrigerators. Based on observation and staff interview the facility failed to label the discard by dates for 2 resident's (R3 and R41) eye drops. These deficient practices puts all residents at risk because improper temperatures of the refrigerators may cause an alteration of the medications stored there and risk for administration of expired eye drops to R3 and R41. Findings Include: 1. During an observation and review of the medication refrigerator temperature records, on [DATE] at 03:36 PM, the refrigerator temperatures were not recorded for four out of seventy one days reviewed. During staff interview, on [DATE] at 03:45 PM, Registered Nurse (RN) 32 acknowledged that the refrigerator temperatures were not recorded for the four days as previously mentioned. After review of facility policy on Refrigerator/Freezer Temperature Monitoring, the refrigerator/ freezer temperatures are to be checked daily and maintained within the temperature ranges specified in this policy . 2. On [DATE] at 01:33 PM while looking through a med cart with S40 found one bottle of eye drops for R3 that was labeled with an opened date of [DATE] and it did not have a discard by date. S40 called the pharmacist and found that these eye drops ([MEDICATION NAME] ophthalmic solution 0.5 % ) have a discard by date of 60 days. Another bottle of eye drops (Latanoprost 0.005% eye drops) for R41 also did not have a discard by date. S40 was able to find out from the pharmacy that these eye drops are discarded after 42 days from opening. S40 confirmed that both bottles of eye drops should have had the discard by date on the label of eye drops from the time the eye drops are opened.",2020-09-01
731,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2018-05-15,842,E,0,1,YF4Y11,"Based on observation, staff interview, and review of resident rights, the facility failed to safeguard medical record information against unauthorized use . With this deficient practice, there is a risk that the facility may constitute violations of the Health Insurance Portability and Accountability Act (HIPAA) privacy or security rules. 1. During an observation on 05/11/18 at 08:57 AM, a laptop screen was left open with the user still logged on. At that time, anyone could have accessed the resident medical records because there was no staff in the immediate vicinity to safeguard against unauthorized use. This laptop was mounted on a medication cart which was located near the recreation lanai. During staff interview on 05/11/18 at 09:01 AM, Registered Nurse (RN) 49 acknowledged that the laptop screen should not have been left open posing the risk for unauthorized use. 2. During an observation on 05/14/18 at 09:54 AM, a piece of paper was covering a laptop screen. However, the user was still logged on and there was no facility staff in the immediate vicinity to safeguard against unauthorized use. This laptop was mounted on a medication cart which was located near the Ilima Nursing Station. 3. During an observation on 05/14/18 at 10:05 AM, a laptop screen was lowered but the user was still logged on. Again, there was no facility staff in the immediate vicinity to safeguard against unauthorized use. This laptop was mounted on a medication cart which was located near the Ilima Nursing Station. During a review of the resident rights, which the facility provides to all residents, there was a section on Privacy and Confidentiality. The section stated that the resident has a right to personal privacy and confidentiality of his or her personal and medical records. The facility failed to provide that.",2020-09-01
732,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2018-05-15,880,D,0,1,YF4Y11,"Based on observation, staff interview, and review of facility policy, the facility failed to exchange suction equipment/canister for one of three residents (Resident (R) 31) reviewed. This deficient practice put the resident at risk for the development and transmission of communicable diseases and infections. Findings Include: 1. During an observation of the suction equipment in R31's room, on 5/9/18 at 08:23 AM, the suction equipment canister contained approximately 150cc of clear foamy liquid. This canister was not dated and there was no way to determine when it was put in use. After staff interview with Registered Nurse (RN) 30 and review of facility policy, the suction equipment/canister should have been dated when it was put in use and replaced in one week. Also, RN30 acknowledged that the clear foamy liquid should have been properly discarded.",2020-09-01
733,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2018-05-15,908,F,0,1,YF4Y11,"Based on observation, staff interview, and review of facility policy, the facility failed to perform routine maintenance, based on manufacturer's recommendation, and failed to keep preventative maintenance records for eight of fifteen oxygen concentrators reviewed. This deficient practice put the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: 1. During an observation and interview with Unit Coordinator (UC) 33 on 05/11/18 at 02:32 PM, UC33 stated the cleaning of all Oxygen Concentrator's Air Intake Filters (external) were done, every Friday, on a weekly basis. However, UC33 was unable to provide the required preventative maintenance records for the past couple years. Additionally, UC33 was not aware of, and did not perform the replacement of the Oxygen Concentrator's Air Inlet Filters (internal) as per manufacturer recommendations. During a review of facility policy pertaining to oxygen, it stated that the routine equipment inspection and maintenance should be performed based on manufacturer's recommendations. The facility failed to perform that. During an interview with Director of Nursing on 05/15/18 at 01:00 PM, it was acknowledged that the manufacturer's recommendations for their oxygen concentrators were not being followed.",2020-09-01
734,ANN PEARL NURSING FACILITY,125048,45-181 WAIKALUA ROAD,KANEOHE,HI,96744,2019-11-08,684,G,1,0,7YJS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide treatment for 1 resident out of 7, resident (R)1 in accordance with professional standards of practice. The facility failed to notify the medical doctor of a declining status and respiratory changes. As a result, R1 developed pneumonia, respiratory compromise which resulted in a cardiac and respiratory arrest. R1 also had a [DIAGNOSES REDACTED]. Findings include: On 11/07/19, review of R1's electronic medical record (EMR) dated 07/16/19 at 03:57 PM, stated Resident with shortness of breath (SOB) this AM and O2 87%. Whenever needed (PRN) updraft administered and 2L(liters) Nasal Cannula (NC) via concentrator applied. O2 achieved 96% and residents breathing became even and unlabored. Denies chest pain and reports she is feeling like she is getting sick with a cold. T 98.5. Tylenol PRN administered which was effective for generalized pain 4/10. On 11/07/19, review of R1's EMR dated 07/16/19 at 09:13 PM stated R1's BP was 105/65, oxygen at 94% on 2 liters. RN2 readjusted the nasal cannula and R1's oxygen saturation came up to 97%. Although R1 replied to the nurse that she felt better, no call was made to the MD of a declining status. Further review on 11/07/19 of a late entry to EMR documents a nursing note dated 07/18/19 states Charge nurse was called by staff to assess resident. Resident found to be tachypneic . Blood pressure 105/69, pulse 120, O2 saturation 88-90% on 4 liters of O2. Breathing at 44 beats per minute (bpm). R1 was unresponsive to voice and touch. A call to the MD was made and facility received an order to send out via Emergency Medical Services (EMS) to emergency room (ER). EMS arrived at the facility at 01:00 PM. Vital signs upon leaving facility were BP 136/80, temperature was 100.0, O2 88% on 8 liters O2 and heart rate 116. There were no documented evidence that showed RN1, RN2 or RN3 had contacted the Medical Doctor (MD) for significant vital sign changes and declining status prior to the event on 07/17/18 at approximately 01:00 PM. The record shows a whenever needed (prn) oxygen order dated 06/04/18 which states: for difficulty breathing, give oxygen at 1-4L via nasal cannula prn for shortness of breath or SPO2 of less than 90%. There were no orders when to notify the MD or parameters when to call the MD. During an interview on 11/07/19 at 09:00 AM with certified nurses aide (CNA)1 who said, I was taking care of R1 on the day she was transferred. R1 was sick for a couple of days before that. That morning, R1 drank water but she never ate anything. I changed her in the morning and I was worried. I discussed R1 with RN1 and asked her if R1 was ok because R1 was not eating. RN1 said she should be ok. I checked on R1 when I was getting her roommate up and she kind of responded that she was ok. When we came back in, she was not responsive at all, but her eyes were open, and she couldn't talk. It was me and two other CNAs who discovered her. I called RN1 to 129-1 right now. During an interview on 11/07/19 at 12:30 PM with RN1. I remember R1. I was the one that sent her off to the hospital. I discovered her. I got report from the nurse the night before. R1 appeared more lethargic and the previous evening, she remained in her room. She usually comes out in her wheelchair. When I did my med pass in the am, R1 was still able to converse with me around 7:30 or 8:00 AM. In the morning, the CNAs were in R1's room and they called me in by walkie talkie to the room. She didn't look good. She wasn't responding. I called for help. She was not verbal. The case manager told me to call her doctor and get the order to send her out. During an interview on 11/07/19 at 02:00 PM with RN2 who said R1 had a call for fever the day before. RN2 stated R1 had shortness of breath (SOB). I want to say that it had started the day before. R1 really perseverated. R1 went low but she came back up. Surveyor asked, how low? RN2 stated to 87-88's saturation. Surveyor asked, Was that a concern for you to call the doctor? RN2 stated R1 gets a little anxious I didn't call the doctor. During an interview on 11/07/19 at 02:30 PM with R2 who said I saw she needed help and was struggling to breathe. R1's above light was on and I could see her. I pressed my light when I saw her head bob and her shoulders slump. I pressed my light and they took about 25 minutes and that is the normal. She was propped up and had a lot of pillows on her back. She started to turn color. I started to ring my manual bell and yell that it was an emergency. I was hoping that R1 would react to the bell and she didn't. When the nurse came in, she was shaking, and she couldn't assess her quick enough. I told her to call 911 right now. The ambulance came quickly. They put her on the monitor. They said glad you guys called right away. During an interview with with RN3 on 11/08/19 at 09:00 AM who said, I don't remember that RN2 said she notified the doctor in the morning, but I felt that she said the resident was getting a cold. RN2 said RN1 hooked R1 up to nasal cannula that AM. I did not listen to her lungs on my shift. I checked her SP02 and it was 94%. I repositioned her nasal cannula and I also asked her how she is feeling, and she said she felt better. She was also propped on pillows. I don't know that I thought about why she had changes, but I just treated her. I set her up for dinner and I don't know how much she ate that night. The protocol is we check the patient and use the PRN orders and if she feels better then we don't call the doctor. I'm not sure if it is written but that is what I was told when I was oriented. During an interview with the Director of Nursing (DON) on 11/08/19 at 02:45 PM, queried DON if there were any records that showed the MD was notified about the change in respiratory status from RA to 02 nasal cannula, blood pressure drop on 07/16/19 to 105/65. DON confirmed that the MD was not notified and that there were no MD notes since June. During a concurrent interview on 11/08/19 at 10:00 am and review of educational materials for competency of staff with DON who said we use Interact organization tool to meet requirements and this has been approved by our doctors. Interact is a tool that tells our staff when to report to the MD or nurse practitioner or physicians assistant when there is a change in condition. Review of facility's Interact SOB carepath titled Vital sign Criteria (any met?) shows that if an oxygen saturation is less than 90%, inability to eat or sleep due to SOB, respiratory changes, staff should notify the MD. The facility also states that the Quality Assurance Performance Improvement (QAPI) committee is tracking changes in condition on a log. DON stated that this change of condition was missed and that the information did not get to the daily huddle via the nurse, charge nurse or DON. Record review (RR) on 11/08/19 reveals that R1 was transferred via ambulance to the nearest emergency roiagnom on [DATE] at 01:00 PM. Family member (F)1 stated that the facility called her and told her that her mother had flatlined and was unresponsive and was taken to the nearest emergency room . RR of the emergency department physician's notes said R1 was diagnosed with [REDACTED].",2020-09-01
735,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2017-05-19,246,D,0,1,JZYH11,"Based on observations and staff interviews, the facility failed to provide one resident (Resident #38) with reasonable accommodations based on individual resident needs. Findings include: Resident #38 understood what her call light was and she was able to follow instructions to press the button to call for assistance. An observation of Resident #38 on the morning of 5/17/17 at approximately 8:30 [NAME]M. found her awake in bed. Resident #38's hands were disfigured and her fingers were crooked. Resident #38 was asked to press her call light. She attempted to press the call light but had difficulty because her fingers were crooked and her hands disfigured. Staff #5 came over to assist Resident #38 by holding onto the call light while the resident pressed the button. An interview of Staff #5 revealed the resident needed assistance with pressing her call light since her hands were disfigured with crooked fingers. An interview of the Administrator on the morning of 5/19/17 revealed that Resident #38, was indeed, able to use her call light. She further noted the facility should provide alternative devices/methods for residents to call the staff. The facility failed to ensure Resident #38 had an appropriate device which she was able to use in order to contact the staff.",2020-09-01
736,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2017-05-19,253,E,0,1,JZYH11,"Based on observations and staff interviews, the facility failed to maintain a sanitary, comfortable interior. Findings include: A tour of the facility on the morning of 5/17/17 found the facility had odors and required maintenance/repair. On 5/17/17 at approximately 11:00 [NAME]M., an observation of the toilet room between rooms 10 and 11 found old/chipped paint and an old pest bait station stuck to the wall in the right corner, close to the ceiling. Observation of the toilet room between rooms 12 and 13 found a strong odor of urine, old/chipped paint and an old pest bait station stuck to the wall in the left corner, close to the ceiling. On the morning of 5/19/17 at approximately 8:30 [NAME]M., an interview of Staff #3 revealed the facility had plans to renovate the facility. Staff #3 confirmed the facility needed repairs and upkeep and the plans were going forward. The facility failed to maintain a sanitary, orderly and comfortable environment for the residents.",2020-09-01
737,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2017-05-19,279,F,0,1,JZYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and staff interviews, the facility failed to develop care plans for 7 of 24 care plans reviewed in stage 2 of the QIS survey. Findings include: 1) Cross reference F323 for Resident #28. Resident #28 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During the month of (MONTH) (YEAR), Resident #28 experienced 2 unwitnessed falls (4/15/17 and 4/23/17). On the morning of 5/18/17, a review of the Minimum Data Set, MDS, with Assessment Reference Date, ARD, of 1/19/17 revealed the Care Area Assessment (CAA) Summary noted Resident #28 was triggered for Falls due to balance problems during transition, and noted that it was an existing problem. Resident #28's CAA summary further noted that Falls were addressed in her care plan. A medical record review for Resident #28 on the morning of 5/17/17 at approximately 10:00 [NAME]M. found the facility did not develop a care plan for falls. An interview of the Director of Nursing on the morning of 5/18/17 at approximately 8:23 [NAME]M. revealed the staff were still getting familiar with the new Electronic Health Record (EHR). The DON confirmed they did not have a current Falls care plan for Resident #28. On the morning of 5/18/17, a review of the facility's policy titled Fall Prevention noted that when a resident was identified as being a high risk for falls, the facility was responsible to, Implement a plan of care based on assessed risk factors. The facility failed to implement a care plan for Falls despite knowledge that Resident #28 was high risk for falls. 2) Cross reference F282 for Resident #39. Chart review: 05/18/17 at 11:00 [NAME]M. Resident #39 (Res#39) was admitted on [DATE] and seen for comprehensive nutritional assessment on 11/25/16. It was noted that Res #39 had lost 21 lbs over a 90 day period starting in 01/01/17. Res #39 is on a regular diet, finely chopped texture, regular consistency. Medical record review for Res #39 found that the facility did not develop a care plan for nutritional risks. Medical record review revealed a careplan for The resident has a nutritional problem or potential nutritional problem, weight gain r/t fluid overload. Interview with Staff #28 on 5/18/17 at 11:11 [NAME]M. was done. Staff #28 stated that Res #39 verbalized that she wants to lose weight and and does not want to gain weight. It was further noted through chart review that Res #39 had not seen a dietician since (MONTH) 12, (YEAR). Staff #28 stated that she was doing the assessments for nutrition. Res #39 chooses what she eats and she eats minimal amount. It was noted that Res #39 was on a dietary supplement of Glucerna 4 oz three times a day with meals. When asked about a careplan for nutritional risk for weight loss, Staff #28 stated they did not have a registered dietician on board. Interview with Staff #60 on 5/19/2017 at 9:47 [NAME]M. Staff #60 was advised regarding weight loss for Res #39 and there was no careplan to address weight loss. Staff #60 stated that they have not had a registered dietician on board and that they just hired a nutritionist last week. Staff #60 agreed that this needs to be followed up and she will look into it.",2020-09-01
738,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2017-05-19,280,D,0,1,JZYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, chart review and staff interview the facility failed to revise 1 of 26 residents, of the Stage 2 Sample residents, Care Plan. Findings include Cross Reference F323 for Resident #36 On 05/18/2017 at 7:41 AM review of MDS, which was filled out on 02/19/2017, was completed and noted that Resident (Res) #36 had a prior fall in the last 2-6 months prior to admission. An antidepressant and hypnotic was given during the last 7 days. Res #36. Res #36 has a [DIAGNOSES REDACTED]. Res #36 had an unwitnessed fall on 04/25/2017 in the dinning room resulting in abrasions to lower extremities from the fall from the wheelchair. On 05/18/2017 at 7:54 AM interviewed staff #28 who reviewed the resident's care plan. Staff #28 stated that there was an investigation done and that the resident had a thing about going back to bed. Staff #28 explained that resident likes to go back to bed at that time and when then tries to go get out of bed on their own. Staff #28 explained that staff try to encourage resident to stay in the dining room where there are more staff to monitor the resident and prevent falls. When asked about activities in the afternoon staff #28 stated that Res #36 refuses, only reads the newspaper a little bit. When asked if resident has an alarm for his wheelchair staff stated they were not sure if resident had an alarm for their wheelchair. Review of Res #36 care plan states to Review information in past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. On 05/18/2017 interview with staff #60 was conducted to see if any changes were made to resident's care plan after the unwitnessed fall. Per staff #60 staff were told not to lock Res #36 wheelchair brakes since resident likes to roll self around. Staff #60 stated that when Res #36 was found on the ground it was noted that one wheel of the wheelchair was locked. The information to not lock the brakes of the wheelchair was not seen in Res #36 care plan. Staff #28 and #60 confirmed this information was missing. The facility failed to revise a care plan for a resident which may result in injury to the resident.",2020-09-01
739,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2017-05-19,282,D,0,1,JZYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and chart review, the facility did not provide a qualified person in accordance with the resident's plan of care. Findings include: Chart review: 05/18/17 at 11:00 [NAME]M. Resident #39 (Res#39) was admitted on [DATE] and seen for comprehensive nutritional assessment on 11/25/16. It was noted that Res #39 had lost 21 lbs over a 90 day period starting in 01/01/17. Res #39 is on a regular diet, finely chopped texture, regular consistency. Interview with Staff #28 on 5/18/17 at 11:11 [NAME]M. was done. Staff #28 stated that Res #39 verbalized that she wants to lose weight and and does not want to gain weight. It was further noted through chart review that Res #39 has not seen a dietician since (MONTH) 12, (YEAR). Staff #28 stated that she was doing the assessments for nutrition. Res #39 chooses what she eats and she eats minimal amount. It was noted that Res #39 was on a dietary supplement of Glucerna 4 oz three times a day with meals. Interview with Staff #60 on 5/19/2017 at 9:47 [NAME]M. Staff #60 was advised regarding weight loss for Res #39 and there was no careplan to address weight loss. Staff #60 stated that they have not had a registered dietician on board and that they just hired a nutritionist last week. Staff #60 agreed that this needs to be followed up and she will look into it.",2020-09-01
740,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2017-05-19,323,D,0,1,JZYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and facility policy review, the facility failed to maintain the safety of three of three residents (Resident #36, Resident #41, and Resident #28) reviewed for accidents. Findings include: 1) Resident #28 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #28 was admitted to a hospice program on 1/17/17 with the [DIAGNOSES REDACTED]. Resident #28 was observed in the Activity Room seated in a Geri chair on the morning of 5/16/17 at approximately 9:30 [NAME]M. She appeared fidgety, in a reclined position with her body leaning toward the right side. On the morning of 5/17/17 at 8:00 [NAME]M. Resident #28 was in the Activity Room seated in a Geri chair in front of the TV. She was alert, quiet, in a reclined position leaning to her right side. On the afternoon of 5/17/17 at approximately 1:45 P.M., Resident #28 was observed in bed, awake. She was quiet and responsive. An interview with Staff #47 on the morning of 5/16/17 at approximately 11:00 [NAME]M. revealed Resident #28 experienced a fall on 4/22/17 which resulted in an abrasion to her right knee. Staff #47 noted that since the fall on 4/22/17, Resident #28 was using a Geri Chair for positioning. Her [DIAGNOSES REDACTED]. According to Staff #27, the facility performed a root cause analysis which determined Resident #28 required use of the Geri Chair. A medical record review found Resident #28's fall occurred on 4/23/17 at approximately 7:45 P.M. when she was found on the pad foam mat on the floor next to her bed. At the time of the fall, Resident #28 denied pain but she had a knee abrasion. She did not lose consciousness. Interview of Staff #8 regarding an incident report for Resident #28's4/23/17 fall revealed the facility did not complete an incident report. Further review found Resident #28 also fell on [DATE] when she was again found lying on the ground next to her bed at 4:15 P.M. An assessment of Resident #28 post fall found she had redness to both knees and a 1 cm skin tear to her right knee. She did not lose consciousness. A review of the Incident Report noted the resident's report that she slid out of her bed and landed on both knees in a kneeling position. Resident #28 was found when the staff heard alarm sounds and went to her bed to found her lying on the floor next to her bed. The facility noted corrective actions/interventions which included, use of a recliner for monitoring (when very restless). In addition to Resident #28's degenerative neurological disease, she was also taking psychotropic medications which could affect her balance and movement. The resident received the following medications: [REDACTED]. Although Resident #28 had two falls during the month of (MONTH) (YEAR), a care plan for falls was not located in the resident's medical record. A review of the Minimum Data Set, MDS, on the afternoon of 5/17/17 found a significant change assessment with Assessment Reference Date (ARD) of 1/19/17 which noted that Resident #28's Care Area Assessment (CAA) Summary triggered falls. The CAA Summary further noted that falls was an existing problem and the problem was addressed in the care plans. An interview of Staff #28 on the afternoon of 5/17/17 at approximately 2:20 P.M. confirmed the facility did not have a falls care plan in place for Resident #28. Staff #28 noted the facility recently (December (YEAR)) changed the format of the care plans and therefore the care plan may not have transferred over to the new system. An interview of the Director of Nursing, DON, on the morning of 5/18/17 at approximately 8:23 [NAME]M. revealed that she and the staff were still getting familiar with the new Electronic Health Record (EHR). The DON also checked the medical record for a falls care plan but confirmed there wasn't one. The DON confirmed that Resident #28 should have a falls care plan based on her history of falling, which placed her at high risk. A review of the facility's policy titled, Fall Prevention on the morning of 5/18/17 at approximately 8:30 [NAME]M. noted, Implement a plan of care based on assessed risk factors. The facility failed to ensure the that Resident #28 received the necessary care and supervision to avoid additional falls/accidents. Additionally, the facility failed to ensure appropriate care and assistance was being provided based on the absence of a Falls care plan for Resident #28. 2) On 05/18/2017 at 7:41 AM MDS, which was filled out on 02/19/2017, review was completed and noted that resident (Res) #36 had a prior fall in the last 2-6 months prior to admission and an antidepressant and hypnotic was given during the last 7 days. Res #36 also has a [DIAGNOSES REDACTED]. Res #36 had an unwitnessed fall on 04/25/2017 in the dinning room resulting in abrasions to lower extremities from the fall from the wheelchair. On 05/18/2017 at 7:54 AM interviewed staff #28 who reviewed the resident's care plan. Staff #28 stated that there was an investigation done and that the resident had a thing about going back to bed. Staff #28 explained that resident likes to go back to bed at that time and tries to get out of bed on their own. Staff #28 explained that staff try to encourage resident to stay in the dining room where there are more staff to monitor the resident and prevent falls. When asked about activities in the afternoon staff #28 stated that Res #36 refuses, only reads the newspaper a little bit. When asked if resident has an alarm for his wheelchair staff stated they were not sure if resident had an alarm for their wheelchair. Review of Res #36 care plan states to Review information in past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. On 05/18/2017 interview with staff #60 was conducted to see if any changes were made to resident's care plan after the unwitnessed fall. Per staff #60 staff were told not to lock Res #36 wheelchair brakes since resident likes to roll self around. Staff #60 stated that when Res #36 was found on the ground it was noted that one wheel of the wheelchair was locked. This information was not seen in Res #36 care plan and staff #28 and #60 confirmed this information was missing. On 05/19/2017 at 11:12 AM interviewed Res #36 who was able to acknowledge that he had a recent fall and reported continued pain in his right leg which the medication nurse was providing PRN pain medication for as ordered. Res #36 stated yes when asked if he had tried to stand up from his wheelchair when he fell . Resident had healing scabs to right shin and left thigh. 3) On 05/18/2017 at 9:13 AM while doing a record review of resident (Res) #41's chart it was noted that resident had MDS significant change assessment done on 12/30/2016 and quarterly MDS done on 04/01/2017 which both showed that resident had wandering behavior that occurred 1 to 3 days. Review of resident's care plan for elopement risk/wanderer, going out of the facility r/t dementia had interventions listed such as Disguise exits: cover door knobs and handles, tape floor. While reviewing the resident's chart and looking at Res #41's room door it was noted that the closest exit, which is right next to the resident's bedroom door, was not disguised in any way, there was a stop sign on the door but the door knob handle was not covered and there was no tape on the floor. The door had an alarm on it but I was told by staff #60 and #28 that the alarm is off during the day shift because the residents spend most of their time in the day room. On 05/18/2017 at 10:50 AM, while walking through the facility with staff #19, the exits in the day room were checked and the alarms on the doors were off at that time. When asked why the alarms were off staff #19 stated that there are more staff working during the day shift. Staff #19 was reminded that residents who wander, such as Res #41, was sitting in the day room. Staff was asked what would happen to the resident if staff were busy with other residents and not aware that the resident walked through the exit and staff #19 stated that the resident could go to the street. Res #41 also has Monitor location every 15 min. every shift. Document wandering behavior attempted diversional interventions in behavior log. as interventions. Record review and interview with staff #28 did not produce any documentation of interventions on a behavior log, no progress notes of wandering behavior or close monitoring, and no behavior log was found. The facility failed to provide an environment as free from accident hazards as is possible which may or has resulted in injury to the resident.",2020-09-01
741,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2017-05-19,329,D,0,1,JZYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and staff interviews, the facility failed to monitor and evaluate the use of [MEDICAL CONDITION] medications for 5 of 5 residents (Resident #28, Resident #12, Resident #34, Resident #18 and Resident #13) sampled for drug regimen review. Findings include: 1) Resident #28 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. Resident #28 was admitted to hospice on 1/17/17 with this diagnosis. Resident #28 was observed in the Activity Room seated in a Geri chair on the morning of 5/16/17 at approximately 9:30 [NAME]M. She appeared fidgety, in a reclined position with her body leaning toward the right side. On the morning of 5/17/17 at 8:00 [NAME]M. Resident #28 was in the Activity Room seated in a Geri chair in front of the TV. She was alert, quiet, in a reclined position leaning to her right side. On the afternoon of 5/17/17 at approximately 1:45 P.M., Resident #28 was observed in bed, awake. She was quiet and responsive. A medical record review found Resident #28 had physician's orders [REDACTED]. The facility utilized Behavior/Intervention Monthly Flow Records for the use of the [MEDICATION NAME] and [MEDICATION NAME]. They did not have a flow record for [MEDICATION NAME]. A review of the flow records found the staff were documenting when the resident displayed behaviors such as yelling/screaming; continuous crying out; and depressive mood as evidenced by poor oral intake. The staff marked the flow records when the resident displayed any behaviors. However, the corresponding interventions/outcomes or any side effects were blank/not documented. A care plan review for Resident #28 on the morning of 5/18/17 at approximately 10:00 [NAME]M. found the care plan noted, Assess for effects of [MEDICAL CONDITION] meds: [DIAGNOSES REDACTED], akithesia, akinesia, rigidity, tremors, etc. An interview of the Director of Nursing, DON, on the morning of 5/18/17 at approximately 10:15 [NAME]M. found that the Certified Nurses Aides, CNAs, were not very likely to understand side effects listed such as [DIAGNOSES REDACTED], akithesia, etc. Additionally, Resident #28's [DIAGNOSES REDACTED]. The facility failed to provide a clear, systematic approach for the management/oversight of the use of [MEDICAL CONDITION] drugs for Resident #28. 2) Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. On the morning of 5/16/17 at approximately 9:00 [NAME]M., Resident #12 was seated in the Activities Room working on a puzzle. She smiled, interacted appropriately, and appeared pleasant. On the morning of 5/17/17 at approximately 8:30 [NAME]M., Resident #12 was being assisted out of bed. She just had breakfast and was getting ready to go to Activities. Observation of Resident #12 on the afternoon of 5/17/17 found her in the Activities Room coloring. On the morning of 5/18/17 Resident #12 was observed participating in the morning exercise activity. A medical record review found Resident #12 had a care plan for the use antipsychotic medications with interventions which included, Observe resident for any adverse side effects and document. The care plan did not describe the side effects to look for. The care plan further noted, Monitor resident behavior and document at quarterly and as needed. Report any negative observations to physician. A review of the resident's Behavior/Intervention Monthly Flow Record found the resident was not demonstrating any behaviors. An interview of the DON on the morning of 5/18/17 revealed the care plan did not, but should have, included the adverse effects for the [MEDICAL CONDITION] medications Resident #12 was receiving. The DON reported that staff used the care plan as an outline for the care provided to the residents. The DON was asked how they determine a medication is necessary if they're not clearly monitoring and documenting it's necessity and adverse effects. The DON confirmed they need to be more specific about adverse effects and the necessity for medications by monitoring and evaluating their use. The facility failed to assess and evaluate the effectiveness and use of [MEDICAL CONDITION] medications for Resident #12. 3) On 05/18/2017 at 8:15 AM medical record reviewed and interviewed staff #28 who was able to show that Resident (Res) #34 had a care plan for depressed mood with interventions and side effects listed to monitor for. Resident is taking [MEDICATION NAME] 20 mg po daily and behaviors agitation walking out of facility and Depressive mood AEB poor po intake are listed on the Behavior/Intervention Monthly Flow Record. On this form there are no side effects listed even though the resident's care plan has the following side effects listed to monitor for: lethargy, change in L[NAME], sleep problem ([MEDICAL CONDITION]), weight changes. When asked staff #28 confirmed that the spaces on the monthly monitoring flowsheet were left empty but in the future would include side effects as listed in the care plan. 4) On 05/18/2017 at 9:42 AM medical record reviewed and interviewed staff #28 to discuss Resident (Res) #18 care plan for [MEDICATION NAME]. Res #18 is on [MEDICATION NAME] 3 mg every evening on Sunday, Tuesday, Thursday and Saturday and takes 2.5 mg every Monday, Wednesday and Friday for [MEDICAL CONDITION] Fibrillation. Resident's care plan lists signs and symptoms Monitor for easy bruising and Monitor for signs and symptoms of bleeding such as melena or black tarry stool, during defecation. On 5/18/2017 at 12:07 PM interviewed staff #11 who was caring for Res #18. When asked for what signs or symptoms that they have to report to the nurse staff stated rash on the groin or legs. Staff #11 denied any bleeding with oral care or bruising noted that day with Res #18. Staff #11 was able to state that every shift the staff documents and reports any changes with resident's skin to the nurse but was not aware that resident is on a high risk for bleeding medication ([MEDICATION NAME]). 5) On 05/18/2017 at 10:24 AM medical record reviewed and interviewed staff #28 who was able to show that Resident (Res) #13 had a care plan in place for mood problem r/t dementia with Paranoia and The resident has depression r/t Dementia. In Res #13 Care Plan for mood problem it states Administer medications as ordered. Monitor/document for side effects and effectiveness. Interventions listed to monitor for were Monitor/record/report to MD prn acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills. In resident's care plan for depression it states Administer medications as ordered. Monitor/document for side effects and effectiveness. Interventions listed to monitor for were Monitor/document/report PRN any s/sx of depression, including: hopelessness, anxiety, sadness, [MEDICAL CONDITION], anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, tearfulness. Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. On Res #13 Behavior/Interventions Monthly Flow Record they did not have any side effects listed to monitor for [MEDICATION NAME] or [MEDICATION NAME] as stated in the care plan. When asked staff #28 confirmed that the spaces on the monthly monitoring flowsheet were left empty but in the future would include side effects as listed in the care plan. The facility failed to provide adequate monitoring for high risk medications which may have an adverse effect on the resident.",2020-09-01
742,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2017-05-19,441,D,0,1,JZYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview facility failed to ensure staff used proper hand-hygiene between residents during meal time; and, disinfected the blood glucose meter to reduce the spread of infections and prevent cross-contamination, used for 5 residents needing blood glucose checks. Findings include: 1) On [DATE] at 11:31 AM during lunch observation, staff # 45 was seen assisting random resident and afterwards put the meal tray with the dirty dishes on the rolling rack and went back to assist another resident without performing hand hygiene between resident care. When questioned about this staff # 45 stated that she washed her hands before assisting first resident but was reminded that she went to help the second resident after putting away the dirty dishes and she stated that she had forgotten to use hand sanitizer or wash hands. 2) On [DATE] at 1:52 PM staff # 47 was asked how she cleans the blood glucose meter that her facility uses to check the resident's blood glucose levels. Staff #47 stated that they use the purple top wipes and showed where the equipment was kept. Staff # 47 stated that staff #5 helps me with this. Staff #5 told surveyor that the blood glucose meter was cleaned with alcohol wipes right now in between resident use because the purple top wipes were expired. On [DATE] at 2:00 PM interviewed staff #60 and asked how the staff disinfected the blood glucose meter at the facility. Staff #60 stated that she had discovered on [DATE] the purple top wipes that they use to disinfect the meter with was expired, with expiration date of ,[DATE]. She could not say how long these wipes were being used but the container that had been pulled was recently opened. Staff #60 pulled the expired wipes from the floor and ordered new wipes which staff # 22 picked-up that day. Staff #60 was able to confirm that PDI Sani-cloth wipes with bleach were obtained [DATE] at 3:52 PM for use at the facility. From [DATE] 2:00 PM - 3:52 PM Staff # 60 brought out 3 new Assure Platinum meters to use for 3 of the 5 resident's receiving blood glucose checks and assigned them for one resident use only. Resident #19 and #12 are ordered blood glucose checks twice a day at 0630 and 1600, resident #37 and a random resident are ordered blood glucose checks Monday, Wednesday and Friday at 0530 and resident #39 is ordered blood glucose check on the 15th of the month at 0600. The facility failed to implement and monitor it's infection control program which may result in the spread of infections and cross-contamination between residents.",2020-09-01
743,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2017-05-19,463,F,0,1,JZYH11,"Based on observations and staff interviews, the facility failed to ensure the Resident Call System was working properly. Findings include: The facility's Resident Call System notified the staff via two methods: Four LED boards located in the hallways throughout the facility; and Pagers which staff carried in their pockets. The call system was noted to have a delay from the time the call light was activated to when the LED boards lit up and the staff pagers rang. On the morning of 5/19/17 at approximately 8:10 [NAME]M., surveyor pressed the call lights, one after the other, for 12A, 12B, 12C, and 12D. The LED display and pager ring for 12A displayed at 8:12 [NAME]M. (2 minutes later); 12B displayed at 8:14 [NAME]M. (4 minutes later); 12C displayed at 8:15 [NAME]M. (5 minutes later); and 12D displayed at 8:20 [NAME]M. (10 minutes later). At 8:15 [NAME]M., surveyor pressed the call lights, one after the other, for 13A, 13B, 13C, and 13D. The LED display and pager ring for 13A displayed at 8:17 [NAME]M. (2 minutes later); 13B displayed at 8:18 [NAME]M. (3 minutes later); 13C displayed at 8:25 [NAME]M. (10 minutes later); and 13D displayed at 8:26 [NAME]M (11 minutes later). The time from when the call light was pressed to when the staff were notified took up to 11 minutes. In addition to the delayed notification time, the residents still needed to wait for the staff to respond to the calls. A review of the call response time (after the staff received notice) during the week of survey found that the response time varied. On 5/17/17 at 4:33 [NAME]M., Room 2 called and waited 24 minutes and 32 seconds. On 5/17/17 at 12:23 [NAME]M., Room 10D called and waited 21 minutes and 3 seconds. On 5/16/17 at 6:00 [NAME]M., Room 5 called and waited 23 minutes and 11 seconds. On 5/15/17 at 8:16 P.M., Room 17A called and waited 28 minutes and 29 seconds. The response times were in addition to the amount of time it took for the call to be registered to the LED board and staff pagers. An interview of the Assistant Administrator on the morning of 5/19/17 at approximately 7:56 [NAME]M. revealed the manufacturer for the call light system was based in Iowa. The Assistant Administrator noted that the person who did the installation of the call light system informed the facility they needed an additional repeater to boos the response of calls. The Assistance Administrator stated he had not yet purchased the repeater. Surveyor asked the Assistant Administrator to provide a report for 5/16-5/19/17 of the call response times. The Assistant Administrator noted that on 5/16/17 he cleared one of the message options which should improve the notification time. He was asked whether he tested the system after making this change. He reported that he tested each room, one at a time. He did not activate the call lights simultaneously but rather waited for each call to register on the display/page before moving to the next room. He was then asked whether they regularly test the resident call system to ensure it's functioning to which he replied no. Additionally, the Assistant Administrator noted he doesn't monitor the staff's response time to the call lights. On 5/19/17 at approximately 9:21 [NAME]M., the Administrator reported they contacted the resident call system manufacturer earlier that morning and was informed that the system could only accommodate 2 or 3 calls at the same time. The Administrator was unaware of this and stated she would immediately correct the problem. On 5/19/17 at approximately 9:54 [NAME]M. the Administrator and Assistant Administrator stated they made changes to the resident call system. The Assistant Administrator noted he deleted several layers of data retrieval/notification steps. After deleting those layers, the Assistant Administrator tested the call system by pushing 10 call lights simultaneously. He reported the display/pagers were activated after one minute and 36 seconds. The issue improved as the Surveyor was able to verify the information by again testing the call system. 2) 05/16/2017 at 9:41 [NAME]M. During Stage I of the survey, this surveyor pushed Resident #47's (Res #47) call light; however, Res #47 not in bed. Alert of call button seen on LED display. Because no one responded after several minutes, this surveyor spoke to Staff #45. who was assisting another resident in the bathroom. Interview with Staff #45 who stated that there is also a bed alarm that alerts to the nurses station but it was off. The LED display does not sound an alert and the CNA was assisting another res in the bathroom, so she would not know if Res #47 had called. 05/16/2017 at 1:32 P.M. a revisit to Res #47's room revealed Res #47 to be confused and attempting to get out of bed. Retrieved Staff #45 and asked about her call bell as call bell is hanging at the side of the bed and her Sensatec Bed alarm did not sound. Staff #45 stated that the Sensatec bed alarm was off. Staff #45 stated that the Sensatec bed alarm was off because the resident's don't like the sound. On further questioning, Staff #45 stated that Res #47 is confused and does not know what her call bell is. At this time, surveyor asked Staff #45 to test her pager with the call bell. Staff #45 stated they turn off. Staff #45 confirmed that resident could not use her call bell because of confusion and that her Sensatec bed alarm was turned off. 05/18/2017 9:44 [NAME]M. Interview with Staff #60. Staff #60 stated, the pager is a little too noisy and it's linked to the call bell. The residents complained they dont like the pager because it startles them. When they press the call light, there are three flashers, one in the hall, one in dining room that faces the nursing station. The three Led display monitors and pager makes a sound. Staff #60 stated that we have aides for each side, A,B,C and D who are accountable for the LED displays. If B, C and A are busy, we have the Rehab aide and Tx aide. The bed alarm wont trigger the LED displays, so for Staff #45, the Sensatec bed alarm should be on. Staff #60 was told by this surveyor of her observation regarding Res #47's back-up system being turned off. Staff #60 stated back up system should not have been turned off. The facility failed to ensure an efficient/effective resident call system.",2020-09-01
744,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2019-07-01,578,D,0,1,T2OW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review (RR) and interview, the facility failed to ensure for a resident who does not have an advance directive (AD), the resident was informed of his or her right to develop one, provided assistance in doing so or was periodically reassessed in his/her decision making capacity to do such for four of 16 residents (Residents (R) 30, 1, 24 and 27). This deficient practice had the potential to affect all new residents being admitted to the facility. Findings include: 1. R30 record revealed there was a written declaration of a surrogate family member, but there was no documentation that attempts to discuss an Advanced Directive (AD) nor the facility's AD policy had been provided to the family member. On 06/28/19 at 03:58 PM, the social worker designee (SWD) confirmed R30 did not have an AD. On 06/28/19 at 04:10 PM, the SWD also confirmed the facility did not have their own AD policy. On 07/01/19 at 09:58 AM the facility drafted a new AD policy. 2. On 06/27/19 at 11:32 AM, RR found R1 only had a financial durable power of attorney, but none for health care or an AD. On 06/28/19 at 03:58 PM, the SWD verified that R1 did not have an AD nor was their facility AD policy provided to the family. SWD stated they discuss it with the family members as needed, but this was not documented. 3. On 06/28/19 at 03:58 PM, per the SWD verified R27 also had no AD. On 06/28/19 at 04:10 PM, the SWD also confirmed the facility did not have their own AD policy. 4. R24 is a [AGE] year old male who had impaired cognitive function and thought processes related to dementia. RR revealed a POLST was present for R24 prepared on 11/30/17 signed by his wife, who was the appointed guardian. There was no AD in the medical record or documentation that it was discussed or offered. Request for documentation made to SWD. During an interview with SWD on 06/28/19 at 04:00 PM, she confirmed there was no documentation regarding a discussion was held with the R24's guardian aboout AD and he did not have one.",2020-09-01
745,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2019-07-01,656,D,0,1,T2OW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop comprehensive care plans for four of 12 residents (Resident (R) 19, 27, 24, 34) selected for review. This deficient practice had the potential to affect all residents requiring a comprehensive care plan. Findings include: 1. On 06/26/19 at 02:28 PM, Resident (R) 19 was observed in bed. She had a dressing on her right lower shin, and on her left shin region, she had areas of purplish discoloration. Then on 06/28/19 at 11:36 AM, registered nurse (RN) 6 was observed to do R19's lower extremity dressing changes. RN6 cleansed the right lower shin with normal saline and then applied [MEDICATION NAME] ointment over the paper tape holding the skin tear together. RN6 then applied a 4x4 gauze over it. RN6 then took off the left shin gauze and stated it's all healed, but the gauze was on for protection. RN6 said the cause of R19's right shin skin tear and purplish area was that the resident may have banged it against something as there were days when she was more restless. During an interview with the Director of Nursing (DON) on 06/28/19 at 02:58 PM, she said once the purplish area (ecchymosis) appears on the resident's shin, it easily becomes a skin tear so they apply [MEDICATION NAME] (a clear dressing) over it. The DON said they follow their skin protocol however, only when there's an actual skin tear. The DON said there were no orders for the [MEDICATION NAME] use although it was applied when any ecchymosis or blood blisters were found. However, the causative factor(s) for the development of these skin conditions were not determined and reviewed by the nursing staff, although they would begin treating it when found. On 06/28/19 at 03:30 PM, the DON and the RN4, the Minimum Data Set Coordinator (MDS-C), said they also had no weekly wound tracking/monitoring of R19's new right shin skin tear and ecchymosis along with no care plan. 2. On 06/26/19 at 03:22 PM, R27 was observed with areas of purplish discoloration (ecchymosis) to her bilateral upper arms. Earlier at lunch, R27 was observed having a strong grip when she held onto the SWD's arm. R27 was not easily redirectable and hung onto the SWD's arm until the SWD was able to free herself. R27 also had [MEDICATION NAME] covering the ecchymotic areas on her forearms. On 06/26/19 at 04:16 PM, record review found the resident did not have a care plan for the ecchymosis to her bilateral upper extremities. There was a care plan for R27's mood/behavior related to her dementia, depression, agitation and to report any risk for harm to self as she had a past attempt at suicide, risky action, intentionally harmed or tried to harm self. On 06/28/19 at 08:56 AM, RN6 was observed treating R27's bilateral forearms. RN6 placed a [MEDICATION NAME] over a quarter sized blood blister to R27's right forearm. RN6 said, We are covering it with this ([MEDICATION NAME]) for it to not open. RN6 said they admitted this resident from home with a lot of skin tears. There was also a [MEDICATION NAME] to the resident's left forearm which was left alone as it was still intact. On 06/28/19 at 03:39 PM, during an interview with the DON, she said there were no standing orders for the use of a [MEDICATION NAME] as a treatment to R27's blood blisters or ecchymotic areas. She also confirmed there was no care plan developed for R27's skin condition when this resident had mood/behaviors that made her prone to potentially injure her upper extremities when she became agitated or restless. 3. R24 was an [AGE] year-old male who received hospice care with a terminal prognosis of Alzheimer's. Other [DIAGNOSES REDACTED]. R24 was at risk for disruption of skin integrity due to his age and skin condition. He was also at high risk for infection due to his Diabetes. On 06/27/19 at 09:00 AM, observed R24 had a clear dressing applied to his right forearm. The skin was noted to be bruised under the dressing. RR of R24's medical records revealed the following: a. 06/25/19 cardex note entered by nursing staff that R24 received skin tear during shower. b. 06/26/19 progress note, Seen by MD (Medical Physician) d/t (due to) skin tear that was sustained during shower with hospice staff yesterday measuring 4 cm (centimeters) x 2 cm. Per MD continue to do skin tear protocol . The skin tear protocol, directed staff to, Cleanse (the wound) with NS (normal saline), pat dry, apply steri-strips (holds the wound together) and thin layer of [MEDICATION NAME] then cover with [MEDICATION NAME] or non-adhesive dressing. Replace dressing daily and as needed until healed. Monitor and notify physician for signs and symptoms of infections as needed for Skin tear. c. 06/28/19 reviewed R24's care plan that revealed it was not a comprehensive plan and it did not include the recent skin tear, or the interventions of the skin tear protocol ordered by the MD. On 06/28/19 at 10:12 AM during an interview with the DON discussed R24's skin tear. Reviewed the skin tear protocol referred to in progress note, and reviewed R24's care plan. DON agreed the skin tear should have been in the care plan. 4. R34 had a cerebral infarction (an area of necrotic tissue in the brain resulting from a blockage) affecting the left non-dominant side and was on aspirin therapy (can help prevent a blockage). R34 was assessed to have fragile skin. On 06/26/19 at 10:49 AM R34 was observed to have a clear dressing on both forearms with bruising noted under the dressings. On 06/26/19 at 11:00 during interview with R34, she said she was not aware of how she got the bruises. R34 stated, I need help with everything and bruise easily. R34's care plan revealed there was a plan in place for actual impairment to skin integrity of the buttocks .r/t (related to) fragile skin. There was also a problem identified that The resident is at risk for adverse reaction from Aspirin therapy. Interventions included, skin assessment every shift ., and to Monitor for . bruising. There was nothing in the care plan regarding the bruising of both forearms or the [MEDICATION NAME] dressings and how to manage them. There was no physician order for [REDACTED].>On 06/27/19 during interview with Registered Nurse (RN)5 inquired about R34's dressings. RN5 said, when we notice any bruising , we put the [MEDICATION NAME] (dressing) on. Asked if there was a policy regarding this practice and she replied, I don't think so. When asked if there was an MD order for the dressing, RN5 said, No. On 06/28/19 during interview with DON, asked what the facility practice was regarding bruising and the [MEDICATION NAME] dressings. DON said, We put it on when we see a bruise and it helps to prevent skin tears on fragile skin. Asked if there was a policy, approved protocol or standing order for this, and DON said she would check. Care plan reviewed with DON, who agreed the dressing to forearms should have been in the care plan. The DON later reported there was not a policy or protocol for the use of the [MEDICATION NAME] dressings.",2020-09-01
746,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2019-07-01,657,D,0,1,T2OW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to revise residents' care plans for two of 12 residents (Resident (R) 5 and 38) selected for review. This deficient practice had the potential to affect all residents requiring a revision to their care plans. Findings Include: 1. Resident (R) 5 was found to have a gradual decline in her weight of -8.2% from her 12/07/18 weight of 122 pounds (lbs) to her current 06/26/19 weight of 112 lbs. The resident was observed able to eat by herself without much assistance. At the time of the 04/07/19 annual nutrition assessment, R5's weight was 119 lbs and her weight was within an acceptable weight range. The goal was to maintain the resident's weight between 115-125 lbs. During an interview with the MDS-C/RN4, on 06/28/19 at 02:25 PM, she acknowledged as a result of R5's gradual weight loss and open wounds to the resident's toes, they put nutrition and hydration interventions in place. MDS-C/RN4 said a nutritional supplement, Juven was ordered 05/31/19, but she was not aware of it until she had to pass medications one day and noticed then that the Juven supplement was being given. However, the implementation of Juven was not found in the resident's current nutrition or wound care plan. Further, the dietitian also did not have any follow-up entry/notation of this supplement being provided. The DON acknowledged R5's care plan had not been revised to include the Juven as an intervention to promote wound healing and/or to provide additional nutritional support given the resident's gradual weight loss. As a result, the efficacy of the Juven was indeterminate as it was excluded from the resident's care plans for wound healing and weight loss. 2. Resident (R)38 was found to have an order dated 05/12/17 for the use of bilateral 3/4 side rails for bed mobility and safety and security per resident's request. During room observations, it was found R38 had the left bed side rail up. During an interview of R38 on 06/27/19 at 02:28 PM, she was unable to state if the use of the bilateral 3/4 side rails was her request for safety and security. Review of R38's record found a consent and care plan for the use of bilateral 3/4 side rails. The care plan stated the resident preferred to have the side rails up for her comfort. However, the consent was done on R38's admission to the facility in (MONTH) of (YEAR) and since had not been re-assessed for the resident's safety or security. On 07/01/19 at 09:20 AM, during an interview with social worker designee (SWD), she verified R38's consent for the use of the side rails was done on admission. When the SWD was asked if R38 was currently capable of making the decision to use the bilateral 3/4 side rails per her request for safety, the SWD stated, No. There was no indication the facility re-assessed the use of the side rails as restraints or the risk/potential for accidents/entrapment given R38's [DIAGNOSES REDACTED]. In addition, review of the facility's restraint policy stated the use of physical restraints was to be assessed quarterly. The last annual MDS of 06/17/19 further showed the resident's side rails were used daily under MDS Section P. Interview with the DON on 07/01/19 at 02:26 PM confirmed there was to be a quarterly assessment for the use of R38's bilateral side rails. She stated it was not being documented by the IDT, and thus, the care plan was not revised to reflect the resident's current assessed status with the use of physical restraints.",2020-09-01
747,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2019-07-01,684,D,0,1,T2OW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR) and interview, the facility failed to provide the needed care and services to one resident (R)24 of 16 residents sampled. The facility failed to change R24's dressing daily as ordered. This had the potential to affect any resident that required a dressing change. As a result of this deficient practice the resident's are at high risk for infecion as the wound is not being monitored. R24 was an [AGE] year-old male who received hospice care with a terminal prognosis of Alzheimer's. Other [DIAGNOSES REDACTED]. R24 was at risk for disruption of skin integrity due to his age and skin condition. He was also at high risk for infection due to his Diabetes. On 06/27/19 at 09:00 AM, observed R24 had a clear dressing applied to his right forearm with bruising/discoloration under the dressing. RR of R24's medical records revealed the following: a. 06/25/19 cardex note entered by nursing staff that R24 received skin tear during shower b. 06/26/19 progress note entry, Seen by MD (Medical Physician) d/t (due to) skin tear that was sustained during shower with hospice staff yesterday measuring 4 cm (centimeters) x 2 cm. c. MD order was to implement the skin tear protocol, that directed staff to, Cleanse (the wound) with NS (normal saline), pat dry, apply steri-strips (holds the wound together) and thin layer of [MEDICATION NAME] then cover with [MEDICATION NAME] or non-adhesive dressing. Replace dressing daily and as needed until healed. Monitor and notify physician for signs and symptoms of infections as needed for Skin tear. d. 06/28/19 reviewed R24's care plan that revealed it did not include the recent skin tear, or the interventions of the skin tear protocol ordered by the MD. e. Nursing staff document dressing changes on the Treatment Administration Record. There was no documentation that R24's dressings had been changed on 06/26/19, or 06/27/19. On 06/28/19 at 10:12 AM during an interview with the Director of Nursing (DON) discussed R24's skin tear. Reviewed the skin tear protocol, R24's care plan, and the Treatment Administration Record. When asked if the dressing was changed and [MEDICATION NAME] ointment applied, DON said, it looks like it wasn't. DON agreed there was no documentation to indicate the dressings were changed according to MD order.",2020-09-01
748,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2019-07-01,695,D,0,1,T2OW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR), observation and interview, the facility failed to ensure that one of one resident (R) 34 sampled was provided the respiratory care and services required. Administration of oxygen (O2) therapy was not delivered as ordered by the physcian and the oxygen tubing was not changed timely. As a result of this deficient practice, R34 was at risk of potential adverse respiratory symptoms, and increased risk of potential infection. These deficiencies had the potential to affect any resident recieving oxygen therapy. Findings include: R34 had a history of [REDACTED]. This thickened, stiff tissue makes it more difficult for lungs to work properly. RR of R34's care plan initiated on 03/07/19 revealed, The resident has oxygen therapy r/t (related to) idiopathic [MEDICAL CONDITION] fibrosis. One of the care plan interventions was, Oxygen settings: O2 via nasal prongs @ 2L (liters) at all times. There were two active orders on the Order Summary report written as below: 1. Active order dated 01/23/17 O2 via nasal cannula PRN (as needed) SOB (Shortness of breath). (MONTH) titrate as needed to maintain O2 saturation 92% or above as needed. 2. Active order dated 02/15/17 Oxygen inhalation at 2 liters per minute via nasal canula every shift. Observed R34's oxygen setting at one liter (1L) on 06/26/19 at 9:30AM, 06/27/19 at 10:AM, and 06/28/19 at 03:30 PM. Observed a label on R34's oxygen tubing that read, Chg (change) 6/18. During an interveiw with R34 on 06/26/10 at 09:30 AM, inquired if she has oxygen on at all times, and she replied, Yes. On 06/28/19 at 03:30 Registered Nurse (RN5) accompanied surveyor to R34's room and confirmed oxygen was currently being delivered at 1L through nasal canula. Asked RN5 what the oxygen order was, and she replied 2L. RN5 turned the oxygen up to 2L before leaving the room. RN5 also confirmed the label on the oxygen tubing indicated the tubing should be changed 06/18/19. RN5 stated, it should have been changed. Review of facility policy and procedure titled, Oxygen Use-Oxygen Delivery Device Cleaning and Replacing dated (MONTH) 2019 directs staff to, During the course of oxygen therapy, staff should adhere to the following for proper infection control measures .Nasal cannulas and facemasks should be discarded and replaced every 14 days .",2020-09-01
749,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2019-07-01,757,D,0,1,T2OW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR) and interview, the facility failed to ensure the use of unnecessary medications include a review of the target behaviors being accurately monitored for two of five residents (Resident (R) 38, 27) selected for review. This deficient practice had the potential to affect other residents prescribed with psychoactive medications. Findings Include: 1. Random observations of Resident (R) 38 during the survey found this resident to be actively engaged in daily activities in the dining room. During a brief interview with the resident on 06/27/19 at 02:24 PM, she stated she enjoyed all the activities and was observed to be engaged working on a wooden puzzle at the time. Overview of R38's medication regimen found she was taking [MEDICATION NAME] 25 milligram (mg) 1 tab orally twice a day for her [MEDICAL CONDITION] and [MEDICATION NAME] 25 mg 1 tab orally at bedtime for her for [MEDICAL CONDITION], among other medications. Review of R38's (MONTH) 2019 Behavior/Intervention Monthly Flow Record however, found the target behaviors for both of these medications were for paranoia and hallucinations, with the side effect being tremors. The [DIAGNOSES REDACTED]. On 07/01/19 at 02:19 PM, during a concurrent RR with the DON, she stated the paranoia and hallucinations would be the observed target behaviors for [MEDICATION NAME], and the [MEDICATION NAME], should be for the depression. The DON said the licensed staff were not monitoring the target behaviors accurately as evidenced by what was written on the form. 2. Similar to R38, a review of R27's (MONTH) 2019 Behavior/Intervention Monthly Flow Record found the target behaviors listed as motor restlessness and verbal agitation, were for three medications, [MEDICATION NAME] and [MEDICATION NAME], which R27 was taking. There were no side effects listed on the form and the [DIAGNOSES REDACTED]. However, the resident also had an increase in her [MEDICATION NAME] dose with her [MEDICATION NAME] dose being reverted to the dose prior to a recent gradual dose reduction (GDR). On 06/28/19 at 02:21 PM, the DON said before they increased any [MEDICAL CONDITION] medication, her staff was to, have at least three days of documentation why we are going to increase. The DON acknowledged this was not done for R27 as evidenced by only one episode of a behavior (June 26th evening shift) on the flow record. The DON stated the licensed staff were not using the behavior flow record accurately and confirmed that the listed target behaviors were specific for the [MEDICATION NAME] and [MEDICATION NAME] use. The DON said the [MEDICATION NAME], should be separated out and is for [MEDICAL CONDITION]. There was no separate flow record for the monitoring of R27's [MEDICATION NAME].",2020-09-01
750,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2019-07-01,838,D,0,1,T2OW11,"Based on document review and interview, the facility failed to address or include the minimum requirements in the facility assessment. The facility assessment did not address staffing, include a competency-based approach to determine the knowledge skills needed, identify cultural needs, and did not involve the necessary individuals in the development to ensure a thorough assessment was done. The facility also did not identify pertinent facts that were present in their population (i.e. hospice, age). As a result of this deficiency there was the potential that resident needs were not identified and that staff may not have had the competencies to ensure residents are able to maintain or attain their highest practicable physical, functional, mental and psychosocial well-being. Findings include: A review of the facility assessment was completed. It did not include several of the minimum requirements for a thorough assessment. The facility assessment did not provide a complete description of all services offered (i.e. intravenous delivery of medication, wound care). The assessment also did not include pertinent facts that were present in the population. The facility had 50% of the residents that received hospice care, and the average age of their residents was stated and observed to be much higher than other facilities. The assessment did not include any ethnic, or cultural factors that may potentially affect the care, but was observed to have a culturally diverse population. The facility assessment did not include an evaluation of the overall number of qualified staff needed to ensure resident needs are met, and did not include a competency-based approach to determine the knowledge and skills needed (i.e. all registered nurses provide wound care, but wound care was not identified as a competency required.) On 07/01/19 at 02:18 PM during interview with the Administrator, Assistant Administrator, and Director of Nursing (DON), asked how the facility assessment was developed. DON said she knew some pieces were missing and needed to add to it. She said I developed it. It was noted there was no date on the document to identify when it was developed or when it would be up for annual review.",2020-09-01
751,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2019-07-01,842,D,0,1,T2OW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the medical record contained an accurate representation of the wound status for one of one resident (R) 5) selected for review of a pressure injury. This deficient practice had the potential to affect any future residents with pressure injuries or skin injuries. Findings include: On 06/28/19 at 09:10 AM, observation of R5's dressing change to her toes was done with RN6. The open wounds were noted to R5's right foot 5th toe, left great toe, left 5th toe and left 3rd toe (gangrenous). RN6 stated these wounds were stage 2 pressure injuries which had worsened from the time she began documenting it starting 04/18/19 on the weekly wound assessments (missing the weeks of 5/5-5/11/19 and 5/19-5/25/19). Further review found R5 had [MEDICAL CONDITION], diabetes mellitus and was declining in weight. Yet, none of these risk factors/[DIAGNOSES REDACTED]. During an interview with the DON on 06/28/19 at 01:41 PM, she said R5's toe injuries, probably an arterial ulcer. Also, at 01:59 PM, the MDS-C/RN4 said she was doing the next quarterly MDS for R5 and said she was going to code it as an arterial ulcer since, not healing and it's peripheral area and not really healing. She's due for her quarterly, so that's why back then, the matrix was coded like that. (MONTH) 18th is the day (RN6) started to document the wound. There was no distinct wound classification however, as to the accuracy and type of wound the facility was treating despite an order for [REDACTED].",2020-09-01
752,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2019-07-01,921,D,0,1,T2OW11,"Based on observation and interview, the facility failed to ensure it maintained a safe and sanitary environment as evidenced by overbed tables with edges separating and cracked in various resident rooms. Findings include: During the initial tour of several resident rooms on 06/26/19 at 10:35 PM, it was observed that one overbed table by Resident (R) 13 had its entire edge worn away and was frayed. Upon touching the edge, it was prickly and rough. On 06/28/19 at 09:29 AM, during an interview with RN6 and CNA6, they stated they use the overbed tables for resident meals and/or other uses, such as for a dressing change. When asked about the condition of the overbed tables in some of the rooms with the frayed edges, the RN6 agreed and acknowledged that some of the tables were old, in poor condition and in need of replacement.",2020-09-01
753,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2018-07-20,550,D,0,1,ZGRD11,"Based on observation, interview and record review the facility failed to treat one resident (R9) with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of her quality of life. Other residents seated around R9 all received their meals prior to R9 who had to wait up to an hour to get her tray and when the others had already finished their meal. Findings include: During a review of the electronic medical record, the quarterly minimum data set (MDS), a clinical assessment of needs, dated 05/08/18, Section G revealed that R9 needs assistance when eating (coded 3) which is an extensive assist. During the dining observation in the dining room on 07/17/18 at 11:21 AM R9 was sitting alone in her chair without her lunch tray during the lunchtime meal. R9 was awake and alert, looking around the room, smiled and lifted her right arm to wave. R9's geri chair was positioned next to another resident on her right who was independently eating her meal. At the table next to R9, there were two residents being assisted to eat by family members. At the table directly in front of R9 were four female residents who were independently eating their lunch. The table directly behind R9 had two residents eating lunch with assistance by family members. Everyone around R9 were eating or being assisted to eat. At 12:07 PM, 46 minutes after the first tray was delivered, R9 received her tray although she was sleeping in her chair. At 12:20 PM certified nurse aide (CNA)34 sat down to assist R9 to eat. On 07/19/18 at 08:32 AM R9 was sitting in the dining room with her breakfast tray on her table that contained two bowls of pureed cereal and 2 glasses of thickened liquid with 90% of the food left uneaten. The residents seated around R9 had already eaten their breakfast meal. At 08:37 AM the tray was removed by staff. During an interview with (CNA58) on 07/19/18 at 02:25 PM whom stated that some times there are only two of us to assist the residents needing help and we can't feed all of the residents at the same time. R9 sits there with all of the other residents who were eating their lunch already because that is where her seat is so she has to wait.",2020-09-01
754,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2018-07-20,580,D,0,1,ZGRD11,"Based on record review and staff interview the facility failed to notify resident (R) 13's physician of a significant weight loss of 13 pounds from (MONTH) (YEAR) to (MONTH) (YEAR). Findings include: On 07/19/18 at 10:03 AM during record review (RR) found that R13 had an unplanned significant weight loss of 13 pounds from (MONTH) (YEAR) to (MONTH) (YEAR). It was noted that R13 had a new care plan (CP) in place for unplanned/unexpected weight loss related to poor food intake that was created 07/16/18 by staff (S) 23. On 07/19/18 at 11:39 AM interviewed S23 regarding R13's CP for unexpected/unplanned weight loss. S23 explained that R13's (MONTH) (YEAR) weight, 122 lbs., was not inputted into R13's electronic medical record (EMR) after he was weighed in (MONTH) (YEAR). S23 explained that during the first week of each month facility staff weigh the residents and inputs these weights into each residents EMR in Point Click Care (PCC). S23 noticed that R13's weight was missing for (MONTH) (YEAR) and she inputted R13's weight into R13's EMR in PCC on 07/16/18. R13's weight in (MONTH) (YEAR) was 135 lbs. S23 initiated the CP for unexpected/unplanned weight loss on 07/16/18 after she discovered the significant weight loss. Inquired if S23 notified the physician of R13's significant weight loss and she stated no. On 07/19/18 at 02:15 PM interviewed S4, who stated that she takes the weights of each resident the first week of the month and logs the weights for all the residents in the EMR in PCC and gives a copy of the Weighing Report to Director of Nursing (DON) with notations of resident weight loss of five pounds or more. S4 stated that she did notate the 13 pound weight loss with R13. Inquired if S4 inputted R13's weight into R13's EMR in PCC and she stated that she believed that she had. S4 appeared shocked when she was shown that S23 had inputted the information into R13's PCC EMR on 07/16/18. On 07/19/18 at 03:17 PM interviewed DON who denied receiving a copy of the Weighing Report for (MONTH) (YEAR), stated that since the facility got Point Click Care (PCC) software last year she no longer gets a paper copy of the weights, that she looks in PCC and will see the significant weight change on her computer dashboard. DON stated that she was not aware of R13's significant weight loss until Monday, (MONTH) 16, (YEAR). DON confirmed that R13 had a 13 pound weight loss from (MONTH) (YEAR) to (MONTH) (YEAR). DON denied being told of this weight loss and stated that S4 would have notified her or RN35. DON denied notifying the physician of R13's significant weight loss. Inquired if any nurse, who worked with R13, documented notifying the physician of R13's significant weight loss and DON stated this information was not found in R13's EMR progress notes. DON confirmed that this would have been documented if it was done. Inquired if this is the practice at the facility, to notify the physician if a resident has a significant change, and DON confirmed that is the facility practice. Requested a copy of facility policy for significant weight loss and was given the[NAME]Malamalama Weight Loss Protocol. Noted the following in the facility's Weight Loss Protocol #1; the Rehabilitative Assistant (RA) will weigh the resident within 24 hours of admission to establish a baseline, then at the beginning of each month thereafter. Also noted the facility's Weight Loss Protocol#10; if resident continues to lose weight (non-intentional) the physician will be notified for medical evaluation and possible lab work. 07/20/18 10:59 AM interviewed Registered Nurse (RN)35 who confirmed that S4 told her of R13's significant weight loss of 13 pounds from (MONTH) (YEAR) to (MONTH) (YEAR). RN35 stated that she did not notify the physician of this significant change with R13. RN35 stated that she notifies the physician if there is a critical value. RN35 stated that from this experience she was told that a weight loss of five pounds or more is reportable to the physician.",2020-09-01
755,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2018-07-20,584,D,0,1,ZGRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to provide a safe commode, in the bathroom between rooms [ROOM NUMBERS], and failed to provide a clean shower room, in good repair, between rooms [ROOM NUMBERS] . Findings include: 1) On 07/18/18 at 01:58 PM while walking from room [ROOM NUMBER] to 11 with CNA7 noted that the commode in the bathroom between rooms [ROOM NUMBERS] had brownish orange areas underneath the seat and all along the legs. CNA7 stated that the brownish orange areas were rust. Spoke with Director of Nursing (DON) who directed that S41 should be interviewed but was gone for the day but she will inform him to expect to be interviewed tomorrow. On 07/19/18 at 08:57 AM interviewed S41 and DON regarding commode in bathroom between rooms [ROOM NUMBERS] and DON stated that the commode is on order and that they were aware of the condition of the commode. DON stated that she would provide a copy of this order with the date when the order was placed. On 07/20/18 at 12:20 PM interviewed DON again, requested the copy of documentation that she had ordered the commode chair prior to 07/18/18 when she was questioned about the commode and she stated that she called the vendor and they told her that they would give her a note stating that she placed the order before 07/18/18 and she said it was ok that she would take the tag. DON did not produce an invoice of order for the commode that was placed prior to 07/18/18 before end of survey. 2) On 07/19/18 at 11:15 AM the shower room in between room [ROOM NUMBER] and 8 revealed a thick coat of dust on the ceiling vent and the floor was dirty with several cracked and missing tiles. During an interview with S44 on 07/20/18 at approximately 9:45 AM in the shower room, the findings were discussed. S44 who agreed that the shower room vent and floors were in need of cleaning and repair.",2020-09-01
756,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2018-07-20,656,D,0,1,ZGRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation, the facility failed to care plan for R1's fungal infection of the mouth, and R26's anticoagulant use. Findings include: 1) On 07/17/18 at 07:59 AM , record review revealed progress note dated 07/03/18 that reflected that R1 started antifungal medication, [MEDICATION NAME] suspension, 5 ml by mouth, four times a day, for ten days for lower gums not improving. On 07/18/18 at 07:31 AM, review of care plan reflected care plan initiated 7/12/18 does not reflect any interventions for R1's fungal infection of the mouth. On 07/18/18 at 11:06 AM, interviewed S22 who searched in facility's electronic medical record and confirmed the fungal infection was not care planned. On 07/18/18 at 11:15 AM, observed R1's mouth with S22 who confirmed that the fungal infection was not fully resolved. 2) On 07/16/18 at 10:45 AM during family interview, R26's family reported that resident is taking Xarelto for an irregular heartbeat. On 07/18/18 at 12:09 PM Record Review (RR) for anticoagulant found that R26 did not have a care plan (CP) in place for use of Xarelto but there is a problem listed on her CP, The resident has altered cardiovascular status r/t chronic [NAME]Fib. There is no mention of an anticoagulant and side effects to monitor for. On 07/18/18 12:20 PM interviewed S23 and she confirmed that R26 is taking Xarelto, an anticoagulant, used to treat R26's [MEDICAL CONDITION] Fibrillation and confirmed that this medication was not in R26's CP and it should have been. Noted that this information was captured in R26's quarterly Minimum Data Set (MDS), a clinical assessment of resident needs, dated 06/12/18. S23 stated that this medication (Xarelto) should have been in resident's CP along with the interventions to monitor for side effects.",2020-09-01
757,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2018-07-20,677,D,0,1,ZGRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assist three residents (R) 13, R27 and R37 who required assistance to eat during meal times. Findings include: Record review (RR) of R13 and R37's annual MDS dated [DATE] and 07/01/18 respectively identified that these residents require total dependence-full staff performance requiring one person physical assist during meal times. RR of R27's quarterly Minimum Data Set (MDS), an assessment of clinical needs identified that R27 requires Supervision-oversight, encouragement or cueing and setup help only by staff. On 08/07/18 at 1:51 PM called DON who assessed that R27 as total dependence at meal times. On 07/17/18 at 12:02 PM during lunch observation found three residents (R13, R27 and R37) sitting in their geri chairs in front of the television waiting to be assisted with their meal. R13, R27 and R37 sat in the front of the dining room as other residents ate their lunch. R27 appeared alert with his eyes open, looking around. R13 and R37 both rested and opened their eyes periodically. These three residents had their hands cleaned with hand sanitizer and lotion applied by staff during the time they waited. At 12:11 PM R27's lunch was set up and he was assisted by CNA19. At 12:16 PM R37's lunch was set up and resident was noted to be sleeping and the tray of food was taken away. R37 was reclined in her geri chair and left sleeping near the table. At 12:28 PM inquired with CNA19 if R13 had been assisted with his lunch and noticed that his clean clothes protector was placed on his chair and had not been used. CNA19 asked CNA11 if R13's food was still available and CNA11 looked at R13 and appeared startled. Inquired with CNA11 and CNA4 why they cleared away dirty plates from other residents when no one had assisted R13 with his lunch. CNA4 stated that she had asked her coworker if R13 was sleeping and she thought he was still sleeping. Inquired if CNA4 should have checked to see if R13 was awake and she agreed that she should have checked on R13 to see if he was awake before clearing away dirty dishes. When asked what the priority is for staff at meal time CNA4 stated that residents eat their meal. Noted at this time that R37 was not at her table, had not eaten her lunch and was taken back to her room in her geri chair. At 12:35 PM went to R37's room to check on her and found her sleeping in her geri chair next to her bed. On 07/17/18 at approximately 2:30 PM met with DON to discuss the lunch observation. DON stated that she talked with the staff and they told her that they were nervous which affected how they did their job. DON told staff to do their job as they have been taught and how they normally work. DON also stated that she assisted R37 with her lunch in her room.",2020-09-01
758,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2018-07-20,689,D,0,1,ZGRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to lock the door to the storage closet where chemicals are used by the housekeeping and maintenance staff. The deficient practice placed the residents at an increased risk for accidents due to exposure by inhalation or ingestion of toxic chemicals. Findings include: During a visit to rooms [ROOM NUMBERS] on 07/16/18 at 11:15 AM the supply closet door between the two resident rooms was found unlocked. Contents of the closet contained several small cans of abrasive cleaners with bleach and gallon containers with clear liquid and labeled with the word hazardous, caution, etc. The outside of the door contained a large sign stating Keep door locked at all times and a hazardous materials (hazmat) biohazard sign. At 11:20 AM, the Director of Nursing (DON) was taken to the supply closet and made aware of the unlocked door. She locked the closet and stated that it should be kept locked since it contains toxic chemicals.",2020-09-01
759,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2018-07-20,757,D,0,1,ZGRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR) and staff interview the facility failed to provide adequate monitoring for R13's antidepressant ([MEDICATION NAME]), antipsychotic (Quetiapine) and anticonvulsant ([MEDICATION NAME]) which are ordered for the following [DIAGNOSES REDACTED]. Findings include: On 07/18/18 at 12:05 PM during RR found that R13 had a care plan (CP) in place for physically aggressive behavior with an intervention to administer medication as ordered. Monitor/document for side effects and effectiveness. Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes in behavior log. 07/18/18 05:05 PM interviewed R13's family member regarding R13 taking [MEDICATION NAME] and she stated that she wanted him to continue to take this medication to keep him stable. R13's family member reported that last year R13 was at a day program and became agitated and was taken to Queen's ER to be treated and he was given [MEDICATION NAME]. R13's family member stated that his doctor discontinued the [MEDICATION NAME]. R13's family member wants to see how R13 does taking only [MEDICATION NAME] at the prescribed dose and maybe later lower the dose of [MEDICATION NAME] in the future. On 07/20/18 at 11:00 AM interviewed Registered Nurse (RN) 35 who stated that the charge nurse monitor's R13's behavior and side effects from [MEDICATION NAME], Quetiapine and [MEDICATION NAME] and documents this on the Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR). Noted that R13's sheet had 4 medications listed (as stated earlier) and 2 behaviors (yelling/verbal agitation and resistive to care) listed but nothing was listed for side effects. RN35 stated that they list the side effect if it is seen. Inquired how would anyone know which side effect was related to the four medications being monitored and RN35 was unable to answer.",2020-09-01
760,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2018-07-20,791,D,0,1,ZGRD11,"Based on interview and record review the facility failed to assist the Resident (R)3 in obtaining routine dental care. The deficient practice placed R3 at risk for a decline in nutrition and a decrease in optimal health due to the loss of a crown. Findings include: During an interview with R3's family member F1 on 07/16/18 at 10:46 AM stated my wife lost a crown while she was eating and needs a new one, I guess I have to take care of this. I don't think the facility can help with this because it isn't an emergency. She is a heavy transfer and they use a lift to put her into bed. I talked to my dentist and he said that he is not sure how to get her into the dentist chair. We also need to transport her there, which presents a problem. Reviewed the most recent inter-disciplinary team (IDT) meeting notes. No documentation noted that there was a dental concern for R9. During an interview on 07/18/18 11:25 AM the Minimum Data Set (MDS) coordinator stated that she was aware of R3's lost crown and that the facility will usually tell the family if they need dental care and if they would like to have the teeth checked by an outside dentist,we can help them with that. F1 mentioned that R3 needed a new crown. An interview was conducted with the social worker designee (SWD) on 07/18/18 at 10:40 AM whom stated that she is aware that R3 needs a new crown and that F1 will need to make the arrangements. She stated that R3 can eat okay without it.",2020-09-01
761,HALE MALAMALAMA,125050,6163 SUMMER STREET,HONOLULU,HI,96821,2018-07-20,812,D,0,1,ZGRD11,"Based on observation, certified nurse aide (CNA) 29 failed to prepare resident (R) 4's lunch drinks (water and supplemental drink) in a sanitary manner in accordance with professional standards for food service safety to prevent the spread of infection. Findings include: On 07/20/18 at 10:53 AM observed CNA29 take R4's lunch tray from the food cart and walk to R4's room. Followed CNA29 into R4's room and observed CNA29 assist R4 set up her lunch tray. CNA29 assisted R4 to a sitting position in her bed, told R4 that it was lunch time and that she was going to assist her. CNA29 performed hand hygiene before taking lids off of the food container and cups. It was noted that R4 was to have nectar thick fluids and CNA29 brought in the container of Hormel Thick and Easy Instant Food and Beverage thickener to add to R4's drinks. CNA29 used a clean spoon to add thickener to each cup and stirred the beverages. It was noted that the liquids were not thick enough and CNA29 needed to add more thickener to each cup. S29 proceeded to stick her ungloved right hand into the container of thickener and dig to reach for the blue scoop that was in the container. At this time CNA29 was asked to stop. It was explained to CNA29 that whatever is on her hand would end up in the resident and could make her sick. On 07/16/18 at 11:53 AM met with DON to discuss what occurred and inquired if this was the practice at the facility and she concurred that this never should have happened. DON confirmed that staff are trained on how to assist resident's with meals and also are provided training on infection control annually.",2020-09-01
762,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2019-01-14,684,D,0,1,4G8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to obtain a physician order prior to administering oxygen to (R)68, obtaining an order for [REDACTED]. Findings Include: R68 was observed on 01/08/2019 at 09:05 AM receiving oxygen via nose prongs (nasal cannula). Review of physician's orders for R68 did not reflect that resident had order for use of oxygen. Progress note dated 01/08/19 at 06:30 AM written by S28, a registered nurse, reflected that resident was receiving oxygen. Progress note dated 01/08/19 at 02:14 PM written by S53, a registered nurse, reflected that resident was receiving oxygen. On 01/14/19 at 06:17 AM Interview with S2, Director of Nursing, S135, Nursing Home Administrator, and S12, Regional Health Director. S2 validated that R68 did not have a physician order for [REDACTED]. S53 validated she was aware that there was no physician order for [REDACTED]. S28 verbalized that since R68 was a hospice resident that there was already a physician order for [REDACTED].",2020-09-01
763,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2019-01-14,686,D,0,1,4G8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent one Resident (R)82 from developing a pressure ulcer to left and right heels. The deficient practice increased R82's risk for pain and infection. Findings include: During an observation and interview with R82 on 01/08/19 at 11:31 AM who stated I have a problem with the skin, they're putting medicine on my heels every day. R82 was laying supine in bed. Noted R82 with dry flaky skin to his face and arms with a large dark bruise to the right forearm. On 01/10/19 at 08:54 AM R82 observed laying supine awake in bed with socks on. The right heel elevated and floating on a pillow, the left heel with an inflated heel protection device. The bed noted to have an air mattress. Health status admission notes dated 11/27/18 reviewed: Newly admitted resident came in at 12:00 PM via wheelchair. admitted with acute [MEDICAL CONDITION]. History of ischemic [DIAGNOSES REDACTED] and status [REDACTED]. No complaints of pain or discomfort at elbow hematoma. Multiple bruises right and left hands. Skin is dry and fragile. Health status note dated 01/03/19 Noted two open areas to R82's right lateral foot, scant bleeding noted. Cleansed with NS, pat dry, applied [MEDICATION NAME] and covered with dressing. Will continue current plan of care. Skilled note dated 01/04/19 reviewed, dark discoloration to right mid outer foot cleaned and applied with dry dressing. Dark discoloration to right heel cleaned then wrapped with dressing, no active bleeding noted or unusual drainage noted. Bilateral foot elevated and floated with pillow. R82 uses the wheelchair for ambulation. R82 needs x 1 extensive assist with bed mobility and is independent with meals. Progress notes dated 01/05/19 reviewed: Acquired right heel pressure unstageable slough/ eschar, first observation no reference. Physician (MD) notified, R82 and wife notified. Necrotic tissue (eschar) present (brown, black, leather 100% of necrosis in the wound bed. Two centimeters (cm) x 1.8 cm x 0 Treatment: Cleanse with normal saline, pat dry, apply [MEDICATION NAME] and cover. Care plan reviewed, 01/05/19 deep tissue injury (DTI) to right lateral foot and unstageable to right heel. 01/07/19 DTI to left heel. R82's disruption of skin surface will remain free from infection and show evidence of healing by next review date. Air mattress to bed. Educate R82 and/or family regarding skin condition and treatment. Elevate heels off bed. Left heel boot applied while in bed. observe for pain and medicate per physicians orders. observe for signs and symptoms of infection or delayed healing and report to physician. Provide diet as ordered. Weekly skin checks. Nutrition note dated 01/10/19 reviewed, will add prosource every day to benefit wound healing. Orders dated 01/10/19 reviewed Prosource 30 ml one time a day for wound healing. During an interview with registered nurse (RN)134 on 01/15/19 at 11:31 AM who stated R82 acquired the pressure sores here, it was identified on 01/04/19. We were in the process of switching over to point click care, the new computer program when the skin assessment was missed. Otherwise it would have been avoided. Wound care is being done by two wound care nurses, they come in weekly and also for the admissions. The staff nurses change the dressings daily. When the wound care nurses come in they update their notes in the computer with the wound assessment tool. As soon as the pressure ulcers were identified an air mattress was implemented.",2020-09-01
764,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2019-01-14,842,E,0,1,4G8S11,"Based on record review, staff interview, and review of policy, the facility failed to use approved abbreviations and/or acronyms when charting in the progress notes, for four out of the eight residents reviewed. With this deficient practice, there was a risk of misinterpreting the un-approved abbreviations and thus causing adverse outcomes for any, or all of these residents. Findings Include: 1. During review of the progress notes for Resident (R) 2, the following abbreviations/ acronyms were used, in various places, in the progress notes: dtr, RP, L[NAME], and GTF. According to facility policy, these abbreviations/acronyms were not approved to be used for charting. 2. During review of the progress notes for R12, the following abbreviation/acronym was used, in two different places, in the progress notes: SCS[NAME] According to facility policy, this abbreviation/acronym was not approved to be used for charting. 3. During review of the progress notes for R46, the following abbreviation/acronym was used, in two different places, in the progress notes: RP. According to facility policy, this abbreviation/ acronym was not approved to be used for charting. 4. During review of the progress notes for R55, the following abbreviation/acronym was used in the progress notes: ST. According to facility policy, this abbreviation/acronym was not approved to be used for charting. During an interview with the Health Information Manager (HIM), on 01/10/2019 at 01:06 PM, HIM acknowledged that all the abbreviations/acronyms (as mentioned above) were not approved by the facility and may be misinterpreted. A review of facility policy on the Use of Abbreviations, Acronyms, and Symbols read the following: Policy - In order to avoid misinterpretation, abbreviations, acronyms, and symbols are used in the medical record only according to the Life Care and/or facility-approved abbreviation list. To ensure the safety of our residents, facilities also comply with the standard LCCA Do Not Use Abbreviation List which was provided. Procedure - the HIM staff are responsible for monitoring the use of abbreviations in the medical record. A printed list of acceptable abbreviations, acronyms, and symbols is available to all individuals documenting in the medical record and to those who must interpret information in the medical record. If a facility commonly uses abbreviations, acronyms, or symbols that are not in the standard list, the additional terms must be approved by the Performance Improvement Committee. They are then added to the facility's abbreviation list and this policy manual.",2020-09-01
765,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2019-01-14,883,D,0,1,4G8S11,"Based on record review, staff interview, and review of policy, the facility failed to provide education regarding benefits and potential side effects for a Influenza Vaccination that was given to one Resident ((R) 7) out of the two residents reviewed. As a result of this deficient practice, R7 and/or R7's Representative was not given the opportunity, or even the discussion, of minimizing the risk for acquiring, transmitting, or experiencing complications from the Influenza vaccination. Findings Include: During a review of the immunization record for R7, it was noted that R7 received the Influenza vaccination on 10/12/2018. However, after further record review, there was no documentation noted that the resident and/or resident's representative was provided education regarding the benefits and potential side effects of the influenza vaccination. During staff interview, on 01/10/2019 at 02:20 PM, the Unit Manager (UM) 86, verified that there was no documentation saying that education regarding the benefits and potential side effects was provided to R7 and/or R7's representative. UM86 also acknowledged that the form titled Informed Consent for Influenza Vaccine, in which the form is used in conjunction with administering the vaccine, was not filled out and missing. A review of the facility policy on Influenza Vaccine read the following: Procedure - Influenza Vaccine. 1. Education is provided to the resident or the resident's representative regarding benefits and potential side effects of the immunization . Education, assessment findings, administration, refusal or did not receive due to medical contraindications, and monitoring are documented in the resident's medical record. Recommendation for documentation include: Education - by nurse on the education flow record . As previously mentioned there was no documentation saying that education regarding the benefits and potential side effects was provided to R7 and/or R7's representative.",2020-09-01
766,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2019-01-14,908,E,0,1,4G8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of facility policy, and review of equipment service manual, the facility failed to ensure routine maintenance, based on manufacturer's recommendation, were done for two out of three oxygen concentrators reviewed for residents receiving hospice care. This deficient practice put the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: During observation, on 01/09/2019 at 10:38 AM, of Residents (R) 46 and 55, it was noted that both residents had an order for [REDACTED]. On 01/10/2019 at 10:45 AM, queried the Maintenance Director (Maint Dir) and asked who was responsible for preventive maintenance on these Oxygen Concentrators. Maint Dir stated that hospice was responsible. However, nobody was able to show records validating the preventive maintenance was being done. A review of the Service manual for the Perfecto2 V Oxygen Concentrator, Section 6 - Preventive Maintenance revealed the following: Cleaning the cabinet filter. There is one cabinet filter located on the back of the cabinet. 1. Remove the filter and clean at least once a week depending on environmental conditions. Note: Environmental conditions that may require more frequent cleaning of the filters include but are not limited to; high dust, air pollutants, etc. 2. Clean the cabinet filter with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. 3. Dry the filter thoroughly before reinstallation. As previously mentioned, there was no record of this preventive maintenance being done. A review of facility policy on Oxygen Administration/Safety/Storage/Maintenance revealed the following: Preventive Maintenance - A separate log for each unit shall be kept for all preventative maintenance completed per State and Joint Commission regulations. This log should be kept current and stored in an area designated by either the Executive Director or Director of Nursing. As previously stated, there was no record of the preventive maintenance being done. During a follow up interview on 01/10/2019 at 01:00 PM, the Maint Dir acknowledged that the preventive maintenance on the Oxygen Concentrators were not being done, as per manufacturer's recommendation. Maint Dir went on to say that they will work on taking care of this issue.",2020-09-01
767,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,550,D,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident was treated with dignity and respect, and that staff's interaction with residents took into account the physical limitations of the resident and failure to appropriately communicate or provide services for them. The failure to provide the residents with respect and dignity occurred for two of 19 residents (Residents (R) 132 and 1[AGE]) selected for review. This deficient practice had the potential to affect all residents residing in the facility. Findings Include: 1) R132 was admitted on [DATE] for short term rehabilitation (STR) services. During an interview with R132 on 02/26/20 at 10:28 AM, R132 could express her thoughts and sentences slowly, and described a particular event involving a night shift staff who recently cared for her. During her interview, R132 stated a certified nurse aide (CNA) on the night shift who, worked two nights ago told her, hurry up, hurry up in order to toilet her. R132, who wore a neck brace due to [DIAGNOSES REDACTED]. R132 stated, She did not treat me with respect and dignity. During the facility's separate, concurrent abuse investigation of this event, a certified nurse aide (CNA53) was identified from the staffing schedule and interviewed on 02/27/20 at 04:42 PM by the surveyor. CNA53 verified she knew who R132 was and was assigned to her during the 02/25/29 night shift from 10:00 PM to 6:00 AM. CNA53 stated R132, is a non-compliant resident who would stand often and, moving to go to the bathroom. CNA53 said she told R132, If you fall down, your husband will be mad and I will be liable for you because I'm on duty that's why. CNA53 said she told R132 this only once to make the resident aware. CNA53 said she knew it was not respectful to say this to R132. CNA53 acknowledged she became frustrated with R132 and said, Maybe because that night she keeps standing and I saw already she go open bathroom alone and I saw her finish going to the bathroom already. And before going home, I saw her again in the hallway. CNA53 also said on that night shift, she had a total of three restless residents which added to her frustration. CNA53 however, recognized and stated it was not respectful telling R132 that she would be a liability to her, especially since R132 required frequent supervision based on CNA53's interview. 2) Resident (R)1[AGE] was admitted to the facility on [DATE]. During an interview on 02/25/20 at 10:17 AM, R1[AGE] stated to this surveyor that he/she is wearing a diaper. They put it on him/her. Surveyor asked, Is it ok with you? R1[AGE] replied No. Observation on 02/27/20 at 0700 AM where R1[AGE] was brought to the activity/TV area. Surveyor observed R1[AGE] in activity room from 0700 AM until 10:59 AM. AT 11:00 AM, he/she went to the main dining area for ice cream gathering. R1[AGE] returned to the activity area after the ice cream gathering from the main dining area around 12:40 PM. R1[AGE] remained in the activity/TV area until 0200 PM. Interview at 02:02 PM - queried with R1[AGE] if his/her diaper had been changed. R1[AGE] said no. Interviews: Query with registered nurse (RN)10 and certified nurse's assistant (CNA)5 if R1[AGE]'s diaper could be checked. Accompanied staff to room with diaper change. At the bedside, it was noted that R1[AGE]'s diaper was saturated with urine. Upon questioning of staff, CNA5 stated that R1[AGE] had not been changed since the am. R1[AGE] re-iterated to RN10 and CNA5 that he/she does not like using a diaper. RN10 and CNA5 agreed that sitting in a wet diaper for six hours could lead to urinary tract infection [MEDICAL CONDITION] and pressure sores. RN10 stated that they could trial using a urinal for urination. The resident suffered for six hours with a saturated diaper for six hours. This deficient practice placed the resident at a potential risk of urinary tract infection and skin breakdown. This practice denies R1[AGE] of his right to self-determination and a dignified existence.",2020-09-01
768,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,578,E,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to obtain documentation that a resident or a resident's representative was given an opportunity to formulate advanced directives or had an advanced directive for 4 of 19 residents (Residents (R) 130, 135, 26 and 15) selected for review. This deficient practice had the potential to affect existing and new residents admitted to the facility. Findings Include: The facility's policy, Advance Directives, (Effective [DATE]), stated, Procedure 2. The Admissions Director or designee interviews the resident and/or family upon admission to determine the need and knowledge relative to advance directives. If the resident has an advance directive, the social worker will request a copy of the directive so that it may become part of the medical record. Documentation of such directives are placed in the Social Services progress notes. The resident's attending physician is made aware of such, and the appropriate orders are incorporated into the resident's care plan. 1) R130 was admitted to the facility for a short term stay on [DATE] to receive skilled rehabilitation services. Review of R130's record on [DATE] at 07:00 AM with the Assistant Director of Nursing (ADON) found on admission, a resident could have a surrogate named, but the social worker was to speak to the resident about it. R130's record review found no clinical documentation that R130's listed surrogate, or the resident himself, received any information about creating an advance directive. 2) For R135, on [DATE] at 04:01 PM, Registered Nurse (RN) 131 confirmed this resident did not have an advanced directive. RN131 said on admission, the social workers were to talk to the residents to offer to make an advanced directive or to see if they already have one. She verified there was no information in R135's record about any other surrogacy or a representative being offered the AD information. On [DATE] at 05:48 PM, the Nursing Home Administrator (NHA), stated they have begun auditing their advance directives on the Wailani unit first and will continue with the Keolamau unit. The NHA stated another surveyor had already discussed this with them and they implemented a performance improvement project (PIP) for it. The NHA acknowledged the listed number of 90 residents having an AD was incorrect and a correction would be made onto the C[CONDITION]-6[AGE] form. 3) During a record review (RR) on [DATE] at 09:58 AM, only a POLST was found in the chart. Interview with the social worker (SW) on [DATE] at 10:38 AM was done SW stated the surrogacy was given to the unit manager. The surrogacy is R26's wife. Queried if the discussion with R26's wife was done regarding advanced directives. SW stated that she has not discussed the advanced directive with R26's wife. Clarification was discussed regarding surrogacy and advanced directives with the SW as per her/his request. SW stated he/she was clear on the difference of being the surrogate and advanced directives. SW stated that the discussion for advanced directives did not occur and verbalized understanding that discussion would need to occur to meet this requirement. 4) Surveyor reviewed medical record (hard chart) for R15. No advanced healthcare directive (AHCD) found. physician's orders [REDACTED]. Surveyor reviewed R15's care plan review date [DATE]: Focus. R15 has no Advanced Directive (AD) in place. Resident newly completed POLST reflects CPR - Full Treatment, dated [DATE]. Date initiated [DATE]. R15 Advanced Directives will be honored. Will assist R15 with completion of AD. Will acknowledge and empower R15 decision making ability. Encourage R15 to complete her Advanced Healthcare Directives. Review date [DATE]. Surveyor interviewed Social Services Director (SSD) on [DATE] 0 at 01:48 PM who stated there is no AHCD in the record, she only has a POLST. Her husband is her Designated power of attorney (DPOA) although she still has decision making capacity.",2020-09-01
769,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,622,D,0,1,U7Q511,"Based on interviews, record and policy reviews, the facility failed to provide the necessary documentation (as outlined in this regulation) to a receiving provider for one resident out of 19 sampled residents (R47). This documentation is needed for a resident's safe and orderly transfer and continuity of care. The missing documentation includes: a written paragraph documented by the resident's physician about the necessity of the resident's transfer and a document of the resident's comprehensive care plan goals. Finding Includes: During record review on 02/26/20, no documentation was found by R47's physician regarding the reason for his transfer. An eINTERACT Transfer Form V4.1 was found for R47 which covered basic care provisions. In an interview with registered nurse (RN) 130 on 02/28/20 @ 08:58 AM, she was asked what documents are sent to a receiving provider when a resident is transferred. She stated that the facility sends the resident's physicians orders for life sustaining treatment (POLST) document, discharge summary from the resident's last hospitalization , an order summary (document listing all current orders for care by the physician) and the resident's family is notified. She stated that the comprehensive care plan is not sent. The Transfers and Discharges policy was reviewed. Documentation from the resident's physician is needed when: transfer or discharge is necessary due to the resident's welfare and needs being unable to be met in the facility. The transfer responsibilities of nursing include submitting the resident's comprehensive care plan goals.",2020-09-01
770,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,623,D,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR) and interviews, the facility failed to notify the Resident (R) representative in writing of the transfer or discharge for one of 19 residents (Resident (R) 26) selected for review. This deficient practice had the potential to affect all residents residing in the facility. Findings Include: On 02/25/20 at 01:52 PM, an interview with R26's representative was done via telephone. R26's representative lives on another island. She/he stated that she did not receive a phone call or a notice in writing when R26 was being admitted to the hospital in December of 2019. Record review (RR) on 02/27/20 was done. RR did not show a notice of transfer or discharge to R26's representative. In conclusion, the facility did not sent out a written notice to resident's representative and this deficient practice would affect all the residents in the facility. On 02/27/20 at 01:00 PM, an interview was done with Registered Nurse (RN) 130. RN 130 stated that she personally called R26's representative and could not get a hold of her and then left a message with R26's relative. However, RN130 stated that she did not send out a written notice. On 02/27/20 at 05:02 PM, a interview with multi data system (MDS) coordinators was done. MDS confirmed that R26 was hosptalized on [DATE]. Record states resident had essential primary hypertension.",2020-09-01
771,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,656,D,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews (RR), the facility failed to adequately care plan the use of transfer equipment for one of 32 residents (R68) sampled for survey. The facility did not establish, document and implement the proper use of a slide board and gait belt to maintain R68's highest practicable quality of care and services. Findings Include: On 02/25/20 at 10:12 AM interviewed R68 as part of initial pool sample. Questioning about any recent falls in facility and R68 responded that he/she was dropped to the floor by CNA51 approximately two weeks ago. According to R68, a slide board is used to transfer from the bed to a wheelchair, and CNA51 never transferred her using the slide board. R68 told CNA 51 that transfer with slide board should be with 2 people but CNA51 insisted that she could do it. During the transfer procedure CNA51 couldn't hold on to R68 and had to drop him/her to the floor. R68 stated that had increased pain to left (L) groin area that was relieved with [MEDICATION NAME]. The minimum data set (MDS) with assessment reference date (ARD) 02/05/20, for R68's functional status, included extensive assistance for bed mobility and transfers that required two people to assist. The MDS balance during transition codes noted that R68 was not steady, and only able to stabilize with human assistance for surface-to-surface transfers (e.g. bed to wheelchair). The MDS also coded R68 with limitation in range of motion (ROM) to both sides of the lower extremities, and used a wheelchair for mobility. The MDS coded R68 on a scheduled pain regimen in the last five days and was on opoids on admission. For the MDS assessment R68 was a participant and the activity of daily living (ADL) and rehabilitation potential care area was triggered for this ARD as well. On 02/27/20 at 11:31 AM reviewed R68's electronic medical record (eMR) and noted care plan (CP) for ADL self-care deficit as evidenced by needs assistance with daily care related to disease process/condition: spinal stenosis, ., s/p T9-10 decompression on 01/21/2020; weakness; and presents with impairments in balance, dexterity, gross motor coordination, mobility, strength (ADLs/Mobility). The interventions included: requires extensive assistance by (1) staff to turn and reposition in bed and as necessary; and, requires extensive assistance by (1) staff to move between surfaces and as necessary. The CP for at risk for fall related to injury as evidenced by history of fall, with fall score >10 unable to perform test for balance without physical support; use of assistive devices (wheelchair and front wheel walker); other decline in ability to perform functional activities without physical assistance, dynamic balance, functional ambulation, and functional mobility, static balance, and strength; noted history of fall on [DATE]. Interventions included: gait belt on with all transfers created on [DATE] ; when rising from a lying position, sit on side of bed for a few minutes before transferring/standing. On 02/27/20 at 2:19 PM interviewed CNA45 and reviewed R68's kardex with her. R68's kardex noted under transfer that resident required extensive assistance by (1) staff to move between surfaces, and as necessary per rehab, to transfer using slide board. Under mobility it was noted that gait belt on with all transfers. The MDS with ARD of 02/05/20 was not reflected in R68's CP for extensive 2 person assistance for transfers and bed mobility. Also, R68's CP did not include the use of the slide board for transfers and the use of a gait belt until after the fall. The nursing CP was separate from the rehab CP and interventions to provide quality care and services to R68 was not measurable.",2020-09-01
772,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,657,E,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to include appropriate goals and interventions for seven residents (Residents (R)15, 61, [AGE], 26, 9, 21 and 132) in the sample. For example, the deficient practice left one resident (R15) without psychosocial treatment for [REDACTED]. R15 has [MEDICAL CONDITION] due to noncompliance with type 2 diabetes due to negative behaviors refusing care. Complications of the disease included a high A1C, [MEDICAL CONDITION] (CKD), diabetic retinopathy and [MEDICAL CONDITION]. The deficient practice placed the resident at a potential risk of vision loss related to her uncontrolled history of type 2 Diabetes. A second Resident (R61)'s care plan did not include interventions for fall prevention that were appropriate for the resident's cognitive status due to a [DIAGNOSES REDACTED]. A third resident, R[AGE]'s care plan was not followed with treatment recommendations to ensure she received restorative care for her left upper extremity which was contracted. The other four residents (R26, 9, 21 and 132) were also affected by this deficient practice, and there is a potential for all other residents to be affected as well. Findings Include: 1) Surveyor reviewed R15's medical record. Nurse Practitioner (NP)10 notes dated 0[DATE] state R15 is a [AGE] year-old female with weakness, history of stoke, Diabetes mellitus type two with renal manifestation, major [MEDICAL CONDITION], mood swings, [MEDICAL CONDITION] [MEDICAL CONDITION], severe obesity with BMI >40 [MEDICAL CONDITION]. R15 is non-compliant with medication regiment. [MEDICAL CONDITION] stage 5, labs done on 05/2019 Creatinine - 3.15, GFR - 14. No eye exam found in hard chart. MDS quarterly review dated 12/31, 2019. Vision coded as adequate and 1. corrective lenses. R15 care plan with review date 01/03/20, no interventions in the care plan to appropriately address the refusal of care and going against medical advice, and noncompliance behavior. The following interventions are written in the care plan: Administer medications as ordered. Allow extra time for R15 to respond to questions and instructions. Communicate with R15 family members about her capabilities and needs. Discuss concerns about confusion, disease process, R15 / family/ caregivers. Face and speak clearly when communicating with R15. Surveyor interviewed the physician (MD) on 02/28/20 at 10:31 AM to inquire if R15 had an eye exam for R15. MD stated that R15 often and frequently refuses care, adding that she refuses to go out for appointments and that the biggest concern is that she is stage 5 CKD and she also refuses to have [MEDICAL TREATMENT]. Surveyor asked the MD why is R15 refusing her [MED]. MD responded that she doesn't like to get poked. Surveyor reviewed the inter disciplinary team (IDT) meeting notes from the care plan conference record on 01/02/20. Resident continues to refuse blood sugar checks, labs pending, resident only wanting to get labs drawn at an outpatient clinic. Frequent refusal of care. Continue current plan of care. The facility is addressing the refusal behaviors in the IDT notes, it was noted in the progress notes that certain staff can give R15 her [MED]. Reviewed the MAR and noted R15 only refused her [MED] in the morning. The evening nurse was able to give the [MED]. There was no documentation in the record that there was a discussion between the Resident and the physician (MD) about refusing the [MED] and the harmful repercussions, i.e. [MEDICAL CONDITION] (CKD) for doing so, or that the MD addressed the concerns and changed the treatment plan. There was no discussion documented in the IDT notes that certain staff were able to give the [MED] and finally, there were no care plan interventions in place to address residents' behaviors with psychosocial interventions. 2) Surveyor reviewed the progress notes for R61. R61 had an un-witnessed fall on 01/26/20; S/P un-witnessed Fall at 0145 AM; 08/13/19 S/P day #3 of unwitnessed fall; found on floor 8/10. Fall huddle on 0[DATE] done for fall? 06/10/19 IDT met to discuss fall precautions. Surveyor observed R61 on 02/28/20 at 03:03 PM sitting up in a wheelchair with other residents in the activity lounge, listening to music. Surveyor reviewed the care plan with review date 02/12/20. Fall risk: Fall risk score >10. Had a previous fall relating to disease process/ condition: Hx of left [MEDICAL CONDITION] and dementia. Care plan interventions include the following: Call light within reach. Place sign Stop/ call nurse on the bathroom door, Educate/ remind resident to request assistance prior to ambulation. Surveyor interviewed Licensed Nurse (LN)14 on 02/28/20 at 03:07 PM who stated since she has fallen, now we take her to the bathroom more often, that seems to be helping. At night every 1 or 2 am, we get her up to the bathroom, but then we have to wait for her because she doesn't use her call light. She has dementia and does not use the call light. Surveyor interviewed the Charge Nurse at on 02/28/20 at 03:30 PM who stated, we meet as a group for the quarterly care plan meeting one week before it is updated. We go through each goal and intervention to check if it is still appropriate. Then we update it. it is done each quarter. R61 does not use her call light, she doesn't remember, nor does she understand. The care plan intervention is probably not appropriate for this resident. 3) Surveyor noted R[AGE]'s contracted left hand during an observation on 02/26/20 at 08:30 AM. R[AGE] was sitting in her wheelchair and noted to have left sided weakness. R[AGE] stated, I have a brace around here somewhere, appeared to look around the room. I think it's over there somewhere, pointing into the corner. Surveyor reviewed R[AGE]'s EMR. Diagnosis: [REDACTED]. Muscle weakness. Not on restorative care. MD order dated 05/22/19. Hand splint to left hand in the morning for left sided weakness and remove per schedule. Care plan review date [DATE]. ADL Self-Care Deficit related to (R/t) Left upper extremity (UBE) flaccid. Hand splint to left hand in the morning for left sided weakness and remove per schedule (see MD orders). Nursing rehab/ restorative: Active assist range of motion (ROM) program #1: Active assistance ROM exercise. Surveyor reviewed the restorative aide schedule. R[AGE] was not on the list of residents in the facility who are receiving restorative care. Care plan and MD orders are not being followed. Surveyor made the following observations on 02/27/20 at 08:57 AM, 11:20 PM, and 02/28/20 at 08:58 AM, and 11:20 PM, noting that R[AGE] was not wearing the arm brace surveyor which was found in the same place on the floor. Surveyor asked LN12 on 02/27/20 at 02:38 PM when does R[AGE] wear the arm, replied she puts it on in the morning and takes it off before lunch. Surveyor interviewed charge nurse (CN) on 02/27/20 at 03:17 PM regarding R[AGE], stating that the rehab director stated that R[AGE] is currently at baseline. She used to get rehab services before for her left arm, but she was discharged . Surveyor interviewed the Rehab supervisor on 02/28/20 at 09:25 AM, who stated that if R[AGE] is refusing to wear the splint because it is uncomfortable when the staff put it on, it warrants an OT referral to see what the problem is with wearing the splint and the care plan should be updated. 4) Resident (R)26 was admitted on [DATE] for [MEDICAL CONDITION], has a [MEDICAL CONDITION] and is on tube feedings. Record Review (RR) on 02/25/20 at 11:00 AM was done R26's current activities of daily living (ADL) care plan (dated 0[DATE]) shows that he/she requires total assist of 1-2 with daily care related to his/her [DIAGNOSES REDACTED]. R26 is totally dependent on (1-2) staff for repositioning and transferring with the use of the Hoyer lift. R26 is alert, nonverbal and non-ambulatory. On 02/25/20 at 02:00 PM, an interview was done with R26's spouse. R26's spouse stated that the staff comes in the room and massage his/her legs Monday, Wednesday and Friday. On 02/27/20 at 10:50 AM, an interview was done with certified nursing assistant (CNA)56. CNA56 said she does not massage R26. R26 is on the restorative nursing program. On 02/27/20 at 10:52 AM, an interview was done with restorative nursing assistant (RNA)1. RNA1 stated R26 is not on the RNA program. An interview on 02/28/20 at 08:38 AM was done with Registered Nurse (RN) 130. RN 130 said to my knowledge, when the CNA's clean her/him, they do range of motion. I personally have not seen the CNAs do ROM. RN130 stated he/she gets a hand and arm massage from activities Monday, Wednesday and Friday. An interview on 02/28/20 at 09:22 AM with the activities director (AD) was done. AD stated, we do sensory stimulation with music, passive range of motion (PROM) once or twice a week. The activity staff (AS) are trained with physical therapy to do PROM of the upper body. We don't work with legs. RR of R26's care plan was not revised to include ROM of the extremities. Interviews with family member, RNA, CNA and RN showed a miscommunication of what is being done for ROM for R26. The care plan did not show a discussion involving the interdisciplinary team interventions to prevent any decline in ROM in a resident who is dependent on staff for range of motion and is non-ambulatory. This miscommunication can lead to decline of range of motion and contractures for R26. 5) Resident (R)9 was admitted on [DATE]. R9 was diagnosed with [REDACTED]. On 02/25/20 at 08:44 AM, an interview was done with R9. R9 stated I don't get range of motion (ROM). Sometimes, I beg for it, but I am told I am not on the list. Sometimes, they come when they have the time. R9 said they hardly have time to work on us and nobody comes to work on my legs. At times, they do it for a little while and they forget and it gets hard on my legs and my legs get stiff. I was wishing for more therapy. On 02/25/20 at 0900 AM, interview was done with staff who requested to remain anonymous. Staff stated that one of RNAs was assigned to the floor to do CNA duties. Therefore, there was only one restorative nursing assistant (RNA) assigned to unit. Review of the RNA treatment logs revealed 28 residents. Observation on 02/25/20, starting from 08:30 AM through 0200 PM. Observation of RNA during course of the day was done. RNA was able to do ROM with five residents. In addition to ROM exercises, the RNA answered call lights, helped with meal hours and transported residents. R9 was on the RNA treatment log; however, RNA was not able to provide RNA program to several rooms/residents on certain units. R9 was one of those residents that did not receive ROM according to the care plan. Record Review on 02/27/20 was done. The record indicated the activities of daily living (ADL) and mobility care plan for nursing rehabilitation/restorative standing frame Program #1. Program #1 is performed standing frame with R9 per the restorative nursing assistant (RNA) program. Care plan record for functional care plan states to provide gentle range of motion as tolerated. On 02/28/20 at 08:30 AM, an interview with Registered Nurse (RN)130. RN 130 said R9 was referred to ortho for her/his right shoulder and he/she got a cortisone shot. R9 has a frequency of refusing to get out of bed and participating in range of motion (ROM). Surveyor asked RN130 if staff has asked why she refuses frequently. RN130 stated that R9 was not asked why she/he refuses so frequently. On 02/28/20 at 08:56 AM record review (RR) and concurrent interview with activity director (AD) was done. Record reveals multiple refusals to get out of bed (OOB). Record states R9 is on ROM with RNA program. Today, records indicate restorative nursing assistants are off because both RNA's have the day off. On 02/28/20 at 09:42 AM, an interview was done with R9. R9 stated she refuses a lot because, she didn't like to get up. When she gets up, she experienced pain to his/her right shoulder. Also he/she was not confident with one of the new staff with the Sabina lift and felt she was not placed on the lift correctly. RR of R9's care plan was done. Care plan was not revised in relation to the lack of resources available (RNA staff) to meet the needs of the resident. Care plan was not revised to show interventions to meet the resident's psychosocial needs related to her refusal of ROM. 6) Resident (R)21 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 02/25/20, interview was done with staff who requested to remain anonymous. Staff stated that one of the RNAs was pulled from RNA to CNA duties. This left only one restorative nursing assistant (RNA) assigned to unit. Review of the RNA treatment logs revealed 28 residents for RNA Observation on 02/25/20, starting from 08:30 AM through 02:00 PM was done. Observation of RNA during course of the day was done. RNA was able to do ROM with five residents. In addition to ROM exercises, the RNA answers call lights, helps with meal hours, transporting residents. R21 was on the list and did not receive RNA treatment. RNA was not able to provide RNA program to several rooms/residents on certain units. (refer Resident 9) On 02/26/20 at 08:22 AM, this surveyor overheard R21 moaning from her room and talking about pain to her legs. Interview on 02/26/20 at 08:54 AM with R21 was done. R21 stated that her legs were sore. Surveyor called certified nursing assistant (CNA)123 to check R21. When the covers were lifted, R21's feet were found to be contracted and contorted around each other. R21's feet were pressed against each other and causing her pain. CNA123 repositioned her feet with pillowcases. Surveyor asked what interventions for comfort and repositioning were in place. CNA123 said well I try to put something at her feet, but she moves her feet back together. Later, returned to R21's room to interview and observe at 10:00 AM. R21 was comfortable. R21 stated, I'm ok now. Care plan review on 02/27/20 reads that R21 has limited physical mobility related to contractures, disease process, [MEDICAL CONDITION], left side affected, mild contracture left hand and shoulder. Care plan did not include contractures of the feet and/or interventions for the repositioning of the feet to meet the need of relief of pain for the feet. Medical record showed an order for [REDACTED]. Right 2-3 sets of 10 repetitions, ROM program #1 . assist to move through tolerated range; support joints above and below lower extremity - left 2-3 sets of 10 repetitions. Interview on 02/28/20 at 09:26 AM with Athletic director (AD). AD stated, R21 has a 1:1 for massage, exercise. We don't work with her legs. On 02/28/20 at 09:26 AM, an interview was done with Registered Nurse (RN) 130. RN 130 said he/she called for pillows for R21. R21's care plan did not include interventions for contractures of legs and comfort measures for positioning of legs while in bed. This deficient practice placed the resident at a potential risk for pain and pressure ulcers. 7) R132 was admitted on [DATE] for a short term rehabilitation (STR) services. R132, who wore a neck brace, had [DIAGNOSES REDACTED]. R132's current activities of daily living (ADL) care plan (dated 02/25/20) found she needs assistance with her daily care related to her diagnoses/health conditions. R132 also requires extensive assistance by one staff to turn/reposition in bed, for transfers, and for toileting. R132's current fall care plan found she is at risk for fall related injuries due to her history of falls, with a fall assessment score >10 and an inability to perform a balance test without physical support. This care plan was initiated on 02/07/20 and revised on 02/25/20 after her initial fall on 02/20/20. However, on the night shift of 02/27/20, R132 had another fall. The record stated, Resident was seen walking in hallway barefoot at around 1:15am. Verbalized she wants to go to the Emergency Department because she has polyuria and may be having [MEDICAL CONDITION]. Resident placed in front of nurse's station in wheelchair for safety. Noted to be standing up from wheelchair approximately every other minute. Resident was seen tripping on the footrest and fell on her buttocks at 1:25am. No injury noted . On 02/27/20 at 02:39 PM, an interview was done with Registered Nurse 131 (RN131). RN131 said the early morning fall was because R132 was very restless. Also, R132's fall risk assessment evaluation showed it had increased to 18, after her first fall seven days prior. On 02/28/20 at 07:08 AM, an interview with the Assistant Director of Nursing (ADON) was done. She stated R132's care plan had been revised, with the revision being not to leave R132's walker at bedside. The ADON said she felt R132 had improved because she could not get out of bed before, but now could get up and around. The ADON stated if the residents are improving, the staff doesn't have to provide more energy for someone who is limited versus more independent. The ADON also said then there should be more frequent monitoring, and she does this by coming to the unit to provide distraction and activities for the resident. However, R132's care plan was not revised to include any changes to her ADL status (i.e., from extensive to limited assistance), nor any interventions to prevent any more falls during the night shift when she had her two prior falls due to her restless behavior. And, for both falls, there was no use of a front wheel walker being (FWW) used. R132 had attempted to put socks on during her first fall. During the second fall, she had been walking around barefoot in the hallway during and placed in a wheelchair but she kept standing up almost every minute per the documentation. She had not been using a FWW. Thus, the interventions to prevent any future falls did not have any correlation to the behaviors she displayed prior to her other two falls, and no other relevant preventive measure were implemented.",2020-09-01
773,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,685,D,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to address one of 19 residents (Resident (R)15's) behavioral health status to ensure the resident was receiving vision treatment and services. The deficient practice placed the resident at a potential risk of vision loss related to her uncontrolled history of type 2 Diabetes. Findings Include: Cross reference to F745. Surveyor reviewed R15's medical record. Nurse Practitioner (NP)10 notes dated 0[DATE] state R15 is a [AGE] year-old female with weakness, history of stoke, Diabetes mellitus type two with Renal manifestation, major [MEDICAL CONDITION], mood swings, [MEDICAL CONDITION] [MEDICAL CONDITION], severe obesity with BMI >40 [MEDICAL CONDITION]. R15 is non-compliant with medication regiment. [MEDICAL CONDITION] stage 5, labs done on 05/2019 Creatinine - 3.15, GFR - 14. No eye exam found in hard chart. Surveyor interviewed R15 on 02/25/20 at 09:12 AM stating, I can read with my glasses, but when I look at you (toward the Surveyor), you look really blurry. I can't remember the last time I had my eyes checked but must have been years ago. Surveyor reviewed R15 medical record. MDS quarterly review dated 12/31, 2019. Vision coded as adequate and 1. corrective lenses. R15 care plan with review date 01/03/20, No interventions in the care plan to appropriately address the vision deficit or the risk of diabetic retinopathy due to her refusal of care behavior's. Noncompliance behavior. Administer medications as ordered. Allow extra time for R15 to respond to questions and instructions. Communicate with R15 family/caregivers regarding R15 capabilities and needs. Discuss concerns about confusion, disease process, NH placement with R15's family/ caregivers. Face and speak clearly when communicating with R15. Orders reviewed: 02/03/20. May have Dental, Podiatry, Audiology, Optometry care as needed. Surveyor queried the physician (MD) on 02/28/20 at 10:31 AM when the last eye exam for R15 was? MD stated that R15 often and frequently refuses care. Adding that she refuses to go out for appointments. The biggest concern is that she is stage 5 CKD and she also refuses to have [MEDICAL TREATMENT]. R15 still has the ability to consent and make decisions. Her husband can make decision for her although she still has capacity. Surveyor asked the MD why is R15 refusing her [MED]. MD responded that she doesn't like to get poked. There was no documentation in the record that there was a discussion between the Resident and the physician (MD) about refusing the [MED] and the harmful repercussions, i.e. [MEDICAL CONDITION] (CKD) for doing so, or that the MD addressed the concerns and changed the treatment plan. There was no discussion documented in the IDT notes that certain staff were able to give the [MED] and finally, there were no care plan interventions in place to address resident's behaviors with psychosocial interventions. Surveyor reviewed the literature from the American Diabetes Association. People with type 1 and type 2 diabetes are at a heightened risk for eye complications. Diabetic retinopathy is a general term for all disorders of the retina caused by diabetes. Proliferative retinopathy progresses after several years when the blood vessels are so damaged, they close off. In response, new blood vessels start growing in the retina. The new vessels are weak and can leak blood, blocking vision. The disorder can result in a condition called retinal detachment.",2020-09-01
774,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,688,D,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow a Physician's order and treatment care plan by ensuring that one of 19 residents (Resident (R) [AGE]) with a contracted left hand and left sided weakness was participating in the Rehab/Restorative program to maintain her current level of function and wear an arm brace as ordered. The deficient practice resulted in the resident's inability to maintain current level of function to decrease fall risk, use her left arm in her activities of daily living (ADL), i.e. setting up her meal tray, use silverware during meals, assist while transferring from wheelchair to toilet and bed, and prevent worsening of the contracted hand. Finally, the deficiency affected the resident's ability to have quality care and remain at the highest practicable physical well-being. Findings Include: Surveyor noted R[AGE]'s contracted left hand during an observation on 02/26/20 at 08:30 AM. R[AGE] was sitting in her wheelchair and noted to have left sided weakness. When the surveyor asked if she is receiving rehab services, R[AGE] stated, I did when I first got here, but was discharged . I have a brace around here somewhere, appeared to look around the room. I think it's over there somewhere, pointing into the corner. The staff come in and put it on really fast, not the right way and it really hurts. I end up not wanting to wear it. If they took the time to put it on properly, then I could wear it. I haven't had it on for about a month. Surveyor reviewed R[AGE]'s Electronic medical record (EMR) on 02/26/20 at 09:13 AM Diagnosis: [REDACTED]. Muscle weakness. Not on restorative care. Care plan reviewed. Self-Care Deficit. Hand splint to left hand in the morning for left sided weakness and remove per schedule (see Physician orders). Monitor skin for redness/ breakdown and update physician (MD) as needed (PRN). MD order dated 05/22/19: Hand splint to left hand in the morning for left sided weakness and remove per schedule. Care plan review date [DATE]. ADL Self-Care Deficit related to (R/t) Left upper extremity (UBE) flaccid. Hand splint to left hand in the morning for left sided weakness and remove per schedule (see MD orders). Nursing rehab/ restorative: Active assist range of motion (ROM) program #1: Active assistance ROM exercise. Surveyor reviewed the restorative aide schedule. R[AGE] was not on the list of residents in the facility who are receiving restorative care. Care plan and MD orders are not being followed. Occupational Therapy (OT) note dated 07/15/19: Skilled Instruction. Patient and Caregiver Training: Instructed nursing caregivers in positioning splint specifically to patient's preference in order to demonstrate pain-free application. Nursing not available during therapy session this day. OT note dated 07/19/19: Had discussion with patient on confirming continuation of OT services to assure she was benefiting enough from treatment. Patient agreed with additional OT, however stated she did not want nursing to work with her afterward. Patient was not specific on the reason why she felt this way. OT note dated 07/29/19: Discussed pending discharge from OT services this week. Patient has changed her mind and would like to be seen by Rehab nurse after OT has ended. Will make arrangement for training staff. Surveyor observed R[AGE] on 02/27/20 at 08:57 AM sitting in her wheelchair in her room, playing computer game, smiling. Noted R[AGE] was not wearing her arm brace and it was noted on the floor in the corner of the room. Surveyor interviewed LN12 on 02/27/20 at 02:38 PM and asked when does R[AGE] put her brace put on? LN12 replied that we put it on in the morning and take it off before lunch. Surveyor interviewed charge nurse (CN) on 02/27/20 at 03:17 PM regarding R[AGE], stating that the rehab director stated that R[AGE] is currently at baseline. She used to get rehab services before for her left arm, but she was discharged . Surveyor noted the brace in the same location in R[AGE]'s room during an observation on 02/28/20 at 08:58 AM . Surveyor interviewed the Rehab supervisor on 02/28/20 at 09:25 AM, who stated that if R[AGE] is refusing to wear the splint because it is uncomfortable when the staff put it on, it warrants an OT referral to see what the problem is with wearing the splint and the care plan should be updated.",2020-09-01
775,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,689,E,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure it provided an environment free from accident hazards by failing to implement interventions to reduce falls and/or prevent recurrent falls for three of 19 residents (Residents (R) 132, 68 and 61) selected for review. This deficient practice had the potential to affect the other residents identified at risk for falls. Findings Include: 1) R132 was admitted on [DATE] for a short term rehabilitation (STR) services. R132, who wore a neck brace, had [DIAGNOSES REDACTED]. R132's current activities of daily living (ADL) care plan dated 02/25/20, found she needs assistance with her daily care related to her diagnoses/health conditions. R132 also requires extensive assistance by one staff to turn/reposition in bed, for transfers, and for toileting. R132's current fall care plan found she is at risk for fall related injuries due to her history of falls, with a fall assessment score >10 and an inability to perform a balance test without physical support. This care plan was initiated on 02/07/20 and revised on 02/25/20 after her initial fall on 02/20/20. On the night shift of 02/27/20, R132 had another fall. The record stated, Resident was seen walking in hallway barefoot at around 1:15am. Verbalized she wants to go to the Emergency Department because she has polyuria and may be having [MEDICAL CONDITION]. Resident placed in front of nurse's station in wheelchair for safety. Noted to be standing up from wheelchair approximately every other minute. Resident was seen tripping on the footrest and fell on her buttocks at 1:25am. No injury noted . On 02/27/20 at 02:39 PM, an interview was done with Registered Nurse 131 (RN131). RN131 said the early morning fall was because R132 was very restless. Also, R132's fall risk assessment evaluation showed it had increased to 18, after her first fall seven days prior. During an interview with CNA53 on 02/27/20 at 04:42 PM, she stated R132, was non-compliant, and would get restless and stand up and walk around unassisted. Yet, there were no new interventions included in the resident's Fall care plan about R132's restlessness especially during the night shift, to alert staff to provide heightened supervision for R132 when she became more restless. On 02/28/20 at 07:08 AM, an interview with the Assistant Director of Nursing (ADON) was done. She stated R132's care plan had been revised, with the revision being not to leave R132's walker at bedside. The ADON said she felt R132 had improved because she could not get out of bed before, but now could get up and around. The ADON stated if the residents are improving, the staff doesn't have to provide more energy for someone who is limited versus more independent. The ADON also said there should be more frequent monitoring, and to provide this, she came to the unit to provide distraction and activities for the resident. The ADON stated she did this during the day shift when she came to work. However, both of R132's falls occurred during the night shift. Record review also found that R132 did not use her front wheel walker (FWW) when she fell . During the first fall, R132 had attempted to put socks on at her bedside. During the second fall, she had been walking around barefoot in the hallway and was later placed in a wheelchair by staff. The nursing documentation noted that R132 kept standing up almost every minute, but, was not using a FWW. Again, the revision to her Fall care plan was not to leave her FWW at her bedside, and did not address the restless behavior preceding the two falls. In addition, although R132 showed improvement in her mobility with STR, there was a lack of understanding that being restless was not being non-compliant. It was moreover, due to her medical condition, which then should have required closer supervision of this resident. This too, was not identified and thus not implemented for R132. As a result, R132 remains more at risk for future falls without a succinct, individualized care plan to ensure she will not risk any future falls in relation to her restlessness at night and her ability to be more mobile than when she was first admitted . 2) On 02/25/20 at 10:12 AM interviewed R68 and inquired if resident fell recently. R68 stated that she fell two weeks ago, when CNA51 dropped her to the floor. R68 elaborated that CNA51 was transferring her from the bed to wheelchair (W/C) using a slide board and improperly tried to lift her. R68 told CNA51 that she required two staff for transfers, but CNA51 insisted that she could do the transfer without help. R68 reluctantly agreed and provided directions to CNA51 on how to properly use the slide board for transfer. After the second slide procedure CNA51 tried to lift her instead, and that's when R68 slid out of CNA51's arms and onto the floor. R68 stated that her left leg twisted under her bottom when she fell to the floor and she screamed in pain. CNA 51 called out for help and two other staffers came running into the room to assist. R68 was admitted to the facility for rehab due to back surgery and legs were weak. R68 stated that the facility did not do X-ray and examine her L leg and pain had worsened. R68 stated that the therapist didn't say anything but provided massage and exercise to both legs. On 02/27/20 at 9:10 AM observed physical therapist (PT)4 use slide board to transfer R68 from bed to W/C and PT4 did not lift R68 into the W/C. R68 stated that CNA 51 lifted her after second slide and shouldn't have. Inquired of PT4 about fall, and he stated that fall happened on a weekend and wasn't working but after the incident trained CNA 51 on how to properly transfer R68 using slide board. PT4 recalled that after the fall, R68 didn't exhibit more pain or raise a red flag to recommend further assessment to nursing. PT4 then assessed R68 for pain and she reported 6 out of 10, (using pain scale of 0 (none) to 10 (worse)), by L groin area. PT4 stated that pain always controlled during PT exercises and R68 only now complaining of L groin pain, which is new to him. On 02/27/20 at 9:24 AM Observed R68 doing therapy exercises with PT4. PT4 assessed R68 for pain throughout exercises and R68 able to do passive range of motion (ROM) exercises with bilateral legs; and exhibited more grimacing on L side. R68 used the easy stand strap stand and stated no pain when PT4 inquired. R68 stated that had operation on back due to four vertebral disc compressed and pain to bilateral legs. admitted to facility for rehab to strengthen legs. PT4 stated that R68 improving in balance, active ROM and strength in legs. PT4 stated that there was no set-back to therapy sessions from fall. The 0[DATE] incident follow-up and recommendation form provided by the facility noted that RN[AGE] saw CNA51 assisting R68 to the floor when she entered the room. RN[AGE] documented that R68 was being transferred with the slide board and the slide board fell off of the chair but CNA51 was holding on to the resident and assisted her to the floor. RN[AGE] noted no injuries and recommended that gait belt be used for R68 transfers. On 02/27/20 at 10:17 AM interviewed RN[AGE] regarding R68's fall incident on 0[DATE]. RN[AGE] stated she heard CNA 51 call for help and when she ran to R68's room, the resident was sitting on her bottom and knees may have been tucked under. RN[AGE] stated that R68 was leaning against bed, and CNA51 was holding onto R68's right arm. RN[AGE] assisted R68 into wheelchair by grabbing the back of her pants with PT assisting, and CNA51 holding R68 from the front under her arms, to place R68 into her wheelchair. RN[AGE] interviewed R68 and asked her what happened and assessed resident for any head injuries or skin tears. R68 had no injuries and/or complaints of pain. On 02/27/20 at 10:32 AM inquired of charge nurse (CN)131 whether R68 was interviewed to determine how she fell , as not noted on risk management report. CN131 stated that the ADON did the full investigation. Inquired of the ADON and she stated that CN131 interviewed R68 after fall but did not document. The ADON provided incident description by resident that her left knee buckled. According to ADON, CNA51 felt confident could transfer R68 competently after watching how CNA45 used slide board. On 02/27/20 at 2:19 PM reviewed R68's Kardex with CNA45 to see how the CNA's were instructed to do R68's transfers. R68's Kardex for transfers required extensive assistance by one staff to move between surfaces and as necessary, per rehab, to transfer using slide board. For mobility, Gait belt on with all transfers. CNA45 stated that she has used the slide board many times since worked at the facility for four years, so did not need training to use slide board. CNA 45 stated that the facility used train-the-trainer to teach new hires like CNA 51 how to use the slide board. On 02/27/20 at 3:11 PM interviewed the director of rehab (DOR), and she stated that use of a slide board is not on the CNA skills competency checklist. CNAs are trained on use of the slide board as needed, for residents on the units. The DOR provided R68's PT progress notes dated 0[DATE] that noted R68 fell 45 minutes prior to PT. R68 had no pain prior to fall but reported pain in back and left lower extremity at that PT session. R68's response to the PT interventions noted that the resident appeared anxious with mild tremors in the upper body at rest. R68 participated in all of the skilled interventions that were modified in intensity due to her fall. R68's PT progress notes dated 02/18/20 noted that CNA51 was instructed on performing slide board transfer and instructed to have 1-2 person to transfer using slide board for safety. The facility did not develop and implement an effective system to address resident risk to minimize the likelihood of an accident when transferring residents with a slide board. 3) R61 is a [AGE] year old female who has had five falls on the following dates. 07/24/19, 09/10/19, 09/17/19, 0[DATE], and 01/25/20. She is diagnosed with [REDACTED]. Surveyor reviewed the incident reports for R61 who had a fall in the facility on 0[DATE] at 01:45 AM and 01/25/20 at 11:45 PM. Resident was heard calling for help. Licensed Nurse (LN) found Resident in the bathroom sitting on the floor with the lights on, wheelchair (WC) brakes were on, and call light not on. Per Resident, she finished voiding and when transferring back to WC, Resident stated knees felt weak and she lowered self to the floor. No obvious injuries noted. Spoke with daughter and she agreed to toilet resident at midnight. Physical assessment for visible skin or muscle/ bone injuries. Resident able to stand up from floor with +one (limited/ extensive) assist and holding onto grab bar and transfer back sitting in wheelchair. Able to transfer from WC back to bed. +1 assist using bilateral WC arm rests to stand and transfer back into bed to sitting then to lying position. Denies pain, discomfort during transfers. On 01/25/20 at 1145 PM Resident was found sitting on the floor with her back leaning against the left side of her bed. Resident was verbally calling out for help but did not use the call light. Per Resident was trying to get up. No injuries noted. Upon further research, Resident has an overlay mattress that provides no traction when on the bed. The mattress was removed from the bed and the daughter was made aware. Reminded the Resident to always use the call button when she needs assistance. Surveyor reviewed the care plan with review date 02/12/20. Fall risk: Fall risk score >10. Had a previous fall relating to disease process/ condition: Hx of left [MEDICAL CONDITION] and dementia. Care plan interventions include the following: Call light within reach. Place sign Stop/ call nurse on the bathroom door, Educate/ remind resident to request assistance prior to ambulation. Surveyor reviewed the progress notes for R61 who had an un-witnessed fall on 01/26/20; status [REDACTED].#3 of unwitnessed fall; found R61 on floor 8/10/19. Fall huddle on 0[DATE] done for fall. Inter-disciplinary team (IDT) meeting notes reviewed on 06/10/19 IDT met to discuss fall precautions. Surveyor observed R61 on 02/28/20 at 03:03 PM and noted resident sitting up in a wheelchair with other residents in the activity lounge. When asked if she recently had a fall R61 responded I used to climb trees all the time, but I can't now, I might fall and break something. Surveyor interviewed Licensed Nurse (LN)14 on 02/28/20 at 03:07 PM who stated since she has fallen, now we take her to the bathroom more often, that seems to be helping. At night every 1 or 2 am, we get her up to the bathroom, but then we have to wait for her because she doesn't use her call light. She has dementia and does not use the call light. Surveyor interviewed the Charge Nurse who stated, we meet as a group for the quarterly care plan meeting one week before it is updated. We go through each goal and intervention to check if it is still appropriate. Then we update it. it is done each quarter. R61 does not use her call light, she doesn't remember, nor does she understand. The care plan intervention is probably not appropriate for this resident.",2020-09-01
776,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,690,D,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to determine for one of 19 residents (Resident ( R) 1[AGE]) was provided services and assistance to maintain continence and/or assess clinical condition if continence is possible to maintain. The facility did not provide services for R1[AGE] for incontinence of bladder for appropriate treatment to prevent urinary tract infection and/or skin breakdown. Findings Include: Resident (R)1[AGE] was admitted to the facility on [DATE]. During an interview on 02/25/20 at 10:17 AM, resident (R)1[AGE] stated to this surveyor that he/she is wearing a diaper. They put it on him/her. Surveyor asked, Is it ok with you? R1[AGE] replied No. (Refer 550) Observation on 02/27/20 at 0700 AM where R1[AGE] was brought to the activity/TV area. Surveyor observed R1[AGE] in activity room from 0700 AM until 10:59 AM. AT 11:00 AM, he/she went to the main dining area for ice cream gathering. R1[AGE] returned to the activity area after the ice cream gathering from the main dining area around 12:40 PM. R1[AGE] remained in the activity/TV area until 0200 PM. (Refer 550) Interview at 02:02 PM - queried with R1[AGE] if his/her diaper had been changed. R1[AGE] said no. (Refer 550) Interviews: Query with registered nurse (RN)10 and certified nurse's assistant (CNA)5 if R1[AGE]'s diaper could be checked. Accompanied staff to room with diaper change. At the bedside, it was noted that R1[AGE]'s diaper was saturated with urine. Upon questioning of staff, CNA5 stated that R1[AGE] has not been changed since before CNA5 got R1[AGE] up this am. R1[AGE] re-iterated to RN 10 and CNA5 that he/she does not like using a diaper. RN 10 and CNA5 agreed that sitting in a wet diaper for six hours could lead to urinary tract infection [MEDICAL CONDITION] and pressure sores. RN 10 stated that they could trial using a urinal for urination. (Refer 550) Surveyor reviewed medical record on 02/27/20. Care plan dated 0[DATE] said .for bowel and urinary incontinence, to assist with toileting as needed. The resident suffered for six hours with a saturated diaper. This deficient practice placed the resident at a potential risk of urinary tract infection and skin breakdown. This practice denies R1[AGE] of his/her right to self determination and a dignified existence.",2020-09-01
777,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,725,F,0,1,U7Q511,"Based on observations, staff interview and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial wellbeing. Findings Include: 1) An abbreviated Resident Council (RC) meeting was held during the survey on 02/26/2020 at 11:00 PM. There were five residents (R) in attendance to RC. They were resident (R) 61, 35, 281, 36 and R8. The question was asked to the residents if they get the help that is needed without waiting a long time and if the staff response to the call light is timely? One of the residents responded that in the morning and in the afternoon, the nurses are doing showers, they cannot see the lights, so you may have to wait.30 minutes. Another resident chimed in and stated, that sounds about right. Resident agreed and said the staff busy are busy and we wait 20 to 30 minutes. Resident went on to say the cna will let the nurse know if we call and they don't answer call lights. It's mostly the shower times, in the morning or in the afternoon. They are short staff most of the time, it doesn't matter what shift. I look at them and they are tired. Every morning, I ask them how many are on and they say two and they look so tired. R35 stated they are able to turn off the call lights without coming to the room, especially at night and I push the button at night and in five minutes, they turn the light off. On our side, they must physically come into the room and turn it on. R36 stated, I don't blame them if they are irritated with me because I have to go to the bathroom, and I think they are overworked. Observation was made on the night shift at 0400 AM during the survey dates 02/25/2020 through 03/02/2020. For the purpose of anonymity, dates and identifiers will not be identified to respect the request of staff who wish to remain anonymous. Entrance to the first unit showed four call lights on. Census was 51. Two registered nurses (RN) and two certified nursing assistants (CNA) were on the floor in rooms. Surveyor timed call light at 9-10 minutes of initial visualization. Entrance to 2nd unit showed three resident lights were on. Standing in hallway, where all halls could be visualized, there was no staff available. Interview with anonymous staff who stated that we budget our time, we have no assignment, it's hard, we just go. Upon return to first unit, interview with anonymous staff who started to cry and said it's overwhelming. Surveyor asked, how do you manage when four lights go off? Staff stated we can't manage. I give good care and the residents feel rushed. I'm sorry. We get in trouble. Staff excused her/himself to the restroom. 2) The facility failed to determine whether their staffing sufficiently met the needs of the residents. Cross-reference to F689. During a telephone interview of CNA53 on 02/27/20 at 04:42 PM, CNA53 said for their night shift schedule, they had two CNAs on the Keolamau unit. CNA53 said at times, two CNAs were enough; however, having restless residents, we really cannot accommodate everybody. She said, I know, always the safety of all. CNA53 said there were three restless residents on that particular night shift (cross-reference to F550), . they are scattered, not one on side, in [AGE]0 and 500. And the half of the 500. So I had to go back and forth. CNA53 said one of the restless residents, R132, whom she described as non-compliant, would stand up and walk around unassisted inside and outside of her room. CNA53 said it was really hard with only two CNAs staffed at night on their unit. She acknowledged she may have been getting frustrated with R132 as the resident kept standing, going to the bathroom unattended, and/or was found standing in the hallway unassisted. As a result, CNA53 said she told R132 that she would be blamed if the resident fell on that shift. Observation of the night shift of the Keolamau unit was done on 02/28/20. At 06:16 AM CNA46 was interviewed and said she worked night shift on this unit a lot. She said sometimes they were short of staff and with only two CNAs at night, that sometimes it was difficult to provide safe care. She also felt at times they were rushing to provide care for their residents and said, If you are doing the others, and a because especially you cannot go out cannot leave them if they are in the bathroom, . and said the night shift could use more help. When she was asked how she was able to complete her work when they were short of staff and with restless residents, she said, We are trying our best. CNA46 said she cared for 10 or 11 residents, but would also help assist the other CNA. She said it got very busy around 4:00-6:00 AM. She would prioritize by, The one that need to go to the bathroom, because they are in a hurry and they cannot hold sometimes. You know already the client that need to be prioritized, I know. You must go at once because they might fall yeah, and identified three residents who were high risk for falls. CNA46 said, Sometimes you are scared yeah about yourself, you must take care of them the best yeah, so that you cannot hurt them or hurt yourself also. On 02/28/20 at 02:26 PM, an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) was done. During the interview, it was found that although they addressed a staffing shortage which occurred during the month of January 2020 due to several employees leaving the facility, there still were no interim measures to assure that for some residents, they received their physician ordered services, (i.e., RNA care), or other needed care. Cross-reference to findings at F550, F622, F623, F656, F657, F6[AGE], F6[AGE], F689, F690, F[AGE]6 and F745, which cumulatively include these other identified residents. There also was no documentation to show whether residents were being adequately monitored on each given shift with the CNA shortage they described.",2020-09-01
778,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,726,D,0,1,U7Q511,"Based on interviews, record reviews and observations the facility failed to ensure nursing staff possessed the competence and skill to use the slide board for one of 31 residents (Resident (R) 68) sampled for survey. R68 was dropped to the floor as a result of being improperly lifted into her wheelchair by CNA51, and the facility did not provide proper training prior to CNA51's attempt to use the slide board on R68 as she recovered from back surgery, Findings Include: On 02/25/20 at 10:12 AM interviewed R68, and he/she reported having pain in the groin area, from a fall during a transfer. R68 stated that fell when a certified nurse assistant (CNA) 51 used a slide board for transfer from the bed to wheelchair, and did not call for assistance. R68 stated that he/she told CNA51 that transfer with the slide board should be two staff to assist but CNA 51 insisted that she could safely transfer him/her. R68 alleged that CNA 51 dropped her to the floor during the transfer with the slide board because CNA51 could not hold on to her. R68 was receiving rehab to strengthen bilateral lower extremities since admission to the facility from an acute hospital after back surgery. On 02/27/20 at 09:10 AM, observed physical therapist (PT) 4 use slide board to transfer R68 from bed to wheelchair. PT4 did not lift R68 into the wheelchair and only guided R68 in three sliding movements. R68 stated that CNA51 attempted to lift him/her into the wheelchair after the second sliding movement, and that is how fall occurred. PT4 stated that R68 fell on his day off, and did not know exactly what happened. When PT4 returned to work, he trained CNA51 on proper transfer of R68 using slide board. PT4 stated that pain always controlled during PT exercises, and new to him of R68's complaint of left groin pain. On 02/27/20 at 09:24 AM, observed R68 doing therapy exercises with PT4. When pain assessment done R68 stated no pain and was able to do passive range of motion (ROM) exercises to bilateral legs. PT4 stated that R68 improving in balance, active ROM and strength in legs and did not see setback after fall. On 02/27/20 at 02:19 PM, reviewed R68's CNA task bar with CNA 45, and under the transfer column, R68 required extensive assistance by one staff to move between surfaces and as necessary, per rehab, to transfer using slide board. CNA 45 stated that she was a seasoned CNA and able to use slide board without assistance because have done slide board transfers many times. According to the ADON, CNA 51 watched CNA 45 how to use the slide board, and felt confident that could transfer R68 competently but she fell . On 02/27/20 at 03:11 PM interviewed the director of rehab (DR) and inquired how new staff are trained to use the slide board for transfers, and to ensure competency. According to the DR, using slide board not on orientation checklist, and training to use slide board for transfers just happens on the floor as needed.",2020-09-01
779,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,745,D,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide behavioral health services to ensure it was meeting the needs of one Resident (R)15 who was refusing medications, blood sugar testing, activities, personal hygiene which exacerbated her type 2 diabetes. The deficient practice resulted in placing the resident at an increased risk of physical harm due to her refusal of care. Findings include: Cross reference to F6[AGE]. Surveyor reviewed R15's medical record. Nurse Practitioner (NP)10 notes dated 0[DATE] state R15 is a [AGE] year old female with weakness, history of stoke, Diabetes mellitus type two with renal manifestation, major [MEDICAL CONDITION], mood swings, congestive and heart failure ([MEDICAL CONDITION]). R15 is non-compliant with medication regiment, stage 5 [MEDICAL CONDITION]. Labs done on 05/2019 Creatinine - 3.15, Glomerular Filtration rate (GFR) - 14. No eye exam found in hard chart. Care plan review date 01/03/20 states R15 is at a nutrition risk and frequently refuses [MED] and blood sugar checks. No interventions noted to address R15's refusal of [MED] and accuchecks. R15 is at risk for fluctuating mood and behavior due to short term memory with some pockets of recent events. Displays rejection of care (medication, change during personal care ) per Nursing. Interventions state administer medications as ordered, allow extra time for R15 to respond to questions and instructions. R15 is at risk for complications related to diabetes through the review date. Dietary consult as needed. Educate regarding medications and importance of compliance. R15 uses antidepressant medication R/t depression. No interventions listed that address refusing of care behavior. Surveyor reviewed the psychoactive drug utilization summary dated January 11, 2020. R15 is taking [MEDICATION NAME], an antidepressant at night, 5 milligrams (mg) each night for depression. The notes state on [DATE] refusing [MED], refusing accucheck, blood draw, 10/13/19. Progress note: no bad behavior, 10/08/19 mood/ behavior continues to fluctuate. 0[DATE] clinical note; no signs of depression. 07/31/19 MD reduced dose from 10 mg to 5 mg every day (QD) and re-evaluate in 1 month before further changes. There is no documentation that R15 refused to allow some nurses and allowed others to give her [MED]. Surveyor reviewed the inter disciplinary team (IDT) meeting notes from the care plan conference record on 01/02/20. Resident continues to refuse accuchecks, labs pending, resident only wanting to get labs drawn at an outpatient clinic. Frequent refusal of care. Continue current plan of care. The facility is addressing the refusal behaviors in the IDT notes, it was noted in the progress notes that certain staff can give R15 her [MED]. Reviewed the MAR and noted R15 only refused her [MED] in the morning. The evening nurse was able to give the [MED]. There was no documentation in the record that there was a discussion between the Resident and the physician (MD) about refusing the [MED] and the harmful repercussions, i.e. [MEDICAL CONDITION] (CKD) for doing so, or that the MD addressed the concerns and changed the treatment plan. There was no discussion documented in the IDT notes that certain staff were able to give the [MED] and finally, there were no care plan interventions in place to address residents' behaviors with psychosocial interventions. Surveyor interviewed the MD on 02/28/20 at 10:31 AM who stated that R15 often and frequently refuses care. Adding that she refuses to go out for appointments to meet with her other specialists. The biggest concern is that she is in stage 5 CKD and also refuses to have [MEDICAL TREATMENT]. R15 still has the ability to consent and make decisions. Her husband can make decision for her although she still has capacity. Surveyor asked the MD why is R15 refusing her [MED]. MD responded that she doesn't like to get poked. Surveyor interviewed Licensed Nurse (LN)12 on 02/28/20 at 01:57 PM who stated that R15 refuses the [MED] most of the time. We go see her and spend time talking with her and encourage her, if she refuses, we honor her wishes. Surveyor reviewed progress the progress notes that revealed the evening nurse is able to give the afternoon and evening medications including the [MED].",2020-09-01
780,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,761,D,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to discard medication from the medication cart and the medication refrigerator that was expired. The deficient practice had the potential to increase risk of illness for the residents residing in the Facility. Findings include: Surveyor conducted a random inspection of medication storage cart on Wailani unit in front of room [ROOM NUMBER] on 02/27/20 at 09:23 AM and discovered a box with [MEDICATION NAME] [MED] oral solution, 100 mg per 5 milliliter (ml) with a discard after date of 09/19 written on the opened bottle. Licensed Nurse (LN)12 verified that the bottle was expired and should be discarded and also was currently in use. LN12 added that we check and endorse to the other nurse at the end of the shift and the head nurse is responsible to check the cart and discard the expired medications. Surveyor interviewed the charge nurse (CN) on 02/27/20 at 09:45 AM who stated, it is the nurse's responsibility to clean out the med cart. At the end of the shift when they endorse to each other they should take the meds out that are expired. Surveyor conducted an inspection of the locked refrigerator in the medication storage room on the Wailani unit on 02/27/20 at 09:47 AM. An opened bottle of [MEDICATION NAME] was discovered that did not contain a date opened on the bottle. The CN took the bottle out of the box and discarded it stating It is the responsibility of the nurses to throw out the discarded items and they should be writing an open date on the bottle. Surveyor reviewed the Long term care (LTC) Facility's pharmacy services and procedures manual 5.3 Storage and Expiration Dating of Medications, Biological's, Syringes and Needles. October 2016. Page 2, paragraph 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff may record the calculated.on date opened on the medication container. Medications with a manufacturer's expiration date expressed in month and year will expire on the last day of the month.",2020-09-01
781,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,842,D,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record and policy reviews, the facility failed to ensure that the medical record for three out of 19 sampled residents (Residents (R) 47, 2[AGE] and 135) were complete and accurate. The medical record must contain an accurate representation of the actual experiences of the resident. It conveys a true portrayal of the resident to the interdisciplinary team and communicates the resident's progress toward their plan of care goals, response to treatment and services and changes in their condition. Findings Include: 1. R47's record was reviewed. The nursing Braden Scale (a document used to predict a resident's risk of developing a pressure sore), portrayed R47 as having a mild risk in developing a pressure ulcer for 8 out of the 9 assessments reviewed. The risk factors for R47 were also not correctly identified. R47 had multiple co-morbidities that could affect his skin integrity. After his discharge on 10/07/19, R47 returned on 10/09/19 with two, stage 2 (skin is broken) pressure sores on his tailbone. R47 also had a recurrent right heel sore that had a previous history of being treated with intravenous antibiotics and surgical resection (surgical removal of damaged skin). While in the facility, R47 has had several debridements (surgical cleaning of dead or damaged skin to promote healthy tissue growth) of his pressure sores to his tailbone and right heel. R47 also refused having a foam dressing to his sores, an air mattress, heel protectors and protein supplements to help maintain his skin integrity. The Pressure Ulcer/Injury Prevention and Management policy states, Adjustment of the patient's level of risk may be indicated and may be noted on the pressure ulcer risk assessment tool. 2) On 02/28/20 at 1:18 PM, conducted RR on R2[AGE] to note timeline of resident's complaint of left (L) knee pain and facility's response. According to R2[AGE], injured L knee during physical therapy (PT) on [DATE] but did not have pain and swelling until that evening. Further review of facility's electronic medical records found late entry progress notes on [DATE]20 and 0[DATE] by LN81 with both late entries dated 02/25/20 at 07:30; and, R2[AGE] denied any pain or discomfort. On 2/28/20 at 5:35 PM interviewed the ADON and inquired about the accuracy of late entry progress notes for R282 on [DATE] and 0[DATE], with both late entries dated 02/25/20 and same documentation by LN81. The ADON later provided other documentation on R2[AGE] to show no lapse in care despite the late entries. R2[AGE] had an X-ray of his/her L knee to rule out a fracture due to pain and swelling on 0[DATE]. The X-ray report impression noted moderate suprapatellar knee joint effusion. R2[AGE]'s Medication Administration Record [REDACTED]. The pain scale levels noted on the MAR for the same dates, went from 3/10 to 7/10, (using a pain scale of 0 (no pain) to 10 (worse pain). Also, inquired of separate medical record system for rehab and how the facility integrates information for accurate assessments of residents'. The ADON stated that the facility was transitioning into a new electronic medical record system and the Administrator concurred that the system still needs improvement. 3) R135 was admitted to the facility on [DATE] for short term rehabilitation (STR) services after having a stroke affecting her right side. R135's also had Type 2 Diabetes Mellitus with long term (current) use of [MED], amongst other diagnoses. She was alert, oriented and stated during a 02/28/20 08:02 AM interview that her blood sugars were, running high in the 300's, with her most recent fingerstick blood sugar testing done by a nurse. R135 also said she used to take more [MED] at home and asked the nurses to check with the physician, but she never heard back from them. She said she was eating less, but her blood sugars were still high. On 02/28/20 at 12:24 PM, during an interview with one of the nursing managers (NM1), she said there was a communication binder kept on the unit. The binder was kept for the resident's specific attending physician to review. For R135, NM1 found a nursing entry in the binder stating, resident has high blood sugar in evenings. 331 today resident on 20 units [MEDICATION NAME]. She stated she gets [AGE] units @ home. Per NM1, she said R135's attending physician will, check it off, upon reading the entries when he came into the facility. NM1 affirmed however, that if they solely relied on the communication binder, there were things which could get missed. NM1 verified their electronic health record (EHR) was the legal record, and further confirmed she could not find the nursing entry about R135's blood sugar of 331, but only as a handwritten note in the physician's communication binder. As such, there was a failure to ensure a resident's blood sugar status/information was accurately documented as part of R135's clinical record.",2020-09-01
782,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2020-03-02,880,E,0,1,U7Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility's policy, the facility failed to provide a safe and sanitary environment which place residents, staff and visitors at risk of acquiring an infection. Hand hygiene infringements by staff, the failure to separate clean supplies from a dirty surface and the separation of a used item from a clean surface were observed. Findings Include: 1. The surveyor observed on 02/27/20 at 11:24 AM, in preparation for a dressing change, RN[AGE] failed to place a clean barrier on the dressing cart before laying out clean dressing supplies. The surveyor queried RN[AGE] as to when the top of the dressing cart is disinfected and she stated that it is wiped only once in the morning. RN[AGE] stated that she should have placed a clean barrier between the dressing supplies and the cart to prevent contamination. 2. On 02/27/20 at 11:46 AM, the surveyor observed RN[AGE] exit a resident's room carrying an object in a pillow case. RN[AGE] stated that it was an ice pack wrapped in a pillow case that a resident used for her leg pain. The surveyor further observed that she placed the used ice pack in a pillow case on her clipboard on the medication cart. She further stated that didn't know where the used ice packs were kept to be disinfected. 3. During observation of lunch on 02/25/20 at 12:25 PM, observed the cart arrival at 12:27 PM. The Certified nursing assistant (CNA)s started room service at 12:28 PM. CNA1 grabbed a tray from the cart. On the way into the room, CNA1 pumped the hand sanitizer (HS) on the wall to her left hand while holding the tray and walked into the room. Surveyor did not see CNA rub HS into her palm. CNA came out of room [ROOM NUMBER] and placed the tray back into the cart without HS. CNA grabbed the next tray without proper HS. CNA delivered the tray to resident in room [ROOM NUMBER]B without proper hand sanitization. In room [ROOM NUMBER]b, CNA assisted the resident with opening lids of food containers and condiments. CNA1 came out of the room after assisting 302b. Discussed with CNA1 regarding cross contamination when she went from room to room without proper hand sanitization and CNA1 stated we are supposed to hand sanitize on going into the room. Surveyor pointed out that she/he did not properly rub HS into her hands and went from one room to another room without hand sanitization. CNA2 arrived and CNA1 left without doing any HS. CNA2 passed the next two trays without HS going into the rooms. CNA2 HS after coming out of the rooms and almost forgot on one occasion, then turned back to HS. CNA2 did not hand sanitize going into the rooms. A review of the Policy and Procedure (P&P) dated 03/16/19 was reviewed on 02/25/20. The P&P states handwashing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infections. Antiseptics control or kill microorganisms contaminating skin and other superficial tissues and are sometimes composed of the same chemicals that are used for disinfection of inanimate objects. The procedure is to utilize the Lippincott procedure for hand hygiene. This deficient practice placed the residents at risk for an unsafe, unsanitary and uncomfortable environment and does not prevent the development and transmission of communicable diseases and infections.",2020-09-01
783,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2018-03-23,550,D,0,1,1OJF11,"Based on observation and interview the facility failed to treat one resident of 19 residents sampled with respect and dignity by calling her a feeder. Findings include: During an observation on 03/22/18 at 12:14 PM at the 400/500 nurses station, Staff (S) (S18 and S49) were sitting at the computer having a conversation with S 49 who's back was turned to the surveyor. When S 18 asked S49 why the resident was sitting at the nurse's station S49 responded she's a feeder. The resident sitting in the wheelchair was within range of the conversation between the two staff. S49 turned around to face the surveyor and quietly said she needs help eating.",2020-09-01
784,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2018-03-23,580,D,0,1,1OJF11,"Based on record review and staff interview, the facility failed to immediately inform the resident's physician, on two separate instances, of significant change to resident's weight. Findings include: Interview with S18 on 3/23/18 who identified that facility progress notes, physician's progress notes, MD communication book, and the facility's 24-hour report of resident's condition and nursing unit activities would reflect notification to the physician in case of resident's change in condition, and confirmed that there was no notification. Additionally, S18 did not know when and who would be responsible to report changes in resident's condition to the physician. Record review revealed the resident lost 6.41% of body weight in a week on 2/12/18, and there was no evidence that the facility notified the resident's physician. The resident gained 7.22% of body weight on 3/6/16, and there was no evidence that the facility notified the resident's physician. Nursing home administrator provided policy and procedure called Weight monitoring which defines a change in weight greater than 5% in month is a severe loss/gain in weight. Nursing home administrator also provided policy and procedure called Changes in Resident's Condition or Status which states that nursing is responsible for notifying attending physician when there is a significant change in resident's physical, mental, or emotional status, and that all notifications must be made as soon as practicable, but in no case, will such notification exceed 24 hours.",2020-09-01
785,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2018-03-23,637,D,0,1,1OJF11,"Based on record review and staff interview the facility failed to report a significant change in status assessment within 14 days for a resident (Resident 26) who was ordered and started Hospice Care. Findings include: Record review of Resident (R) 26's Electronic Medical Record (EMR) found that resident had an order dated 08/21/17 for Hospice Care. It was noted that R26 had a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) submitted on 09/14/17, which is 24 days from the ordered Hospice care. On 03/23/18 at 11:13 AM interviewed staff 134 who confirmed that R26 was ordered Hospice care on 08/21/17, this was a significant change for R26 and that a MDS SCSA was submitted on 09/14/17. Staff 134 explained that the staff assigned to R26 was not aware that they had to submit the MDS SCSA within 14 days. Staff 134 confirmed that the MDS SCSA should have been submitted within 14 days from 08/21/17.",2020-09-01
786,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2018-03-23,657,D,0,1,1OJF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview the facility failed to revise the residents care plan to include the respiratory care treatment the resident was receiving. Resident (R) 241. one of 19 sampled residents. Findings include: On 03/21/18 at 09:21 AM R 241 was observed to be sitting at the bedside, hunched forward, having shortness of breath (SOB) and wearing a nasal cannula (NC) for oxygen use. Review of the medical record revealed that R 241 was diagnosed with [REDACTED]. Review of the physician orders [REDACTED]. Review of the nursing progress notes dated 3/21/18 revealed that R 241 gets SOB and expiratory wheezing when she transfers from bed to chair and for toileting. S7 concurred that R 241 has a very difficult time when moving around without getting SOB or wheezing. Review of R 241 care plan did not include respiratory care treatment. On 03/23/18 at 10:22 AM an interview was conducted with S7. Nursing staff are administering the O2 and nebulizer treatments since there is no Respiratory Therapist available. The charge nurse (CN) updates the residents care plan and the nursing staff document the treatment and evaluation on the residents' Medication Administration Record [REDACTED]",2020-09-01
787,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2018-03-23,761,D,0,1,1OJF11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to store medications used for dressing changes in a locked cart. Findings include: On 03/22/18 at 9:50 AM observed S21 gather their supplies to do [DEVICE] dressing change at a treatment cart. After S21 gathered up their supplies they walked away from the treatment cart and left it unlocked. Surveyor called S21 to come back and lock the cart. S21 apologized for leaving the cart unlocked and appeared nervous. On 03/22/18 met with DON in the afternoon who confirmed that all medication and treatment carts are to be locked prior to licensed nurses leaving them unattended.,2020-09-01
788,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2018-03-23,812,E,0,1,1OJF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to properly label and store food items in their kitchen and resident's nourishment cabinets and refrigerators; and failed to monitor their sanitizing solution with unexpired test strips. Findings include: On [DATE] at 10:02 AM staff 130 escorted surveyor into the unit nourishment room. While looking through the cabinets it was noted that there were open plastic bags containing various condiments (sugar, ketchup, etc.) with discard by month and day but not year date labels. The thickener container had a use by date of ,[DATE] and no year and the lid was not tightly closed. There also appeared to be staff's personal items in the cabinet such as a lunch bag, two cups, and food items (cup of noodle soup, mochi crunch). S130 disposed of staff's food items. While opening the drawers found a crumpled up paper towel and an empty plastic cup. On [DATE] at 10:55 AM met with S15 and S182 to look over the kitchen. At this time kitchen staff were asked to test their sanitizing solution. During this time it was found that the Hydrion testing strip, that was used to check the sanitizing solution, was expired with an expiration date of [DATE]. S15 brought a new roll of test strip and tested the solution again and it was at 200 Parts Per Million (PPM). S15 stated that they did not know there was an expiration date on the Hydrion test strip. On [DATE], in the afternoon, observed in the kitchen that there were large flour, rice and sugar bins that did not have any dates of when the items were opened and when to discard by date. Noted there was an open Miso paste container in the kitchen refrigerator that did not have an open and discard by date. Also found a container of opened egg whites which was not closed shut and did not have an open and discard by date on the container. While walking in the kitchen noted that the storage rack, where the pots and pans are kept, had what appeared to be a dark brownish orange colored substance on the metal that the pans were touching. During these observations spoke with S15 who concurred that the open on and discard by dates should have been on the aforementioned items.",2020-09-01
789,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2018-03-23,880,E,0,1,1OJF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to (1) Perform hand hygiene while distributing lunch trays between residents; (2) Clean the glucometer with an environment protection agency (EPA) registered disinfectant between resident use. Findings include: 1) On 03/20/18 at 12:35 PM observed lunch being served in the main dining room. S2 was observed returning a dirty lid and tray with trash that they threw away, did not perform hand hygiene, and took a new lunch tray to another resident and helped to set up the meal for that resident to eat. When interviewed, S2 stated that hand hygiene is done after the second tray is delivered. When queried S2 stated that they can distribute two trays before doing hand hygiene. When asked if hand hygiene is performed between tray service S2 concurred with this. When queried about hand hygiene training done in (YEAR), S2 stated that they missed it because they were on vacation. During this lunch observation S69 was seen passing out lunch trays without performing hand hygiene between 4 lunch tray deliveries. Review of facility Hand Hygiene policy, which was last revised 04/01/2015, stated Handwashing: When hands are visibly dirty, contaminated, or soiled, wash with non-anti-microbial or anti-microbial soap and water. Also Waterless Handwashing Products: If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations other than those listed under Handwashing above. On 03/20/18 after lunch met with S164 who concurred that all staff are to perform hand hygiene between meal tray service. 2) On 03/22/18 at 1:48 PM interviewed S99, who was using the 300 hall med cart. Inquired how and when they clean the glucometer. S99 stated they have never tried to clean it and only has one resident who has glucometer checks. On 03/22/18 at 3:25 PM met with S56 and inquired who provides training to the licensed staff for glucometer cleaning. S156 stated that the floor nurses train the new nurses on glucometer use. On 03/23/18 at 7:20 AM walked past a S141, who was observed, wiping a glucometer with an alcohol wipe. Inquired with licensed nurse about how they clean the glucometer and they stated that they wipe it with an alcohol wipe before and after each resident use. This licensed nurse stated that they had just had an in-service on this the day before. On 03/23/18 at 7:50 AM observed S13 wipe the [MEDICATION NAME] EZ glucometer down with a 1.2 inch by 2.6 inch McKesson 70% [MEDICATION NAME] wipe after testing a resident's blood glucose. Inquired with staff who provided training on how to clean the glucometer and staff stated that they had an in-service that morning with S164. On 03/23/18 at around 8:30 AM met with S164 and administrator who provided the facility policy for glucometer use. It was noted that the facility policy Cleaning and Disinfection of the Glucometer which was added 03/10 stated 7. Pick up the glucometer from the first barrier and disinfect it with a Super Sani-Cloth wipe or an equivalent product that kills [MEDICAL CONDITION] and bloodborne pathogens. Review of facility's [MEDICATION NAME] EZ Operator Test - Answer Key dated 08/10 found 10. What is the procedure for cleaning the [MEDICATION NAME] monitor? Before and after using the glucometer, wipe all visible surfaces of the glucometer to clean and/or disinfect it. Acceptable cleaning solutions include 10% bleach, 70% alcohol, and 10% ammonia; or a Sanicloth may be used. Remove any gross blood as soon as possible. Cleaning may be done in the resident's room or at the medication cart. Wipe down the glucometer again prior to putting it away after final use. S164 and facility administrator were shown the Blood Glucose Meters passage under Infection Control from the State Operations Manual (SOM) Appendix PP which states Blood glucose meters, can become contaminated with blood and, if used for multiple residents, must be cleaned and disinfected after each use according to manufacturer's instructions for multi-patient use. And The FDA has released guidance for manufactures regarding appropriate products and procedures for cleaning and disinfection of blood glucose meters. Plus An excerpt from this guidance reads: The disinfection solvent you choose should be effective [MEDICAL CONDITION].[MEDICAL CONDITION], and [MEDICAL CONDITION] virus. Outbreak episodes have been largely due to transmission of [MEDICAL CONDITION] and [MEDICAL CONDITION]. However, of the two, [MEDICAL CONDITION] virus is the most difficult to kill. Please note that 70% [MEDICATION NAME] solutions are not effective against [MEDICAL CONDITION] bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device.",2020-09-01
790,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2018-03-23,921,E,0,1,1OJF11,"Based on observations, review of policies and procedures, and staff interviews, it was determined that the facility failed to provide a safe, functional, and sanitary environment for residents, staff, and the public. Findings include: 1) During observation of an emergency stat cart (located on the Keolamau unit), on 3/20/18 at 1:01 PM, it was noted that the required daily staff checks was not done for one out of the twenty eight days reviewed; for the month of (MONTH) (YEAR). According to review of facility policy and procedure, the emergency stat cart will be checked by licensed nursing staff, and the checklist signed each time. Again, this was not done for one out of the twenty eight days reviewed. 2) During observation of the facility laundry room, on 3/21/18 at 9:45 AM, it was noted that required lint removal and dryer inspections were not done for nine out of the twenty seven days reviewed; for the months of January, February, and (MONTH) (YEAR). According to S176, and review of facility policy and procedure on 3/22/18 at 11:00 AM, the cleaning out of the lint trap and dryer inspection will be done and documented every two hours in order to ensure the proper and safe operation . Again, this was not done for nine out of the twenty seven days reviewed, as previously mentioned. 3) During observation of the facility laundry room, on 3/21/18 at 9:55 AM, it was noted that the wall, behind the washing machines, had extensive damage. The damage extended approximately twelve inches in height along the bottom of the wall. During an interview with staff 172, on 3/21/18 at 10:15 AM, S172 stated the facility was aware of the damaged wall, and that the damage was likely caused by water flooding. Additionally, S172 acknowledged the possibility of mold buildup after any type of water flooding. 4) On 03/22/18 at 10:31 AM while observing the lunch tray line noted that the floor in the kitchen was very sticky and had black colored substance in the grout and on the tile. Inquired with S15 who cleans the floor in the kitchen and how often is it done. S15 stated that the housekeeping department takes care of cleaning the floor and has a schedule to do it. After observing lunch tray line, interviewed S176, who stated that they wash the kitchen floor once a month and the last time the floor was cleaned was on (MONTH) 3, (YEAR) which was 48 days prior. Afterwards met with facility administrator who concurred that the kitchen floor is to be kept clean.",2020-09-01
791,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2017-05-01,157,D,1,0,4WVG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to ensure that the resident's family member was notified of the changes to one resident's (Resident #1) condition during the resident's stay at the facility. Finding includes: Cross-reference to findings at F309 and F514. Resident #1 (Res #1) was admitted to the facility on [DATE] from an acute hospital. His admitting [DIAGNOSES REDACTED]. The resident was also admitted for skilled rehabilitation services (physical and occupational therapy or PT and OT) with the intent to be discharged to home per the 12/29/16 social service assessment. Clinical closed chart review revealed the resident was progressing well until approximately 1/6/17, nine days into his admission. The record revealed that Res #1 began complaining of right lower leg and hip pain starting from the night shift into the day shift on 1/6/17. The pain flow sheet showed Res #1 was given pain medication and this was verified by Staff #2 during her interview on 5/1/17 at 10:10 AM. Staff #2 stated she recalled Res #1 complaining of pain and believed the pain level to be 5 on a scale of 1 to 10 (10 being the worst pain). Staff #2 was asked whether Res #1 described what kind of pain he was having. Staff #2 said, No, I didn't ask him. She also said, If there was any kind of new thing, such as changes to the resident, or new orders, I would then chart on the resident. Yet, based on an interview of the Assistant Director of Nursing (ADON) on the afternoon of 5/1/17, she recalled that on 1/6/17, Staff #2, .grabbed me and said (Res #1's) heart rate was elevated and seems short of breath, do you mind coming in to see him. The ADON stated she concurred with Staff #2's assessment and said the resident's heart rate was in the 130's and I knew at that time (NP) was leaving the building, so I stopped her and asked her to look at (Res #1). Mine was like a three minute assessment. I just went in to verify that it was elevated and it was irregular. The ADON confirmed she was there when the NP came in to assess Res #1 and that Staff #2 was also present in the resident's room. Further, the ADON reiterated when there is a change in condition or a medication is ordered, the family should be notified. She said the nurse would have called and/or the NP usually followed up with the families. She said if the NP did not, then the nurse usually does. The ADON reviewed the chart and said, Doesn't look like she did. (Staff #2) may have done it, but there's no note on it. There was a failure by the facility to notify Res #1's listed family member/representative of a change to the resident's condition, including the start of a new heart medication on 1/6/17.",2020-09-01
792,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2017-05-01,309,G,1,0,4WVG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interviews and review of the facility's inservice documents, the facility failed to ensure that a resident receives optimal care and services in accordance with professional standards of practice in order to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for one resident (Resident #1). Finding includes: 1) Cross-reference to findings at F157 and F514. Resident #1 (Res #1) was admitted to the facility on [DATE] from an acute hospital. His admitting [DIAGNOSES REDACTED]. The resident's clinical record revealed that during his acute hospitalization , he had been started on a [MEDICATION NAME] drip for his [MEDICAL CONDITION] flutter, but upon discharge, was prescribed aspirin 81 milligram (mg) as he was noted to be a poor candidate for anticoagulation given his history of falls and gait instability. Upon entry into the facility, the social service assessment of 12/29/16 found Res #1 to be alert and oriented x 3 (name, place and date), aware of his environment and knew his reason for being in the facility. He was also receiving rehabilitation services (physical and occupational therapy or PT and OT)) and the resident's family member helps resident with personal and legal matters. Resident will be discharged to home. Review of the daily OT rehab report found from the time of Res #1's initial OT evaluation, whereby he was a moderate to maximum assist, he eventually progressed such that by 1/6/17, he was primarily contact guard to minimal assist for his therapeutic activities. However, it was revealed by 1/8/17, Res #1 required maximum assist in performing all the tasks with significant change in assistance .Pt (patient) required MaxA (maximum assist) to complete transfer with max cues for correct sequencing. Therapist notified nursing staff of change in functional ability and increased level of assistance required for transfers today. Interview with Staff #3 on 5/1/17 at 9:00 AM revealed that she was familiar with Res #1. She verified her clinical entry of 1/8/17 and stated she worked with Res #1 quite frequently and had worked with him the week prior to Res #1 being emergently transferred out of the facility to the hospital on [DATE]. Staff #3 said she worked with him on functional transfers, bed mobility, strengthening exercises to get his legs stronger and walking. Staff #3 stated, He was progressing, he was contact guard assist for transfers. For ambulation, we weren't walking too far yet because of his [MEDICAL CONDITION], but that Res #1 was motivated to progress in therapy, worked very hard at it, and wanted to go home. However, when she returned to work on Sunday, 1/8/17, she saw a definite change to his legs with a noticeable decline in his function. She said, I worked Sunday through Thursday with (Res #1) and then I was off on Friday and Saturday. So when I came back on the 8th (1/8/17), a Sunday, my biggest concern was more discoloration that was mid-calf and it was a noticeable change and it was cool to touch and my concern was that there was some circulation stuff going on. Regarding the change to Res #1's level of function, she said, To get him in and out of bed was a like a max assist and I had to give him about 75% to stand him up so I wasn't sure if he was really fatigued and that was the biggest thing for me. Usually he was 25% or under and I would just give him contact guard assist that whole week. CGA or contact guard assist means you are touching them but not giving or assisting much, it's more like verbal cues and sequencing, like where to put his hands and all. Staff #3 said for her, it was a significant change seeing the resident like this. She said, Yeah, big time for me, because during that whole time he was at CGA and it was consistent. She said the resident denied being in pain but said he never complained of pain to her and was a coherent individual. She said he denied feeling cold and recalls he did not like having the bedsheets on himself as a personal preference. Staff #3 was aware the resident came in with discoloration to his lower extremities. Staff #3 was shown Res #1's 12/28/16 admission weekly skin assessment diagram. Upon reviewing the diagram and how it was generally circled, Staff #3 said the discoloration during the time she worked with him and before 1/8/17, was lower and more to the resident's bilateral feet and above the ankle region. She said it was not how it was drawn as one large circle to both of the resident's lower legs (shin region) with dark discoloration written by nursing staff. Further, she said by Sunday (1/8/17), although the discoloration was still below the knee, it was front and back, both shin and calf and it was going up to the calf area. But it wasn't as concerning as Monday (the day the resident was transferred out). She said on Sunday the noticeable change was that it was a little bit darker but rising up the right calf. However, on the next day when she went in to see him, she said, Monday, it was very dark purple and cold to touch. Staff #3 also recalled that on Sunday, 1/8/17, We finished our treatment and I reported it to his nurse (Staff #4) after therapy and told her to come look at his leg and the discoloration went up a little more. She came in and wasn't too concerned about the leg. Staff #3 also stated although Staff #4 felt the resident's leg, her response was that he did not usually have his sheets (bedsheets) on and attributed that as a reason why the resident's right leg felt cool. Staff #3 said Staff #4 then took his vital signs and although Staff #3 recalled asking her, What about the coloring? It looks like it's going up and it's colder to touch and it compared to the resident's left leg. Staff #3 said she also told Staff #4, I'm a little worried there may be some circulation problems going on. Staff #4 did not say anything back, but after taking the resident's vital signs, Staff #3 said Staff #4 told her the resident may be having an off day with the maximum assist he was needing. Staff #3 said Staff #4 did not say anything more about the discoloration and coolness to his legs. Staff #3 confirmed she touched and felt the resident's right calf and had Staff #4 touch it too. Of note, review of the facility's weekly skin assessment flowsheet did not document anything more about the initial dark discoloration found on the 12/28/16 admission assessment diagram to the resident's front bilateral lower extremities. Thus, by the next weekly skin assessment of 1/3/17, there was no documentation whether the dark discolorations to his bilateral lower extremities had resolved, diminished or was being monitored by the nursing staff. There was no description of the characteristics of the dark discoloration to the resident's lower legs, including the color, size/measurements and specific location of the noted dark discoloration circled around both lower legs on the diagram. Staff #3 repeatedly affirmed that her observation was the resident had discolorations to his lower extremities and that a noticeable darker discoloration was going up the right calf with coolness to touch when she saw him on 1/8/17. Nursing staff failed to address this. Then by 1/9/17, Staff #3 said she brought the resident his breakfast tray as he was going to have therapy in bed. And I saw his leg, it was very dark, it was like an icebox to my touch and told (Staff #4) about it. I think she was busy at the time, and I went straight to our communication log and wrote down change in color and cold to touch. Staff #3 said because it was very disconcerting she escalated her concerns to her directors. Staff #3 stated she did not hear of what happened to the resident thereafter, and denied having any type of inservice after this incident. Record review found Staff #4 had no entry of any assessment she performed on 1/8/17, and her next entry on Res #1 was on the day of his transfer on 1/9/17 at 12:13 PM. There also were no other clinical entries to state that the resident's lower right leg was being monitored. Staff #4's sole entry stated, Resident found this morning with cyanotic right lower leg. Cool to touch, dark color, toe color purple. Unable to palpate pedal pulses .Staff reported tarry stool and amber color urine, NP (name) notified and assessed at 0930. 911 called @ 0945 with (NP's) confirmation. Spoke to resident's (family) and nurse (name) from (hospital) emergency room at 1000. EMC arrived and pick up resident @ 1015 . Staff #4 has since left her employment at this facility and could not be interviewed. 2) On 5/1/17, during an interview with Staff #2 at 10:10 AM, she recalled Res #1 complaining of pain and believed the pain level to be 5 on a scale of 1 to 10 (10 being the worst pain). Staff #2 was asked whether Res #1 described what kind of pain he was having. Staff #2 said, No, I didn't ask him. She verified she gave Res #1 pain medication twice on 1/6/17, once at 9:30 AM for right hip pain and then again at 1:00 PM for his right leg pain. She said from what she remembered, Res #1 was complaining of pain to the right lower leg. She acknowledged the prior night shift nurse documented giving pain medication at 3:05 AM that morning for right leg pain. Thus, there were 3 occasions which pain medication was given to the resident within a 12 hour period. However, when Staff #2 was further queried if R #1's pain was significant because it was a different location (unlike the left leg or back pain he was admitted with), she did not have a clear response but stated she left her shift and endorsed it to the on-coming shift. Staff #2 was asked about her assessment of the resident on 1/6/17 and was asked if she looked at the resident's legs. She replied, No, I don't believe so. I just asked him his pain level. I didn't look or touch his legs. He was just in bed She verified she passed it off on report for the last pain medication she gave. She verified the NP was also there on 1/6/17 to the see resident but did not remember why. Staff #2 also stated ever since this incident, I really do do the assessment. Not just for him, but I changed my assessment. She said she was inserviced after this incident by Staff #1 and recalls it was about the documentation, or better assessment. 3) During the entrance on 4/28/17, Staff #1 told the SA that she remembered this incident because the resident went to the hospital and she did an in-service specific to that unit. She produced the content, Expectation of Charge Nurse - Proper Documentation re: (Res #1) and other residents. Staff #1 said, If it's not documented, it's not done. The overall failure by the facility to critically assess/monitor Res #1's lower extremities from admission, and the failure to recognize a need to intervene by 1/6/17 through 1/8/17 until his emergent discharge to the hospital on [DATE], is such that the harm (right leg amputation) may have been avoidable. This resident's hospitalization and admission history indicated he was at risk for potential [MEDICAL CONDITION] events, and although facility staff did have nursing encounters with him based on their interviews, these assessments were not documented in his clinical records. Thus, the resident potentially could have had interventions placed sooner than having a negative outcome of having his right leg amputated above the knee. During the interview with the NHA on 5/1/17, the NHA was informed that based on the staff interviews, it was revealed the resident had started complaining of pain to his right leg (new onset) on 1/6/17 with ensuing shortness of breath and [MEDICAL CONDITION](rapid heart rate) that same day. Although he had also been seen by Staff #2, the NP and the ADON on 1/6/17, there were no clinical entries/notes to describe or endorse to the oncoming shift what had occurred and what they should assess for, including any changes in the resident's condition with the start of a new heart medication. Then by 1/8/17, other notable changes were witnessed by Staff #3 of his decline in his functional level with increased discoloration to his lower right leg, which she reported to the resident's nurse caring for him, but again, was not documented or assessed as a concern. The NHA stated she was aware Res #1 was transferred to the hospital on [DATE] with subsequent amputation to his right leg.",2020-09-01
793,KA PUNAWAI OLA,125051,91-575 FARRINGTON HIGHWAY,KAPOLEI,HI,96707,2017-05-01,514,D,1,0,4WVG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interviews and review of the facility's policies and procedures, the facility failed to ensure that timely and accurate clinical information was documented in one resident's clinical record related to changes in the resident's medical condition, and for a resident deemed to be a short stay resident (Resident #1) for skilled rehabilitation services. Findings include: 1) Cross-reference to findings at F309 and F157. Resident #1 (R #1) was admitted to the facility on [DATE] from an acute hospital. The resident was also admitted for skilled rehabilitation services (physical and occupational therapy or PT and OT)) with the intent to be discharged to home per the 12/29/16 social service assessment. Clinical closed chart review revealed the resident was progressing well until approximately 1/6/17, nine days into his admission. The record revealed that R #1 began complaining of right lower leg and hip pain starting from the night shift into the day shift. Staff #2 was asked whether R #1 described what kind of pain he was having. Staff #2 said, No, I didn't ask him. She also said, If there was any kind of new thing, such as changes to the resident, or new orders, I would then chart on the resident. Staff #2 verified she gave R #1 pain medication twice on 1/6/17, once at 9:30 AM for right hip pain and then again at 1:00 PM for right leg pain. Staff #2 said from what she remembered, R #1 was complaining of pain to the right lower leg. She acknowledged the prior night shift nurse documented giving pain medication at 3:05 AM that morning for right leg pain. Staff #2 said because she already documented on the pain flow sheet, she did not think to document anymore and felt it was adequate. However, when Staff #2 was further queried if R #1's pain was significant because it was a different location (unlike the left leg or back pain he was admitted with), she did not have a clear response but stated she left her shift and endorsed it to the on-coming shift. Staff #2 also said the Nurse Practitioner (NP) was making her rounds that day (1/6/17) and believed she notified her, but don't know if it was specifically for the pain. I remember he was in the B bed and we repositioned him up in bed and I don't remember why, but (NP) came in to see him. Staff #2 was then asked, if she did, should there be documentation that she notified the NP and the reason for it. Her response was, There should be. R #1's clinical record revealed there was no documentation by Staff #2 regarding her notifying the NP to see R #1 on 1/6/17 on the day shift. There were two evening shift entries, with one being a 1/6/17 nursing note at 3:40 PM stating that R #1 was seen by the NP .today. New order received for [MEDICATION NAME] 125mcg PO QD dx Afib, [MEDICAL CONDITION], but none by Staff #2 as his primary day nurse. Yet, based on an interview of the Assistant Director of Nursing (ADON) on the afternoon of 5/1/17, she recalled that on 1/6/17, Staff #2, .grabbed me and said (R #1's) heart rate was elevated and seems short of breath, do you mind coming in to see him. The ADON stated she concurred with (Staff #2's) assessment and said the resident's heart rate was in the 130's and I knew at that time (NP) was leaving the building, so I stopped her and asked her to look at (R #1). Mine was like a three minute assessment. I just went in to verify that it was elevated and it was irregular. The ADON confirmed she was there when the NP came in to assess R #1 and that Staff #2 was also present in the resident's room. There was a failure by Staff #2 and/or the NP to have timely and accurate clinical entries about their assessments and interventions related to R #1's status during the day shift. Further, Staff #2 and the NP failed to notify the family member/ representative of the change to the resident's condition and the start of a new heart medication. This was verified by the ADON during her interview on 5/1/17. She responded, Yes to the question of whether Staff #2 should have documented in the resident's clinical record about the 1/6/17 encounter. The ADON said she did not see a clinical note by Staff #2 and that would have been her expectation. There also was no timely note by the NP after the encounter as well to detail the reason for the start of the [MEDICATION NAME] so the next shift and all following shifts would have concise and timely clinical information on R #1 and what to look for. Further, the ADON reiterated when there is a change in condition or a medication is ordered, the family should be notified. She said the nurse would have called and/or the NP usually followed up with the families. She said if the NP did not, then the nurse usually does. The ADON reviewed the chart and said, Doesn't look like she did. (Staff #2) may have done it, but there's no note on it. In addition, another 1/6/17 nursing entry written at 11:24 PM revealed that R #1 was reported to have dark red tinged amber yellow urine in urinal .New order for [MEDICATION NAME] was clarified with NP, to hold if HR The NP's written note for her 1/6/17 encounter with the resident was not part of the closed record. The State Agency (SA) had to specifically request the NP's notes. It was revealed the NP's 1/6/17 encounter (visit) note was completed on 1/9/17 at 10:44 PM and completed after the NP wrote her 1/9/17 discharge note of the resident being transferred to the hospital. In addition, the NP's 1/6/17 encounter note was accepted by the attending physician on 1/22/17, approximately 13 days after the resident was discharged . The ADON was queried who monitored the nurses' clinical entries and assessments, and she replied the Director of Nursing (DON) did. The ADON said she did not know the criteria the DON used for it. The DON was unavailable as she was out-of-town. During the exit interview with the Nursing Home Administrator on 5/1/17 at approximately 2:40 PM, she said the submission of a note by the NP depended on when the person dictated it. The NHA said in this case, they notified the NP involved and asked her to get it to them. It was during a 1/24/17 meeting with the resident's family that they became aware they did not have the NP's note. The NHA was asked if she had any concerns related to this and she stated it would have been clearer as to what had happened and what had taken place. The NHA acknowledged that on 1/6/17 when things were happening with this resident, the failure of documentation was evident by the lack of it from the NP, Staff #2, the ADON and Staff #4. The NHA was further informed that one of the reasons for the identified harm to the resident was due to the facility's failure to ensure their clinical entries were timely and accurately stated what happened to this resident. The NHA was informed much of this was revealed through the various staff interviews done by the S[NAME] It was this failure of the lack of documentation, especially when it was found that R #1's condition began to notably change on 1/6/17. The NHA also acknowledged that R #1 had a change in his medical condition. The NHA said to prevent this from occurring in the future, I think documentation is key, it is a clear sign of lack of communication and follow through on the documentation by the nurse to notify the physician, and acknowledged the lack of the follow up. The NHA was aware and stated to the SA that R #1 was transferred to the hospital on [DATE] with subsequent amputation to his right leg. 2) The Nursing Documentation policy produced on 5/1/17 stated the .following outlines basic nursing documentation .Procedures .Nursing assessments - system review are to be done every shift x 7 days (no change) and then done daily on the day shift .Charting every shift on a resident with skilled classification is generally the expectation, particularly when changes occur .Incident Follow-up: 1. For residents on incident follow-up, vital signs and a nursing assessment/observation are to be documented every shift x 72 hours. 2. Incident follow-up: b. New medication in the following categories: Cardiac drugs .After the incident, alert charting should be initiated per facility protocol. Review the care plan and make other required assessments, making updates where necessary to reflect the resident's current status and reduce the risk of future incidents. The facility failed to follow their policy as the nursing documentation for R #1 occurred only on the evening shifts (policy was not updated), and with the start of his new medication ([MEDICATION NAME]), there was no charting by nursing every shift x 72 hours nor any alert charting started and no update to the resident's plan of care. 3) Review of the in-service that was given to the licensed staff, Expectation Of Charge Nurse found Staff #2 signed it on 2/13/17. The contents included: 1. Complete documentation to validate in nursing notes that you have provided care for your resident (document chronologically (date and time), document interventions, observations, resident outcomes, resident response). Document all conversation with physicians, family and other healthcare professionals. Chart just the facts (what you saw, heard, smelled, touched, etc.). 2. Alert charting should be completed prior to clocking out, examples includes .changes in condition to name a few. Document changes in condition and other changes that need to be communicated on 24 hour report by end of shift. 3. Documentation needs to be specific and objective .When other healthcare professionals such as rehab (OT, PT, ST) .comes to you and report a problem in regard to your resident - ensure to investigate right away, look what is going on with your resident, prioritize. Take measures to resolve the issues immediately. And lastly - make sure to D[NAME]UMENT your assessment, interventions, outcomes, who did you notify, etc. When there's a complaint from family - immediately follow up on the complaint, if in regards to your resident - make sure to investigate, follow through and D[NAME]UMENT. The facility failed to ensure their staff followed basic clinical standards of practice to ensure R #1's complete clinical record contained an accurate and functional representation of the actual experience of the resident in the facility. This would have included enough information to show the facility staff knew about the status of the resident, had an updated plan of care, and had sufficient evidence of the effects of the care being provided, including on-going assessments, responses to new treatment and changes in the resident's condition preceding his emergent transfer to the hospital on [DATE].",2020-09-01
794,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2017-06-09,247,D,0,1,PJ7B11,"Based on observation, resident and staff interviews, and a review of the facility's notification process, the facility failed to ensure the resident was given the right to receive written notice, including the reason for the change, before the resident's roommate in the facility is changed for 1 of 23 residents (Res #145) in the Stage 2 sample. Finding includes: During an interview with Res #145 on 06/06/17 at 1:36 PM, she was asked if she had a roommate change in the last nine months. The resident stated since her arrival to the facility, she has had different roommates, as they were here for short term rehabilitation, and said, but now it's empty. Res #145's room had one unoccupied bed with no current roommate. Res #145 said she was not given notice by the facility of any of her roommates who have come and gone. She stated, No. They just put her in (last roommate) and introduced me. They never told me who it's going to be. She confirmed there have been no written notices provided to her for any of her roommate changes. On 06/08/17 at 11:47 AM, during an interview with Staff #1, who stated if a resident's roommate was discharged and a new resident enters the current resident's room, it is just a verbal notification and this would be documented in the clinical notes. Staff #1 produced a form which was a notification form used for a room change, but it did not include notification to a resident when the roommate was changed or a reason for the change. On 06/09/17 at 9:45 AM, the unit's care manager confirmed that Res #145 had maybe about two roommates. He stated there was no process for the notification to the residents when they have roommate changes for the short term stay residents. He verified for Res #145, there was no documentation in her record of the notification of the roommate changes she has had. On 06/09/17 at 10:27 AM, Staff #3 confirmed there was no documentation for the roommate changes noted by Res #145. Staff #3 also stated their process will also be reviewed to include the regulatory requirement of the written notification and reason for a roommate change. The right of this resident to be notified in writing of her roommate changes and the reason for each roommate change was not provided to her by the facility.",2020-09-01
795,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2017-06-09,279,D,0,1,PJ7B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of a self-reported incident report (IR) submitted to the State Agency (SA) and investigated through record review, staff interviews during the recertification survey on (MONTH) 9, (YEAR), the facility failed to develop, review and revise the resident's comprehensive care plan. Findings include: On 06/08/2017 record review reveals Resident #191 (R#191) was admitted on [DATE]. On 04/17/2017 @ 0745, R#191 returned to their room after physical therapy. Physical therapy left resident standing in the room next to their bed near their bed with front wheel walker. One minute later, R#191 was found on the floor. R#191 sustained a fall on 04/17/2017 that resulted in an injury. At 12:15 p.m. R#191 demonstrated significant changes. R#191 was very sleepy, would not eat and developed nausea and a headache. Emergency medical services (EMS) left the facility at 1330 and took the resident to Kona Hospital. Diagnostic workup at Kona Hospital revealed multiple areas of [MEDICAL CONDITION] with recommendation for Magnetic Resonance Imaging (MRI) for suspicion of [MEDICAL CONDITIONS]. R#191 was transferred to Queen's Medical Center in Honolulu with multiple bleeds and a questionable [MEDICAL CONDITION]. Interview on 06/08/17 at 3:06 P.M. with Staff #5. Staff #5 stated that the resident was not on any blood thinners. R#191's daughter was very involved with decision making. She was hesitant about sending R#191 to the hospital but when lunch came around and neurological changes occurred, she agreed to send to the hospital. He was then transferred to Kona Hospital and then to Queen's Medical Center. Record Review on 06/08/2017 revealed that R#191 had an initial interim careplan dated 4/08/17. Interventions for interim careplan stated 1) Assist of 1-2 for transfers, standby assist with front wheel walker. 2) Assist of 1-2 for ambulating CGA with front wheel walker. 3) Provide assistance for bed mobility, transfers or ambulation, specific: Staff assist 1-2 person. 4) Monitor and encourage use of proper foot wear. On 4/12/17 physical therapy cleared resident for approximately 150 feet with 4-wheel-walker. The patient is now safe for 4-wheel-walker independent in hallways. Although the physical therapy cleared R#191 for 150', the nursing facility did not update their careplan.",2020-09-01
796,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2017-06-09,323,D,0,1,PJ7B11,"Based on observation, resident and staff interview the facility failed to provide an environment as free from accident hazards as is possible for 1 of 35 residents from the Stage 1 sample. Findings include: 1) On 06/06/2017 at 12:07 PM after interviewing resident (Res) #64 in his room, sitting on his bed, with his O2 running through his nasal canula, noticed a spray bottle on resident's bedside table labled 20 Neutral Disinfectant Cleaner and Ecolab. Res #64 was interviewed at that time and resident denies using the spray bottle, thought housekeeping might have left it there. Interviewed staff #6 who confirmed that spray bottle with 20 Neutral Disinfectant Cleaner it is not supposed to be there, picked up the spray bottle and put it away in the locked medication room on the unit. Review of Safety Data Sheet from Ecolab for 20 Neutral Disinfectant Cleaner from their website (https://safetydata.ecolab.com/svc/GetPdf/20_Neutral_Disinfectant_Cleaner_English?sid= 8&cntry=US&langid=en-US&langtype=RFC1766LangCode&locale=en&pdfname=20_Neutral_Disinfectant_Cleaner_English.pdf) has the following Hazard statements: Harmful if swallowed or if inhaled. Causes severe burns and eye damage. The Precautionary statements listed are: Wear protective gloves. Wear eye or face protection. Wear protective clothing. Use only outdoors or in a well-ventilated area. Avoid breathing vapor. Wash hands thoroughly after handling. The facility failed to provide an environment as free from accident hazards as is possible for Res #64 which may have resulted in harm if the 20 Neutral Disinfectant Cleaner were swallowed or inhaled.",2020-09-01
797,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2017-06-09,431,F,0,1,PJ7B11,"Based on observation, staff interview and review of the facility's policies and procedures on Medication Storage and Controlled Drugs the facility failed to store refrigerated medication at proper temperatures and ensure that the narcotic count sign sheet was signed daily by the oncoming and off going nurses. Findings include: 1) On 06/08/2017 at 10:09 AM while doing an observation of the medication room on the Reflections unit it was noted that the Temperature Log for Refrigerator-Fahrenheit form was not filled out completely. Reviewed the temperature log sheet with staff #6 who confirmed that there were missing entries. Staff #6 stated that there are supposed to be 2 temperature checks done daily by the nurses and this is documented on the form along with their initials. One check is done in the AM and one in the PM. On 06/08/2017 at 11:18 AM requested and was given facility policies on Medication Storage and Controlled drugs by staff #3. Staff #3 was interviewed at this time and confirmed that the nurse managers on the units are responsible for making sure that the medication room refrigerator temperatures and the narcotic count/sign sheet are filled out appropriately. The facility policy and procedure, which is provided by Life Care Centers of America, Inc., Medication Storage states Pharmaceuticals requiring refrigeration must be stored in a refrigerator located in a locked area. The Temperature of the refrigerator must be checked every day. The medication refrigerators were kept in a locked room on the units but a review of temperature logs, facility wide, from (MONTH) 1, (YEAR) - (MONTH) 8, (YEAR) found 14 days when there were no temperatures documented at all. These were the following dates: January 6, (YEAR) February 1, (YEAR) March 1, (YEAR) March 3, (YEAR) May 7, (YEAR) May 16, (YEAR) May 17, (YEAR) May 24, (YEAR) May 25, (YEAR) May 26, (YEAR) May 29, (YEAR) May 30, (YEAR) May 31, (YEAR) June 7, (YEAR) 2) On 06/08/2017 at 11:33 AM reviewed the Narcotic Count/Sign Sheet on medication carts 1 and 2 on the Kohala unit and requested that staff #9 make copies of the logs. At that time staff #8 was interviewed about the process that the nurses do to sign the Narcotic Count/Sign Sheet. It was explained that the two nurses count the narcotics to make sure that the count is correct and then pass the key to the cart onto the next oncoming nurse. Both nurses at that time are to sign the sheet, nurse who is starting their shift (Nurse coming on) and the nurse who is going off of shift (Nurse going off). Review of these logs, facility wide, found that there were numerous occassions when the on coming or out going nurse or both did not sign the Narcotic Count/Sign Sheet. The Controlled Drugs facility policy stated 7. Narcotics are counted at the change of each shift by the off-going and the on-coming nurse and both sign the Change of Shift Count Record. Review of the logs for the Kohala medication cart 1 found nurse coming on signature missing for 06/01/2017 0600-1800 and nurse going off signature missing on 06/01/2017 1800-0600. The Kohala medication cart 2 was missing signatures from it's Narcotic Count/Sign Sheet for the following: Nurse going off shift on 04/19/2017 at 0600, 04/30/2017 Nurse coming on 0600-1800, 04/30/2017 Nurse going off 1800-0600, 05/05/2017 Nurse going off 1800-0600, 05/06/2017 Nurse coming on 0600-1800, 05/18/2017 Nurse going off 0600-1800. The Ka'u medication cart had signatures missing from it's Narcotic Count/Sign Sheet for the following: 05/12/2017 0600 Nurse coming on and Nurse going off at 0600 and 1800, 05/13/2017 Nurse going off at 0600, 06/01/2017 Nurse coming on at 1800, and 06/05/2017 Nurse going off at 1800. The Reflections medication cart had signatures missing from it's Narcotic Count/Sign Sheet for the following: 05/18/2017 Nurse coming on 1800-0600, 05/19/2017 Nurse coming on and Nurse going off 0600-1800, 05/20/2017 Nurse coming at 0600-1800, 05/20/2017 Nurse going off 1800-0600, 05/31/2017 Nurse going off shift at 0600, 06/05/2017 Nurse coming on at 1800, and 06/06/2017 Nurse going off at 0600. 06/08/2017 at 12:02 PM interviewed staff #6 and asked when the nurses at the facility are trained in how to monitor the medication refrigerator temperature and signing the narcotic count/sign sheet. Staff #6 explained that this occurs when the nurses are orientated on the unit. Staff #6 explained that the nurses are told to check the medication refrigerator thermometer twice a day, at the start of their shift, and document this informaiton on the log. The facility failed to store refrigerated medication at proper temperatures which may result in a change in potency of medication administered to the residents. The facility failed to monitor nurses for completeness of signing the Narcotic Count /Sign Sheet which may result in poor reconciliation of the narcotics.",2020-09-01
798,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2017-06-09,441,D,0,1,PJ7B11,"Based on observation, resident and staff interview and policy review, the facility failed to put practices in place to prevent the spread of infection, including proper hand washing techniques or hand sanitization. The facility is expected to utilize proper personal hygiene practices including proper hand washing to prevent cross contamination. During observation of medication administration pass with Resident #34 (R#34). Staff #4 passed approximately thirteen medications, of which three were inhalers. Staff #4 was not seen to hand wash or hand sanitize before entering room to pass meds after preparation of medications. Medications were carried into room by Staff #4 without wearing gloves. After R#34 had taken their first puffer, Staff #4 used a tissue to wipe the perimeter of the mouthpiece of the puffer and placed the puffer into her pocket. This process was repeated for three different puffers in which after cleaning with tissue, the puffers were cleaned with a tissue and placed into their pocket. After passing R#34's meds, Staff #34 did hand wash.",2020-09-01
799,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2017-06-09,514,D,0,1,PJ7B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review the facility failed to maintain an accurate medical record for 1 of 23 residents from the Stage 2 Sample. Findings include: 1) On 06/08/2017 at 2:03 PM while reviewing the medical record for resident (Res) #127 it was noted that the resident was admitted on [DATE] with orders written at 4:00 PM by staff #10 for wound vac dressing change three times weekly On Monday/Wednesday/Friday Pressure ulcer of sacral region, stage 4 and another order written the same day and time for air mattress Pressure ulcer of sacral region, stage 4. Res #127 was admitted from North Hawaii Community Hospital after she had surgical debridment done on 03/25/2017 and wound vac placed on site. MDS completed on 04/06/17 shows that resident was admitted to the facility with 1 stage 4 pressure ulcer. On 06/09/2017 at 8:00 AM while reviewing Res #127 medical record it was found that staff #10 wrote in their discharge summary, for Res #127, on 04/20/2017, which was signed on 05/01/2017, the medical reason for discharge sacral decubitus stage III ---> stage IV with osteomylitus. At 8:35 AM on 06/09/2017 staff #10 was interviewed. The above information was shared with staff #10 and asked to clarify if Res #127 had a stage 3 or 4 decubitus when admitted and they stated that they would amend their documentation because Res #127 had a stage 4 decubitus ulcer when they were admitted on [DATE] and discharged on [DATE]. On 06/09/2017 at 10:11 AM interviewed staff #11 who explained what they do for a sharps debridment of a wound. Staff #11 stated that they assess the wound to determine what is viable and what needs to be cut away. Sharps debridment was done for Res #127 on 04/14/2017 and 04/17/2017 by staff #11. On 04/19/2017 staff #11 took staff #10 to see Res #127 while the dressing change was being done because he/she was worried about how the wound appeared. It was discovered at that time, during the dressing change, what appeared to be bone fragments in the wound bed, this was collected and sent out for testing. The facility failed to maintain an accurate medical record resulting in an incorrect recording of health deterioration prior to discharge.",2020-09-01
800,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2019-07-26,550,D,0,1,3PL011,"Based on a confidential family interview and record review, the facility failed to ensure a resident had a right to a dignified existence. Findings include: On 07/23/19 at 12:45 PM a confidential family interview was done. The family member shared observation of some staff members providing care found they do not acknowledge the resident's presence by speaking to the resident. The family member further shared some staff members speak to the resident and others don't talk too much. A record review found a care plan was developed to address the potential for social isolation related to impaired cognition. The intervention included all staff to converse with (name of resident) while providing care.",2020-09-01
801,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2019-07-26,578,D,0,1,3PL011,"Based on record review, interview with staff members, and review of the facility's policy and procedures, the facility failed to ensure advance directives were maintained in the medical record for 2 (Residents 48 and 62) of 11 residents sampled. Findings include: On the morning of 07/24/19, a record review found no documentation of Resident (R)48 and R62's advance directive. On 07/25/19 at 08:36 AM concurrent record review was done with the Social Worker (SW). The SW confirmed R48's advance directive was not in the chart. The SW reported R48 was readmitted for respite while on vacation. The SW also confirmed R62's advance directive was not in the chart. The SW recalled R62 went to the hospital and the advance directive was probably sent with the resident. The SW was agreeable to check her files and the business office for copies. On 07/26/19 at 08:53 AM, the SW provided a copy of R48's durable power of attorney for financial management. The SW reported R48's family provided a copy of the document on 07/25/19. The SW was unable to locate an advance directive for R62. The SW stated she is positive R62 has an advance directive and contacted R62's family. The family member will bring a copy next week. The SW explained the facility keeps three copies of residents' advance directives, one is in the residents' charts, the second is filed in the SW office, and the third copy at the business office. On 07/26/19 the facility provided a copy of the policy and procedure entitled Advance Directives, revised 02/2018. The policy notes the following: .if the resident has an advance directive, the social worker will request a copy of the directive so that it may become part of the medical record .Note: The advance directive copy should always remain in the resident's record, protected in a plastic cover, even if the chart is thinned.",2020-09-01
802,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2019-07-26,689,D,0,1,3PL011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, and staff interview, the facility failed to identify a potential electrical accident hazard for one (Resident (R) 33) of eight residents reviewed. As a result of this deficient practice, the facility put the safety and well-being of all the residents as well as the public at risk for accident hazards, such as a fire. Findings Include: During an observation of Resident (R) 33's room, on 07/23/19 at 10:41 AM, two electrical power strips were connected, in sequence, when plugged in to one power source/electrical outlet. The first power strip (from the wall outlet) had two items plugged in: 1. the bed, and 2. cable box. The second power strip (which extended from the first) had two additional items plugged in: 3. a lamp, and 4. television. During a second observation of R33's room on 07/24/19 at 08:30 AM, the findings were the same as previously described on 07/23/19 at 10:41 AM. R33 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R33 was awake, oriented to person, place, and answering questions appropriately at the time of interview on 07/24/19 at 08:30 AM. R33 said that only one wall outlet was working so that was the reason for using a second power strip. On 07/25/19 at 09:56 AM, the Environmental Services Director (ES Dir) was queried about the above findings. ES Dir acknowledged that the two power strips should not have been connected to one another because the potential for a circuit overload and/or electrical fire.",2020-09-01
803,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2019-07-26,758,D,0,1,3PL011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to ensure 1 (Resident 62) of 5 residents reviewed for unnecessary medication review was monitored for efficacy for the use of [MEDICATION NAME] to treat a sleep disorder ([MEDICAL CONDITION]). Findings include: Resident (R)62 was readmitted to the facility on [DATE] following hospitalization for bilateral pneumonia. R62's [DIAGNOSES REDACTED]. A record review on 07/25/19 at 12:42 PM found a physician's orders [REDACTED]. The facility developed a care plan to address R62's alteration in sleep pattern (inability to fall asleep for 6-8 hours a night). The record review found no documentation of monitoring of the number of hours of sleep for R62. On 07/25/19 an interview was conducted with Unit Care Coordinator (UCC). The UCC was asked whether the facility is monitoring R62's sleep as the resident receives [MEDICATION NAME] for sleep disorder. The UCC replied the facility does monitor R62's number of hours of sleep. The UCC reviewed the unit's behavior monitoring folder and found R62 did not have a monitoring sheet for sleep. The UCC confirmed R62 should be monitored for the number of hours of sleep he has nightly to assess the efficacy of the [MEDICATION NAME].",2020-09-01
804,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2018-08-31,689,G,1,0,BINJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a facility reported incident (HI 619), and subsequent onsite investigation that included record review and staff interview, the facility failed to ensure that Resident (R)24 received adequate supervision to prevent accidents. As a result, R24 fell and sustained harm, two fractures of the right side of the face, and a right eye injury. Findings include: Record review reflected that R24 was a known fall risk, had fallen on 11/03/14, 02/11/15 and 02/08/17 without injury, and fallen 02/10/18, and 08/12/18 with injury. The resident had also been care planned for falls and interventions prior to the fall that occurred on 08/12/18. Interventions included falls risks assessments, reporting falls to primary care physician and responsible party, reporting to primary care physician any side effects associated with resident medication use, place items frequently used within reach, offer snacks and monitor closely and provide activities to reduce agitation, provide opportunity to transfer out of bed and use toilet during rounds at night, and resident door to room will remain open. Following the 08/12/18 fall, the care plan added that two staff members will perform all activity of daily living while resident is in bed. The resident's [DIAGNOSES REDACTED]. Resident's [DIAGNOSES REDACTED]. During interview with facility Director of Nursing (DON) and Nursing Home Administrator (NHA) on 08/30/18 at 10:39 AM, the DON confirmed that the facility was aware that the resident was at risk for falls prior to the 08/12/18 fall, that all care plan interventions were maintained, the fall was avoidable, because the Certified Nurse Aide (CNA)25 had raised the bed to a high position, and should not have turned her back on R24 while gathering supplies, and could not prevent the resident from falling from the bed while resident called out that she was falling. DON went on to say that after the facility completed their investigation, they had determined that it was a training issue, the nurse aide needed education and corrective action, treated the incident like an immediate jeopardy incident, put together a performance improvement plan to ensure that no other residents were at risk. DON said, If I were a state surveyor I would treated it as a harm. DON said that moving forward that she monitors care of residents in bed to ensure care is provided safely, did competencies with CNAs after this occurred to ensure this would not happen.",2020-09-01
805,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2018-08-31,755,D,0,1,BINJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review (MRR) and staff interviews the facility failed to ensure that the Pharmaceutical Services process was monitored to ensure accurate interpretation and reconciliation of prescriber's orders for 1 of 39 residents, Resident(R)36, on the sample resident list. Findings include: On 08/30/18 at 09:04 AM reviewed R36's medication orders for unnecessary medications for use of the anticoagulant medication, [MEDICATION NAME]. In the (MONTH) (YEAR) medication orders, there is one medication order for [MEDICATION NAME] and in the (MONTH) (YEAR) medication orders there are two medication orders for [MEDICATION NAME]; the first dated 07/23/2018 [MEDICATION NAME] 1 mg tablet administer 1 1/2 tabs equals 1.5 mg by mouth daily, and the second dated 08/13/2018 [MEDICATION NAME] 2 mg tablet by mouth daily. On 08/30/18 at 09:35 AM interviewed Licensed Nurse (LN) 17 who signed that she double-checked R36's (MONTH) (YEAR) medication orders. Inquired of LN 17 why R36's (MONTH) medications orders had two different orders for [MEDICATION NAME] when the previous (MONTH) (YEAR) medication orders had only one order for [MEDICATION NAME]. Also inquired which [MEDICATION NAME] order was discontinued on 08/27/18, as new order for 1.5 mg [MEDICATION NAME] was written on that date. According to LN 17 the monthly medication orders was printed out by medical records staff and LN17 did double check on 08/29/18. LN pointed out that [MEDICATION NAME] 2 mg tab by mouth daily was written on 08/13/18. Queried LN17, that on 08/27/18 Physician/Prescriber telephone order was written to discontinue previous [MEDICATION NAME] order, and whether the 08/13/18 [MEDICATION NAME] order was the previous order. LN 17 could not provide an answer because she was on her way to start work at another unit. On 08/30/18 at 10:07 AM interviewed R36's Primary Care Physician (PCP) and Advanced Practice Registered Nurse (APRN) to inquire whether they wanted R36 to have increased [MEDICATION NAME] doses of 1.5 mg and 2 mg beginning (MONTH) (YEAR) as medication orders printed and in R36 medical record. The APRN stated that she was more familiar with R36 and that the 2 mg dose was discontinued on 08/27/18 and the printed medication order was in error. The PCP stated that he did not sign to endorse R36's medication order that was double checked and signed by LN 17 on 08/29/18. The PCP further stated that printed medication orders, and Physician/Prescriber telephone order slips are old-fashioned, and thankful that error was spotted. The APRN immediately crossed off order for 2 mg [MEDICATION NAME] on the Sept (YEAR) medication orders and initialed the order to endorse it. On 08/31/18 at 08:14 AM interviewed Licensed Nurse (LN) 22 to review R36's MAR for Sept (YEAR) and was directed to look in Medication Administration Record (MAR) binder for September. The MAR for R36 had two orders of [MEDICATION NAME] and inquired of LN 22 if MAR and Physician order [REDACTED]. LN 22 stated that nurses are scheduled to do double check between medication orders and MAR and the schedule was at the unit nurses station. The Minimum Data Set Coordinator (MDSC)2 reviewed the Medication Administration Record (MAR), printed medication orders and schedule for nurses to do double check. On the schedule for nurses to do MAR double check, R36's room number was crossed off. MDSC2 stated that LN 22 was assigned to do double check between MAR and printed medication orders but wasn't sure if crossed out room number reflected that LN22 had completed the double check. The Director of Nursing (DON) explained the medication order error and stated that [MEDICATION NAME] order on the Sept (YEAR) printed medication order and MAR would have been caught by [MEDICATION NAME] flow sheet that is used alongside the MAR. According to DON, although the Sept (YEAR) MAR was printed and in the binder the final checks are done by the night shift nurse, and error would have been noticed the night before the next month's medication orders began. The facility's policy and procedures for [MEDICATION NAME] double checks were reviewed, it was noted that a [MEDICATION NAME] audit tool is used, and results reported to the Quality Assurance Performance Improvement (QAPI) committee. Requested from the administrator any [MEDICATION NAME] Quality Assurance (QA) reports from past 6 months. The DON provided [MEDICATION NAME] audit done in Aug (YEAR) and stated that [MEDICATION NAME] audit tool use started in (MONTH) (YEAR). The DON did not analyze any data collected up to this date but did address a [MEDICATION NAME] error for R36, (nurse did not call MD/NP with a below therapeutic level, checked today 8/9 - in therapeutic range.) The facility staff had multiple opportunities during double-checks on telephone orders, medication orders and MAR, but still included the 2 mg [MEDICATION NAME] order for R36, that should have been discontinued on 08/27/18.",2020-09-01
806,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2018-08-31,761,D,0,1,BINJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a PRN (as needed) medication label was changed to reflect the current physician's orders [REDACTED]. This deficient practice had the potential to affect other residents for whom physician order [REDACTED]. Findings Include: On 08/30/18 at 07:51 AM, the Licensed Nurse (LN) 13 was observed passing medications to R9. LN13 poured the [MEDICATION NAME] 0.5 milligram (mg) tablet out of the blister pack and into a medication cup. Review of the [MEDICATION NAME] blister pack label reflected that [MEDICATION NAME] to be given twice daily as needed (PRN) for involuntary movement. LN13 was asked about the PRN dosing because she said it was to be given four times daily. LN13 reviewed the electronic Medication Administration Record [REDACTED]. LN13 verified the label on the two blister packs for the [MEDICATION NAME] as inaccurate as it was no longer a PRN medication. Record review found the 08/22/18 Physician order [REDACTED].O. (orally) four times daily hold for dizziness or unsteady gait. There was a failure by LN13 to ensure the correct dosing instructions for the [MEDICATION NAME] also included the precautionary instructions to hold the medication for dizziness and unsteady gait.",2020-09-01
807,LIFE CARE CENTER OF KONA,125052,78-6957 KAMEHAMEHA III ROAD,KAILUA KONA,HI,96740,2018-08-31,812,D,0,1,BINJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to ensure proper hand-washing procedures are followed when passing out meal trays and beverages to prevent cross-contamination of bacteria [MEDICAL CONDITION] to residents. Findings include: On 08/28/18 at 11:31 AM on Ocean View Hallway observed Certified Nurse Aide (CNA)33 passing lunch trays and hot cocoa to residents in their rooms without sanitizing her hands between each resident contact. When CNA33 was queried about the proper way to distribute food to residents, she verbalized she should have sanitized/washed her hands before and after each resident served. CNA33 was observed to continue passing trays without proper hand sanitizing/washing. On 08/31/18 at 09:20 AM interviewed Licensed Nurse (LN)26 who stated staff should already have the knowledge about proper hand sanitizing/washing technique for food distribution. On 08/31/18 at 10:31 AM interviewed the Director of Nursing (DON) who confirmed that CNA33 had her hand hygiene training class (Certified Nursing Assistant Competency/Skills Checklist) on 08/17/16. There were no annual updates for hand-hygiene in-service attended by CNA33.",2020-09-01
808,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2019-03-29,802,F,0,1,YEWM11,"Based on observation, interview and record reiew, the facility failed to ensure kitchen staff had appropriate competencies and skills to safely and effectively carry out the functions of the food and nutrition service. Findings include: Observation and concurrent interview on 03/28/19 at 11:00 AM with staff (S)3 who was asked how would you respond to a kitchen fire? S3 needed a lot of prompting regarding steps to respond to a fire. S3 did quote steps of pulling Ansuls. Further questioning of what to do if pulling the Ansul did not put out the fire? S3 was unsure of his answers to evacuate, pull fire pull (911), Rescue, Alarm, Contain, Extinguish (RACE) or Pull, Aim, Squeeze, Sweep (PASS). Interview on 03/29/19 at 0900 AM with S2 and asked the question regarding training for fire safety in the kitchen. S2 stated that he trains his staff and goes over PASS and and RACE but he did not have documentation. We all get the fire safety training with human resources. Human Resources gives out the cheat sheet for badges. Surveyor asked S2 what did you expect S3 to know when asked him about the kitchen fire? S2 stated I went over with him and told him about the silver tank. If that doesnt work, we pull the Ansul, evacuate the kitchen and then pull the fire alarm. Interview and concurrent record review on 03/29/19 at 11:00 AM with S4 who provided record showing that S3 has had Mandatory Annual Training for Fire Safety for (YEAR) and 2019 which includes the acronyms RACE and PASS.",2020-09-01
809,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2019-03-29,812,F,0,1,YEWM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: Observation [DATE] at 08:00 AM during initial kitchen tour reveals staff (S)1 putting away arrival of goods. S2 accompanied this surveyor to inspection of refrigerator #1. Refrigerator #1 reveals bell peppers that has a label stating opened on [DATE] and use by [DATE]. Explanation from S2 states that he tells his staff that it is anticipated that it should be used seven days after opened. Further inspection to refrigerator #2 reveals a bin of won ton that is uncovered, rack of lamb that is defrosting without any cover. Other food items with questionable labeled dates were corn meal - open date [DATE] and use by date [DATE], S2 stated it was good for one month. Cocktail sauce opened [DATE] and use by [DATE] - S2 stated it should be dumped. Garlic oil opened on [DATE] and use by [DATE]. Query to S2 why are the dates expired and inconsistent? S2 agreed that the process in labeling dates was inconsistent and confusing. Continued inspection of kitchen area and while walking through the beverage area reveals the vent with high velocity of air blowing throughout the beverage area. Noticeable particulates on vent, walls and light casing. S2 was asked if he agreed that the air was blowing into the kitchen and he agreed. S2 was asked to wipe the vent with a white paper towel and after doing so, he stated it's dirty. S2 agreed that all the air coming out of the vent was blowing dust throughout the beverage area which contained clean glasses and beverages. Continued observation with S2 in which a portable fan mounted on wall was in the clean area and S2 stated the fan was dirty. In the cooking/grill area, below the kitchen vent hood, were splash panels with a large build-up of dark grease. S2 stated that we have a contractor that comes to clean once a week and the cook also cleans this area. Contractor cleaning documents were requested but not produced and no documentation of cleaning by the cook was produced. S2 agreed it looked longer than a week since cleaning. Revisit to kitchen on [DATE] at 07:20 AM with S2 who shows this surveyor of the cleaning that was done in the kitchen. Observation revealed that the walls, vents in beverage area were wiped clean. Walk in refrigerator revealed re-labeling of foods with current dates. S2 stated that inservicing was done last night with staff regarding proper labeling of foods and relabeling was done. Rack of lamb was covered. S2 created a double sign in sheet for cleaning to be signed by utilities person and cook. Observation on [DATE] AT 10:00 AM of dishwasher sanitization. Staff stated that the temperature does not meet regulations of hot water at 165 degrees Fahrenheit. The temperature was noted to be below 165 degrees Fahrenheit. S2 stated that they use chemical sanitizing solution in addition. S2 was asked how they test for proper chemical sanitizing and asked to perform this test. Test strips were not labeled with identification or expiration dates. Testing of chemical sanitization showed no chemical reaction to solution test strips. S2 shut down the dishwasher and stated that the contractor was coming as the contractor services machines every Tuesday.",2020-09-01
810,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2019-03-29,880,D,0,1,YEWM11,"Based on observation, interview and record review, the facility failed to ensure the hand hygiene procedures were followed by staff involved in direct resident contact. Findings include: Observation on 03/28/19 at 12:00 PM of Staff (S)5 passing meds during dining time. S5 spoon fed a resident their meds crushed in pudding. S5 returned to cart, touched computer, scratched head and touched S5's face. No hand hygiene was noted. S5 then went to pass medications to another resident in a room. No hygiene was noted. Upon leaving resident's room, no hand hygiene coming out of room. S5 returned to cart and poured another med in a cup, drank two cups of water. S5 then grabbed meds without hand hygiene and walked to another resident's room to pass meds. Subsequent observation on 03/28/19 at 01:00 PM, S5 had gloves on and emptied trash. S5 threw gloves away, went back to cart without hand washing or hand hygiene. Interview: Surveyor approached S5 and explained the observations and the lack of hand hygiene and hand washing. S5 started to say but I had gloves. After explaining, S5 agreed she could do better. Record review on 03/28/19 at 02:30 PM reveals in the policy to wash hands after touching garbage.,",2020-09-01
811,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2017-04-28,241,D,0,1,R7VL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a confidential interview with a resident, the facility failed to provide care for a resident in a manner that promotes resident's quality of life. Findings include: On 4/26/17 at 7:17 [NAME]M. a confidential interview was conducted with a resident. The resident reported pushing the call light and at times having to wait five minutes before a staff member responds to the light. The resident reported the call light is being pressed for assistance with toileting. The resident reported there are times the staff member responds too late resulting in bowel and/or bladder incontinence. Observation on 4/27/17 at 9:06 [NAME]M. at the nurse's station, the call light was heard ringing. At the station, there is a monitor which displayed the room [ROOM NUMBER]A, bathroom and 6:51. Observation at 9:13 [NAME]M. of room [ROOM NUMBER] found the residents were not in their beds and the bathroom door was closed. Also noted two other entries displayed on the screen: room [ROOM NUMBER]A, routine and the time was 6:57 and room [ROOM NUMBER]A, routine and the time was 6:58. Upon return to the nurse's station a staff member was observed to check the screen and headed down the hall. The call light ringing for room [ROOM NUMBER] stopped. On 4/27/17 at 2:20 P.M. an interview and concurrent observation was done with Staff Member #268. The staff member clarified the monitor will display information when the call light is pressed. The information provided includes the room number, location and the time (how long the bell was activated). The facility failed to respond to a resident's call light for assistance with the restroom resulting in incontinence for an alert resident who was admitted for short-term rehabilitation.",2020-09-01
812,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2017-04-28,329,D,0,1,R7VL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 1 (Resident #3) of 5 residents sampled for drug regimen review was free from unnecessary drugs. Findings include: Cross Reference to F514. Resident #3 was admitted to the facility on [DATE] from an assisted living setting. Resident #3's current [DIAGNOSES REDACTED]. A record review on 4/25/17 at 9:40 [NAME]M. found a physician's orders [REDACTED]. tablet ([MEDICATION NAME] HCL), increase to 100 mg. by mouth daily from 3/27/17 for a [DIAGNOSES REDACTED]. The documented medication was [MEDICATION NAME] for (MONTH) (YEAR) and (MONTH) (YEAR). Further review found a form entitled Monitoring Log for Side Effects of Antipsychotics which included the following side effects: suicidal thoughts or ideation; excessive sedation (drowsiness) and increased restlessness. A review of the care plan found a plan for [MEDICAL CONDITION] drug use. The plan notes Resident #3 was on [MEDICATION NAME] for back pain and depressed mood; however, medication was tapered from 20 mg. daily to every other day on 1/16/17 then discontinued after a week. Also noted Resident #3 was started on [MEDICATION NAME] (antidepressant) on 2/27/17 and due to signs and symptoms of depression [MEDICATION NAME] was increased on 3/27/17. The interventions included to daily monitor for the side effects of [MEDICATION NAME] included daytime drowsiness, dizziness, headache, hallucination and agitation. Further review of the Behavior/Intervention Monthly Flow Record found for the month of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) there is missing documentation of staff members' initial for their shifts and missing entries for documentation of the number of behavior episodes for each shift. Although there was an increase of [MEDICATION NAME] on 3/27/17, the behavior flow records does not indicate an increase in behavioral episodes. The form for (MONTH) (YEAR) notes one episode of negative verbalization on 2/18/17 during the evening shift. The rest of the entries are documented with 0 (zero) number of episodes. On 2/27/17 Resident #3 was started on [MEDICATION NAME]. A review of the resident's behavior monitoring flow record for (MONTH) (YEAR) found 24 missing entries across three shifts for the behavior of negative verbalization. Also for the month of (MONTH) there are 51 entries over the three shifts for the three identified behaviors. On 4/27/17 at 12:45 P.M. an interview was conducted with the Director of Nursing (DON). The DON was queried regarding how the facility monitors the resident for the side effects related to the use of an antidepressant. The DON responded the facility utilizes the Monitoring Log for side Effects of Antipsychotics. The DON also reported the side effects for the use of an antidepressant includes suicidal ideation, change in appetite and behaviors as well as nausea and vomiting. The facility failed to adequately monitor Resident #3's behaviors related to the use of an antidepressant. Also, the facility failed to adequately monitor the side effects for the use of [MEDICATION NAME]. The monitoring log for side effects addresses the side effects related to the use of an antipsychotic, not an antidepressant. Also the behavior monitoring log has incomplete documentation.",2020-09-01
813,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2017-04-28,371,F,0,1,R7VL11,"Based on observations and staff interviews, the facility failed to maintain and store foods in a sanitary manner. Findings include: 1) During an initial tour of the kitchen on the morning of 4/25/17 at approximately 8:30 [NAME]M. found expired food items and food items without expiration dates noted. Two food items were being stored in the walk in refrigerator but was expired: Oriental dressing, 1.5 gallons, expired 2/217; Ken's Tartar Sauce, expired 2/3/17. Four food items were stored in the walk in refrigerator which didn't have expiration dates: LaScala dressing, no expiration date; Chicken base, no expiration date; Demi Glace, no expiration date; Beef Glace, no expiration date. An interview of Staff #206 on the afternoon of 4/27/17 at approximately 2:30 P.M. revealed the facility went through the above named dressings/sauces quickly. The Staff #206 stated the LaScala dressing, Chicken base, Demi Glace, and Beef Glace came in a large cardboard box where the expiration dates were noted. When the items are removed from the cardboard box, the expiration dates weren't noted on the individual food items. Staff #206 stated he would need to look at this issue and figure out how they'll transpose that information onto the individual containers. 2) A follow visit to the kitchen on the afternoon of 4/27/17 at approximately 2:30 P.M. found the facility kept a walk in freezer outside. The outdoor freezer had foods stored on the floor of the freezer. Areas of the floor in the outdoor freezer were iced and slippery. The ceiling of the outdoor freezer was frosted. The outdoor freezer's fan was found to have a lot of ice build up. The fan sounded loud and the air flow was limited due to the large amount of ice build up. An interview of Staff #206 on the afternoon of 4/27/17 at approximately 2:45 P.M. revealed the staff were expected to maintain the outdoor freezer and keep it clean. On the afternoon of 4/27/17 at approximately 2:45 P.M., Staff #206 was asked for a policy for maintenance of the kitchen equipment. At the time of exit, the policy was not provided to the surveyor.",2020-09-01
814,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2017-04-28,431,E,0,1,R7VL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to properly label medications to reflect the resident's current physician's orders and dispose of expired biological. Findings include: 1) On [DATE] at 8:05 [NAME]M. during medication administration observation, Resident #16 had a physician's order which read, Metoprolol XL 12.5mg orally every day. However, the blister pack read, Metoprolol XL 25 mg orally every day. Staff #280 cut the pill in half to administer 12.5 mg. When asked what the correct order was, Staff #280 was able to state, Metoprolol 12.5 mg daily. The disparity between the physician's order and the label on the medication blister pack did not match. 2) On [DATE] at 7:52 [NAME]M. during medication administration observation, Resident #3 had a physician's order dated [DATE], Amlodipine Besylate 10 mg tab orally every 12 hours. Hold for systolic blood pressure An interview with the Director of Nursing, DON, on the morning of [DATE] revealed the staff correctly administered the medications to Residents #3 and #16. However, the DON acknowledged the medication blister pack label was inconsistent with the current physician's orders. 3) On [DATE] at 2:20 P.M. concurrent observation was done with Staff Member #268. Observation found a multi-dose vial of Tuberculin, Purified Protein Derivative labeled with an open date of [DATE] and expiration date of [DATE]. The staff member confirmed the biological is expired and will be thrown out.",2020-09-01
815,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2017-04-28,465,F,0,1,R7VL11,"Based on observations, staff interview and facility policy review, the facility failed to maintain safe temperature levels in a two resident's rooms (Rooms 488 and 490). Findings include: During a tour of the facility on 4/25/17 at approximately 12:20 P.M., resident's rooms 488 and 490 had high water temperatures at the sinks and showers. When the surveyor turned the water on to the hottest temperature, the water felt too hot to leave a hand under it. On 4/25/17 at 1:15 P.M., Staff #234 and #229 both came to the fourth floor to check the water temperatures. Staff #234 used the facility's laser thermometer to check the temperature in Room 490. The shower in Room 490 went to 120.8 degrees Fahrenheit. On the fifth floor, the basin in Room 594 registered at 121.5 degrees Fahrenheit. A review of the facility's water temperature logs from (MONTH) (YEAR) through present found the temperatures were logged above 120 degrees on multiple occasions. On 12/16/16 in Room 480, the temperature measured 121 degrees and 123 degrees Fahrenheit for the shower and basin respectively. On 2/3/17 in Room 572, the temperature measured 120 degrees and 121 degrees in the shower and basin respectively. On 2/17/17 in Room 478, the temperature measured 121 degrees in both the shower and basin. The logs did not contain documentation of interventions when the temperatures were measured above 120 degrees. An interview of Staff #234 on the afternoon of 4/25/17 at approximately 1:15 P.M. revealed the facility kept the thermostat at 115-120 degrees. Staff #234 further noted the facility utilized an outside Contractor to maintain their hot/cold water mixing valves. A review of the facility's policy titled, (Facility's) Thermostatic Valves with effective date of 6/20/12 revealed, The acceptable temperature range for hot water is between 105 degrees and 120 degrees Fahrenheit. The policy further noted, F. If the temperature falls outside the acceptable range (either too cold or too hot) an adjustment will be made at the source (three mixing valves in the machine room).",2020-09-01
816,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2017-04-28,514,E,0,1,R7VL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with staff member and a review of the facility's policy and procedures, the facility failed to ensure 2 of 8 medical records reviewed were complete. Findings include: 1) Cross Reference to F329. The record review for Resident #3 found the facility was monitoring the resident's behavior related to the use of an antidepressant. The behaviors being monitored included: sad facial affect, isolation/refuse participation in activity and negative verbalization. A review of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) found the documentation was not complete, staff members failed to initial their entries and there was also missing documentation for various days/shifts. The review found for the month of (MONTH) (YEAR) staff members did not initial documentation for sad facial affect on the following days/shifts: (MONTH) 2, 3, 6, 7, 8, 10, 13, 18, 20, 21, 22, 23, 27, 28, 29, 30 and 31. The staff members did not initial documentation on the following days/shifts related to isolation/refuse participation in activity for the following: (MONTH) 2, 3, 6, 7, 8, 10, 18, 20, 21, 22, 23, 27, 28, 29, 30 and 31. The staff members did not initial documentation for negative verbalization on the following days/shifts: (MONTH) 2, 3, 6, 7, 8, 10, 20, 21, 22, 23, 27, 28, 29, 30 and 31. There was no documentation of behavior or initial on the following days: (MONTH) 13 (x 2) and 24. A review for the month of (MONTH) (YEAR) found missing documentation for (MONTH) 26 and 27. The staff member did not initial documentation on (MONTH) 15 and 17. A review for the flow sheet for (MONTH) (YEAR) found no documentation for number of behaviors for negative verbalizations with staff initials on the following dates/shifts: (MONTH) 3, 4, 5, 6, 7,11, 12, 13, 14,16, 17, 26, 27, 28, 29, 30, and 31. Further review found no staff initials for the three behaviors on the following dates/shifts: (MONTH) 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, 16, 17, 26, 27, 28, 29, 30 and 31. 2) Record review done on 4/25/17 at 9:37 [NAME]M. found a physician's orders [REDACTED]. twice a day for [DIAGNOSES REDACTED]. Further record review was done on 4/27/17 at 8:11 [NAME]M. The facility developed a Behavior/Intervention Monthly Flow Record for Resident #12 for the use of [MEDICATION NAME]. The identified behaviors that the facility monitored the resident for included: crying/sad facial expression, negative behavior and poor appetite. The flow record for the month of (MONTH) is missing documentation for the number of episodes and initials for the following dates/shifts: (MONTH) 11, 21, 23, 24, 25, 27, and 28. The flow record is missing initials for the following entries: (MONTH) 2, 3, 4, 13, 14, 17, 18, 19, 20, 21, 23, 24, 26, 27, and 28. A review for the month of (MONTH) (YEAR) also found missing documentation on the following dates/shifts: (MONTH) 4, 5, 6, 7, 9, 11, 12, 13, 14, 16, 17, 20, 21, 26, 27, 28, 29, 30, and 31. Concurrent review with Staff Member #252 on 4/27/17 at 12:45 P.M. confirmed the missing documentation for Residents #3 and #12. A review of the facility's policy and procedure provided by the facility on 4/28/17 at 10:00 [NAME]M. for Medical Records notes Medical record entries (either paper or electronic) must be dated, the time entered and be manually or electronically signed and/or initialed.",2020-09-01
817,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2018-05-24,812,E,0,1,H61611,"Based on Observation and staff interview the facility did not store food in accordance with professional standards for food service safety. A large box of meat was found open in the large freezer and there was a thick layer of ice buildup on the floor which compromised the sanitary storage of food. In the walk in refrigerator food items were stored directly on the floor and items were found with no open or discard dates on their labels compromising food safety. This deficient practice compromised the health of residents, placing them at risk for food borne illness. Findings include: During the initial tour of the kitchen on 5/22/18 at approximately 8:30 AM. The outdoor walk in freezer contained one box of frozen meat that was partially open exposing meat patties. A two to four inch layer of ice buildup was observed on the entire freezer floor. Next to the door, a hammer was found to be laying on the shelf. During an interview the chef stated that the ice is very difficult to control and we are not able to defrost so we chip the ice off the floor with a hammer. In the small walk in refrigerator a large bottle of barbecue sauce and fish base containers were found open and without labels. A Large Box of lettuce was sitting directly on the floor. During a follow up visit to the kitchen on 5/24/18 at 10:15 AM a large box of lettuce and bag of onions were found on the floor in the walk in refrigerator. During an interview, the chef stated there was a produce delivery that morning and the lettuce was placed there only briefly. The chef stated that the produce will be moved off the floor.",2020-09-01
818,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2018-05-24,842,D,0,1,H61611,"Based on record review and staff interview the facility failed to maintain accurate medical records for two residents (R6 and R10) in the sample. R6's medical record contained a consultation report that was not documented with the date of consult or consulting physician's name. R10's record contained inconsistencies in the resident's advanced directives. Findings include: 1) During a record review an orthopedic consultation report was found in R6 record without the consultation date or the name of the orthopedic physician. It was difficult to determine the chronological sequence of events following a fall for R6. During an interview, the Director of Nursing (DON) was queried about the missing information. The DON logged into the Electronic Medical Record (EMR) and read a typed progress note about the orthopedic appointment that occurred on 05/01/18. When surveyor asked the DON about the missing information on the consultation report, she took the consultation report from the hard chart and wrote in the name of the consulting physician and date of consult. The DON concurred that the information was missing from the report but was in the EMR. 2) A review of R10's Advanced Care Planning documents revealed the Provider Orders for Life-Sustaining Treatment (POLST) and AD forms have conflicting information. The POLST (Section C, Artificially administered nutrition) signed by R10, dated 10/13/16 includes an order to provide a Defined trial period of artificial nutrition by tube. The AD (Part 2 Section B, Artificial Nutrition and Hydration) signed by R10, dated 02/13/2006, indicated R10 did not wish to have artificial nutrition provided. The AD is marked Choice not to Prolong life which includes no artificial nutrition. On 05/23/18, a concurrent record review and interview was conducted with the Director of Nursing (DON). The DON confirmed the discrepancy on the two documents. In addition, the facility did not follow their own policy titled, Advanced Care Planning dated 01/27/16. The policy states: 1. Upon admission to Nursing, the Director of Social Services or designee will inquire with residents and families if there are any existing advanced care planning documents. 2. The Director of Social Services or designee will review with Resident and families if the wishes expressed in the documents are accurate and current. 3. If changes are desired, the Director of Social Services or designee will assist in the completion of a new AHCH (Advanced Healthcare Directive)",2020-09-01
819,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2018-05-24,908,F,0,1,H61611,"Based on observation, staff interview, record review, and review of facility policy, the facility failed to perform routine maintenance, based on manufacturer's recommendation, and failed to provide preventative maintenance records for seven of seven oxygen concentrators reviewed. This deficient practice put the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: 1. During staff interview with the Director of Nursing (DON) on 05/24/18 at 11:30 AM, DON stated that the cleaning of all Oxygen Concentrator Air Intake Filters was done, once a week, by the night shift Certified Nursing Assistant (CNA). DON also provided daily checklists which the night shift CNA used. However, during staff interviews with CNA1 and CNA17 on 05/24/18 at 01:54 PM, they both said that they were not aware of and did not perform the required cleaning of the Oxygen Concentrator filters as indicated previously. Also, during review of the CNA checklists, it did not specify when the required weekly cleaning of the Oxygen Concentrator filters was performed. After review of facility policy pertaining to Environmental Infection Control, it stated that the routine care of reusable resident equipment/Oxygen Concentrators, should be performed based on manufacturer's instructions. The facility failed to perform that.",2020-09-01
820,HI'OLANI CARE CENTER AT KAHALA NUI,125055,4389 MALIA STREET,HONOLULU,HI,96821,2018-05-24,921,D,0,1,H61611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to: 1) Secure one out of five drawers from a treatment cart located on the fifth floor; and 2) Safely store all free-standing oxygen cylinders which may create a hazardous environment. As a result of the eficient practices the facility put the safety and well-being of the residents as well as the public at risk. Findings Include: 1. During observation of a treatment cart on 05/22/18 at 10:30 AM, it was noted that all the drawers were locked except the third drawer down from the top. This drawer contained generic supplies such as kerlix dressing, bandages, and tape. It also contained resident specific medications which was not secured. During staff interview with the Assistant Director of Nursing (ADON) on 05/22/18 at 10:36 AM, ADON acknowledged that the drawer should have been locked and the contents secured. 2) During an interview on 05/22/18 at 11:08 with Resident (R2) in room [ROOM NUMBER]A, observation revealed multiple oxygen cylinders in the corner of the room. There were four full oxygen cylinders (25 cubic feet, E-size) and two empty oxygen cylinders in a rack. An additional oxygen cylinder was securely attached to a wheelchair located next to the rack. The empty and full cylinders in the storage rack were not clearly segregated or identified as full, or empty. R2 was observed to be using an oxygen concentrator. The oxygen concentrator does not require the use of an oxygen cylinder. R2 said she uses the oxygen concentrator all the time when in her room. She said she leaves the room only a couple times a day to go to the dining room for lunch and dinner. When R2 leaves the room, she uses a wheelchair with an oxygen cylinder attached. During an interview on 05/24/18 at 12:26 P.M. with Licensed Nurse (LN1), it was confirmed R2 uses an oxygen cylinder only for transport and when out of the room. LN1 stated R2 is receiving hospice care, and the hospice staff take care of all her supplies, including the oxygen. The hospice oxygen cylinders are a separate inventory from the facility's oxygen inventory. LN1 stated, The hospice staff keeps their oxygen in the R10's room. The number of oxygen cylinders for immediate use in the resident's room should be based on an assessment of the Resident's need. All other cylinders should be stored in a separate designated, secure area. The full and empty cylinders must be clearly segregated. In addition, the facility did not follow their own policy and procedure titled, Oxygen Tanks Use, dated 06/06/17. The policy and procedure defines in use versus in storage cylinders. In use cylinders are cylinders properly secured to a wheel chair. In-storage means that the tanks are properly secured in the designated storage room. There is a designated, secure oxygen storage room on the fourth floor located off the medication room.",2020-09-01
821,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2017-08-30,241,D,0,1,MO9C11,"Based on resident interview, the facility failed to treat and care for each resident in a manner and in an environment that promotes or enhances his or her quality of life recognizing each resident's individuality for 1 of 14 residents that were interviewed in the Stage 1 sample. Findings include: On 8/22/17 at 2:30 P.M. an interview was conducted with Resident #56. The resident reported there was a day when she requested a staff member rinse the tube that she uses for breathing treatment. Resident #56 stated the staff member got so angry and told the resident that she was busy serving breakfast. Resident #56 shared that she felt hurt by this staff member; however, was unable to recall the staff member's name. Subsequently, Resident #56 reported the incident to the nurse. The nurse told her not to mind the staff member and would later inform staff members of the need to clean Resident #56's equipment after use. A review of Resident #56's quarterly Minimum Data Set with an assessment reference date of 7/2/17 notes the resident yielded a score of 15 (no cognitive impairment) on the Brief Interview for Mental Status. The facility did not treat Resident #56 with dignity upon the request for assistance to clean her equipment resulting in the resident feeling hurt by the staff member's response to the request.",2020-09-01
822,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2017-08-30,242,D,0,1,MO9C11,"Based on resident and staff interviews, the facility failed to provide 3 residents (Resident #2, Resident #24, and Resident #79) with the opportunity of choice with showers and waking times. Findings include: 1) An interview of Resident #2 on the morning of 8/23/17 at approximately 9:30 [NAME]M. revealed he was not given a choice of how many showers he received. He stated that he received showers on Sundays and Wednesdays but would like one more shower every week. 2) An interview of Resident #24 on the afternoon of 8/22/17 at approximately 2:20 [NAME]M. revealed he was not given a choice of when he wakes up in the morning. He noted the Certified Nurses Aides, CNAs, woke him according to their schedules. He stated that he would like to awaken when he's ready and not when they tell him. 3) An interview of Resident #79 on the morning of 8/24/17 at approximately 8:15 [NAME]M. revealed she was not given a choice of how many showers he received. She stated that she wants to shower every day but the facility told her they give showers three times per week. An interview of Staff #1 on the morning of 8/24/17 at approximately 11:40 [NAME]M. revealed the residents were wiped down daily. She further noted the residents received two showers per week. If a resident or family members requested more frequent showers, the facility would try to accommodate them. She stated they would provide the additional showers but it may not be on the particular day the resident/family members requested. An interview of the Administrator on the afternoon of 8/29/17 at approximately 1:30 P.M. revealed residents/families were informed of the facility's shower schedule at the first family meeting after the resident was admitted to the facility. The Administrator further noted they review personal care during residents' quarterly reviews, not specifically about showers. The facility failed to provide residents with choices of their daily schedules and preferences for shower frequency.",2020-09-01
823,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2017-08-30,253,D,0,1,MO9C11,"Based on observations, the facility failed to provide housekeeping services to maintain a clean and comfortable interior. Findings include: On 8/22/17 during the lunch meal observed green curtains drawn closed across the buffet in the dining room. There were round spots and splatter marks on the curtain. The area of the curtain with the majority of the stain marks was next to the table where Resident #16 dines. On 8/28/17 at 11:43 [NAME]M. concurrent observation of the green curtains in the dining room was made with Staff Member #2. Inquired what those spots were, the staff member reported the area where the female resident sits is probably due to the resident spilling coffee. The staff member reported that there isn't a schedule of when the curtains are cleaned or changed; however, they can call for it to be cleaned. On 8/28/17 at 11:56 [NAME]M. concurrent observation was done with Staff Member #3. The staff member acknowledged the stains and was agreeable to call housekeeping to have the curtains cleaned. The staff member was also agreeable to follow up on a schedule for curtain cleaning.",2020-09-01
824,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2017-08-30,279,D,0,1,MO9C11,"Based on record review, interview with staff members and review of the facility's hospice contract, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #56) of 13 resident care plans reviewed of the 29 residents in the Stage 2 sample. Findings include: Cross Reference to F309. Resident #56 was admitted to the facility with a contracted hospice provider services on 4/26/17. The record review found no documentation of a joint plan of care involving the facility and the hospice provider. The interviews conducted with staff members, hospice provider and resident found there was no coordination of services to ensure the resident received services to maintain her highest practicable physical, mental and psycho-social well-being.",2020-09-01
825,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2017-08-30,309,D,0,1,MO9C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members and resident, the facility failed to ensure 1 (Resident #56) of 1 residents selected for hospice review received the necessary care and services to ensure end of life services to maintain the highest practicable level of physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Findings include: Cross Reference to F279. Resident #56 was admitted to the facility on [DATE] with hospice services. The resident's [DIAGNOSES REDACTED]. On 8/24/17 at 12:30 P.M. the hospice binder was provided by Staff Member #4. A review found no documentation of a plan of care. Staff Member #4 was interviewed regarding the services hospice is providing, the staff member reported an aide comes twice a week to provide showers and the hospice nurse comes to assess the resident and the chaplain and social worker also comes to visit. Inquired what services is the hospice nurse providing that the facility nurses do not provide. The staff member replied the nurse assesses the resident, taking vitals and assists in the recertification for hospice services. Inquired whether a hospice representative and resident participated in the development of the plan of care, the staff member recalled a hospice representative was present on the admission meeting; however, did not participate in the quarterly update. The binder contained notes from hospice staff members on a form labeled for chaplain and social worker. Queried Staff Member #4 whether the authors of the documents was the chaplain or social worker. The staff member had to call the hospice provider to clarify the roles of the staff members completing the forms. Concurrent review of the care plan was done with Staff Member #4. Inquired whether the facility's plan of care included hospice services, the staff member replied the plan of care is mostly for the facility staff; however, the hospice provider is available for consultation. Staff Member #4 contacted the hospice provider and requested a copy of the plan of care via facsimile. Further queried whether the facility has a copy of the hospice certification, Staff Member #4 requested a copy of the certification. A copy of the hospice plan of care was provided on 8/24/17 at 1:49 P.M. The hospice certification was sent via facsimile to the facility on [DATE] at 3:12 P.M. An interview was done with Resident #56 on 8/24/17 at 1:00 P.M. The resident reported the nurse comes twice a week, takes vitals, provides showers and talks a bit. Resident #56 also reported two ladies come to keep her company; however, the resident was not aware of the names of the ladies. Inquired whether the resident is aware of when the hospice staff members are scheduled to visit, the resident replied she is not aware of when they are coming back but has the phone number to contact them if needed. On 8/24/17 at 1:10 P.M. a telephone interview was done with the hospice nurse. The nurse reported hospice is providing durable medical equipment (bed, wheelchair, oxygen concentrator, nebulizer), aide services (bath twice a week) and the chaplain, and the social worker and volunteer visit the resident three to four times a month. On 8/24/17 at 2:00 P.M. a review of the hospice contract provided by the facility was done. The documentation at 3.1.7 notes the following: .Hospice shall provide Hospice Services to each Patient in accordance with the Joint Plan of Care for that Patient and with accepted standards of professional practice . In section 3.1.17 Coordination of Services, the hospice provider will provide facility with the following information specific to each Hospice Patient resident at facility: (i) the most recent Plan of care .(iii) the Physician certification and recertification(s) of the terminal illness . In section 3.2.12 Coordination with Hospice notes (i) For each Hospice Patient in the Facility obtain (e) the most recent Plan of care .(iii) physician certification and recertification of the terminal illness, (iv) names and contact information for Hospice personnel involved . In Section 3.3 Joint Responsibilities/Mutual and Hospice Promises, Facility admits a Hospice Patient to the facility, Hospice and Facility shall jointly develop and agree upon the Patient's Joint Plan of Care .Facility shall be responsible for implementing those portions of the Patient's JP[NAME] for which Facility is responsible . The facility failed to develop a joint plan of care (JP[NAME]) with the hospice provider to ensure Resident #56 receives coordinated hospice/end of life services to maintain the highest practicable physical, mental and psychosocial well-being. The facility also failed to ensure a copy of the hospice provider's care plan and recertification document were obtained.",2020-09-01
826,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2017-08-30,320,D,0,1,MO9C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 1 (Resident #77) of 2 residents selected for behavioral and emotional status review received appropriate treatment and services to correct the problem to attain the highest practicable mental and psychosocial well-being. Findings include: Cross Reference F329. On the afternoon of 8/28/17 a record review was done. Resident #77 was admitted to the facility on [DATE] after hospitalization at an acute hospital. The admitting [DIAGNOSES REDACTED]. A review of the comprehensive/admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 3/22/17 notes in Section E0200A, physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing other sexually) found behavior was not exhibited; however, in comparison the quarterly assessment with an ARD of 6/19/17 notes the aforementioned behavior occurred 1 to 3 days. A review of the Care Area Assessment (CAA) dated 3/29/17 notes Resident #77's refusal of care was extensive on the initial days of admission which may have been related to an adjustment to placement. The resident was noted to refuse care, medications, meals and therapy. The family reported to the interdisciplinary team that Resident #77 was provided with an antidepressant ([MEDICATION NAME]) during the hospitalization for two days due to agitation. The facility developed a care plan for adjustment to placement with the identified problem that Resident #77 needs time and assistance to adjust to placement with interventions to encourage activity attendance of choice and provide the resident time to form words. This care plan was discontinued. Further review found a care plan for mood and behavior/antidepressant use noting the resident has verbal behavior directed at others as well as refusal of care and therapy with short temper outbursts. The interventions include: monitor pattern of behavior (time of day, precipitating factors, specific staff or situations); respond in a calm voice, maintain eye contact, remove from area if verbally abusive to others; and 5/17/17 interdisciplinary team (IDT) recommend for physician to review for gradual dose reduction [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME] 5/28/17 (consider to reduce [MEDICATION NAME]), if there is weight loss consider [MEDICATION NAME], if there is increase in mood/behavior consider increase of [MEDICATION NAME] to 20 mg. or psychiatric re-evaluation). A subsequent quarterly review by the IDT noted the resident's behaviors have lessened in frequency since his initial admission and since he has gotten used to his caregivers and routine. A review of the physician order [REDACTED]. at hour of sleep due to noted increased behavior) with start date of 4/25/17; and [MEDICATION NAME] (100 mg. twice a day) with a start date of 5/15/17. A review of the facility's progress notes from 3/17/17 through 5/10/17 found documentation of Resident #77 refusing morning medication (6:00 [NAME]M.) on the following dates: 3/22/17, 3/24/17, 3/25/17, 3/28/17, 3/29/17, 3/30/17, 3/31/17, 4/12/17, 4/14/17, 4/16/17 and 4/17/17. There is documentation of the resident refusing meals and medications at dinner. On 4/11/17 there is documentation of the resident found on the floor. On 4/17/17 the resident threw the medication on the floor and threw the cup of water at the staff member. Subsequently, Resident #77 was documented to have falls on 6/20/17 and 8/24/17. A review of the social services clinical note dated 4/3/17 with the resident's family does not address resident's previous behavior with the exception of providing the family with a review of medications, including the status of [MEDICATION NAME]. There are no subsequent social services notes. Resident #77 was evaluated by a geriatric psychiatrist on 5/13/17. The impression was [MEDICAL CONDITION] with mood changes. The psychiatrist recommended the addition of [MEDICATION NAME] 100 mg. twice a day and titrate for mood (already on [MEDICATION NAME] 20 mg. daily and [MEDICATION NAME] 7.5 mg. at night). On 8/28/17 at 10:08 [NAME]M. and 12:41 P.M. interviews were conducted with Staff Member #4. Queried the staff member regarding the efforts the facility made prior to the inception of two antidepressant medications to address the resident's refusal of care with monitoring of the resident's pattern of behavior. The staff member replied the resident was on [MEDICATION NAME] while hospitalized and the staff members were monitoring the resident's behavior every shift. Inquired whether at the time the resident began to display the behaviors if the interdisciplinary team identified probable causes of medication and care refusal with non-pharmacological interventions to assist the resident in adjusting to the facility (i.e. change the time of morning medication, adjusting the facility's routines to meet the resident's customary routine) and what did the facility provide to support the resident's loss of independence. The staff member confirmed there is no documentation of reviewing patterns of the behavior and consideration of non-pharmacological attempts to address the resident's behavior. Also, a review of the record with the staff member we were unable to ascertain the resident's placement prior to hospitalization . The facility failed to ensure a resident with psychosocial adjustment difficulty was assessed and accommodated to address his usual and customary routines to maintain the highest level of psychosocial functioning. The facility did not ensure an assessment of causal factors for the decline in behaviors was done by the IDT. Although the facility indicated in the care plan to assess the resident for patterns of behavior with precipitating events, there was no documentation this was done. Also, there was no evidence of the facility's attempts to utilize non-pharmacological interventions prior to the inception of [MEDICATION NAME] and subsequently [MEDICATION NAME] (two antidepressants).",2020-09-01
827,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2017-08-30,329,E,0,1,MO9C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview and facility policy review, the facility failed to ensure that the medication regimen for five residents, Residents #31, #42, #54, #73, and #77, were closely monitored for mood and behaviors. Findings include: 1) Cross Reference to F320. Resident #77 was admitted to the facility on [DATE] from an acute hospitalization . The admission [DIAGNOSES REDACTED]. Record review was done on the afternoon of 8/28/17. A review of the physician's orders [REDACTED]. one time daily due to refusal of care and medications and appears to isolate self) with start date of 4/22/17; [MEDICATION NAME] (7.5 mg. at hour of sleep due to noted increased behavior) with start date of 4/25/17; and [MEDICATION NAME] (100 mg. twice a day) with a start date of 5/15/17. A review of the geriatric psychiatrist evaluation dated 5/13/17 notes the use of [MEDICATION NAME] and [MEDICATION NAME] with a recommendation for the use of [MEDICATION NAME] 100 mg. twice daily. Interview and concurrent record review was done with Staff Member #4. Inquired why the resident receives two antidepressants, the staff member reported the resident was on [MEDICATION NAME] while hospitalized and [MEDICATION NAME] is also an appetite stimulant. Further inquired whether the [MEDICATION NAME] is being used as an appetite stimulant, the staff member reported the two prescribed antidepressants are being administered to address the resident's behavior. Staff Member #4 further reported the interdisciplinary team (IDT) met on 6/28/17 and the recommendations of the team included: nursing to discuss with the physician possible discontinuation of [MEDICATION NAME] and [MEDICATION NAME] and a gradual dose reduction of the [MEDICATION NAME]. However, if there is an increase in behavior the team will consider an increase of [MEDICATION NAME] from 10 mg. to 20 mg. or to refer for a psychiatric evaluation. The staff member clarified on 6/29/17 the resident's physician was in agreement to discontinue the [MEDICATION NAME] and [MEDICATION NAME] and referred to the psychiatrist for re-evaluation of the [MEDICATION NAME] use. The staff member reported the resident was not referred to the psychiatrist for possible discontinuation of [MEDICATION NAME] usage. The facility failed to assess the duplication of medications, the use of two antidepressants ([MEDICATION NAME] and [MEDICATION NAME]) to address Resident #77's behavior. Also, the facility did not follow through with the physician's recommendation for the possible discontinuation or gradual dose reduction of the [MEDICATION NAME] with the geriatric psychiatrist. The facility also did not ensure based on a trial of non-pharmacological interventions to address the resident's refusal of care and agitation was done before prescribing and administering antidepressants. 2) Observation of Resident #73 on the morning of 8/23/17 at approximately 10:00 [NAME]M. found her laying in bed. She was able to appropriately respond to questions asked and was cooperative. Observation of Resident #73 on the morning of 8/24/17 found her seated in her room. She was friendly and responsive. Observation of Resident #73 on the morning of 9/28/17 at approximately 11:00 [NAME]M. found her laying on her bed calling out for help. Staff were not present at the time. She continued to call for help for 10 minutes before a Certified Nurses Aide, CNA, came to assist her. Observation of Resident #73 on the afternoon of 8/29/17 found her seated in her wheelchair in front of a TV near the nurses station. She sat quietly and responded appropriately when asked questions. On the morning of 8/25/17 a review of Resident #73's medical record found she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., and Anxiety Disorder. physician's orders [REDACTED]. A concurrent record review and staff interview with Staff #1 on the morning of 8/25/17 at approximately 10:30 [NAME]M. revealed the facility utilized a form titled, Mood and Behavior Monitoring Summary to monitor mood and behaviors in residents. Staff #1 noted the facility utilized this system to monitor residents' moods and behaviors either when the physician orders [REDACTED]. When the Mood and Behavior Monitoring Summary is initiated, Staff #1 reported the facility initially monitors behaviors every shift for 7 days. If the resident is stable, they monitor the resident weekly. If the resident remains stable over a period of eight weeks, the facility stops the routine monitoring. Thereafter, the resident is monitored like any other resident without behaviors on a quarterly basis. Staff #1 noted that if the same and or new behaviors surface or a medication is added, the facility would start the process again. Staff #1 showed the Mood and Behavior Monitoring Summary for Resident #73 which was last completed on 12/11/16 when it was noted Resident #73 had stable mood/behavior for 8 weeks and therefore the facility determined they would discontinue mood/behavior monitoring at that time. A review of the facility's policy titled, Mood and Behavior Management Policy and Assessment Procedure, with revision date of 2/16 noted details of the facility's policy as summarized above. On the morning of 8/29/17, a review of Resident #73's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/27/17 noted: A Brief Interview for Mental Status (BIMS) score of 14/15, an indicator that she was cognitively intact; Mood score=1, indicating a relatively stable mood; and did not display behaviors such as rejection of care, wandering, and/or physical/verbal/other behaviors towards others. Resident #73's next MDS was a quarterly assessment with ARD of 6/22/17 and noted: BIMS=12/15, an indicator of moderately impaired cognitive status; Mood score=4, for difficulty sleeping for 7-11 days, and poor appetite or overeating for 7-11 days; for Behaviors Resident #73 was experiencing hallucinations and it was noted her behaviors got worse since the last assessment on 3/27/17. The Care Area Assessment (CAA) for Resident #73 did not trigger mood/behaviors. The facility did not follow their policy by initiating the Mood and Behavior Monitoring Summary when Resident #73's behavior symptoms worsened on the 6/22/17 assessment. A review of Resident #73's care plan on the afternoon of 8/24/17 revealed a care plan for [MEDICAL CONDITION] Drug Use, with interventions which included, Implement mood and behavior monitoring as needed per policy. Observe for episodes of anxiety. Initiate behavior monitoring per protocol. On the morning of 8/25/17 at approximately 10:30 [NAME]M., an interview of Staff #1 found her acknowledgement that the CNAs may not know the signs/symptoms of anxiety nor would they understand the side effects of [MEDICAL CONDITION] medications. Despite Resident #73's worsening of behavior symptoms, the facility failed to ensure the effectiveness and necessity of Resident #73's medications. Additionally, the facility's system for monitoring mood/behaviors failed to immediately address Resident #73's new mood/behavioral symptoms (hallucinations). 3) Medical Record Review of Resident #54 showed that the resident was receiving 0.75mgs [MEDICATION NAME] twice daily PO for physical aggression, including kicking, hitting and punching staff during care. The resident was also receiving the medication [MEDICATION NAME] 7.5mgs twice daily for anorexia and dementia with behavioral disturbances with pinching, hitting and kicking. Care plan was in place for use of [MEDICAL CONDITION] drug use with intervention to identify target behaviors and document in clinical record. The care plan did not have interventions that specifically outlined ongoing monitoring of specific behaviors, nor which behaviors to monitor for, along with no intervention for the monitoring of side effects of [MEDICAL CONDITION] medication that was being administered to resident. Behaviors had been monitored according to the facility policy, but no monitoring of behaviors had been done since (MONTH) 30, (YEAR) for Resident #54 and there was no documention of monitoring of side effects of these medications. This puts the resident at risk of receiving unnecessary [MEDICAL CONDITION] medication with inadequate monitoring in place. 4) Medical Record Review of Resident # 31 showed that the resident was receiving antipsychotic and antidepressant medications. These medications were [MEDICATION NAME] 7.5mgs to be given at hour of sleep for major [MEDICAL CONDITION] and anxiety disorder, [MEDICATION NAME] 50mgs one time daily for restlessness and agitation and [MEDICATION NAME] 0.5mgs PRN for anxiety disorder. Care plan was in place for the use of Antipsychotic/Antidepressant use with intervention to identify target behaviors and document in clinical record. The care plan did not have interventions that specifically outline ongoing monitoring of specific behaviors. Behaviors had been monitored according to the facility policy, but no monitoring of behaviors had been done since (MONTH) 10, (YEAR) for Resident #54 and there was no documentation of monitoring of side effects of these medications. This puts the resident at risk of receiving unnecessary [MEDICAL CONDITION] medication with inadequate monitoring in place. 5) Medical Record Review of Resident # 42 showed that the resident was receiving an antidepressant medication. The medication was Duloxetine 20mgs one time daily. Care plan was in place for the use of Antidepressant use with interventions to identify specific target behaviors and to monitor for specific side effects. Monitoring of behaviors had been monitored according to the facility policy up until Week 5 of the facility's protocol but had not been continued after that. This ceased on (MONTH) 30, (YEAR). There was no documentation to show monitoring had taken place for side effects of this medication. This puts the resident at risk of receiving unnecessary [MEDICAL CONDITION] medication with inadequate monitoring in place.",2020-09-01
828,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2017-08-30,371,E,0,1,MO9C11,"Based on observation, interview with staff member and a review of the facility's policy and procedures, the facility failed to ensure food was stored in accordance with professional standards of food services safety. Findings include: 1) On 8/22/17 at 10:10 [NAME]M. an initial tour was conducted with the assistance of Staff Member #5. Observation found three metal pans on a cart of chopped meat with no label of the content and when it was prepped. Staff Member #5 identified the meat as pork and confirmed that the pans of meat required a label to indicate when it was prepped. Observation of walk-in refrigerator #4 found a thermometer at the entrance of the refrigerator which was read at 50 degrees Fahrenheit and another thermometer in the back of the refrigerator was 45 degrees Fahrenheit. The staff member reported the refrigerator temperature should be 41 degrees. In this refrigerator was a plastic container of commercial garlic in oil and a large plastic container of commercial oriental sesame seed dressing that were not labeled with an open date. A tour of the pantry found an opened box of white cake mix that was labeled with an open date of 12/4/16 and an opened box of devil's food cake mix with an open date of 7/29/17. Inquired how long will these dry cake mixes after opening last, the staff member tossed the two opened boxes of cake mix out. 2) Subsequent observation was done on 8/29/17 at 8:30 [NAME]M. Observation found the temperature in refrigerator #4 was 55 degrees Fahrenheit. Further observation found a small fan by the puree station with black substance on the fan propellers as well as on the front and back grids. A large standing fan was observed to have gray fluffy substance on the front and back grid of the fan. Observation of the vegetable and fruit prep area with Staff Member #6 and #7 was made and found a brown insect with long antennae on the wall close to the fly trap over the sink where papayas and lettuce were being prepped. Also observed a green insect on the outside of the screen. The staff members reported that previously the insects would go into the fly trap above the prep area and when zapped would land outside of the tray under the trap; however, this has been corrected. Concurrent observation and interview was done with Staff Member #5. The staff member confirmed the observations made by the surveyor. The staff member reported refrigerator #4 was no longer in use, the items were transferred to #5 and maintenance was called to check on this refrigerator. The staff member removed the small fan and agreed to call housekeeping to clean the large fan. Further observations with Staff Member #5 found a refrigerator with labeled food items with white labels affixed to it. The white label has areas to document the following: Product, Date, Prep By and Mgr. Inquired how does staff members use these labels as one small covered metal pan was labeled as tuna filling as the product and another tray containing prepared food items were labeled as dinner. There was one pan of food with an expiration date written on the label. The other items were not labeled with expiration dates. Further queried what is the instruction for documenting the date, the staff member responded the prep date. The staff member further clarified prepared/perishable foods are discarded after 3 days; however, other food items are discarded based on the manufacturer's expiration date. The staff member further reported the facility utilizes a system for dry storage and for refrigerated items. The dry storage is labeled with the date it comes in, the date the item is first used and then the expiration date is based on the manufacturer's expiration date. The prepared food items are labeled with the date it is made then the date it is to be thrown out (which is three days from the preparation date). The staff member commented the labeling is confusing. A review of the facility's policy entitled Food Storage notes under procedures: Each item is clearly labeled and dated before being refrigerated. All stock and supplies will be labeled and date when opened .perishable foods are used within 2-3 days or discarded .refrigeration, temperatures should be between 34-41 degrees Fahrenheit . The facility failed to ensure the refrigerator was in working order to maintain the appropriate temperature and expired items were discarded. Also, the facility failed to develop a consistent system for labeling food items to identify the product and the date of preparation with discard date.",2020-09-01
829,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2017-08-30,428,D,0,1,MO9C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure irregularities are reported to the attending physician and these reports must be acted upon for 1 (Resident #18) of 5 residents reviewed for medication regimen. Findings include: Resident #18 was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. On 8/24/17 at 11:00 [NAME]M. a review of the pharmacist drug regimen review was done. The review found documentation dated 4/7/17 by the pharmacist requesting the resident's physician review the medication regimen to assure medications are sufficient to control symptoms and progression of illness, but are not excessive in number as the resident receives more than 9 medications. There is no further documentation of whether the physician reviewed the resident's medication regimen and made any recommendations. On 8/25/17 at 9:10 [NAME]M. concurrent record review and interview was done with Staff Member #4. The staff member reported the notes from the pharmacist is provided to the attending physician, the physician will sign the note and document any recommendations then the completed note is sent via facsimile to the pharmacist. The staff member reported the nurse may document the recommendation in the resident's electronic record. Staff Member #4 confirmed there is no documentation of the physician's response to the pharmacist's request to review the resident's medications. On 8/25/17 at 9:48 [NAME]M. an interview was conducted with Staff Member #8. The staff member reported the pharmacist's recommendations/notes are usually uploaded in an attachment and sent to the physician for review, then the physician will respond. On 8/25/17 at 10:31 [NAME]M., the staff member provided a copy of the :Note to Attending Physician/Prescriber notification dated 4/7/17 which did not include a response from the physician. The staff member also confirmed there is no documented response from the resident's physician. The facility did not ensure the attending physician responded to the pharmacist's request to review Resident #18's medications.",2020-09-01
830,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2017-08-30,431,D,0,1,MO9C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain proper labeling on medication for Resident #41 on one unit of the facility. Findings include: During medication administration observation on the morning of 8/29/17 at approximately 11:20 [NAME]M., Staff #9 provided Resident #41 with Tramadol. The blister pack noted, Tramadol 50 mg 1 tab orally every 6 hours as needed. However, the physician's orders [REDACTED]. Staff #9 noted the order was changed and Resident #41 now received Tramadol 50 mg orally three times daily. Staff #9 noted that the facility was using the rest of the medications from the as needed order but should've placed a sticker on the blister pack to note the order had changed. The blister pack did not have a sticker to note the order had been changed. An interview of Staff #4 on the morning of 8/30/17 at approximately 10:30 [NAME]M. revealed the staff should've placed a sticker on the blister pack for Resident #41 stating the order had changed.",2020-09-01
831,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2019-08-30,550,D,0,1,CFPU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide one Resident (R)4 sampled with privacy by exposing the resident's urinary catheter bag in view of the window and door to the residents room. The urinary catheter bag was not covered with a bag or other item to provide the resident with appropriate privacy. This deficient practice violated the resident's right to dignity while residing in the facility. During an observation on 08/27/19 at 10:45 AM in room [ROOM NUMBER] (R4's room) noted a urinary catheter collection bag in view of the window and front door. The catheter collection bag appeared to be on the left side of the bed (in view of the door) 3/4 full with bright yellow urine. No cover was in place over the bag. During an interview with Licensed Practical Nurse (LPN)66 on 08/27/19 at 12:48 PM while standing in the doorway looking into room [ROOM NUMBER] at the Foley catheter bag hanging from the bed asked LPN66 when do staff cover the catheter bag for the resident? LPN66 replied, no need because she is in her room. We would cover the bag when we take the resident out of her room. Discussed with LPN 66 that the catheter bag is in clear view of the window and door and whether this violates the residents privacy. LPN66 responded well, we should close the curtain. During an interview with the Charge Nurse (CN)96 at 03:30 PM, discussed the resident's privacy regarding the urinary catheter bag being exposed to people who pass by room [ROOM NUMBER]. CN96 responded I will take care of this so that the resident's urinary catheter bag is covered.",2020-09-01
832,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2019-08-30,554,D,0,1,CFPU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the interdisciplinary team (IDT) fully assessed and determined a resident was capable of self-administering her medications for one of five residents Resident (R)43 in the sample of residents selected for medication administration review. This deficient practice had the potential to affect other residents who may be able to self-administer their medications. Findings Include: Observation on 08/29/19 at 08:06 AM found R43 in bed, holding onto tubing and doing her own nebulizer treatment. The registered nurse (RN)34 had prepared R43's morning medications to administer and entered the room to give them to the resident. The State Survey Agency (SA) queried how R43 started her treatment when RN34 had the [MEDICATION NAME] vial in her possession for the medication administration with the SA to observe. On 08/29/19 at 08:15 AM, RN34 said R43, always keeps a stock and it's the nurse who gives it. RN34 said this resident self administered her [MEDICATION NAME] on her own. RN34 was asked whether licensed staff giving this resident her [MEDICATION NAME] vials tracked the number of the vials given to R43 and how it was monitored. RN34 said, If we give something, we put it in the system and all as needed (PRN) ones also. We put it in a bedside drawer. She (R43) has an order to self administer and we actually watch her take it. She is very alert. R43's 2019 (MONTH) medication order noted routine and as needed orders for: 1) [MEDICATION NAME] sulfate 2.5 mg/3ml (0.083%) solution for nebulization (1 Vial) three times daily for shortness of breath, and 2) [MEDICATION NAME] sulfate 2.5 mg/3ml (0.083%) solution for nebulization (1 Vial) . As Needed Every Four Hours for shortness of breath. A review of R43's care plan for her impaired respiratory function related to [MEDICAL CONDITION] fibrosis found interventions which stated the resident was able to independently operate her oxygen concentrator and nebulizer machine. But, it did not state the resident could self-administer any medications or keep them at her bedside. The intervention stated, Administer inhaler(s) or nebulizer as ordered, and document effectiveness. Further review of R43's clinical record found there was no physician order for [REDACTED]. There was no clinical documentation specific for this in R43's record. On 08/29/19 at 09:20 AM, during an interview with R43, she said, Yesterday they gave me one (vial) for this morning, because the nurses are sometimes late and I need to take it at eight o'clock. But they come at eight-thirty. And this morning the nurse said just call her. When R43 was asked if this was an on-going practice for the nurses to leave the [MEDICATION NAME] medication vial at her bedside, she stated, Only lately--not too long ago. They would give me one, whoever is the nurse--it's because we have all different people. She could not give a definitive time frame except it may have been more than a week ago that this practice of leaving the vials with her has been occurring. R43 said because she needs to take it, three times a day and four hours apart, so if the nurse is late at 08:30, then the next one is 12:30 and I make sure the next one is every 4 hours after. R43 also said, and when they found out here I could do it, they let me. She explained when she got a new [MEDICATION NAME] vial from the nurse, she placed it in front of her small clock on her overbed table, to remind me, and pointed to a vial already placed there for her next treatment. The facility's policy stated, Medication Administration Self-Administration by Resident, at Section 7.3, Policy Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe, . Procedures 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process, .The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process . During an interview with the Administrator on 08/29/19 at 11:24 AM, verified that R43, has not been assessed for it, to self-administer her own medications, nor to keep her medications at bedside. In addition, the Administrator stated she did not find a physician's order for R43 to self-administer the [MEDICATION NAME] sulfate routinely or as needed.",2020-09-01
833,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2019-08-30,689,G,0,1,CFPU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review (RR), and Policy review, the facility failed to prevent two of six Residents (R)49 and R30 investigated for accidents from multiple falls with one fall (R49) resulting in major injuries. The deficient practice caused R49, who is a [AGE] year old female resident with a severe cognitive impairment at high risk for falls to suffer harm by sustaining multiple facial fractures that resulted from being left to sit in a wheelchair unsupervised and R30 has had eight documented falls and is at a potential risk for major injuries. In addition, the facility failed to accurately assess the safety of a third Resident (R)40 while smoking. This deficient practice has the potential to cause [MEDICAL CONDITION] injury to the resident with contractured fingers who was smoking unsupervised and without safety devices to prevent smoking accidents like a an apron. Findings include: 1) During an observation on 08/27/19 at 12:09 PM at the dining table in the common area in between room's 143 and 148, R49 was sitting in her wheelchair alone at the table. R49 appeared to have multiple purple marks (bruising) on both lower arms and forehead. A fall alarm was attached to her wheelchair. R49 was moving around in her chair and appeared agitated when she suddenly stood up from the wheelchair and when the chair alarm started to beep very loud she sat back down. During a tour of the Lanai unit on 08/27/19 at 12:26 PM, did not note any signage to indicate potential fall risk outside of any of the individual resident rooms. The facility provided matrix revealed that R49 was listed with a fall with a major injury. RR revealed that R49 is a [AGE] year old female diagnosed with [REDACTED]. During an interview with the Charge Nurse (CN) on 09/29/19 at 03:32 PM stated that R49 had a fall and was sent to the hospital and diagnosed with [REDACTED]. When asked how to identify a resident at risk for falls since there are no signs outside the rooms to identify those resident's, she responded that there isn't a protocol in place. Clinical notes report reviewed. Fall history: a. 03/07/19; 04:40 AM staff found resident in supine position on the floor next to her bed; no injuries sustained. At 0535 AM, staff responded to the care sense alarm and found resident on supine position near the foot of her bed. R49 sustained a hematoma to left frontal area. b. 03/09/19: R49 was out of bed ambulating without assistance and started to fall. The certified nurse aide (CNA) assisted her to the floor at 03:10 PM, no injuries. c. 03/14/19 R49 standing up a ambulating on her own with unsteady gait. d. 03/15/19: Restless this evening, standing up from wheelchair, chair, bed; triggering alarm. e. 03//16/19: Witnessed fall at 09:00 AM. CNA noted resident standing from wheelchair. Pushed her bed side table to her left side and started to ambulate two - three steps forward. CNA attending to other resident and unable to assist R49 who fell . No injuries. f. 03/18/19: R49 observed getting up from her wheelchair multiple times during the shift. g. 03/21/19 R49 got up from bed and started calling out loudly. h. 07/09/19 12:25 PM CNA found resident on floor; laying left side. Noted left forearm (LFA) skin tear approx. 2.5 centimeters (cm) skin tear; dressed with steristrip noted with guarding and complaint of pain to LF[NAME] Noted bruising to upper lip; nose bleed to right nare only. Hematoma 7 cm diameter approx. to left cheek with skin tear 2.5 cm in length. Noted small 1 cm cut to left upper eye lid. Approx 3 cm hematoma to mid forehead. R49 was transported by ambulance to the Emergency Department (E). At 05:44 PM received report from ER nurse that R49 will be returning to the facility and that she sustained multiple facial fractures. During an observation of R49 on 08/28/19 at 08:31 AM. R49 laying in bed with eyes closed. Skin tear on her left lower leg. The hospital bed was in the medium position and the mattress was scooped. The call light was under R49 bed out of her reach. Per the clinical notes dated 03/16/19 Power of Attorney (POA) requested use of a lap buddy while R49 is in her wheelchair and foam noodles underneath her bed mattress. Something, that will keep her safe from falling. Further review revealed the Lap buddy was not implemented. 07/10/19 POA requested for padded floor mats. In spite of the resident having several falls prior to the fall on 07/09/19, floor mats were ordered. Each of the falls staff reported responding to the chair alarm, although when they were able to attend to the resident, she had already fallen. Care plan dated 12/04/15 to present reviewed. Noted the following interventions for risk for fall/ injury. 1. Monitor R49 frequently in case she forgets to call for help. 2. Ensure that R49 is supervised while sitting in her wheelchair or other device. 3. Keep call light secured and within easy reach. R49 was not supervised while in her wheelchair or in her bed when each of the falls occurred. R49's call light was found under her bed on 08/28/19 at 08:38 AM while lying in bed. Facility Falls and Fall Risk, Managing Policy reviewed. Resident-Centered Approaches to Managing Falls and Fall Risk 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Monitoring Subsequent Falls and Fall Risk. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interveions. During an interview with Licensed Practical Nurse (LPN)90 on 08/30/19 at 08:59 AM to discuss the account of R49 fall on 07/09/19 described that it was a witnessed fall. R49 fell right in front of the nurses station. I went to another residents room to help because the sensor alarm in that room was beeping. I remember hearing a sensor alarm go off near the nurses station but I was unable to go help since I was already assisting the other resident. I learned that R49 fell from a standing position after getting up from her wheelchair. I called the medical doctor (MD) to report the fall and the PO[NAME] R49 was taken to an acute care facility by ambulance. Prior to the fall R49 was restless, calling out to her family members a lot. We try very hard to keep the residents restraint free. When asked what the protocol after a fall is, LPN90 replied that we assess them if its appropriate to keep them here. If there is significant injuries we call the Nurse Practitioner (NP). We assess what happened prior to the fall. Although the alarms help, if you cant get to the resident in time they can still fall. I know the staff here work very hard to get to those residents when their alarms are going off. When asked after the fall what kinds of interventions were in place, LPN90 replied that our main goal was to keep her comfortable. The mat was ordered, she already had her care sense alarm in place. Staff monitored her closely, to make sure she wasn't doing the same thing again. During an interview with the Administrator and DON, when asked how this fall could have been prevented, the DON stated that we don't have the ability to provide 1:1 supervision. The administrator added we could implement more frequent checks on the resident. From my experience, the lap belts don't necessarily stop falls. Especially if we don't want to restrain them. After the fall we had an IDT and resident care council (RCC). Physical Therapy (PT) will do an evaluation. I would like our facility to eventually stop using the chair alarms. 2) R30 is an [AGE] year old female resident diagnosed with [REDACTED]. R30 has had eight documented falls since being admitted to the facility on [DATE]. During an observation on 08/28/19 at 1:00 PM R30 stated, I got to get out of here, its too hot . she was restless and agitated, moving around in her bed. The bed was noted to be in the medium height position. EMR reviewed. Clinical notes reviewed. Fall history: [NAME] 12/08/18: 07:35 staff found R30 on the floor with her head partially under the bed near the footboard. Noted a lump on the left aspect of lower occipital lobe and a lump & abrasion to right shin. B. 12/10/18: Resident was hollering out and was found face down beside the bed, alarm tab still intact. C. 01/16/19 R30 found on floor, no injuries. D. 03/21/19 found on floor at 0925 AM. No injuries. E. 03/22/19 found on floor at 0715 AM, no injuries. F. 05/22/19 R30 found sitting on floor mat, no injury. [NAME] 05/26/19 R30 found kneeling on the floor mat, no injury. H. 08/06/19 R30 found sitting on the floor mat, no injury. During an observation on 08/28/19 at 4:30 PM, noted R30 sitting in a semi fowler position in her bed. Bed at medium level height. Eyes open and alert. Care plan dated 12/05/18 to present reviewed. R30 is at risk for falls and injuries due to poor safety awareness and/ or impulsiveness related to dementia and unsteady balance. Interventions include: 1. Keep bed in the lowest position with wheels locked. 2. Monitor resident frequently in case she forgets to call for help. During the four days of the survey R30 was observed to have her bed in the mid level position. During an interview with LPN66 on 08/29/19, when asked how the residents are identified as having a high fall risk, she replied that it is in their Kardex and care plans. LPN66 did not know how residents are being identified to new staff or temporary staff without looking in the EMR. LPN66 stated that we check on the residents at least every two hours during rounds. 3) R40 is a paraplegic who does not have use of his lower extremities and limited use of upper extremities due to contractures to both hands. He requires the full assistance to transfer him into a wheelchair which is his primary mode of transfer. On 08/27/19 at 03:00PM during an interview with R40, he stated he likes to go to the lanai (patio) to smoke about three times a day and that he can smoke without supervision. He said, this is my private time. Asked R40 where he kept his lighter and cigarettes, and he said, I use to keep them in the pouch on the side of my wheelchair, but one of the resident's took them, so now I keep them with me, or in my room. RR revealed R40's care plan documented he was at Risk of injury due to smoking. The goal stated Risks for self-injury related to smoking will be minimized. R40 will abide by the smoking policies of the facility. Interventions identified included the following: a.Per resident's preference, R40 keeps his cigarettes and lighters on his person in his room. He is fully alert and fully cognitive and able to make his own decisions. b. Per medical physician (MD) orders, will continue to discourage R40 from smoking, but he continues to smoke against medical advice. c. R40 knows to smoke in only the designated smoking areas. If discovered smoking outside designated smoking boundaries, remind and encourage him in practice of appropriate policy guidelines of facility. Notify charge Licensed Nurse (LN), Director of Nursing (DON), or Social Service Worker (SSW) if inappropriate behavior. d. Smoking aprons are encouraged R40 is non-compliant. He prefers not to use a smoking apron. e. Monitor R40 for signs [MEDICAL CONDITION] clothes, skin. Report to charge nurse and interdisciplinary team (IDT) if any evidence found. f. Monitor R40's ability to understand and practice good safety precautions during smoking. g.At this time, R40 is safe to smoke independently. IDT to perform smoking assessment annually and if experience change of condition. Review of the facility policy dated (MONTH) (YEAR), titled, Smoking Policy states Smoking by residents shall be permitted if, after initial assessment by the IDT, it is determined the resident can safely handle a cigarette. The policy also states, The assessment shall also include whether the resident is capable to storing and handling smoking materials independently. Residents deemed capable of storage and handling will be provided a locked bedside drawer. Residents deemed not capable will have smoking materials kept at the nursing station. RR of R40's, Resident Smoking assessment dated [DATE] stated, The resident must be evaluated with the following physical abilities to be permitted to smoke per facility policies and procedures. The facility identified 11 physical tasks the resident must be able to perform .to be permitted to smoke with supervision. R40 could not perform the following two of those physical tasks required. a. Ability to touch thumb to each finger on each hand. This task was marked N/A (not applicable with the hand-written entry, Joint contractures to both hands. b. Ability to open and close index finger and middle finger is scissor motion with each hand. This physical task was marked N/A with the hand-written entry, Joint contractures to both hands. The box minimal assistance was checked on the assessment form which was defined as Resident exhibits physical ability to smoke with minimal assistance as evidenced by the evaluation of motor skills. On 08/28/19 at 12:05 PM R40 was observed smoking in the lanai area. He was in a motorized wheelchair and had a small cylinder ashtray resting on the right side of his abdomen propped in place with a rolled-up washcloth. His lighter, cigarettes and two vaping products were also organized for access on his lap. While holding the cigarette in his mouth, observed R40 use both hands to light the cigarette. Because he wasn't able to hold the cigarrette with his contractured fingers, R40 used a hair comb with missing teeth to place the cigarette. He could hold the comb while he smoked. When R40 was done smoking he put the smoking product in the ashtray, which extinguished right away. R40 had no supervision while out in the lanai smoking. On 08/29/19 at 09:34 AM during an interview with Social Worker (SW) asked if he was familiar with R40's smoking assessment. SW said he is very familiar with the situation and that he works with resident's rights. The IDT monitors and reassesses every year. Reviewed the facility policy titled, Smoking Policy-Wailuku revised date of (MONTH) (YEAR). The policy states that, Smoking by residents shall be permitted if, after initial assessment by the IDT it is determined the resident can safely handle a cigarette. The policy also states, The assessment shall also include whether the resident is capable of storing and handling smoking materials independently. Resident's deemed capable of safe storage and handling will be provided a locked bedside drawer. Residents who are not deemed capable will have smoking material kept at the Nursing Station and distributed . On 08/29/19 at 11:27 AM during an interview with RN57, asked if R40 had a locked drawer in his room to store his cigarettes and lighter, and she replied, I'm not sure. RN57 later reported that there was no locked drawer in R40's room and agreed that he would not be able to open a locked drawer due to the contractures in his hands. R40's smoking products were not secure and were accessible to any resident that wandered in to the room. On 08/30/19 at 02:30 PM during an interview with the DON, she stated R40 is due for his annual smoking assessment. We are going to be using a different assessment form . The DON agreed that R40 was not able to perform all the physical tasks the facility had identified necessary to allow a resident to smoke safely without supervision.",2020-09-01
834,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2019-08-30,698,G,0,1,CFPU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that residents who require [MEDICAL TREATMENT], receive such services consistent with the professional nursing standards of practice, including accurate assessments of the resident's condition to monitor for complications of the arteriovenous fistula (AVF) (an access site in the arm for [MEDICAL TREATMENT]), specifically after HD treatments for one of one resident Resident (R)1 selected for review. R1 is at high risk for increased [MEDICAL CONDITION] (occlusions) and has a history of occlusions to his access site. Good post [MEDICAL TREATMENT] care of the AVF site is crucial to prevent negative outcomes that may result in the following: Occlusions; hemmoraging (bleeding out from the site) and/ or death. R1 did not receive professional nursing care of the site as evidenced by a licensed nurse who took blood pressures readings on R1's left (L) arm which has the AVF access site. Since R1 is at a high risk and has a history of occlusions, he should not have had blood pressure readings done on his left arm. In addition, the licensed nurse did not consistently document R1's post [MEDICAL TREATMENT] nursing assessment. This deficient practice, had the potential to cause serious harm and/ or death to R1, and any other resident residing in the facility who receives [MEDICAL TREATMENT] treatments. Findings Include: R1 is an alert and oriented resident who has a [DIAGNOSES REDACTED]. During an interview with R1 on 08/27/19 at 12:22 PM, he said he goes out to receive HD treatments at an outside certified [MEDICAL TREATMENT] center on Mondays, Wednesdays and Fridays during the evening shift. R1 pointed to his left upper arm (LUA) and said his access site was there. He said it was an AV fistula. R1 also said he twice underwent surgery when it got clogged. They had ballooned it to open up the blockages in the AVF. R1 said he has no blockages to his access site at present. When asked whether the licensed staff checked the site when he returned to the facility he said sometimes, and that staff did not always check him thoroughly, i.e., heart and lung sound assessments, AVF site assessment, vital signs check, etc. R1 said one thing he did know was that he would give the [MEDICAL TREATMENT] communication form to the nurses upon his return to the facility. He said that form had his HD treatment information which the [MEDICAL TREATMENT] staff completed each time he left the center. A sample review of R1's HD treatment record was done. It was found that R1's most recent HD treatments were on the following days: 08/28/19; 08/26/19; 08/23/19; 08/21/19; 08/19/19; 08/16/19 and 08/14/19. However, review of licensed practice nurse (LPN) 34's vital sign entries for R1 upon his return from HD on 8/7/2019, 8/16/2019 and 8/21/2019, found her entries had L Arm Sitting. LPN34 had documented that she was taking R1's blood pressure (BP) on the arm where R1's AV fistula access site was. There were two additional entries by LPN34 on the Vital Signs form for 8/9/2019 and 8/14/2019 which noted Right (R) Arm Sitting. LPN34 was the only licensed staff on this form performing BP checks on R1's left arm from 07/15/19 to 08/28/19. The other licensed staff were documenting the BP checks were being done on R1's right arm. Vascular access fact sheet American Nephrology Nurses Association (ANNA) (YEAR) states the AVF can provide good blood flow for many years of [MEDICAL TREATMENT]. Recent studies show that patients with AVFs have the least amount of complications such as infections or clotting .Caring for a Fistula. Good AVF care will help maintain the patency of the vascular access. Measures can be taken to prevent clotting or infection to the access .The access should be kept clean and free of injury or restriction to prevent clotting of the access . Not allow blood pressure to be taken in the access arm. The Fresenius Medical Care 2013, NephroCare Patient Training Focus On: Fistula Care Protecting Your Lifeline, states to, minimize the danger of infection or [MEDICAL CONDITION], which are the most common dangers for your fistula . Avoid pressure of any kind on your fistula arm, as it can lead to [MEDICAL CONDITION], . Measuring your blood pressure in the fistula arm with a blood pressure meter, as inflating the cuff induces a compression of the blood vessels .The mechanism of [MEDICAL CONDITION] can be activated by so-called 'hemodynamic mechanisms' such as low blood speed, change in temperature or changes in blood pressure. The fistula arm of a [MEDICAL TREATMENT] patient is particularly vulnerable to these phenomena for a number of reasons. After repeated cannulations the fistula becomes sensitive and delicate. In addition, within the Resident Notes Report, there was no entry by LPN34 of the resident returning to the facility on [DATE] 22:02 (10:02 PM), except for a L Arm Sitting blood pressure reading of 114/62 found on the Vital Signs form. There also was no nursing entry in the Clinical Notes Report by LPN34. On 08/29/19 at 02:09 PM, an interview with the Director of Nursing (DON) was done. The DON was queried what their standard of care was for her nursing staff to provide to residents returning from [MEDICAL TREATMENT] treatments. The DON stated she would expect her staff, would be monitoring the site for vital signs, adverse bleeding, infection, and stated it would include the assessment of the bruit and thrill for a fistula. The DON was informed that R1's HD days and the nursing entries did not coincide with the nursing assessments which she stated should be be done. An example included a 08/17/19 weekly skin assessment by a registered nurse which stated, LUA AV shunt + bruit and thrill; no infection and bleeding noted. Lotion to dry skin. Cont to monitor weekly as ordered. However, R1 did not go for his HD treatment on 08/17/19 and went on 08/16/19, of which there was no nursing entry except for the sole blood pressure reading which LPN34 took on the resident's left arm. There was a failure to identify, and consistently monitor the clinical condition and patency of the left AVF for R1. The licensed staff failed to follow a 07/30/18 physician order [REDACTED]. This was not found to be done every shift in R1's clinical entries. As a result, the facility did not ensure R1 was provided with safe, consistent clinical assessments and monitoring post-HD treatments for the patency of the left AVF.",2020-09-01
835,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2019-08-30,726,D,0,1,CFPU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review (RR), the facility staff failed to document and communicate pertinent information about an incident involving one of one Resident (R)68 sampled to other caregivers so interventions could be put in place to prevent a reoccurrence of a similar event. A family member of 68 attempted to feed her food she was not allowed. This put R68 at risk of aspiration or choking. The deficient practice of staff not communicating pertinent findings/events to other caregivers could affect any resident in the facility, and potentially affect the quality of care and safety of the residents. Findings include: RR revealed R68 was admitted to the facility on [DATE]. R68 had cognitive impairment due to dementia and had a recent stroke with left sided weakness. As result of the stroke, R68 had dysphasia (difficulty swallowing) and required the insertion of a gastrostomy tube ([DEVICE]) through her abdomen wall and into her stomach for feeding. R68 received 100% of her nutritional needs through the [DEVICE]. RR of the Speech Therapist (ST) Daily Treatment Notes revealed the following documentation: 05/27/19: Trialed nectar thick liquids via cup. Edu (educated) pt. (patient) and husband on use of single sips, double swallow . 05/28/19: Husband present for session. Facilitated trials of puree (Cream of wheat). Pt completing double swallow verbal cues. Edu pt. and husband on oral clearance strategies (double swallow .) 05/29/19: . Recommended pleasure feeds of puree and nectar liquids with use of double swallow and aspiration precautions. Informed nursing and provided written education on diet and strategies. After the ST evaluation, an order for [REDACTED]. RR revealed a nursing clinical note in R68's record dated 08/14/19 by RN30 at 08:25 PM that read, Spouse brought manapua (pork bun) from Costco tonight per resident's request. Per Power of Attorney (spouse), resident was unable to swallow couple of pieces because it was too doughy: but resident sucked on the juice of the dish. RN30 did not document resident condition, a physical assessment or if education was provided to the spouse to prevent further events. On 08/29/19 at 08:53 AM, during an interview with the Registered Dietician (RD)118, said she was not aware that the husband of R68 attempted to feed her food the texture she was not allowed. She stated, R68 was a new admit and was on just tube feedings when she came. After ST evaluation, the puree and pleasure food were added. I know the spouse was involved and educated by ST. RD118 said. If we had known, we could have done follow up with the spouse. On 08/29/19 at 03:03 PM during an interview with RN30, he said he recalled the incident when R68's spouse attempted to feed her a manapua. RN30 stated, I did not see it, he came to me after and said he tried to give the manapua to her and she couldn't swallow it, so spit out a couple of bites. I assessed her, and she was fine, not in distress. I educated the spouse. RN30 said he did not recall if he recorded the incident for the next shift and agreed the clinical note he documented did not include pertinent information. On 08/29/19 at 03:33 PM during an interview with the Charge Nurse (RN57), she said she was not aware of the incident on 08/14/19. RN57 checked the desk calendar in the nursing station to see if there was a written note on that day. There was no notation on the calendar. RN57 stated, The staff should pass that information on. In this situation, they should educate the spouse, do an assessment, document findings, and pass the information on to the Charge RN and next shift. RN57 said they communicate, by writing it on the calendar for me to follow up the next day, and then tape record anything pertinent. The oncoming shift listen to the two previous shift tape recordings. RN57 did not recall the incident being recorded. When asked what RN57 would have done if she had been aware of the incident, she replied, If I had heard it, I would have called the spouse and remind him again and let him know what appropriate meals are. Remind him of the ST evaluation and risk for aspiration. If needed, I would do a Risk versus (vs) Benefit Form. Maybe if spouse is here, watch for what he offers her. On 08/30/19 at 10:31 AM during an interview with the Director of Nursing (DON), asked what she would expect from staff involved in this incident. DON said, I would expect them to check the diet ordered, educate the husband, document the conversation, and follow up with any further education that might be needed such as RD, or involve administration who can decide if the Benefits vs Risks Form consent should be signed. I expect there would be communication to the charge nurse, and communication between shifts.",2020-09-01
836,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2019-08-30,758,D,0,1,CFPU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the resident was assessed by the attending physician with documented clinical notes for the increase in a psychoactive medication for one of five Residents (R)51 selected for review. This deficient practice had the potential to affect all residents receiving psychoactive medications. Findings Include: R51 was observed during the survey either sleeping and/or being assisted to eat by the nurse aides. Record review found the resident was on several psychoactive medications and a review of R51's drug regimen was done. R51 was found to be taking [MEDICATION NAME] 50 milligrams (mg) one daily, [MEDICATION NAME] 25 mg one daily, [MEDICATION NAME] 0.5 mg one daily and [MEDICATION NAME] 10 mg one daily. R51's [DIAGNOSES REDACTED]. Review of the provider's notes however, did not show an entry by the physician to have assessed or provided a rationale to add [MEDICATION NAME] 50 mg one time daily (ordered 05/29/19 and started 05/30/19). The last physician progress notes [REDACTED]. On 08/29/19 at 01:20 PM, during an interview with the Assistant Director of Nursing (ADON) of their other facility, she stated their current electronic record review did not show the current physician reports. On 08/29/19 at 01:51 PM, the ADON verified she could not find anything where the physician made an entry/note to explain the increase in R51's [MEDICATION NAME] dose.",2020-09-01
837,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2019-08-30,790,D,0,1,CFPU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assist the resident with a timely dental referral for one Resident (R)44 who needed dentures. This deficient practice violated the residents right to quality care. Findings include: During an observation and interview with R44 on 08/27/19 at 09:30 AM, in room [ROOM NUMBER] R44 stated that she was waiting to get her dentures for two months. R44's upper teeth were noted to be edentulous. R44 stated that she wondered when she would get her denture. Progress note dated 06/25/19 reviewed. Patient stated to the nurse practitioner (NP) that she is upset about her teeth and feels embarrassed to be seen by family without dentures. Waiting on dental and social work to arrange it so that she can receive oral care and be fitted for dentures. Progress notes reviewed dated 06/26/19: Social services (SW). Contacted Hui No Ke[NAME]Pono, Inc. (HNKOP), (a health management and health care referral agency for the community of Maui). HNKOP staff confirmed the application for dental services was on file and not sure why there was a delay in services being scheduled. The SW requested that HNKOP contact resident as soon as possible to provide update to services and schedule an appointment.",2020-09-01
838,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2019-08-30,812,F,0,1,CFPU11,"Based on observation, interview and document review, the facility failed to consistently monitor one freezer's (number 10) temperature to ensure it was functioning properly for safe food storage. In addition, the facility staff failed to consistently monitor and record the dish machine final rinse temperature and did not always report it to the supervisor when the temperature was out of range. As a result of this deficient practice, the facility could not ensure the dishes were properly sanitized and ensure safe storage of food in freezer 10. This could potentially expose all residents to a higher risk for foodborne illness. Findings include: Review of the facility policy dated 04/02/13 titled, Dish Machine Temperature Log stated Staff will be trained to record dish machine temperatures for wash and rinse cycles at each meal. The policy also stated, Dishwashing staff will be trained to report any problems with the dish machine to the nutrition services supervisor as soon as they occur. Review of the facility policy dated 04/02/13 titled, Cleaning dishes/Dish machine directs staff to Run one item through the machine and record the wash and final rinse temperatures on temperature log sheet. If .the sanitizing rinse is less than 180-degree Fahrenheit (F), run another item through and test the temperature again. If still not within range, notify the supervisor or call maintenance repair line. Review of the dishwasher temperature log for (MONTH) 2019 revealed the temperature of the dinner final rinse was not documented three times. It also revealed the dietary staff documented the final rinse was less than 180F 14 times with no documentation of a repeat temperature or notification to the supervisor. Review of the refrigerator/freezer temperature log, stated at the top of the log the safe freezer temperature range is less than zero degrees. The (MONTH) 2019 temperature log for freezer 10, revealed no documentation the temperature was checked five times (June 11 AM, (MONTH) 16 AM, (MONTH) 19 AM, (MONTH) 20 AM, and (MONTH) 26 AM). On (MONTH) 28th, the temperature was 28F and the unit was taken out of service. The food was relocated until the freezer was repaired. Review of the (MONTH) 2019 temperature log for freezer 10 revealed the temperature was not documented 17.7% of the time (11 of 62 times). On 08/30/19 at 8:00 AM during an interview with the Director of Nutritional Services (DNS), reviewed the dish machine temperature logs. DNS stated she had a new employee working on the dish machine and felt the low temperatures may be because the new employee was taking the temperature at the beginning of the cycle. DNS confirmed there was missing documentation on the (MONTH) dish machine temperature log and said she had not been notified on the 14 days that were documented to be out of range. DNS reviewed freezer 10 (MONTH) temperature log, and stated, that is the freezer located down the elevator and outside the building. It is the PM staff's responsibility to check the temperature. They usually check it when they go there to get something, but if they don't need anything, because of the location, they might forget.",2020-09-01
839,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2018-09-21,580,D,0,1,1LJ011,"Based on record review and interview, the facility failed to immediately notify R61's physician of significant weight losses. This deficient practice had the potential to affect the remaining 5 residents identified on the facility matrix as having excessive weight loss without a prescribed program if their physicians are not notified of their excessive weight loss and treated. Findings include: Record review reflected that R61's weight on 05/08/18 was 139.8 lbs, a 7.42% weight loss from the prior month, and notification of significant weight loss to R61's physician was documented on 05/15/18. On 07/02/18 R61's weight was 129.2, a 5.42% weight loss from the prior month, and notification of significant weight loss to R61's physician was documented on 07/10/18. On 09/20/18 at 02:47 PM during interview with Dietician1 (D1) who defined significant weight loss as 5% in a month, said facility's policy is for the nurse to inform the dietician, physician, and the resident's Power of Attorney right after the weight is recorded. D1 also validated that R61's physician was not informed immediately of significant weight changes.",2020-09-01
840,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2018-09-21,623,D,0,1,1LJ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman of resident (R) 15's discharge and transfer to an acute hospital. This deficient practice had the potential to affect all the residents at the facility who were discharged and transferred to an acute hospital. Findings Include: On 09/18/18 at 02:03 PM met and interviewed R15 who stated last month he went from [MEDICAL TREATMENT] to the emergency room (ER) for chest pain and shortness of breath (SOB). R15 stated he was admitted to the hospital for 3-4 days and stated he went from the facility to ER and was admitted to the hospital after he got dizzy and blacked out on his bed. Record review (RR) of R15's medical record found that he was sent from the facility to theER on [DATE], was admitted to the hospital, treated and returned to the facility on [DATE]. RR found that R15 was admitted to the hospital with [REDACTED]. R15 was treated with intravenous (IV) fluid for volume depletion. R15 was stabilized and returned to facility. Power of Attorney (POA) was notified of transfer per DON and bed hold policy sent with R15 at time of transfer. On 09/21/18 at 09:45 AM interviewed administrator and inquired if the State Long-Term Care Ombudsman was notified of R15's discharge to the hospital on [DATE] and she stated that the facility's interpretation of this regulation did not include resident's discharged from the facility who were admitted to the acute hospital if they were expecting them to return to the facility. Administrator stated that the ombudsman was not notified of R15's discharge from the facility and transfer to the hospital.",2020-09-01
841,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2018-09-21,637,D,0,1,1LJ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to recognize a decline in resident (R) 37's Activities of Daily Living (ADLS) of bed mobility, transfer and eating and failed to submit a significant change for R37's decline in ADLS. This deficient practice had the potential to affect the remaining 56 residents identified as having a [DIAGNOSES REDACTED]. Findings Include: On 09/19/18 at 10:46 AM record review (RR) of R37's medical record found that R37 is a [AGE] year old female with a Dx of Alzheimer's with late onset, Dementia in other diseases classified elsewhere with behavioral disturbance, [MEDICAL CONDITIONS] and systolic [MEDICAL CONDITIONS]. Review of res 37's last two Minimum Data Set (MDS) quarterly assessments dated 05/03/18 and 07/30/18 found that R37 had a decline in bed mobility, transfer and eating. R37 went from a rating of 2 which is limited assistance-resident highly motivated in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance to a rating of 3 which is extensive assistance-resident involved in activity, staff provide weight-bearing support. On 09/20/18 at 08:51 AM RR of R37's medical record found that the decline in ADLS was unavoidable due to R37's advanced age and multiple health conditions. Facility was providing support with R37's decline to meet her needs as evidenced by update to R37's care plan (CP) and observation of staff and family assisting R37 with her ADLS. On 09/20/18 at 11:15 AM interviewed MDS Coordinator and Director of Nursing (DON) who confirmed that R37 had a decline in her bed mobility, transfer and eating which went from a rating of 2 to 3 which is limited assistance to extensive assist. MDS coordinator confirmed that a significant change was not submitted to MDS but the Interdisciplinary Team did meet and discuss R37's decline on 08/08/18.",2020-09-01
842,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2018-09-21,656,D,0,1,1LJ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review (RR) and staff interview the facility failed to develop and implement a care plan (CP) for resident (R) 15's use of insulin to treat his type 2 Diabetes Mellitus (DM). This deficient practice had the potential to affect the residents at the facility who have type 2 DM, treated with insulin, and are not being care planned for this. Findings Include: On 09/21/18 at 08:35 AM RR found that R15 had a [DIAGNOSES REDACTED]. Review of R15's medications found an insulin order made on 08/16/18. Review of R15's CP did not find a CP for his [DIAGNOSES REDACTED]. On 09/21/18 at 09:10 AM interviewed Director of Nursing (DON) and Minimum Data Set (MDS) coordinator who both confirmed that R15 had a [DIAGNOSES REDACTED].",2020-09-01
843,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2018-09-21,657,D,0,1,1LJ011,"Based on resident interview, staff interview and electronic medical record review (RR) the facility failed to ensure resident (R) 29 or her representative were involved in developing the care plan and revision of the care plan. This deficient practice had the potential to affect the remaining 69 residents at the facility if not given the opportunity to develop and revise their individual care plans. Findings Include: On 09/19/18 at 09:35 AM met and interviewed R29 and inquired if she had participated in her care plan (CP) meeting and she stated she had not had a formal meeting with facility staff for her CP and was not sure if her daughter attends. Electronic medical RR found on R29's Minimum Data Set (MDS) quarterly Brief Interview for Mental Status (BIMS) dated 07/23/18 summary score was 15 showing that resident was cognitively intact. On 09/20/18 at 12:06 PM interviewed Director of Nursing (DON) who gave a copy of the You're Invited handout which was given to R29's daughter to invite her to the Resident Care Conference which was on 08/01/18. This handout was mailed to R29's daughter. DON did a record review but did not find any documentation that R29's daughter was notified or updated of R29's CP. On 09/20/18 at 12:40 PM inquired if residents are notified of their CP meeting and DON stated the clerk gives the resident an invitation to attend the CP meeting but this is not documented in R29's medical chart. DON was unable to find any documentation that R29 attended any CP meetings or that R29 was invited to the CP review with the Interdisciplinary Team (IDT). Electronic medical RR found that R29's CP was created on 04/26/17, last reviewed on 08/01/18 and IDT had met and reviewed CPs and quarterly MDS on 05/01/17, 07/26/17, 10/23/17, 11/02/17, 01/30/18, 04/24/18, and 07/23/18.",2020-09-01
844,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2018-09-21,689,D,0,1,1LJ011,"Based on observation and staff interview, the facility failed to properly install a black wire in resident (R) 18, 25, 44 and 57's shared bathroom. The black wire ran near the ceiling, drooped down touching the bathroom light fixture and light bulb. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk for an electrical accident hazard. Findings Include: During an observation of the bathroom for R18, 25, 44 and 57, on the Molokai unit, on 09/18/18 at 11:00 AM, a black wire was seen drooping down, from the ceiling, touching the bathroom light fixture. The light was turned on and it also appeared that the drooping wire had direct contact with the light bulb. On 09/18/18 at 11:30 AM, housekeeper 1 (H1) was interviewed about the drooping wire. H1 acknowledged that the wire should not have been touching the light fixture and that maintenance personnel would be notified.",2020-09-01
845,HALE MAKUA HEALTH SERVICES,125056,1540 LOWER MAIN STREET,WAILUKU,HI,96793,2018-09-21,700,D,0,1,1LJ011,"Based on observation, resident interview, staff interview and medical record review (RR) the facility failed to assess resident (R) 15 for bed rail entrapment prior to installation of bed rails on his bed, failed to obtain informed consents for bed rail use with R1, 15 and 29 or their representative. The deficient practice has the potential to affect the remaining 67 residents at the facility if they have bed rails on their beds but have not been assessed for risk of entrapment prior to installation, have not been told of the risks and benefits of bed rails and have not obtained informed consent to use bed rails prior to them being installed on the bed. Findings Include: 1) On 09/18/18 at 02:14 PM met and interviewed R15 who stated he requested all 4 bed rails on his bed so that he could move around in his bed and would not fall out of bed. Noted R15's right and left legs were amputated above the knee. Inquired if R15 signed an informed consent, that he was told of the risk and benefits of the side rails and R15 denied signing an informed consent for bed rail use. On 09/20/18 at 11:26 AM medical RR of R15's CP noted that R15 requested to have full bed rails up on his bed so that he can have full bed mobility by using the rails to move in his bed. Medical RR also found R15 did not have a bed rail assessment for entrapment completed and there was no signed informed consent for bed rail use. Inquired with DON about bed rail assessments and informed consents to use bed rails and she stated the facility does not have this for all residents and is working on this. 2) On 09/19/18 at 09:55 AM observed and interviewed R29 in her room in bed with bilateral quarter upper bed rails on her bed. Inquired if staff talked to her about the risks and benefits of bed rails and had her sign an informed consent and R29 denied that staff talked to her about the bed rails on her bed or that she signed an informed consent for bed rail use. 3) On 09/19/18 during assessment of R1's environment noted that there were quarter side rails on resident's bed. On 09/20/18 at 10:47 AM Interviewed MDS coordinator who confirmed R1's bed rail assessment was done as an enabler, for safety, dated 12/27/17 which stated 1/4 side rail up on the right and the left was dc'd, not at risk for entrapment. Went to R1's room with MDS coordinator who confirmed that the left side rail was still on R1's bed. During medical RR unable to find an informed signed consent for bed rail use by either R1 or their responsible party. On 09/20/18 at 10:56 AM interviewed DON who stated the facility is in the process of getting bed rail assessments and informed consents signed for the residents. Facility is working on getting all the assessments done but the informed consents have not been done yet.",2020-09-01
846,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2019-11-08,641,D,0,1,PEVE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to identify and accurately code a fall on the quarterly minimum data set (MDS) for Resident (R) 16. Findings include: During a review of the facility provided matrix, it was noted that R16 was coded for a fall. Further record review revealed that R16 fell on [DATE] at 03:45 PM while ambulating on the unit, staff assistance, using a gait trainer (a wheeled walking assist device). A review of the Incident Event Report describes, on 7/30/19 R16 fell with the gait trainer on its side. Activity aide (AA)1 documented R16 may have gotten tangled in the portable pulse oximeter (on R16's toe) cord. The report identified balance/gait impairment as the only contributing factor. As a result of the fall, R16 sustained swelling, bump to the left posterior skull. A review of the daily skilled nurse's note, registered nurse (RN)1 documented on 07/30/19 (day shift), At 15:50 resident fell from gait trainer in common area Bump noted to L (left) posterior head. On 07/30/19 at 04:05 PM, the physician (MD) wrote, (R16) fell while in her walker in the activity area. The fall was not seen by an adult, but adults quickly noticed she fell . She hit the top of her right occiput on the floor. Reviewed the quarterly, Minimum Data Sheet (MDS) with a Assessment Reference Date (ARD) of 08/30/19. Section J1800, Has the resident had any falls since admission/entry or reentry or prior (OBRA or Scheduled PPS) whichever is more recent was coded No and did not reflect R16's fall on 07/30/19.",2020-09-01
847,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2019-11-08,656,D,0,1,PEVE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview with staff the facility failed to implement interventions for resident (R)16's risk of falls related to mobility/active. As a result of this deficient practice, R16 was at a greater risk for falling. Findings include: On 07/30/19 at 03:45 PM, R16 fell while using a gait trainer (a wheeled walking assist device) to assist in walking around the facility. R16 is a seven (7) year old resident and is one of three residents that ambulate in the facility. A review of the Incident Event Report provided by the director of nursing (DON) documented, She (R16) was on the gait trainer & I (activity aide, AA1) glanced away briefly to my table then I looked back & she (R16) was falling with the gait trainer on it's side. It seemed like maybe she got tangled in her portable pulse ox. but prior to this, she was walking fine for about 20 minutes. The report identified balance/gait impairment as the only contributing factor. As a result of the fall, R16 sustained swelling, bump the the L posterior skull. On 07/30/19 (day shift), registered nurse (RN)1 documented in a progress note, At 15:50 resident fell from gait trainer in common area .Bump noted to L (left) posterior head. The physician (MD) documented 07/30/19 at , (R16) fell while in her walker in the activity area. The fall was not seen by an adult, but adults quickly noticed she fell . She hit the top of her right occiput on the floor. On 11/06/19 at 01:04 PM observed R16 ambulating on unit with staff, using the gait trainer and the pulse oximeter was located on R16's foot. On 11/07/19 at approximately 11:00 AM, observed R16 ambulating on the unit with staff, using the gait trainer, with one shoe lace untied. The shoelace dragging on the floor was approximately 6 inches long, potentially a fall risk. On 11/08/19 at 09:45 AM during an interview, the DON confirmed the facility did not address safeguards identified in the plan of corrections, which included the trial use of the pulse oximeter on R16's finger instead of toes. The facility utilizes a Fall Risk Assessment form to assess the resident's risk factors for falling on a point scale of 0-18. A score of 0 is a low fall risk, and a 18 represents a high risk for falls. A review of R16's Fall Risk Assessments (completed on 02/24/19, 05/27/19, 07/31/19), revealed that R16's total score equaled 13 and 15 (08/26/19). The Falls Risk Assessment documents If total score is 8 to 16, initiate a fall prevention program .Proceed with care plan. During review of R16's care plan dated 03/20/18 and 09/07/19, it documented a risk of falls related to [MEDICAL CONDITION] disorder, and mobile, active. However, the interventions listed on the care plan did not address R16 mobility/active needs. Furthermore, there was no documentation the care plan was updated after the fall on 07/30/19.",2020-09-01
848,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2019-11-08,657,D,0,1,PEVE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update the care plans for two residents (R) 10 & (R) 16 who had falls. The deficient practice placed the residents at an increased risk for accidents. Findings include: 1) During a review of the facility provided matrix noted that Resident (R)10 was coded for a fall. Further record review showed that R10 fell on [DATE]. R10 is an eleven year old male who attends school in the community. He is one of three residents in the facility who are ambulatory. A review of the facility incident/ investigation report dated 09/24/19 stated the following: on 9/24/19 R10 fell on floor in shower room after using the toilet. The certified nurses aide (CNA) reported the incident to the registered nurse (RN). Assessment was done by the RN and R10 was not complaining of pain. No injury or bruising was noted. Skin intact, movement & mobility unaffected and within normal limits (WNL). Factors contributing to event: Impaired balance/ gait. During a review of R10's care plan, it stated Falls problem dated 02/2018, at risk for decreased stress tolerance related to (r/t) decreased balance and resident being tethered to medical equipment. However, since this last fall on 09/24/19, it was noted that the care plan fall problem was not updated. During an interview with the Director of Nursing (DON) on 11/08/19 at 09:50 AM stated that we have care plan meetings every Wednesday. The care plans are updated based on the care conference meetings, family meetings, and physician orders. The plans are resident and family centered. If the resident has a fall, an investigation is done, then we update the care plan and do shift reports. We also do live huddles. We keep all of these activities in our inservice binder. When asked why the care plan for R10 was not updated after the most recent fall on 09/24/19 he responded saying there seems to be a gap in the communication and roles and responsibilities of the nursing staff. I ask the charge nurses to take on more of the responsibility of teaching the newer staff about the care plan process. On 11/06/19 at 02:24 PM, R10 was observed in activity area, playing a singing game, standing, dancing and singing into the microphone. However, the vent tubing was noted to be flowing down to the floor placing R10 at an increased risk for a fall. 2) During a review of the facility incident event report, it stated the following: R16 fell on [DATE] at 03:45 PM, while ambulating on the unit with a gait trainer to ambulate. The gait trainer was on it's side when staff observed R16 in the fall incident. Activity aide (AA)1 wrote, R16 may have gotten tangled in the portable pulse oximeter (on R16's toe) cord. Balance/gait impairment was identified as the only contributing factor in the Incident Event Report. As a result of the fall, R16 sustained swelling, bump the the L posterior skull. The Incident Event Report plan of correction for R16's fall identified safeguards to: 1) communicate with the activities staff the importance of remaining in close proximity to R16 while walking in the gait trainer 2) trial of placing the pulse oximeter cord on R16's finger instead of the toe. On 11/08/19 at 09:45 AM during an interview, the DON confirmed the facility did not address safeguards identified in the plan of correction previously listed. On 11/07/19 at 11:25 AM, reviewed R16's care plan. The care plan problem list, dated 03/20/19, documented R16 is at risk for falls related to [MEDICAL CONDITION] activity and/or hypertonia and risk of falls related to [MEDICAL CONDITION] disorder, and mobile, active. The mobile, active was handwritten on the care plan with no date, time, initial. Thus, the care plan was not updated after R16's fall on 07/30/19. Also, reviewed the care conference dated 08/27/19 which did not provide documentation R16's fall on 07/30/19 was addressed during that meeting as well.",2020-09-01
849,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2019-11-08,842,D,0,1,PEVE11,"Based on review of medical records and staff interview, the facility failed to maintain accurate documented medical records for two residents (R) 20 and (R) 10 out of eleven residents chosen for review. As a result of this deficient practice, the facility put the resident at risk for miscommunication of the overall care. Findings Include: 1) During a review of two separate worksheets in R20's medical record (dated 09/17/19 and 09/22/19) titled; Respiratory Care Progress Notes, the notes were hand-written, but was written very small and illegible. Even with multiple attempts to determine what was written, it was still illegible. On 11/07/19 at 10:50 AM, Registered Nurse (RN) 2 was asked to determine what was written on the two worksheets (previously mentioned). RN2 acknowledged that the writings were written very small and was illegible. 2) While reviewing the quarterly care conference notes for Resident (R)10 dated: (MONTH) 12, (YEAR); (MONTH) 04, (YEAR); (MONTH) 27, (YEAR); (MONTH) 19. 2019; (MONTH) 21, 2019; (MONTH) 20, 2019; for R10, it was noted that the Date of Birth (DOB) found on the top left corner of each quarterly conference note for R10 read 1008 on each of the care conference notes. The correct DOB for R10 is 2008. During an interview with the Director of Nursing (DON) on 11/08/19 at 09:50 AM discussed the error noted in R10's medical record. DON verified that the DOB should read 2008.",2020-09-01
850,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2018-12-03,578,E,0,1,6J2811,"Based on interview and record review, the facility failed to obtain documentation that a resident or a resident's representative was given an opportunity to formulate advanced directives or had a valid advanced directive for five of 12 residents (Resident (R) 11, 12, 20, 25 and 14) selected for review. This deficient practice had the potential to affect residents admitted to the facility. Findings Include: 1) On 11/28/18 11:44 AM, review of R11, R12, R20, and R25's records did not reflect documentation that the resident or resident's representative was given an opportunity to formulate advanced directives or had an advanced directive. On 11/30/18 09:18 AM Social Worker 1 (SW1) was interviewed and asked if she had advanced directive documentation for R11, R12, R20, and R25. SW1 responded those residents had POLST documentation. SW1 was informed that the POLST is not an advanced directive. SW1 validated that if the POLST is not an advanced directive, then R11, R12, R20, and R25 do not have advanced directives. 2) On 11/30/18 at 10:20 AM, during an interview with SW1, she confirmed for R14, per the court order in the clinical record, R14's legal guardians are allowed to formulate an advance directive. SW1 acknowledged that although an advance directive for R14 was talked about during their annual review of the resident's code status, SW1 verified it was only discussed and was not documented. SW1 stated going forward, the information about and a formulation of an advance directive will be reviewed with R14's guardians.",2020-09-01
851,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2018-12-03,580,D,0,1,6J2811,"Based on interview and record review, the facility failed to notify the physician immediately of one of 12 residents (Resident (R) 25) who experienced weight loss in a month and was selected for review. This deficient practice had the potential to affect all 17 residents in the survey sample. Findings Include: On 11/28/18, R25's record was reviewed, and it reflected R25's weight loss on 11/01/18. The facility's Daily Skilled Nurse's Note, dated 11/01/18 did not reflect that the physician was immediately informed of R25's weight loss. R25's care plan was reviewed and it also did not reflect the weight loss recorded on 11/01/2018 nor that it was reported to her physician. Communication logs to the physician were reviewed and they also did not reflect the weight loss was reported to physician on 11/01/2018, or thereafter. On 11/30/18 at 09:27 AM, the Director of Nursing (DON) was interviewed. He was asked if R25's weight loss was reported to the physician. The DON replied that he didn't know and would have to check documentation. DON was given the opportunity to review R25's documentation. DON validated the physician was not informed immediately of R25's weight loss.",2020-09-01
852,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2018-12-03,656,D,0,1,6J2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of 12 residents (Resident (R) 14 and 22) selected for review, which includes measurable objectives and timeframes to meet a resident's medical and nursing needs. This deficient practice had the potential to affect all 17 residents in the survey sample for which a care plan may need to be developed. Findings Include: 1) On 11/29/18 at 08:24 AM, during a family interview conducted for R14, the family member stated the bottom part of R14's teeth had a lot of plaque build-up. The family member was not sure when the facility's dental consultant last saw her. Record review revealed a dental consultant's (licensed dentist) note, which stated R14's last dental screening was done on 02/20/17. The dental consultant's comments were: Improve oral hygiene - recommend [MEDICATION NAME]. On 11/30/18 at 10:13 AM, during an interview with registered nurse (RN) 1, she confirmed the resident's dental [MEDICATION NAME] (cleaning) had not been scheduled since the 02/20/17 recommendation by the dental consultant. RN1 said their dental consultant (a licensed dentist), was scheduled to come and see her in (MONTH) (YEAR), but he didn't come in and we haven't heard from him since. Further review found R14 did not have a comprehensive care plan developed for her dental/oral hygiene status. On 12/03/18 at 08:48 AM, a telephone interview with the facility's consultant MDS (Minimum Data Set) coordinator (MDS-C) was done. He acknowledged completing R14's annual MDS dated [DATE], and the 11/09/18 quarterly assessment. Both areas for Section L, oral/dental, showed that nothing had been marked. He was not aware that the last time R14 was examined by the dental consultant was in (MONTH) of (YEAR) with a recommendation for dental cleaning. The MDS-C said he should have reviewed this, but confirmed he failed to do so. Thus, there was no oral/dental assessment completed and no oral/dental comprehensive care plan developed. 2) For R22, a review for unnecessary medication use for insulin was done. R22 has a [DIAGNOSES REDACTED]. R22 also receives [MEDICATION NAME] R (regular) insulin 5 units by SQ injections if his blood sugar goes above 200 mg/dl (milligrams per deciliter). Record review however, found there was no comprehensive care plan developed for R22's insulin use. On 11/30/18 at 09:46 AM, both the Director of Nursing (DON) and the Staff Development Coordinator (SDC) confirmed there was no comprehensive care plan for the resident's insulin use and RN1 was developing one.",2020-09-01
853,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2018-12-03,791,D,0,1,6J2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for Medicaid funded residents, the facility failed to promptly provide or obtain from their dental consultant, a licensed dentist, routine dental services to meet the resident's needs for one of 17 residents (Resident (R) 14) selected for review. This deficient practice had the potential to affect all residents currently residing in the facility. Findings Include: On 11/29/18 at 08:24 AM, during a family interview conducted for R14, the family member stated the bottom part of R14's teeth had a lot of plaque build-up. The family member was not sure when the facility's dental consultant last saw her. Record review revealed a dental consultant's (licensed dentist) note, which stated R14's last dental screening was done on 02/20/17. The dental consultant's comments were: Improve oral hygiene - recommend [MEDICATION NAME]. On 11/30/18 at 10:13 AM, during an interview with registered nurse (RN) 1, she confirmed the resident's dental [MEDICATION NAME] (cleaning) had not been scheduled since the 02/20/17 recommendation by the dental consultant. RN1 said their dental consultant (a licensed dentist), was scheduled to come and see her in (MONTH) (YEAR), but he didn't come in and we haven't heard from him since. RN1 acknowledged there was no follow-up by the facility since.",2020-09-01
854,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2018-12-03,880,D,0,1,6J2811,"Based on observation and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. Findings Include: Observation of medication administration on 11/30/18 at 09:40 AM for resident (R) 6 with Registered Nurse (RN)2 demonstrated a compromise in infection control. During the passing of the medications for R6, the RN2 put one set of gloves on and then touched the feeding tube, drew the curtains closed, touched the foot board of the bed and attempted to open a drawer. RN2 did not change gloves and started passing meds via tube feeding. During an interview with RN2 after the medication pass, she stated, I forgot to change gloves.",2020-09-01
855,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,550,E,0,1,K7B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure each resident received care with dignity in a manner that promotes or enhances his or her quality of life for 4 of 16 residents (Residents #7, #14, #18 and #25) in the survey sample. Findings include: 1) Observation of Resident #7 (Res #7) revealed staff failed to care for him such as to maintain or enhance his quality of life, as this resident is unable to make his requests for assistance known. On 12/20/17 at 12:29 PM , Res #7 was observed laying in his bed connected to the ventilator. He had a large amount of saliva and drool that was bubbling and coming out of his mouth, down and under his chin and pooling by his [MEDICAL CONDITION] (trach) site. Unable to talk or speak, the resident's left arm was moving up and down. On 12/20/17 at 1:00 PM, Res #7 still had a lot of secretions coming out of his mouth. No staff had gone in to suction him or check on him. Then at 1:02 PM, two staff were seen entering the room to suction and care for the resident. That afternoon at 1:29 PM, the resident was again observed with large saliva bubbles forming at and around his mouth and his chin and neck area were wet again with the secretions. The resident was kept home from school this day due to brace fitting by a local hospital. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. The resident's care plan: At Risk for Ineffective breathing and airway r/t (related to) mucus plug and [MEDICAL CONDITION]/ventilator dependent stated to maintain a patent airway at all times, suction as ordered and as needed via nasal, oral and tracheal routes. The resident's care plan also had not been updated since (MONTH) (YEAR). During an interview with Staff #119, she stated the resident was to be suctioned as per the orders and care plan, but this was not being done. The facility failed to provide quality and safe care to the resident in a dignified manner. 2) On 12/19/17 at 09:31 AM, observed R#18 at the facility's onsite school. The resident was lying supine on a table with Staff#24 massaging his/her extremities. When Staff#24 was queried on what she was doing, she replied she was performing range of motion (ROM) exercises on R#18's extremities. Christmas music was playing on a computer tablet, but Staff#24 did not speak to R#18 while performing ROM on the resident. On 12/21/17 at 10:49 AM observed R#18 in the activity area being positioned in a stander by Staff#79. Staff#88 came to talk to R#18 and stated that resident used to smile and laugh more but changed from a year ago. Queried Staff#88 whether change in R#18 due to new staff and she replied that after experiencing more [MEDICAL CONDITION] his countenance changed. Staff#79 then started to wipe R#18's face and stated that she was doing resident's facial massage. Staff#79 was more attuned to the task at hand and only said a few words to the resident, e.g., Ok, relax your face. On 12/22/17 at 07:25 AM observed Staff#117 providing a bed bath to R#18. Upon entering through the privacy curtains, surveyor observed that R#18 was naked on the bed with damp skin and visibly shaking his arms and legs. Staff#117 was removing a tub of water from the bed and queried if R#18 is feeling cold. Staff#117 replied, He's always like that, as she stepped away from the bed to get a towel. Staff#117 then covered R#18 with a towel and wiped the resident dry. When Staff#117 removed the towel to dress the resident, his hands were still visibly shaking. Staff#117 covered R#18 with a blanket after dressing him and went to turn on a fan that blew directly onto the resident. Queried Staff #117 why the fan was turned on and she replied that they always leave the fan on for the resident. The room was cool so surveyor and other staff had sweaters on. Staff#117 then decided to turn the fan off. On 12/22/17 at 03:37 PM, R#18's medical record review (MRR) found two care plans dated 6/11/17 for Communication: cognition altered related to multi-congenital anomalies, and Development altered related to: Developmental Delay. Care plans (CPs) Plan of Action included: Assess ways resident attempts to communicate such as crying, laughing, smiling, touching, etc; Use touch as appropriate to communicate; Smile and speak calmly so as not to startle resident; Always tell resident what you are going to do with him; Use visual and tactile cues with resident; Talk to child with direct eye contact; Touch and stroke child during contact; Provide interactive activities. 3) On 12/20/17 at 01:37 PM interviewed R#25's family member (FM) at the resident's bedside. The FM wanted to express feelings of frustration and annoyance on observations of nurses unfamiliar with R#25, that rush through care and not speak to the resident. These new nurses just do their task, rush and R#25 starts to cry. The FM stated, I know when R#25 is afraid of someone because she won't look at them and cries. She did not feel that the agency nurses became familiar with R#25 before providing care or that they were reliable. The good doctor is gone. (R#25) senses and knows who she can trust by her body language. The FM reported her concerns to Staff#66, Staff#82 and Staff#61, but no changes--still mostly agency nurses. On 12/27/17 at 02:52 PM, R#25's MRR found a CP dated 12/26/16, Self care deficit related to [MEDICAL CONDITION] and developmental delay; with Goals: to keep resident safe, clean and comfortable. The CP had Reassessment date (MONTH) (YEAR) >12/2017. Also noted in the Interdisciplinary Progress Notes, dated 10/17/17 at 1800, was documentation of a meeting between the resident's FMs and the facility's licensed social worker (Staff #61). At this meeting the FMs voiced their concern and frustration about the care that was being provided to R#25. The plan after this meeting was for Staff #61 to speak with the facility's CEO to present their concerns and to request a meeting with the CEO on their behalf. Yet, there was no documentation in the MRR that this meeting with the CEO occurred or that the FM's concerns were fully addressed. 4) Observation of Resident #14 (R#14) revealed staff failed to care for her such as to maintain or enhance her quality of life, as this resident is unable to make her requests for assistance known. On 12/19/17 at 8:30 AM, two CNAs entered the resident's room talking with each other and did not announce or knock upon entering the room. This surveyor was in the room reviewing bedside records and the two staff were surprised to see surveyor in the room. Observation on 12/19/17 at 10:30 [NAME]M., noted Staff #118 entered the room without any announcement. Observation on 12/20/17 at 8:00 AM, noted Staff #20 entered the room without any announcement too. Staff did not treat the resident with respect and dignity by failing to knock or announce themselves.",2020-09-01
856,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,641,D,0,1,K7B512,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment by qualified staff, for 1 of 17 residents (Res #8) in the revisit sample. Finding includes: Cross-reference to findings at F686. For Res #8, record review found a 12/22/17 facility wound care skin integrity evaluation report, based on a durable medical equipment (DME) nurse's assessment which documented Res #8 developed a sacral wound, full thickness, unstageable pressure ulcer with an onset date of 12/17/17. The wound measured 2.5 x 3.0 cm (L x W) with a 1.0 cm depth with no tunneling or undermining, was facility acquired, with the wound bed showing brown slough, 70% yellow adherent [MEDICATION NAME] slough, 5% tendon/muscle/ bone and 25% red, pink/red healthy granulation. A second assessment by the same DME nurse, and submitted as the facility's 1/19/18 wound care skin integrity evaluation, showed the wound remained a full thickness, unstageable sacral pressure ulcer with an increase in size to 3.0 x 2.5 x 1.7 cm (L x W x D). The wound bed was noted with 100% yellow adherent [MEDICATION NAME] slough, with no tunneling or undermining and minimum exudate. Review of Res #8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/5/18 under Section M for determination of pressure ulcers at M0210 was coded as 0 = No, this resident does not have one or more unhealed pressure ulcer(s) at Stage 1 or higher. The section for the number of unstageable pressure ulcers due to coverage of the wound bed by slough and/or eschar was not completed; nor was the section at M0610 - Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar. On 3/2/18 at 7:35 AM, interview with the contractor RAI Coordinator (RAI-C) for the facility, found he was familiar with Res #8 and came to the facility at least weekly to do his MDS submissions. During a query of his MDS quarterly submission dated 1/14/18 with an ARD of 1/5/18, the RAI-C confirmed he completed Section M, but coded it as moisture associated skin [MEDICAL CONDITION] (MASD), and not as an unstageable pressure ulcer, with worsening of the wound. The RAI-C said he came to that determination by, .just look at the notes, interview some of the staff and compare it to the previous MDS, so I know this one, this wound documentation, sometimes it gets 'all over.' Like inconsistent, so I just based it mostly on interviews with the staff and it has always been coded as moisture associated skin damage yeah. I'm not sure if I saw any documentation if it's a pressure ulcer. The RAI-C said he saw the treatment order for 12/22/17, but his decision was to code it as a MASD. I should have asked for more information after seeing the (MONTH) one .I went with and kinda favored the MASD, because it's what he always had, but it's wrong. He acknowledged he should have coded it differently and reiterated the nursing documentation was all over the place. The RAI-C stated he was going to submit a modification to the (MONTH) MDS quarterly assessment, once we determine what was the proper stage. Upon query as to who has the expertise to stage it, the RAI-C stated, I would think it's the charge nurses, or maybe the DON. They didn't even do weekly before. They didn't have detailed assessments. I would have to dig for measurements. There was a failure by the RAI-C to ensure Res #8 received an accurate assessment for an unstageable pressure ulcer.",2020-09-01
857,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,645,E,0,1,K7B511,"Based on record review and staff interviews, the facility failed to promptly coordinate with a state-designated mental health or intellectual disability authority to conduct a PASARR Level II evaluation for 4 of 16 residents (Residents #19, #20, #10 and #27) in the survey sample, after having re-evaluated the Level 1 screen for these four residents in (MONTH) (YEAR). Finding includes: During the record reviews for Res #19, #20, #10 and #27, it was found these residents were part of an updated PASARR Level I screening. These were completed by the former medical director on (MONTH) 29, (YEAR) for Res #19, 20 and #10 and on 8/7/17 for Res #27. During an interview with Staff #30 on 12/27/17, she stated the facility could not get someone from the State to evaluate these residents. Staff #30 said their former medical director re-evaluated these residents, but after he left, she had no knowledge of what happened as to why the Level II screens were not done. On 12/28/17, during an interview with Staff #82 at 12:31 PM, she stated the previous PASARRs were completed inaccurately, and although they got to the point where their former medical director understood how to correctly answer the screening questions, they ran into issues trying to find someone to do the Level II screens thereafter. Staff #82 said although they contracted a certain individual to do the Level II screens, she verified that to date, this individual has not done them and confirmed these residents did not receive their Level II screens.",2020-09-01
858,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,656,D,0,1,K7B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews (MRR) and staff interviews the facility failed to establish a comprehensive care plan, and document and implement the care and services to be provided for 2 of 16 residents (R#25, R#14), to assist each resident in attaining or maintaining his or her highest practicable quality of life. Findings include: 1) On 12/27/17 at 03:14 PM, the MRR on R#25 noted on a speech language pathologist (SLP) evaluation report dated 11/19/17, the resident was assessed with [REDACTED]. The dysphagia note addendum documented that R#25 was seen for communication and dysphagia treatment. It was also reported that the family was found feeding yogurt to R#25, despite repeated warnings not to engage in oral trials without presence of Rehab. Issues and concerns were discussed with the nurse practitioner (NP) and nursing staff. The importance of balancing safe feeding trials with decreasing oral aversion was discussed at length with the family and they provided return demonstration techniques. The plan was for the family to demonstrate positive eating models in front of R#25 and have the resident feed them too, in order to encourage positive feeding experiences. The family agreed to the plan and nursing was informed. On the SLP evaluation dated 11/28/17, the resident was assessed to have oral dysphagia and suspected/possible pharyngeal dysphagia; characterized by significant oral aversion, minimal oral intake, poor lip seal, poor bolus manipulation, and oral motor coordination deficits for feeding. The functional summary documented that R#25 was still demonstrating oral aversion by turning away from food presentations. The resident's oral intake was minimal and they were working towards increasing intake so a modified [MEDICATION NAME] swallow study (MBSS) could be done. On 12/05/17 the SLP documented in a SOAP note, .A: R#25 continues to present with delays in communication & feeding .Feeding - continues oral aversion. Took only one bite volitionally, all other intakes by swipes to mouth. P: Continue to work on increasing intake; Continue to work towards MBSS. The Care Plan Conference Summary dated 12/12/17, documented, Discharge Planning: Parents unable to provide care at this time, inadequate housing, currently trying to find housing. Interdisciplinary Team Follow-up: Resp: Currently remains on vent at rest, will continue to assess and wean as able .Nursing: working on [DEVICE] feeds,[MEDICAL CONDITION], suctioning .Activities: Using developmental play; plan for field trip end of December/Jan (YEAR) .CNA: Has all her current. On 12/29/17 at 09:25 AM interview of Staff#30 found that R#25 was scheduled for surgery in Feb (YEAR) to close soft palate. According to Staff#30, food play was not working for R#25, as resident did not want anything near her mouth, and demonstrated oral aversion. Staff#30 further stated that was typical for residents with a trach/vent to have oral aversion due to not used to placing things in their mouths. Queried Staff#30 on R#25's comprehensive CP to address oral aversion and food play. Staff#30 stated that R#25 has been here only for a year and usually early intervention services (EIS) is in place that consists of an OT, PT, SLP who develops a comprehensive CP. She said EIS usually alerts the resident's primary care physician (PCP) for changes to the CP for food play and/or oral aversion. Staff#30 stated that she requested the MBSS to ensure R#25 was not aspirating through her trach, but R#25 unable to swallow enough [MEDICATION NAME] to do the test. Staff#30 also cound not find a CP for the resident's oral aversion and food play, and stated, I don't do the CPs. The resident was evaluated by EIS on 1/24/17; and under Suggested Activities and Strategies: Provide safe, pleasant experiences for oral care and play; Make sure she is in a stable seated position for better head and trunk control; Make sure she is not exhibiting upper airway congestion/ wet vocal quality before starting; Provide variety of safe teethers/toys for name to explore; If providing input to her then grade it in a comfortable manner when approaching her face/mouth; You can add singing or providing the input at a comfortable rhythm on your approach. The facility did not develop and implement a person-centered comprehensive care plan to meet R#25's goals for oral feeding, and address the resident's medical, physical, mental and psychosocial needs. 2) R#14 is a [AGE] year old quadriplegic resident with encephalitis who is dependent on the nursing staff for all activities and care. It was observed by this surveyor, that R#14 did not participate in the activities in the common area for the duration of the survey. Record review (RR) for R#14 showed the activity schedule log mainly consisted of stimulation from the TV and music played in her room. RR on 12/28/17 revealed an activity quarterly progress note on R#14 stating, She participates in activities daily in the common area or 1:1 room visits. The adult activity attendance log showed the resident participated the majority of the time watching TV/movies in her room. Further record review revealed no comprehensive care plan for activities. Interview with Staff #88 was done on 12/29/17 at 08:36 AM. She stated, The family had asked staff to take R#14 out on shower days and there were six aides and they didn't bring her out. It's because we have agency aides and they don't bring the adult residents out of their rooms. She further stated that R#14's family's preference was for R#14 to be in the common area after she gets cleaned up as tolerated. A lot of people don't come out because the nurses didn't [MEDICAL CONDITION]. The nurses prefer we wait for them to [MEDICAL CONDITION] before bringing them out but then they don't get [MEDICAL CONDITION] until change of the shift. We do standing therapy, it's for physical therapy. We are only budgeted for two people. We can't even do our regular people with our budget. So much staff left and now we have 95% agency. We have 8 standers (residents who use a standing device). The nurses are supposed to [MEDICAL CONDITION], G tube, feeding, meds. Activities does tracking, massage, visual, sometimes we help with diaper change. Interview with Staff #61 on 12/29/17 confirmed that the family preference was for R#14 to engage in the common area activities. 12/29/17 at 08:58 AM, interview with Staff #92 was done. She said, We base our program from orders from physical therapy. This is based off family preferences. Before, (R#14) was able to make her needs known but we still do the same activities. I believe that the (family member) requested highlights and a professional came and did haircuts and highlights for her. Her family also requested her to come outside as well. The CNAs are responsible for them to come outside to participate with activities. If they don't come out then we bring the activities to them. The facility did not develop and implement a person-centered comprehensive care plan to meet R#14's goals for activities, the family's preferences and failed to address the resident's medical, physical, mental and psychosocial needs.",2020-09-01
859,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,657,E,0,1,K7B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and a review of the facility's policy and procedure, the facility failed to ensure the comprehensive care plans were reviewed and revised to be current for 4 of 16 residents (Residents #14, #1, #7 and #23) in the survey sample. Findings include: 1) R#14 is a [AGE] year old quadriplegic resident with encephalitis who is dependent on the nursing staff for all activities and care. R#14's history found frequent urinary tract infections (UTIs). Record review (RR) on 12/21/17 at 09:31 AM revealed that R#14 was admitted with an indwelling catheter because of a [MEDICAL CONDITION] bladder. R#14 has had frequent UTIs. Lab tests were done for [DIAGNOSES REDACTED]. On 9/7/17, R#14 had an episode of hematuria during the night and her physician was aware. On 10/02/17 a urine sample with reflex to culture and sensitivity (C&S) was done and a [DIAGNOSES REDACTED]. Per the progress notes, R#14 had a temp of 39 degrees centigrade and continues with foul odor urine. Urine draining concentrated dark yellow urine with large amount of sediments and foul odor. On 11/8/17 another urine sample with reflex to C&S was done. Her urine sample again revealed a UTI. Then on 12/18/17 another urine sample with reflex to C&S revealed another [DIAGNOSES REDACTED]. RR dated 12/12/17 at 11:00 [NAME]M. showed a physician's orders [REDACTED]. However, the medication administration review (MAR) found the resident did not receive this order 18 times over an 18 day span because it was not available. On 12/21/17 at 9:55 AM, Staff#72 stated, I don't know about the care plans but they do interdisciplinary plan of corrections. She does have sediments in her urine. RR on 12/21/17 of the interdisciplinary care team meeting notes on 11/14/17 did not document R#14's treatment or care for her repeated UTIs. Further review of the resident's care plans on 12/21/17 did not mention the order for cranberry juice administration for her UTI. On 12/22/17 interview of Staff#120 was done. She stated, We only had three nurses for 25 residents from 11:30 to 7:00 a.m. The other night we had only two nurses. She was queried regarding how this affected resident care and she said, Staffing has been an issue. We have been told to focus on the care of airway, meds and feeding. The things that would not get done is [MEDICAL CONDITION], [DEVICE] care and urinary catheter care. The agency nurses are not able to get everything done or they don't know how to do it. Administration told us to prioritize our care this way. 2) On 12/21/17 at 9:06 AM, Res #1 was observed in bed connected to the ventilator. Staff #15 stated the resident's heart rate is going down a bit, looked around and then left the room. The Masimo set monitor found the resident's oxygen saturation at 98%, but his heart rate was between 46 to 51 beats per minute (bpm) per a six minute observation period. The resident had his eyes open and was blinking, but could not verbalize anything. At 9:12 AM, Staff #98 came into the room with Staff #15 and placed an additional blanket on the resident. Staff #15 was asked when she noticed the resident bradying down (staff were using this term as a drop in the heart rate), and she stated it was around 9:00 AM when she changed the resident's shirt. Staff #15 also said the blankets had been pulled off of him. Staff #98 stated the resident's usual heart rate was around 65 bpm and took his temperature at 97.2 degrees Fahrenheit (F). Staff #98 said she had a pager and notified the nurse to let her know he's bradying down more. Staff #98 said with four blankets he should be okay. The licensed staff attending to the resident did not come in to assess him during this time. There was a Bair Hugger next to the beside but it was not being used for this resident. On 12/22/17 at 7:56 AM, the resident's O2 sat was at 99%, and his heart rate was between 47 and 49 bpm. He only had one blanket on. His assigned nurse aide and licensed nurse were not in the immediate area. On 12/27/17 at 12:19 PM, during an interview with Staff #98, she said Staff #15 was an agency staff whom she was training about what can happen when the resident's shirt is taken off. Staff #98 confirmed she informed the nurse on 12/21/17 but was told she was busy passing medications. She also said they put the Bair Hugger on the resident if his temperature went below 96 degrees F, and, if his heart rate is low, that means he is cold. Or I'll try and keep his head warm. Staff #98 said she was involved in Res #1's care plan and knew about the use of the Bair Hugger, but we (aides) do a lot more to be honest. If the nurse is extra busy and we're short staffed, they would ask us to put the Bair Hugger. The nurse is supposed to put it on--it's the nurse duties. Not the CNAs. She stated for the nurse assigned to the resident, you just keep reminding them. On 12/27/17 at 2:52 PM, interview of Staff #66 was done. She stated a clarification she recently heard was to check Res #1's temperature and it was not to be based on the low heart rates. Staff #66 also nodded in agreement the resident's care plan had not been updated to include what the nurse aides were doing, i.e., putting on the blankets, recent clarification of temperature checks, ensure licensed staff assess the resident if he is bradycardic (Staff #98 said, when he's cold, and his heart rate will start dropping, although his temp 97.2), and, who/when to apply the Bair Hugger with clear monitoring parameters. Staff #66 concurred the current vital signs log was inconsistent with missing information, of which should include those interventions being implemented as part of Res #1's care plan. Staff #66 said she and her licensed staff were responsible for updating the care plan. Staff #66 also confirmed for Res #1, 14 of his care plans had not updated/reassessed since (MONTH) (YEAR) and one care plan since (MONTH) of (YEAR). This was a total of 15 plans of care for Res #1 not reviewed/revised. 3) For Resident #23, he had one care plan for nutrition which had a To Date of 5/23/17. Five other care plans had a last reassessment date of 08/17 and two care plans developed on 5/28/17 had no follow-up review or reassessment dates. 4) For Resident #7, his two care plans were last reassessed in 8/2017. On 12/27/17 at 2:50 PM, Staff #66 verified the overall care plans for their residents had not been updated. On 12/21/17 at 3:05 PM, Staff #66 also acknowledged for the facility's policy and procedure on Comprehensive Care Plans, the terminology for RAPs was outdated. Staff #66 said their MDS coordinator left them and said, this too (their policy), hasn't been updated.",2020-09-01
860,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,686,G,0,1,K7B512,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure that a resident with a facility acquired pressure ulcer receives the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent the wound from worsening for 1 of 17 residents (Res #8) in the revisit sample. Finding includes: On 2/28/18 at 12:25 PM, the SA observed Res #8's coccyx wound with Staff #55 during wound care. Staff #55's knowledge was the resident's wound developed in the facility and it was determined to be an unstageable wound. Staff #55 measured the wound to be 3.0 cm (length) x 2.0 cm (width) x 1.8 cm (depth). She said, he does have undermining and measured it to be 4 cm at 12 o'clock spot. She also measured the wound at the 1:00 o'clock to 3 o'clock areas with a swab and noted 2 cm of undermining there, and 2 cm at the 7 o'clock to 12 o'clock areas. She said at the 6 o'clock spot, there was no undermining, some serosanguinous drainage, but no odor. Staff #55 said although the wound had been improving with less slough, the measurements were smaller prior to the dressing change, and surprised there was 4 cm of undermining found. The resident's right and left buttocks showed intact, pinkish white scar tissue, but the coccyx wound itself presented as a deep, circular coccyx wound with minimal slough. She stated there was no bone, but just tissue. She packed it with several dry woven gauze and applied absorptive dressing over it per the physician's orders [REDACTED]. Record review found this resident had a history of [REDACTED]. However, the first entry for the observed sacral/coccyx wound was found on a weekly skin assessment diagram of 12/11/17 which noted a general 3 x 2.5 cm open area. Then there were additional entries which noted the following: 12/18/17 - coccyx open wound measured 2.8 x 3 cm; 12/25/17 - Buttock with pink moist wound inferior to coccyx approx. 2.5 x 3.0 x 1.1 cm; 1/22/18 - See TAR; 1/29/18 - See TAR; 2/5/18 - coccyx wound 3 x 2.5 x 2.5. Of note, for each weekly skin assessment, licensed staff were charting Decubitus as None. Yet, the facility's wound care skin integrity evaluation report based on a DME nurse's assessment, documented Res #8 developed a sacral wound, full thickness, unstageable pressure ulcer with an onset date of 12/17/17. The wound measured 2.5 x 3.0 cm (L x W) with a 1.0 cm depth with no tunneling or undermining, was facility acquired, with the wound bed showing brown slough, 70% yellow adherent [MEDICATION NAME] slough, 5% tendon/muscle/ bone and 25% red, pink/red healthy granulation. A second assessment by the same DME nurse, and submitted as the facility's 1/19/18 wound care skin integrity evaluation, showed the wound remained a full thickness, unstageable sacral pressure ulcer with an increase in size to 3.0 x 2.5 x 1.7 cm (L x W x D). The wound bed was noted with 100% yellow adherent [MEDICATION NAME] slough with no tunneling or undermining and minimum exudate. Within the resident's record, various interdisciplinary (IDT) progress notes by licensed staff were found to be inconsistent about the sacral/coccyx wound they were treating, and failed to identify when the wound increased in diameter/size although daily measurements were being done, and failed to document whether the physician was notified when changes were found. Res #8's coccyx wound included the following documentation: 1/2/18 - 3 cm x 3 cm x 1 cm coccyx wound with slough; 1/12/18 - unstageable wound to coccyx measuring 3 cm x 2.5 cm x 1.5 cm; 1/14/18 - unstageable coccyx measured 3 cm L x 2.5 cm W x 2 cm D. Noted developing undermining at 3 (degrees) and 11 (degrees) positions. Noted with moderate amount slough and small amount pink granulation tissue. By 2/3/18, a nursing entry in the Treatment Administration Record (TAR) noted, Unstageable wound to coccyx noted with slough to perimeter and mid-wound. Also noted with moist pink tissue. No s/s infection. Noted with moderate amount of sero-sanguineous drainage. Measures 3 cm L x 2.5 cm W x 2.5 cm D. Undermining noted to 9 (degree) position measuring 2.7 cm. Treatment done as ordered .Continue to monitor. There was no documentation in the clinical record that any action was taken by licensed staff related to the developing undermining (no measurements found) on 1/14/18 with increase to the depth of the wound. The failure to notify and document treatment changes or perform a reassessment of the wound was similarly found for the 2/3/18 entry. The licensed staff were also found to document continue to monitor, but the on-going daily wound entries were not being reviewed by anyone. The monthly nursing notes and TAR entries found varied and inconsistent documentation which included the following: Monthly Nursing Notes: - 12/15/17 Section for Skin condition: Buttock wound - MASD; Other - Drsg and powered collagen, turning/repositioning. - 1/29/18 Section for Skin condition: Unstageable buttock wound, drsg with oints, pressure relieving devices, turning/ repositioning. - 2/16/18 Section for Skin condition: Ulcers: Stage III, coccyx pressure ulcer, pressure relieving devices, nutrition or hydration, turning/repositioning, ulcer care, Medications within past 30 days: Santyl. Daily Pressure Ulcer Documentation from the TAR: - 2/14/18 Stage IV to coccyx with loose slough to perimeter 3.75 cm x 3 cm x 2.5 cm. Wound improving with pink moist tissue. No odors, no s/s infection. Scant amount serosanguinous drainage on drsg. Treatment done as ordered .Will continue to monitor. - 2/15/18 PRN dressing change done for soiling .Undermining present to entire perimeter. - Another 2/15/18 nursing entry: .Measured 3 cm L x 2.5 cm W x 3 cm depth. Undermining to perimeter. Deepest at 12 (degree) at 3 cm undermining .absorptive dressing . - 2/16/18 Stage IV to coccyx with slough to perimeter, 3 cm x 3 cm x 2.5 cm, undermining 12 (degree) . - 2/21/18 Wound measures 3 cm L x 2.5 cm W x 2.5 cm D with undermining from 12-3 (degrees) position measuring 2.5 cm . - 2/27/18 Coccyx wound is unstageable measures 3 cm x 1.8 cm x 2.1 cm with undermining and slough to perimeter. Moderate amount of yellow serous drainage with slight odor to dressing . Then the attending physician's entry of 2/15/18 documented the coccyx wound as Stage IV wound. Cross-reference to findings at F710. The facility failed to track the progress of the wound, which was facility acquired and which increased in size. As a result of the wound not being monitored by licensed staff and the physician, coupled with the failure of the licensed staff to report changes and accurately identify the wound (proper wound staging), the potential for harm existed. Interview with Staff #55 on 3/1/18 at 3:31 PM revealed she was uncertain whether she could stage the wound. She stated her training to classify wounds was to go by the recommendation of the wound nurse. She confirmed if there was a change to the appearance of the wound, she would notify the physician and consult with the wound nurse. However, there was no documentation to evidence this. She said Staff #30 informed her it was unstageable. Staff #55 stated, I'm not sure in response to the query of what the facility's clinical guidelines were for wounds and staging of wounds. She also stated she saw the inconsistency with the clinical documentation with the nurses charting different things about the coccyx wound. Her rationale as to why the wound got bigger, was, looks like it got debrided and that's why it got bigger. Yet, the tunneling was significantly greater at 4 cm per her wound measurement on 2/28/18, and for the past two months, licensed staff failed to recognize and consistently monitor/document the changes to the wound. On 3/2/18 at 7:35 AM, interview with Staff #35 was done. Staff #35 stated she knew the wound was getting bigger, but was uncertain whether we can stage the ulcer. On 3/1/18 at 5:08 PM, interview with Staff #30 revealed she had not seen the wound for some time and acknowledged she was not tracking Res #8's wound status. Staff #30 and Staff #1 also were not aware their wound care consultant was not a consultant, but in fact a nurse certified in wound care that was employed by a DME supply company the facility contracted with. Staff #30 stated it was always a struggle to determine what the MASD was. Coupled to the lack of a comprehensive care plan for the unstageable sacral pressure ulcer and the failure of the physician's involvement related to the progression of the wound, there was a failure to provide this resident with the necessary treatment to prevent and heal a facility acquired pressure ulcer. Cross reference to findings at F726, F867.",2020-09-01
861,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,695,K,0,1,K7B512,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews and a review of the policies and procedures, the facility failed to ensure its residents are free from unplanned decannulations for 5 of 17 residents (Res #2, #7, #20, #24, #25). As a result, there was a failure to protect these residents from respiratory trauma/complications due to the number of unplanned decannulations. Residents who experience these unplanned decannulations suffer from oxygen desaturation, trauma and even the likelihood of death. An immediate jeopardy (IJ) was identified as the facility failed to recognize the serious nature of the decannulations, failed to track the incidence and rate of decannulations occurring in the facility, failed to identify the root cause(s) of the decannulations, failed to develop and implement care plan interventions to prevent the recurrence of decannulations, and failed to train or in-service staff about the decannulation risk for all residents in the facility. Finding includes: During the revisit survey, the SA observed an unplanned decannulation (removal of the [MEDICAL CONDITION]) on 2/28/18 at 11:10 AM for Res #20. This happened while she was attending her in-facility school program. Three respiratory therapists responded to a call for help and worked on the resident to re-insert the tube and re-establish her airway. The pediatric resident, was observed gasping with tears as her oxygen saturation level dropped to 69%, with a pulse of 164. Review of the facility's incident report found the cause of decannulation was due to the resident's [MEDICAL CONDITION] ties being extremely loose. Then the next day on 3/1/18 at 8:15 PM, another pediatric resident, Res #7, experienced a decannulation during his bed bath. Separate interviews of Staff #25, Staff #124, and Staff #98 were done, and it was found that Res #20 and Res #7 were known to decannulate frequently, but that it was not being addressed. The SA's manual tally taken from the facility's nursing 24-hour daily shift reports, found a total of 7 decannulations accounted for in (MONTH) (YEAR). In addition, the SA found a total of 8 decannulations which included the (MONTH) 28th decannulation of Res #7. This was compared to Staff #1's tracking report which noted her total for (MONTH) (YEAR) was the same (7 decannulations), but for (MONTH) (YEAR), she had recorded only 3 decannulations through (MONTH) 27th. Interview of Staff #124 on 3/1/18 at 8:35 AM found that during a decannulation, the primary goal was to re-establish the airway for oxygenation and to stabilize the resident. Staff #124 said previously, the decannulations were tracked by the previous director of nursing and the previous medical director, but currently, the Administrator signed off on the incident reports. Staff #124 stated, When the critical questions are asked, who witnessed this, who is going to write the report, no one wants to do the reporting. Staff #124 stated the decannulations were not discussed in the QA meeting and did not know if there was a critical number being reported, as the Incident Event Reports and Initial Investigative Findings were not routed to the respiratory therapy (RT) department. Staff #124 also stated there was no head charge nurse to complete these reports as well. Interview of Staff #25 on 3/1/18 at 10:12 AM revealed that licensed staff were aware that Res #20 decannulates because she was very active and often got wrapped up in her pulse oximetry tubing along with the ventilator tubing. Staff #25 said Res #20 desats so much and decannulates and once she goes down, she goes down fast because this girl has a lot of [MEDICAL CONDITION] too. Staff #25 said they have to check her almost every half hour when she was put into her crib. She said they're supposed to check [MEDICAL CONDITION], but was not certain if everybody did this. Interview Staff #1 on 3/1/18 at 10:53 AM revealed for the decannulations, she wanted to see what was happening with the numbers. The SA queried what Staff #1 has done about the occurrence and recurrence of decannulations. Staff #1 stated she was going to have to ask Staff #30 what she has done about it in her huddles and this was new data since their meeting three weeks ago. She further stated, We noticed these things (decannulations) going on and we need to get the numbers down. We need to find out what's going on with it. Big red flag. Staff #1 stated she was going to ask Staff #30 to pull everything about the decannulations and provide it to the S[NAME] During Staff #30's interview on 3/2/18 at 8:48 AM, she stated, We have a high rate of decannulation so we need to monitor them more closely and adequately do [MEDICAL CONDITION], like (Res #20), so we don't want them to pop out. (Res #2) does it frequently. But, I think monitoring more closely. This is the first time I've seen loose ties on her (Res #20). Staff #1 stated she did not know the reason for the loose ties. Regarding the discrepancy in the number of decannulations which the SA counted versus what Staff #30 had tracked and whether she was tracking the frequency/occurrences of it, Staff #30 stated, I don't think so, I think we just started in January. I don't think there's any actual running log of what was being done. When Staff #30 was made aware the SA's manual count taken from nursing's 24 hour daily shift reports totaled 8 decannulations in (MONTH) versus the 3 she had, she stated, Eleven decannulations (her total of 7 in (MONTH) plus her count of 3 in February) is very high, but when you look at three days, to me, in a pediatric population, I don't know if it's very high. The SA clarified if she meant one decannulation every three days and she said, Yes, I don't know if it's really high or not. Staff #30 was further queried whether she had implemented anything with the identification of the 7 decannulations she tracked in the month of (MONTH) alone. She stated, No, I haven't started anything. I have not done a breakdown, no, (i.e., which nurses, which shift, etc.). Interview of Staff #98 on 3/2/18 at 9:09 AM revealed there was an under reporting of the incidence of decannulations. Staff #98 stated for the decannulation which occurred for Res #7 at night on 3/1/18, There's no charge nurse, and usually it would be the charge nurse. The nurse who had the patient--she wasn't even aware she was supposed to write it up. So I told her I would show her how to write it up and what needs to be done. I showed her where in drawer and I called the doctor and then I asked the nurse to call the family .The nurse said she's had several decannulations and that she has had several decannulations but no one has ever told her about this. So I'm wondering if I didn't initiate writing a report, would they have wrote the report, called the doctor and family? Staff #98 said it was important to address decannulations because, Some of the residents they don't have any reserve, they desat so quickly . so our one resident, (Res #20), she's had quite a few decannulations so she's one of them where she desats very quickly. She's active in her bed, so oftentime, when she's alarming, she's all caught in her tubing, and she's just very active, and for one, they need to make sure the ties are tight enough. We've been physically checking and sometimes we can fit our whole hand in it. I can't pinpoint, it's all these new staff, because it's all new staff for us. We address it if we know who the nurse is, and we'll just let them know--I just let them know. I did that with the nurse for 2B one time and said I can fit my whole hand in there. I believe it was an agency nurse, but at night time, what do you do--call 911, but by that time, the kid is dead. So are they going to know what to do? This is coming from (Staff #1), that the new nurses should be able to jump onto the floor. But they're not paying attention to the desats, [MEDICAL CONDITION], and right after they leave the room after [MEDICAL CONDITION], they leave the room, but the secretions often loosen and they need suction and desat right after doing [MEDICAL CONDITION]. It's okay to be afraid, but if people are offering to be with you, you should try to do it because we're there if something goes wrong. So if you bring in [MEDICATION NAME], they should know how to do it. The SA found for the month of (MONTH) (YEAR), there were 4 decannulations which were not reported: Res #20 on 2/12/18; Res #21 on 2/16/18; Res #18 on 2/27/18 and Res #7 on 2/28/18. This data showed there were other residents who had decannulated and had not been identified as one of the high risk residents. This information substantiated some of the facility's staff's concerns related to the under reporting of such events. In addition, although the facility staff and management were aware of the decannulations, the incidence rate, accurate reporting procedure, staff education, review of the comprehensive care plans to prevent future decannulations, and quality performance improvement measures with a root cause analysis for each prior occurrence, were not being done. All of the facility's residents have a [MEDICAL CONDITION], are ventilatory dependent and dependent on staff for their airway management/life support. On 3/2/18 at 2:33 PM, per Staff #30, she said she could not find any inservice on decannulation, nor was there a policy available for it. On 3/2/18 at 7:05 AM, Staff #120 stated she could not find a current policy and procedure on unplanned decannulation. She also stated if it occurred, she would check the treatment for [REDACTED]. On 3/2/18 at 3:40 PM, an IJ was identified by the SA and the facility's management team was notified of it. The facility's abatement plan was accepted on 3/2/18 at 5:18 PM.",2020-09-01
862,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,710,D,0,1,K7B512,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility's policy and procedure, the facility failed to ensure the physician reviewed the resident's care plan and re-evaluated the effectiveness of the resident's medical care, including a thorough evaluation and treatment of [REDACTED].#8) in the revisit sample. Finding includes: Cross-reference to findings at F686. It was found the attending physician for Res #8 was aware as of 12/21/17, that Res #8 had a sacral wound and had a treatment order for it on 12/22/18. However, he also combined his wound documentation with entries of buttock [MEDICAL CONDITION] or excoriations, which made it confusing as to whether he was treating one wound versus a new, different buttock wound. The physician's clinical documentation was noted as follows: - 12/21/17 documentation: New eschar at sacral wound .Scant eschar sacral wound. Assessment and plan: wound care. Santyl. - 1/4/18 documentation: No new respiratory or skin issues according to the nursing staff. - 1/25/18 documentation: Buttock [MEDICAL CONDITION] slow to heal .[DIAGNOSES REDACTED] and openings along buttock area. Assessment and plan: skin care. Changed topical dressings this week . - 2/1/18 documentation: Buttock excoriations healing gradually .[DIAGNOSES REDACTED] on buttocks. Excoriations Noted .Skin care. Continue barrier cream and topical agents . - 2/8/18 documentation: No new respiratory or skin issues according to the nursing staff .Sacral wound without significant drainage. Assessment and plan: sacral wound. Nickel sized santyl. Monitor. [MEDICAL CONDITION]. Medical therapy has maintained current functional status . - 2/15/18 documentation: Wound along coccyx slow to heal .3 by 3 centimeter stage four wound with scant brown drainage Assessment and plan: stage four. Pressure relief and topical dressing as ordered. Area in size increased due to eschar being whittled away. Monitor .Plan of care. Here for long term care. - 2/22/18 documentation: No new respiratory or skin issues according to the nursing staff .Sacral wound less eschar .Wound care. Changed dressing. Healing well. Plan of care. Here for long term care. Although Staff #55 stated the attending physician was notified when changes were noted to the sacral wound, there was no documentation found in the clinical record. However, it was the attending physician who staged Res #8's coccyx as a 3 cm x 3 cm Stage IV wound on 2/15/18. Yet, the attending physician failed to recognize and supervise the immediate care being provided by the licensed nurses as evidenced by the inconsistent documentation in the clinical record. The physician's plan of care was here for long term care, but did not include a review of the comprehensive care plan for the wound (which was not developed), nor intervening when the undermining to the wound bed was found to start as early as 1/14/18. In addition, to the physician's 2/22/18 documentation, sacral wound less eschar, there was no decision to reclassify the wound or provide additional documentation of what a new plan or treatment would be. Of note, the 1/9/18 care quarterly care plan conference summary stated, New concerns: buttock wound appears to be transitioning to a possible stage observe closely. The attending physician's medical supervision of the care to ensure the sacral wound was healing without any tunneling and/or undermining was not done, and was not evident by the physician's own clinical documentation over a two month period.",2020-09-01
863,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,725,L,1,1,K7B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, interviews and review of the facility's policies and procedures, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies/skills sets to provide nursing and related services to ensure each resident received care that was safe, and able to maintain their highest practicable physical, mental, and psychosocial well-being. It was found there was an insufficient number of licensed staff with a lack of competency training required to provide quality care for their residents who were all ventilatory dependent and required total care by staff. As a result, an immediate jeopardy (IJ) was identified for the systemic problems and potential for serious harm to occur to all their residents. Findings include: Cross-reference to findings from F550, F645, F656, F657, F726, F759, F760, F835, F837, F841, F851. 1) On 12/19/17 at 08:25 AM, during the initial tour of the facility, surveyor observed Staff#42 and Staff#8 flushing R#24's peripherally inserted central catheter (PICC) line. Staff#42 was assisting Staff#8 who held 2 syringes filled with liquid, and asked, Which syringe do I use first? Do I flush it with all (syringes)? After the nurses completed the task, they were queried whether it took 2 nurses to flush R#24's PICC line. Staff#42 stated that she worked the night shift (N[NAME]) and was supposed to have flushed R#24's PICC line but was too busy, so assisted the day shift nurse with the PICC line flush before going home because this resident was more complicated. Staff#42 further stated there were only 2 nurses working the night shift (N[NAME]) and the day shift nurse had to work until 2300 to provide residents [MEDICAL CONDITION]. The nurses reported that on 12/18/17 from 2300-0400 there were only 2 nurses on duty and a respiratory therapist on duty from 2100-0700. Staff#8 reported that since she started working with the facility as an agency nurse, 2 charge nurses have resigned and they were short staffed. On 12/22/17 at 07:12 AM, observed Staff#120 flushing R#24's PICC line with 10 mls of normal saline, and then 0.4 mls of [MEDICATION NAME] to lock the line, as the resident slept comfortably. Staff#120 said she was not sure who she was handing over care to for R#24, as her N[NAME] shift ended. Staff#120 voiced concern over R#24's care as he was the only resident in the facility with a PICC line for which he received total [MEDICATION NAME] nutrition (TPN). Staff#120 related on 12/18/17, she was the only permanent nurse staff on day shift and an agency nurse was assigned to R#24. The agency nurse was not familiar with R#24's care, and Staff#120 had to perform the dressing change to the resident's PICC line and guide the agency nurse to flush and start R#24's special TPN formula. The agency nurse also did not know how to start the portable TPN pump used in order for the resident to attend outside activities. Staff#120 said she could not understand why an agency nurse was assigned, who was not familiar with R#24 and had no orientation on his care. Staff#120 stated the DON made the nursing assignments, and that R#24 was the only one receiving TPN in the facility. 2) On 12/22/17 at 07:25 AM, observed Staff#117 providing a bed bath to R#18. Upon entering through the privacy curtains observed that R#18 was naked on the bed with damp skin and visibly shaking his arms and legs. Staff#117 was removing a tub of water from the bed and queried her whether R#18 was feeling cold. Staff#117 replied, He's always like that, as she stepped away from the bed to get a towel. Staff#117 then covered R#18 with a towel and wiped the resident dry. When Staff#117 removed the towel to dress the resident, his hands were still visibly shaking. Staff#117 covered R#18 with a blanket after dressing him and went to turn on a fan that blew directly onto the resident. Queried Staff#117 why the fan was turned on and she replied that they always leave the fan on for the resident. The room was cool and surveyor and other staff had sweaters on. Staff#117 looked at surveyor, then decided to turn the fan off. After the bed bath, Staff#117 reconnected R#18's gastrostomy tube feeding (TF) and restarted the TF pump. The TF bag was dated 12/21/17; 0600; with 100 ml of formula in the bag. The TF pump was running at 40 ml/hr; volume delivered /dose limit read 736 mls. On 12/22/17 at 07:37 AM, queried Staff#119 about R#18's TF bag and when the formula was poured in. Staff#119 replied she did not know this facility's staff routine, but at other places the TF bags were changed at 12 midnight. The DON was not in and Staff#119 then asked the N[NAME] shift nurse before she went home. The N[NAME] shift nurse did not care for R#18 on her shift and had to ask another N[NAME] shift nurse. Staff#119 then reported that the resident's formula was made and stored in the refrigerator and staff were to follow their feeding schedules and all residents had their TF bags changed at 0600, but sometimes it was done at 0800. On 12/22/17 at 07:49 AM, Staff#119 then went into R#18's room to turn off the feeding pump and stated, Because we don't know. Staff #119 looked at R#18's MAR and found that the N[NAME] shift nurse, Staff#19, administered the TF formula at 0600 on 12/22/17. Staff#119 stated this agency nurse probably used the 12/21/17 feeding bag instead of the new TF bag dated 12/22/17, that was also hanging on the TF pole, when she poured the 0600 TF formula. The N[NAME] nurse used the wrong, outdated TF bag. 3) On 12/21/17 at 11:01 AM, observed Staff#72 administer [MEDICATION NAME] powder to R#16. Staff#72 got a new container of [MEDICATION NAME], used a plastic spoon to get the scooper out, measured out 2 scoops of powder and placed the scooper back into container before closing it. The licensed staff did not know to remove the scooper and keep it out of the container to prevent contamination. 4) On 12/29/17 at 06:59 AM, interviewed Staff#8, an agency nurse, as to why R#16 had missing doses of meds. According to Staff#8, the meds were usually ordered by the charge nurse (CN) II position but currently all nurses were responsible. The med blister packs were delivered by the pharmacy and marked as 1 of 3 (1/3), 2/3, 3/3 (usually 3 blister packs for each med). The nurse who opened the blister pack and marked 3/3 should order a refill from the pharmacy. She said previously it was the CN II's responsibility. Since 12/14/17 all the CN II positions have been vacant, and Staff#91 taught nursing staff how to order meds on 12/13/17. Staff#8 further stated that she received her nursing orientation on 10/29/17, and had experience in GT [MEDICAL CONDITION] but not vents. 5) During the course of the recertification survey, interviews were conducted with staff, administration and family members. Various individuals approached and asked this surveyor to speak with them on matters and concerns that were related to resident care in the facility: 5a) On 12/19/17 at 08:30 AM, interviewed staff #33 who stated, All the RNs are agency except for one RN. Last night there were only two nurses. They mandated the three aides yesterday to stay. They always mandate. Last night one nurse from Kulana stayed back again because they were short .We work 12 hours, then we are mandated. Nowadays, people just pass when the call light goes on. I don't know what is going on. I've been here ten years and this is the worst that it has ever been. 5b) On 12/20/2017 at 10:30 AM, interviewed staff #118 who stated, We have lost a lot of caring and conscientious nurses and aides too. Within the past year, the majority of people left because of management on the nursing side. We don't have any charge nurses anymore. We don't have a code nurse. If we have a code, the agency nurse may not be able to help, especially at night time .The patient workload for the nurses - alarms would be going off all the time. The nurses are going, going, going and no lunch. The nurses paid time off (PTO's) got denied and so they couldn't take any time off. My main concern is the safety. The norm is seven nurses. I know at one point, getting agency nurses increased our medical errors. 5c) On 12/19/17 at 11:25 AM, interviewed staff #20 who stated regarding her workload, four (residents) is good. If anything else, I have to do like urinary tests, etc., then it becomes challenging. She stated, I have seven residents--these four and two kids in the other room. 5d) On 12/20/17 at 09:20 AM, interviewed staff #39 who stated, We are supposed to be five RNs and five CNAs. If you go below 25, the aides can go to four. Staff #66 is working on the floor today to make the five and assumes charge roles. This was confirmed on the nursing daily assignment sheet as well. 5e) On 12/20/17 R#25's family member (FM) requested to speak to this surveyor. Resident #25's FM stated, I am worried about (R#25's) safety. I went by chain of command and I went up to the RNs and stated some of the issues. For example, they repeatedly will take the blood pressure on the same side of (R#25's) arm and not with just one person but others. They would leave her and others' bed rails down. If it's left down and they are doing other things, like turning around, she could fall because she is fast .I came every day, every night and every evening because they are short staffed and I'm worried. How do I know if she fell , how do I know if I'm not here? She holds onto me when somebody not good. She cries when someone is mistreating her. They are short staffed. Every night they are short staffed. When I need help, there is no charge nurse. I have to stand around and look for someone. A lot of times, the roommate'[MEDICAL CONDITION] is off and the other families don't come and these kids cannot call for themselves. (R#25) has butt rash because of neglect and she has had dodo (poop) in her diaper that needs to be cleaned. Why did all these nurses leave here? The RNs here are doing a lot. Two nights ago, I asked the nurse to help clean my daughter up but she said she could not because she had ten patients and we are short staffed. Later on, someone told her to do it. I brought it to the director of nursing and administrator but they said 'there are changes and there have been bad apples'. I brought it to the owner and he told me that staffing when they leave because they have more experience and they move on but others stay because they live close by. I asked him how come he cannot hold on to the oldies and the newbies. People are rushing to get things done here .My main concern is that they lack safety protocol, and management training. I feel if I vocalize, I feel there will be retaliation. I feel like they know because the way they look at me and the way communication has changed. They don't wash their hands and come and take care of my daughter. I talked to the administrator and asked to talk with the doctor and she said I cannot talk with the doctor and she said to talk with the director of nursing because she has all the answers. The last time I talked to him when he told me that she is losing weight and it is good for her body--it was September. 5f) On 12/20/17 at 01:49 PM, observation was made at the nursing station where a monitor at the nursing station displays oxygen saturation and pulse. It was observed that the alarms were sounding for 20 minutes and this surveyor did not see any nurse, management or ward clerk address this. Queried Staff #32 regarding who looked at the alarms and she stated, I do or any immediate nurse or I go to the director of nursing. Queried Staff #110 who stated, I am not trained for the monitors, mostly the CNAs and nurses. If it's red, I call somebody for a sound. There is no unit clerk at night and at night we don't have a charge nurse. The charge nurse would usually help everyone here and monitor the screen too. But, not enough nurses, mostly agencies .Worked here almost 8 years. Sometimes I help them answer the call light and there's no one to answer because they don't have enough staff. When there is a delivery, I go to the back too. Observation on 12/20/17 at 03:00 PM revealed a red alarm with a heart rate that went down to 39 beats per minute and an oxygen saturation level of 91%. Staff #32 was sitting at the nurses station and did not show an urgency for a red alarm. 5g) On 12/21/17 at 07:50 AM, interviewed staff #34. She said, Because of what is going on, I decided to work the minimum. I feel that with the whole staffing issues, my license is on the line. Last night was four staff, me and the other nurse--had a total of 9 patients. There was no charge nurse and the last charge nurse left. The night shift, we don't have support for anyone to come in if one of us is sick. If there was a storm to come, I don't know where the back up generator is. I know that the management is back up but I don't feel that they are there for us. I feel like the patient safety and care is being compromised. For instance, repositioning, especially when the aides are short and changing them when they (residents) are soiled.[MEDICAL CONDITION] and catheter care is compromised. There are times when we were short and the management has said not to do [MEDICAL CONDITION] .With the new agency staff coming in, they don't know the patients like we do and the agency nurse actually passed one of her narcotics which was scheduled for 10:00 P.M. at midnight (two hours late). Because there is no charge nurse, there is no one to oversee. With the agency nurses, their expectations are probably higher than what it actually is. For instance, the agency nurse did a straight cath into the chucks. The agency nurses are asking their aide's to do the work instead of them doing it. There are a lot of med passes. If there is a med pass error, who is accountable for it? For example missing the dose or doubling the dose and this happens mainly because we are short staffed. 5h) On 12/22/17 at 07:45 AM, interviewed Staff #120 who stated, I have worked here for four years. The other night, there were only two nurses. I was supposed to get off at 7:30 PM and I stayed to 11:30 PM. I was mandated. Two nurses were new and I was the third person. I stayed to do care and pass meds. We only had three nurses for 25 from 11:30 pm to 7:00 am. There was only two for 25 and I don't think the agency carried a load. It's been like this for one year, staffing has been an issue. Easter there was just two. We told management we cannot accept this. Management told us that we can accept the assignment or we can leave but suffer consequences. Management said to focus on the care, airway, meds, feeding. Although we have a respiratory therapist, suctioning gets pushed to the side. The things that would not get done is [MEDICAL CONDITION], [DEVICE] care and urinary catheter care. I am able to get my care done but I am rushed. The agency nurses are not able to get everything done or they don't know how to do it. The charge nurses were slowly leaving and they weren't replaced. I put my name down and I never got trained. I'm leaving because it is too unsafe and I may come in and I may have the whole building to myself. Last night, there were four of us, then one nurse was sick and she went home. That left us with three nurse. There is two of us that have nine patients and the other one has seven. 5i) Interview with Staff #88 on 12/29/17 at 08:36 AM revealed that, The family had asked staff to take R#14 out on shower days and there were six aides and they didn't bring her out. Staff #88 stated that it's because we have agency aides and they don't bring the adult residents out of their rooms. Cross-reference to findings at F656. 5j) The SA also confirmed the RN staffing based on these interviews to the nursing daily assignment sheets from 12/20/17 and found it to be accurate to what the staff were reporting. Although the 12/18/17 staffing assignment was requested by a surveyor, it was not produced. However, Staff #66 affirmed during an interview on 12/22/17 that, we are still having problems with staffing and she worked that night shift when they only had 2 RNs for their 25 residents. 6) During the observation of Res #1 on 12/21/17 at 9:12 AM, Staff #98 stated the nurse aides usually are assigned to care for five residents each. Only when we get 7 or 9, it's very hard. Yesterday we had 7 each, because 1 CNA called out. Since recent, because people leave, we're getting help from agency, but we have a lot of staff turnover. You just feel overburdened and and tired, and can't take your break on time and extra exhausted and then they (administration) will mandate you, like when they only have 3 CNAs at night. They mandate you to stay until 11:30 PM if they are short on night CNAs. And then when you are working 12 hours, you feel so exhausted already and have to work extra. Yes, I feel that way. I will tell my charge nurse--but now we don't no more (have a charge nurse). Now I have to call (DON) to talk to her. I think the first time I was mandated, I told her I worked 2 days straight and mandated to stay over and then working the next day, so for me to work I'm not going to be able to focus and they should get somebody else. She said they are currently using 2 or 3 agency CNAs at this time as well and she is training Staff #15. 7) Interview with Staff #82 on 12/22/17 at 12:39 PM confirmed their nurse staffing had been affected by a large number of staff who resigned within the past several months. On 12/27/17, Staff #82 also produced the first printout of their payroll based journal (PBJ). She acknowledged the difference of 3,575.75 staff hours from the previous quarter ending 9/30/17 compared to the one ending 12/27/17. Cross-reference to findings at F838 and F851. 8) On 12/22/17 at 8:16 AM, interview of Staff #34 was done. Staff #34 said a couple of months ago, the nurse staffing ratio to resident care was either 7, 8 or 9 residents to a nurse, and the census was more than 25. Staff #34 believed due to poor care, some residents had to be sent to the hospital such as Res #28. With the current census at 25, Staff #34 did not feel like the residents were receiving the proper care they deserved such as checking the residents hourly, especially when they are hypotensive and bradycardic. Staff #34 said the respiratory therapists (RTs) come in at 10:00 AM and they do the ventilator checks every 4 hours. The new nurses and the agency nurses don't know what to do about the vent settings, and you have to check it on the log. Some of the new hires are more task oriented, so they surpass that because 'it's the RTs job', but it's not the RTs job. I feel the CNAs should have vent competency too, but it hasn't been scheduled by the DON. For medication administration, Staff #34 said she was trained by two nurses no longer at the facility. She was taught to put two tablets into separate medication cups to crush. Staff #34 said the water flushes for the medications were only given before and after the administration. She said, No annual competency check that I know of. Staff #34 said the agency nurses were trained on 3 night shifts and 3 day shifts. The recent ones have experience, but the first ones, like (Staff #16), had no experience. 9) On 12/22/17 at 8:50 AM, interview of Staff #119 was done. Staff #119 said she told Staff #66 of the medication (med) errors that there were a lot of them, this is a lot of errors. so the ones making errors, they had to re-read. Staff #119 stated the med errors had to do with a dot system and symbols. If the nurse put a med into a med cup, they would put a dot on it. But she said some would give it, or they would forget, or they gave a double dose, and they don't count how much meds. Staff #119 said, old nurses say its the new ones doing this, but something is wrong with the system. They're not doing it right, they sign the MARs (Medication Administration Record) late, and they making their own symbols. Staff #119 said the orientation for new nurses is 3 days of training. Staff #119 stated she recognized the procrastination in every area. For the medication errors, she told the administration they will have to answer to it because they were not keeping track of it. She also said the night shift staffing on 12/21/17--everyone called in sick and I told (DON) if you don't have a staff member coming in, then you have to come. You're getting rid of these people but you also gotta train them. Staff #119 further confirmed the nurses were not having their skills competency checked with their orientation. 10) On 12/22/17 at 10:10 AM, interview of Staff #65 was done. Staff #65 stated it has been escalating to the point where he has asked the night shift RTs to do their first rounds at 10 pm by checking airway clearance, do assessments and complete any night treatments. By morning, we prepare the children for school and told them (RTs) to mainly concentrate on if these residents are being suctioned--that's the most important thing, because if they let them settle into their secretions, you don't want it to settle into their lungs. Staff #65 was asked about the licensed nurse's role in conjunction with the respiratory therapists. He replied, It's more frequent with the agency nurses. The therapists asked me about it too, and we're not picking on them, but they seem to be overwhelmed with their work and they think that tracheal suctioning is like second priority. We notice they seem to be overwhelmed with passing meds. Staff #65 stated as a result, the nurses will rely on the RTs to suction because they are behind on passing medications. Staff #65 was asked who did the ventilator training competencies, and replied, The turnover has been so fast and furious we cannot keep up with who has done it and who didn't do it yet. I approached (DON) about vent competency and to give me an hour or so, but she can't even pull them off the floors. I don't think the agency is done because I don't remember doing any of them. When they (new hires) first come on, we do the suctioning with them, and if find they're not doing it competently, like there's tracheal bleeding due to trauma, we identify that nurse who shouldn't be doing it until we do their competency again and we deem them competent. Staff #65 stated as for the health and safety of the residents at this time, it's like something is going to happen--I hope not, but it's just when. You cannot depend on luck. 11) On 12/22/17 at 3:35 PM, interview of Staff #72 was done. She stated they were all hired on as a charge nurse. She said she was not trained as a charge nurse however, and questioned how could fulfill this duty if they were not trained for it. Staff #72 said, We're always short (staffed). I did Tuesday night, 7pm to 7am, but didn't leave then. She stated because they are constantly short of staff, they are mandated to stay. She had seven residents to care for during her day shift today including orienting a new nurse. So you just juggle, and our load is normally like 7 or 8 (residents) and when they hire, they tell you it's 6. The DON has ultimately the end say. It's just frustrating. We haven't had a monthly nursing meeting forever, and now two more long term staff are leaving. She stated she did not know where their current nursing policies and procedures were but that another agency nurse had asked her about it as well. Staff #72 said, for tonight's shift, one scheduled RN called in sick, so the 7-7 (night shift) will only have 3 RNs. They're probably going to mandate one of us to stay back or the DON will have to.",2020-09-01
864,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,726,L,0,1,K7B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews and review of the facility's policies and procedures, the facility failed to ensure there was sufficient nursing staff with the specific competencies and skill sets necessary to safely care for each residents' needs, as identified through resident assessments, and described in the plan of care. It was found there was an insufficient number of licensed staff with a lack of competency training required to provide adequate and safe nursing care for the capacity of residents who were all ventilatory dependent and required total care by staff. As a result, an immediate jeopardy (IJ) was identified as the potential for serious harm to occur for all their residents existed. Findings include: Cross reference to findings at F550, F645, F656, F657, F725, F759, F760, F835, F837, F841. 1) On 12/22/17 at 10:10 AM, Staff #65 stated for the ventilator competency training, it has been difficult to track which staff completed their training due to the rapid turnover of staff. Staff #65 stated he did not think the all of the current nursing staff had completed the ventilator competency training. He was uncertain if Staff #66 had initiated any of the same training but if so, he was unaware of it. 2) During an interview with Staff #119 on 12/22/17, she verified the nursing staff was not being competently trained. The SA found evidence of this by a) a 92% medication error rate found during their medication review task, b) incomplete documentation and monitoring without corrective measures of the facility's high rate of medication errors/omissions, c) missing documentation of ventilator competencies of 8 regular licensed staff and an unknown number of the agency staff without ventilatory competencies and d) missing documentation of the staff's annual [MEDICAL CONDITION] suctioning competencies. Staff #119 confirmed she told Staff #66 and Staff #82 about these issues since she knew she needed to complete her competencies for the nursing IVs by (MONTH) (YEAR), but had been unable to do so. Staff #119 stated the systemic problem in this facility in every area has been procrastination. Staff #119 also verified for the medication error tracking, Staff #91 developed the handwritten notes given to the SA on 12/22/17 two days ago. She said they have not been tracking nor monitoring it, although the MAR and their medication error reports showed there were many errors. The SA's initial attempt to reconcile Staff #91's report found a discrepancy between Staff #91's count and the SA's (more were found). On 12/22/17, Staff #82 stated she would have it re-done by Staff #91. However, by 12/28/17, Staff #66 was asked by Staff #82 to re-do it, instead of Staff #91. Staff #66 initially said from (MONTH) to (MONTH) of (YEAR), there was no tracking for the medication errors/events. Staff #66 produced a (YEAR) Medication Event Report Summary, and it revealed a trend of missed doses, improper med administration, etc. For the month of (MONTH) (YEAR) alone, there were 29 extra doses or overdoses administered by licensed staff as well as 5 missed doses. In addition, record review found extra, unaccounted missed doses of an antibiotic in (MONTH) (YEAR) for Res #28, as well as one extra dose given to Res #21 (i.e., given 25 milligrams of Dantrolene instead of 12.5 mg) in the facility's event report. This was verified by Staff #82 on 12/28/17 at 4:35 PM. Staff #82 stated Staff #66 was not trained to track these things and the medication errors were more than what was documented on the summary reports given to the S[NAME] 3) On 12/22/17 at 3:25 PM, interview with Staff #18 was done. She stated as an agency nurse, her skills were checked through the facility's recruiting agency. She had 3-4 days of floor orientation once employed at this facility with a verbal review of their policies. She did not recall having a written skills competency checklist as part of her orientation and signing off on it. She also said she did not know where to access the facility's current policies and procedures, but they're probably in one of the binders. Staff #18 said, I wish we had a charge nurse, after she asked Staff #72 about what to do with the ordered labs. 4) As part of the identified IJ, and during a 12/22/17 meeting at 12:39 PM with Staff #82, #119, #65 and #66, it was revealed the ventilator training was not being done. Staff #119 also queried to everyone, Can we learn these vents in one hour? Staff #82 agreed they would have to provide training and said, we have to deem them (their staff) competent. Part of the IJ abatement plan accepted by the SA on 12/22/17 at 7:00 PM was to ensure starting on 12/22/17, that all staff's competencies were reviewed and would include: 1) tracheal suctioning for the licensed nurses, respiratory therapists, nursing CNAs and activity CNAs, 2) [DEVICE] flushing for the licensed nurses and CNAs, 3) medication administration for [DEVICE] and J-tube for licensed nurses only and 4) ventilatory use for licensed nurses, respiratory therapists, nursing CNAs and Activity CNAs. As a result, the facility provided various skills documentation checklists as part of their initial plan to ensure all their staff were going to be deemed competent in their scope of work. 5) On 12/28/17 at 8:57 AM, Staff #119 verified a physician's orders [REDACTED].#119 was further asked what nursing standards of practice were used at this facility and she said, I actually don't know. I read some of their policies, but they're kinda old. We followed the policies from (pharmacy). Staff #119 also said for the use of the Bair Hugger, the licensed nurses were to apply it and not the CNAs. She said the CNAs however, are doing it and for one resident, once applied, they have to take a temp every 15 minutes, otherwise they can heat up. For Res #1, record review found when the Bair Hugger was applied, there was no order as to the frequency of monitoring his temperature and his (MONTH) vital signs log sheet showed his temperatures were only recorded hourly, yet, missing documentation of when the Bair Hugger was applied or not. Staff #119 confirmed there was no policy for the staff to follow regarding the application of the Bair Hugger. The facility failed to ensure all of their staff were competently trained in their respective disciplines of practice.",2020-09-01
865,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,759,L,0,1,K7B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews and review of the facility's policy and procedure, the facility failed to ensure the facility's medication error rates are not 5 percent or greater for 4 of 16 residents (Residents #25, #14, #16, and #23 ) in the survey sample. In addition, the facility's practice of medication administration was not based on current standards of practice as evidenced by the actions observed of the licensed staff and others who were interviewed. As a result, there existed a high potential for harm to the health and safety of all their residents and an immediate jeopardy (IJ) was identified on 12/22/17. Findings includes: Cross-reference to findings at F725, F726, F760, F835, F837, F841. 1) On 12/21/17 at 09:28 AM, surveyor observed Staff#109 administering medications (meds) via R#25's gastrostomy tube (GT). Staff#109 opened the [MEDICATION NAME] capsule and mixed it with distilled water, used a 1 ml (milliliter) syringe for the multi-vitamins, a syringe of 0.3 ml [MEDICATION NAME], and syringe of 2.5 ml [MEDICATION NAME]. Staff #109 stated that for R#25, she used 5 ml of distilled water before and after her med administration. After administering each syringe of med one after the other via the GT, Staff#109 flushed the resident's GT with 5 ml distilled water at the end. Staff#109 stated that she had her nursing education and training in California and was taught to flush between meds when administering via the GT. When Staff #109 was hired at this facility however, she was told the facility protocol was to just flush before and after med administration. On 12/21/17 at 09:02 AM, the MRR for R# 25 noted on the (MONTH) (YEAR) physician order [REDACTED]. 2) A medication pass observation of Staff #20 on 12/20/17 at 9:28 [NAME]M. for R#14 revealed the following meds administered via the [DEVICE]: 1) Multi-vitamin tab, 1 tab. 2) Potassium 15 ml (20 MEQ) poured. 3) Senna 8.6 mg tab, 2 tabs. 4) [MEDICATION NAME] Immunity caps, 1 cap. 5) [MEDICATION NAME] 20 mg tab, 1 tab. 6) Fludrocortisone 0.1 mg tab, 1.5 tabs. 7) Levetiracetam 100 mg/ml solution, [MEDICATION NAME] 7.5 ml (750 mg) poured. The liquid meds were poured together into a 60 ml syringe in which they were administered via [DEVICE] and mixed with 30 ml of water, pushed in by a syringe. The medication tabs as above, multi-vitamin, Senna, [MEDICATION NAME] and Fludrocortisone were all crushed in a baggie and placed in a 30 ml cup, then poured into a 60 ml syringe. Staff #20 stated that physician orders [REDACTED]. 3) On 12/22/17 at 9:35 AM, a medication pass observation was done for R#16. Staff #20 administered the following medications to her: 1) Dantrolene 25 mg cap, 1 cap. 2) [MEDICATION NAME] 20 mg tab, 1 tab. 3) Multi-vitamin tabs, 1 tab. 4) Polyeth Glyco Powder 3350 NF, 1 capsule (17 gms). The nurse stated, Now I am going to crush meds and place it into the same cup with other meds. I like to pour it into one cup. Meds were poured into a 60 ml syringe and pushed through the [DEVICE] with no flushes in between. The physician orders [REDACTED].#16 were: 1) After tube feedings: 185 ml distilled water. 2) Before tube medications: [REDACTED] 3) After tube medications: [REDACTED] There were no orders for the crushing or mixing of these medications. 4) On 12/21/17 at 9:39 AM, Staff #12 was observed during the medication administration for Res #23. Staff #12 was observed to open and place the capsule contents of [MEDICATION NAME] 50 mg in a medication cup and added the [MEDICATION NAME] to it. He then drew up 10 ml of [MEDICATION NAME] Sodium into a syringe and left it on the side. In another medication cup, Staff #12 added the following medications into it: Atorvastatin 10 mg tablet, [MEDICATION NAME] 1000 mg tablet, [MEDICATION NAME] HCL 5 mg 1 tablet, Multivitamin 1 tab, Senna 8.6 mg 1 tablet and Vitamin C 500 mg 1 tablet, crushing all these medications together. He then added it into the med cup with the [MEDICATION NAME] and [MEDICATION NAME] to equal one med cup containing all the medications mixed together. Then he added the contents of the [MEDICATION NAME] 20 mg packet into a small plastic solo cup, added 15 ml of water and stirred it. Staff #12 also had cranberry juice to give the resident. At 9:51 AM, Staff #12 then added 5 mls of distilled water into one 10 ml syringe after removing the plunger, added half of the crushed medications into it, added more water and then replaced the plunger before shaking the syringe to mix the contents. He repeated the same method by taking another 10 ml syringe and added the rest of the crushed medications into it. At the end, Staff #12 had two 10 ml syringes, both with contents of a brownish color and pointed out that one syringe had 10 mls and the other measured 8.5 mls because he added a little more water to it. He then placed the syringes in a plastic cup to take to the bedside. The CNAs were providing care at the time, so the medication administration to the resident occurred at 10:06 AM. Staff #12 drew up the preflush of 60 mls of distilled water and administered it via Res #23's [DEVICE]. The first medication he administered thereafter was the [MEDICATION NAME], then the first syringe with the mixed medications, the second syringe of medications and last, the [MEDICATION NAME] drawn up in a separate syringe. After the [MEDICATION NAME], Staff #12 flushed it with an additional 15 ml of water. Next, Staff #12 opened the cranberry juice, drew up 30 mls and administered it to the resident via the [DEVICE]. Staff #12 then flushed the [DEVICE] with 60 ml of water. During the medication administration, Staff #12 was observed to only flush before and after the medications were administered via the [DEVICE] and after the [MEDICATION NAME] as per the physician's orders [REDACTED]. The licensed staff who were observed during medication administration was found to crush all medications together and administer them via the residents' gastrostomy tubes ([DEVICE]s) after mixing the crushed medications with distilled water in random amounts using syringes. As the medication pills/tablets were all crushed and mixed together, the water flushes between each medication did not occur, even when interspersed with the liquid medications (or juice) that was given. The only water flushes given were before and after the medications were administered. There also were no orders to crush medications. The SA's calculated total medication error rate was found to be 92%. The SA team had a combined total of 25 medication administration observations or opportunities for errors and 23 medication errors identified based on the facility having 1) no orders to crush the medications, 2) the licensed staff were crushing and combining the crushed meds to administer in syringes with random amounts of distilled water to mix it with, 3) crushed medications as well as liquid medications (i.e., [MEDICATION NAME]), and administered one after the other without any flushing between each medication, and 4) there was no current clinical standard of practice for the staff to follow as the facility's nursing policy and procedure, [DEVICE]/Pe[DEVICE] Feeding/Medications referenced 1996 clinical standards of practice. Staff #66 confirmed on 12/27/17 at 3:30 PM that the last time they reviewed their policy was in 2012. 5) On 12/27/17 at 1:40 PM, during an interview with Staff #66, she stated for medication errors, the general is to aim for less than 5%. Given the SA's observations and the identification of the IJ on 12/22/17, she stated she started off by tracking the medication errors but at some point, started to get behind. She also attributed to the fact that staff were not completing their forms correctly. She said, I do recognize that the med errors are happening and since (Staff #119) has joined us, she's happening to tackle all that too, maybe the way we do our MARs. We did recognize this is happening, and we have a lot of new faces. Staff #66 acknowledged she has not been keeping up with the log. The SA had to wait for Staff #66 to compose the medication error summary sheet as there was none except for the handwritten one produced on 12/22/17. Staff #66 stated no one taught her about QAPI either and she replied, No, when queried if there was anything she could show as to what changes she has made, identified or captured. On 12/28/17 at 3:56 PM, Staff #66 brought in a revised medication event report summary and said she was told by Staff #82 to put the tracking log together for (MONTH) to (MONTH) (YEAR). Of note, Staff #66 initially stated there was no tracking for (MONTH) through (MONTH) (YEAR). When the SA queried what Staff #66 was tracking, she identified the number of event reports instead of the actual number of medication errors. Staff #66 stated she did not know what the SA was asking for and then stated she could re-do it. Staff #66 however, failed to identify the trends and the actual number of medication errors as the critical components to be monitoring and improving. 6) On 12/28/17 at 5:00 PM, Staff #82 affirmed they had to find a new tracking system and more training for Staff #66 to track the medication errors. Staff #82 also acknowledged the reports were only being developed once the SA began asking for them from the beginning of the survey and recognized there was no system in place as the SA found it was being developed during the survey.",2020-09-01
866,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,760,L,0,1,K7B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews and review of the facility's policy and procedure, the facility failed to ensure that its residents are free of any significant medication errors for 4 of 16 residents (Residents #25, #14, #16, and #23 ) in the survey sample. As a result, there was a failure to protect from potential adverse medication consequences, a failure to have concise physician's orders [REDACTED]. In addition, it was found there were insufficient numbers of licensed staff who lacked the training for medication administration to adequately provide safe, competent nursing care for these residents who were all ventilatory dependent and required total care by staff. Further, the facility's practice of medication administration was not based on current standards of practice as evidenced by the actions observed of the licensed staff and others who were interviewed. As a result, there existed a high potential for harm to the health and safety of all their residents and an immediate jeopardy (IJ) was identified on [DATE]. Findings includes: Cross-reference to findings at F725, F726, F759, F835, F837, F841. 1) On [DATE] at 12:39 PM, the SA met with Staff #82, #66, #65 and #119. The facility staff was informed of the IJ based on the SA's medication error rate at 92%. Staff #119 stated she recognized the flushing of the medications was an issue, and it was not being done when the nurses were passing their medications to the residents. Staff #119 said this is the standard protocol to follow but that their previous medical director did not think it was necessary. She stated the administrative staff were all aware of this practice of not flushing between medications and it has been taught this way. Staff #119 concurred the standard of practice was to also ensure crushed medications administered via the [DEVICE] were not to be given all mixed together. The SA observed during the medication administration observation of various licensed staff that they were also drawing up random amounts of distilled water to dilute the combined medications. There were no resident specific orders to crush all the medications, nor orders to mix all the medications together, nor how much water to mix or dilute the medications with, and/or what the specific flush amounts were between the medications. The facility had 20 pediatric residents and 5 adult residents, however, there were no specific, individualized orders based on each resident's medical history and condition. 2) During an interview with the consultant pharmacist on [DATE] at 9:29 AM, she said they mostly have residents on fluid restriction in this facility. She was asked whether she observed the nurses performing medication administration at this facility, and she said no. Thus, when she was informed by the SA how the nurses were observed randomly drawing up free amounts of distilled water to dilute all of their crushed medications together, that if their residents were on fluid restriction, it would make it worse (fluid overload with no parameters). She then stated, we will need to tighten it up. The consultant pharmacist also said her recommendation was to get a physician's orders [REDACTED]. She said it was to be available in (MONTH) and thought they would have a policy in time. She acknowledged their policies and procedures were yet to be revised although she was aware of the Phase 2 implementation of the federal regulations for long term care facilities. 3) Staff #82 verified the policies and procedures had not been reviewed/revised by the end of the extended survey. Staff #82 stated, No, in all honesty, no, as her response. She had been discussing it with their interim medical director and re-did the abuse type policy as well as creating a binder for the administrative policies. She confirmed the facility's existing policies and procedures have not been reviewed/revised for a long time. (Staff #66 had confirmed it was last done in 2012). Staff #82 also stated there was a loss of their regular licensed staff with the largest exit of staff starting around ,[DATE] weeks ago. She said these were the nurses who were at the facility ,[DATE] years, and currently, there was almost no licensed staff with this many years of experience. She also stated their facility assessment is going to the QA committee. 4) The facility's IJ abatement plan was accepted on [DATE] at 7:00 PM. It included the facility's corrective measures for 1) medication administration which a review of their current policy and procedure and and all resident orders to be reviewed. This included immediate training/orientation starting with shift huddles on the evening of [DATE]. The plan included the crushing of individual pills to mix with 5 ml of distilled water to dissolve it, flushing the [DEVICE] and/or J-tube with 5 ml of distilled water before giving the med, followed with a 1 ml flush of distilled water between each medication, unless ordered differently, and after giving the medication to follow with 5 ml of distilled water flush. It also included staff competency reviews at the start of each shift to ensure all staff were signed off for [DEVICE] flushing (licensed nurses and CNAs) and medication administration for [DEVICE] and J-tube (licensed staff only). It was revealed during the observations and interviews of many staff, that licensed staff were learning how to administer medications based on who previously taught them, and were not following clear physician/NP orders or have updated and current policies and procedures to follow. 5) On [DATE] at 11:01 AM, observed Staff#72 administer [MEDICATION NAME] powder to R#16. Staff#72 then crushed a multi-vitamin tab and mixed it with distilled water to administer through R#16's gastrostomy tube (GT). Staff#72 then mentioned the medication for R#16's [DIAGNOSES REDACTED] was not given at 1000 because it was not available. In addition, on the medication administration record (MAR), the resident had Dantrolene 25 mg cap, take 1 cap per GT 4 times daily (0500; 1000; 1700; 2200) DX: [DIAGNOSES REDACTED]. However, according to Staff#72 the med was last given by the N[NAME] shift nurse at 0500 and that the order from the pharmacy was not in yet. Staff #72 failed to administer this routine dose. Staff#72 stated that R#16 received 30 mls of distilled water flush through her GT before and after med administration. Staff#72 said she received her nursing education and training at a Hawaii university and was taught to flush between meds but was told this facility's protocol was to flush before and after all meds were administered. On [DATE] at 06:59 AM, based on review of R#16's MAR and documentation for Dantrolene 25 mg caps per GT 4 times daily (DX: [DIAGNOSES REDACTED]); it was found the med was not given at 1000 on [DATE], but also at 1700 with not available, written in the date/time blocks. 6) On [DATE] at 02:43 PM, observed Staff#72 administer meds to R#2. The resident had just returned to the facility from school. The resident's mouth was full of secretions with drool dripping from both sides of his mouth. Staff#72 stated that a portable suction was brought to school with R#2, and a school nurse rides home in the bus with the resident. Staff#72 did not know why school nurse did not suction R#2 as needed. Staff#72 then administered meds for R#2's secretion management. Staff#72 stated she was giving the resident his 1100 dosage of [MEDICATION NAME] 1 mg tabs 2.5 tab (2.5 mgs) per GT, because the school nurse won't administer the med at school via his GT. Thus, it was only on weekends and holidays which R#2 received the 1100 dose of glycopryrrolate at the facility. On [DATE] at 02:23 PM, the MRR on R#2 found noted on a physician order [REDACTED].#30; Hold [MEDICATION NAME] 40 mg doses until medication comes in from pharmacy. The (MONTH) ,[DATE], (YEAR) MAR documented First [MEDICATION NAME] 2mg/ml had missed doses written on the date/time blocks for: ,[DATE] at 1700; ,[DATE] at 0500 & 1700; and ,[DATE] at 0500. The PO dated [DATE], included: First [MEDICATION NAME] 2mg/ml; take 20 ml (40 mg) per [DEVICE] twice daily (DX: [MEDICAL CONDITION], recurrent GI bleeding) [DATE]; and [MEDICATION NAME] 1 mg tabs 2.5 tab (2.5 mgs) per G - tube 4 times daily (DX: secretions management); 0500; 1100, 1700, 2300. Yet, on a [DATE] Medication Event Report it was noted, ,[DATE]-,[DATE] (0500); Medication [MEDICATION NAME]; Explanation of what happened: Medication was noted to be expired [DATE], medication was still given while expired. Describe effect/adverse reactions as a result of incident: No adverse effects to patient. Staff nurse notified Staff#30 and TORB given to hold until medication comes in from pharmacy. 7) On [DATE] at 10:34 AM, a closed MRR was done for R#28 who was discharged from the facility on [DATE]. The resident was emergently discharged on [DATE] due to a sudden change in status, and noted by nursing staff to be unresponsive, hypotensive and with [MEDICAL CONDITION]. The discharge summary dated [DATE] gave the reason for discharge as, acute decompensation; [MEDICAL CONDITION] and unresponsive. On the facility's form, Events During ___Stay, there was documentation on: [DATE] continued abscess + [MEDICAL CONDITION] - Therapy Results: PICC line 4 Fr. (hospital); Meropenum 1 g IV q 8 x 14 days; Pus culture ,[DATE]: no growth - ,[DATE]: extend Meropenem add'l 6 days; [DATE] neck Abscesses [MEDICAL CONDITION] L submandibular Therapy Results: Linezolid for abscesses + [MEDICAL CONDITION]; cult of serosang drainage+ . On [DATE] 2025 a shift note (,[DATE]) documented .Trach stoma pink moist with open abscess to L side above trach, [MEDICATION NAME] cream applied as ordered. Neckline intact .New orders: Start Linezolid 600 mg tab per [DEVICE] BID x 6 months. Orders documented & carried out . Upon further review of R#28's medical record, it was noted on a physician order [REDACTED]. Skip the doses for ,[DATE] (1000 & 2220), ,[DATE] (1000). Resume Linezolid ,[DATE] at 2200; Signature of Physician: former medical director ; Date: [DATE]. Linezolid is an antibiotic and was originally prescribed to be given twice daily for six months. The facility's practice was to discontinue medications when they were not available and the quality assurance oversight for nursing and pharmacy services failed to track and monitor this, including the concomittant rates/trends of medication errors.",2020-09-01
867,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,835,F,0,1,K7B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews and review of the facility's policies and procedures, the facility failed to be administered in a manner such for it to use its resources effectively and efficiently to ensure each resident is able to attain or maintain their highest practicable physical, mental and psychosocial well-being. Finding includes: The cumulative findings of this survey, including the IJ and other cited deficiencies revealed that Staff #82 was aware of and ackowledged the systemic problems found during the survey. For one, the facility assessment was incomplete and Staff #82 stated on 12/22/17, it was going to their QA (quality assurance and performance improvement committee). However, she verified their QA committee has not met since (MONTH) (YEAR). Yet, there were no emergency QA meetings noted, despite the fact their staffing patterns had changed, they lost their medical director, and that Staff #82 had to recruit a large number of agency nurses, most without deemed competency skills training revealed in this survey, in order for the facility to operate/care for all of its [MEDICAL CONDITION]/ventilatory dependent residents. During the interview with Staff #119 on 12/22/17, she stated that Staff #82 and Staff #66 were aware of these problems but nothing was being done about it. Staff #119 stated she was asked to help Staff #66 learn the role of being the director of nursing (DON), although she has been a DON now for two years. Staff #119 also stated due to a lot of internal dissension with the former medical director and administrative staff, the outcome has been this procrastination and a loss of approximately 10-14 nurses leaving the facility in the past four to six weeks. On 12/28/17 at 3:56 PM, Staff #66 brought in a revised medication event report summary and said she was told by Staff 82 to put the tracking log together for (MONTH) to (MONTH) (YEAR). Although earlier she stated there was no tracking for (MONTH) through May, she put together a report which included the entire year. Staff #66 verified that when she was asked about the medication errors identified on the report, she identified the number of event reports instead of the actual number of medication errors, although the number of errors were the critical values to focus on. On 12/28/17 at 5:00 PM, Staff #82 affirmed they had to find a new tracking system and more training for Staff #66 to track the medication errors. Staff #82 also acknowledged the reports were only being developed once the SA began asking for them from the beginning of the survey and recognized there was no system in place. Staff #82 verified the policies and procedures had not been reviewed/revised by the end of the extended survey. Staff #82 stated, No, in all honesty, no, as her response. She had been discussing it with their interim medical director and re-did the abuse type policy as well as creating a binder for the administrative policies. She confirmed the facility's existing policies and procedures have not been reviewed/revised for a long time. (Staff #66 had confirmed it was last done in 2012). Staff #82 also stated there was a loss of their regular licensed staff with the largest exit of staff starting around 4-6 weeks ago. She said these were the nurses who were at the facility 7-9 years, and currently, there was almost no licensed staff with this many years of experience. She also stated their facility assessment is going to the QA committee. On 12/28/17 at 12:31 PM, the initial payroll based jounal (PBJ) was given to the S[NAME] During this interview with Staff #82, she stated acknowledged that based on the PBJ and the difference in staffing numbers, that this was a trend occurring from (MONTH) (YEAR). Although aware of this, Staff #82 did not produce documentation of how this was being addressed with the governing body or with Q[NAME] Staff #82 also discussed the medication errors as reflected on their summary report compiled by Staff #66. Staff #82 said initially, people were saying it was the agency nurses with the medication errors and aware that double doses were being given. She said her goal was to get Staff #66 and Staff #119 to work together to develop their programs. She said they need to implement a system to make sure the errors were going down. She acknowledged they did not have the last QA meetings and said she was feeling upset as to why the medication errors were not completely accounted for. Staff #82 stated, We have an ongoing problems with meds. We needed (Staff #119) to come in to help us with all the med errors and help us. However, there was no indication this was brought up to the governing body, if the QA meetings were not being held. Staff #82 also confirmed for the facility's policies and procedures and with Phase 2 of the long term care requirements, their policies that are in place were pretty ancient, were not being updated. We have two different levels that we are going on. This was more on the administrative side. I have been going through them one by one trying to ensure that things were updated. She their policies and procedures have not been worked on since 2012. Staff #66 also confirmed this previously. With regard to the development of the facility assessment, Staff #82 stated because of their facility type as a long term care pediatric and adult ventilatory dependent resident facility, she was trying to figure out how to do the ICD codes, what the areas were to review, and that because they had the data, taking the next step, such as do we need to look at the equipment. She stated she asked Staff #30 about helping her understand it. She stated their governing body is going to approve it at their (MONTH) meeting, but they have to get the QA approval first. The SA informed Staff #82 their facility assessment is incomplete and stated there were no evaluations of their programs in place, they had not updated their policies, staff has not been fully trained, it did not include their resources at hand, competencies were not there, and the facility assessment was to have been completed prior to this survey. Staff #82 was also informed that during our meeting with the owner on the morning of 12/27/17, he stated he never saw the facility assessment report. Staff #82 also stated, We don't have an active infection control (IC) committee. She stated the former medical director and their current IC consultant did not collaborate. She said the physician did not believe in obtaining lab cultures and was set in his ways, and was to have trained Staff #66, but that too did not occur as a result. She stated the IC consultant came to the facility around six months ago to work with Staff #66 instead, so she has had six months. Staff #82 stated by 1:51 PM of this interview, that they should be using the new IC forms which were given to Staff #66 to use. For the PASARR finding, Staff #82 verified after the former medical director left, they were not done. Thus, based on the survey findings and interviews, observations of care and record reviews conducted, it was determined the overall lack of action by the administrator, governing body, medical director, and other administrative personnel, who were aware of their deficient practices, failed to demonstrate what corrective measures/ actions were undertaken and/or documented to show it was being done.",2020-09-01
868,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,837,F,0,1,K7B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility's policies and procedures, the facility's governing body failed to ensure there was a clear process by which the administrator informed and acted upon the problems affecting the operations of the facility. Finding includes: The cumulative findings of this survey, including the IJ are cross-referenced to this citation. During the interview of Staff #82 for the QA interview on 12/28/17 at 12:31 PM, there was no clear process by which she could demonstrate how often she reported to the governing body and in turn, how the governing body responded to on-going concerns. These should have included the quality of care and treatment of [REDACTED]. Staff #82's facility assessment given to the SA was also incomplete. On the morning of 12/27/17, the owner and as a member of the governing body, he stated he had not seen this facility's facility assessment.",2020-09-01
869,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,838,F,0,1,K7B511,"Based on record review, interviews and a review of the facility's assessment, the facility failed to ensure it had a facility wide assessment to determine the resources necessary to completely care for its residents during both day-to-day operations and emergencies. Finding includes: The cumulative findings of this survey, including the IJ are cross-referenced to this citation. The facility wide assessment which Staff #82 produced was incomplete. The facility assessment she produced failed to outline how the facility assessed their resident population, including an evaluation of the diseases, conditions, acuity of the resident population, etc., and how it affected the planning for services the facility must provide in order to care for its residents. The disease type, number of residents, special equipment if needed, environmental modifications, actions and additional or competency needed, special clinical needs and appliances form was blank with only a handwritten notation, Breakdown and further analysis occurring written on it. For the workplace profile section for both administrative staffing and direct care staffing the information was incomplete, without an evaluation of the overall number of qualified staff included. The section for competencies related to resident care and training needs was also blank. During an interview with Staff #121 on 12/29/17, he stated he turned in a portion for the environment; however, he was still waiting to hear from Staff #82 as to what more he had to do. A note attached to the facility assessment for Building and Physical Environment stated, to meet on this on 12/4. discussed and he will work on basic info and we will meet again. It had not been done. The facility failed to develop its facility assessment per the long term care regulatory guidelines effective 11/28/17.",2020-09-01
870,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,841,F,0,1,K7B511,"Based on record review, interviews and a review of the facility's assessment, the facility failed to ensure its former and interim or temporary medical directors implemented resident care policies and conducted the coordination of medical care in the facility. Findings include: The cumulative findings of this survey, including the IJ are cross-referenced to this citation. It was revealed during the survey from interviews with the various administrative staff that their former medical director left the facility sometime in (MONTH) (YEAR). In the interim, their temporary medical director, who primarily oversees the adult residents in the facility, was also overseeing the care for the pediatric population. However, it was found the facility's quality assessment and assurance committee had not met for half a year, the facility's policies and procedures were dated and not reviewed since 2012, and, along with the staffing issues, problems with medication errors, this inherent lack of the medical director's on-going participation in policy development with strategies for improvement, was found to be a failure in the medical director's role in the overall coordination of care and services in this facility.",2020-09-01
871,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,842,E,0,1,K7B511,"Based on observations, record reviews and interviews, the facility failed to ensure the medical records were accurately documented for 2 of 16 residents (Residents #1 and #3) in the survey sample. Findings includes: 1. On 12/27/17 at 12:19 PM, Staff #98 verified she made a recordation error by omitting the 12/21/17 vital signs she took on the CNA log sheet for Res #1. She said it is the aide's responsibility to log the vitals. Staff #15 said they put the Bair Hugger on the resident if his temperature went below 96 degrees F, and, If his heart rate is low, that means he is cold. Or I'll try and keep his head warm. Interview with Staff #66 found she concurred that the current vital signs log was inconsistent with missing information. This was information that should be included as interventions to implement into Res #1's care plan. Staff #66 said she was responsible for this as well as the licensed staff. 2. Resident #3 was observed on 12/19/17 at 11:25 AM to have a small quarter sized bruise like spot in the inner aspect of his right forearm during his range of motion exercise while in the 60 degree standing position. Staff #103 was there assisting the resident with his activities. On 12/21/17 at 11:12 AM, Staff #88 showed Res #3's right forearm and said it looks like a small rash. but Staff #103, said she saw it on 12/19/17 and it looked like a bruise. Staff #103 said it looks like rash and then Staff #12 came over to do an assessment of it. Record review on 12/22/17 found Staff #12's progress note (shift report) date was incorrect. Staff #110 confirmed this. Staff #12 wrote 12/20/17 but it should have been 12/21/17. There also was no documentation of Res #3's skin condition although Staff #103 was observed looking at it and saying it looked like a rash. There were no new orders as well. On the 24 hour charge nurse report, there also was no documentation of it by Staff #12, although Staff #110 said it should be there.",2020-09-01
872,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,851,D,0,1,K7B511,"Based on record review, interviews and a review of the facility's payroll based journal (PBJ), the facility failed to ensure it met the CMS requirements for the accurate submission of staffing information. Finding includes: During the extended survey, the SA found the PBJ was incomplete. On 12/28/17, Staff #82 gave the SA the facility's staffing summary reports from (MONTH) through (MONTH) (YEAR), and (MONTH) through 12/27/17. There was a notable difference of 3,575.75 staffing hours shown between the last quarter of the year, compared to the July-September period. Another tracking sheet for (MONTH) (YEAR) was also provided; however, the information for it and the two summary reports did not include information to differentiate between the direct care staff, agency staff, contract staff, resident census data nor information on direct care staff turnover and tenure and hours paid for all required staff each day. Staff #82 was asked to review and resubmit it. On 12/29/17 at 1:03 PM, Staff #82 stated the facility's financial officer was working on it but the reports would be run for each individual and would be a lot of paper. At this time, the SA informed Staff #82 the requirements for the PBJ were noted in the State Operations Manual and she said, I know. The facility failed to produce and ensure it had an auditable and verifiable PB[NAME]",2020-09-01
873,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,867,F,0,1,K7B511,"Based on record review, interviews and review of facility policies, the facility failed to maintain a quality assessment and performance improvement (QAPI) program that identified and prioritized quality deficiencies it was aware of, and failed to systematically analyze the underlying causes of identified quality deficiencies, toward the development and implementation of corrective action plans or performance improvement activities, including the monitoring and evaluation of the effectiveness of their corrective action/performance improvement activities. Finding includes: The cumulative findings of this survey, including the IJ are cross-referenced to this citation. During a meeting with Staff #82 on 12/28/17 at 12:31 PM, she stated there were two performance improvement areas which the facility identified. These had to do with bathing of residents and dignity issues and staff's use of personal protective equipment related to splashbacks. However, when Staff #82 was queried whether the rate of medication errors, lack of policy review/revision to current standards of practice, staffing concerns and lack of an active infection control committee were documented and identified with a study and/or documented improvement processes to better resident care, services and outcomes, Staff #82 could not elaborate further as to how they identified and/or were improving these areas within their facility. Record review on 12/29/17 at 12:22 PM found the facility's quarterly meeting was last held on 7/28/17. The next scheduled QA meeting on 10/18/17 showed it was canceled but included the consultant pharmacist's third quarter report. On 12/29/17 at 1:03 PM, Staff #82 verified the last time their QA committee met was in (MONTH) (YEAR). Staff #82 stated she will be requesting one in (MONTH) (YEAR).",2020-09-01
874,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,868,F,0,1,K7B511,"Based on record review, interviews and review of facility policies, the facility failed to meet at least quarterly and as needed to identify issues with respect to which quality assessment and assurance activities are necessary. Finding includes: The cumulative findings of this survey, including the IJ are cross-referenced to this citation. On 12/29/17 at 1:03 PM, Staff #82 verified the last time their QA committee met was in (MONTH) (YEAR). Staff #82 stated she will be requesting one in (MONTH) (YEAR). Although queried whether given the potential findings with the IJ and other concerns found during this survey, if the QA committee considered meeting sooner since so many of their staff (and family members) verbalized systemic quality of care issues. Staff #82 replied they did not.",2020-09-01
875,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,880,F,0,1,K7B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews and review of the facility's policies and procedures, the facility failed to ensure its infection prevention and control program (IPCP) included a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents and, failed to ensure the use of an updated system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. Finding includes: On 12/27/17 at 1:55 PM, interview with Staff #66 was done. She stated she is the assigned infection preventionist (IP) for the facility. She stated the criteria she has includes new forms (McGeer criteria) which their consultant IP provided to her, but the new forms has to pass through Q[NAME] Staff #66 confirmed she was not using the McGeer criteria forms and it's a work in progress. She stated she does random observation surveillance of the facility to identify any breaches in infection control. When Staff #66 was queried if she documented the any misses related to such, she stated, I usually do a verbal and then if it happens again, will do a note to file. She also stated she sends her surveillance to the consultant who reviews and numbers and the report. She the past leadership preferred not to work with her and the former medical director was to have guided her, but it didn't happen so starting Jan (YEAR), I had to make the call to switch gears and I started to work with (consultant IC) more. Staff #66 also said there were no cultures being done because the former medical director didn't really do cultures, but the nurse practitioner is of the mindset to do them. Staff #66 was queried about the facility's (MONTH) (YEAR) respiratory tract infection (RTI) rate of 11, compared to 6 RTIs in May, 2 RTIs in (MONTH) and and 1 in (MONTH) (YEAR). She was asked about this higher RTI number for tracheitis and said they did things such as daily reminders and staff huddles to ensure they are doing proper care. When she was asked if she did observations as the tracheitis rate in (MONTH) decreased to 1 case, she said she could not pinpoint this change, except that in (MONTH) some of the residents went back to school. Staff #66 said she would send her monthly surveillance reports to their consultant IP and recently received clarification that the consultant will have access to lab results as well. Staff #66 stated for their next coming QA meeting, they will be looking at who we want on the ASP team. Before the ADON, we were going to have me and (Staff #30) do it. On 12/28/17 at 7:47 AM, interview of Staff #65 revealed there was a prior system that tracked the facility's infection rates for pneumonia, tracheitis and other respiratory infections. The data showed trends from 2011-2016, but after that, there was no data that tracked these events/incidences. Per Staff #65, he stopped receiving this data and said it was tracked per 1000 vent days or [MEDICAL CONDITION] vent days as an example, and they also identified the actual pediatric and/or adult resident as delineated on the diagrams. Staff #65 believed this system was effective and allowed differentiation, such that as an example, some of it is, or can be exacerbation of bronchietasis, and too, if it's not the vent, it's the disease. On 12/29/17, Staff #82 stated she is in touch with an organization to see how their benchmarking surveys will compare to this facility. Although the facility began utilizing an outside IP consultant, the data tracking for (YEAR) did not demonstrate how for potentially high risk areas, given that all of their residents are on trach/ventilatory support, did not show how the RTIs were being analyzed using a data driven tracking method. The previous system delineated the pneumonia and tracheitis rates with a further breakdown between vent [MEDICAL CONDITION] and between the adult and pediatric population on ventilatory use. This was not evidenced in the (MONTH) to (MONTH) (YEAR) reports. The IP consultant also documented, The facility did not provide the total residents day information for May-Sept. This report can be completed once consultant receives this information. Staff #66 stated this has not been done and she also had not sent the resident care plans which the IP consultant also requested. On 12/28/17 at 12:30 PM, Staff #82 acknowledged that for an antibiotic stewardship program (ASP) to develop, they would have to track the pediatric and adult rates and not how the current IP report is done. On 12/29/17 at 11:22 AM, Staff #119 said the ASP never went to QA but it should have. Staff #119 stated there also was no project selected for the ASP and they are not monitoring the use of antibiotics as a result.",2020-09-01
876,KULANA MALAMA,125057,91-1360 KARAYAN STREET,EWA BEACH,HI,96706,2017-12-29,881,E,0,1,K7B511,"Based on record review, interviews and a review of the IPCP program, the facility failed to ensure it included an antibiotic stewardship program (ASP) that includes antibiotic use protocols and a system to monitor antibiotic use. Finding includes: Cross-reference to findings at F880, and to F835, F837, F841. On 12/28/17 at 12:30 PM, Staff #82 acknowledged that for an antibiotic stewardship program (ASP) to develop, they would have to track the pediatric and adult rates and not how the current IP report is done. On 12/29/17 at 11:22 AM, Staff #119 said the ASP never went to QA but it should have. Staff #119 stated there also was no project selected for the ASP and they are not monitoring the use of antibiotics as a result.",2020-09-01
877,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2017-06-30,246,D,0,1,BF7Y11,"Based on observation, record review and interview with staff member, the facility failed to ensure 1 (Resident #12) of 29 residents exercised the right to receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Findings include: A review of Resident #12's record found the resident is totally dependent on staff for activities of daily living. The resident is alert and able to interview. On 6/28/17 at 8:30 [NAME]M. during the initial tour, Resident #12 requested that the surveyor press the call light as it could not be reached. The resident had a splint applied to the left hand and the call light pad was placed on the resident's right pelvic area below the abdominal fold. The resident demonstrated that the call light could not be reached with the right arm or hand. The call light was not affixed to the resident's clothing and was pulled by the cord and placed on the bed, the resident brought the right arm/hand down and was able to press the call light. Resident #12 wanted to call for assistance to get out of bed to attend activity program. On 6/30/17 at 8:00 [NAME]M. a record review found the care plan for activities of daily living with the intervention to encourage Resident #12 to use touch pad to call for assistance, resident prefers to have call bell placed on the stomach and under the right hand. Subsequent observation on the morning of 6/30/17 found Resident #12 in bed. The resident requested the surveyor press the call light which was placed to the right side, approximately at the abdominal fold toward the groin area. The resident demonstrated the inability to raise the right arm to reach the call light. Resident #12 reported the call was to request for assistance to get out of bed to attend activities. Staff Member #1 was called to assist Resident #12. Concurrent observation with the staff member found the call light was not within reach for the resident. The staff member reported the resident is able to move the right arm side to side; however, the call pad was too low to reach. Concurrent review of the resident's care plan with Staff Member #1 confirmed the intervention is to place the call light on the resident's stomach under the right hand. The staff member reported the call light may have slid off the resident's stomach and applied the clips of the call pad to the resident's clothing. The facility did not ensure reasonable accommodation was provided to enable Resident #12's use of the call light. The call light pad was out of reach for the resident to effectively press the call light.",2020-09-01
878,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2017-06-30,323,D,0,1,BF7Y11,"Based on observations, electronic medical reviews (EMR) and staff interviews, the facility failed to ensure that implement interventions to reduce fall risks for 1 of 24 residents (R#34), on the Stage 2 sample resident list. Findings include: On 06/29/2017 at 1:51 PM observed R#34 sleeping on a lowered bed with hands holding the grab bars on the left (L) side of the bed. Looked into R#34's EMR and noted on the care plan, the resident has actual falls related to history of: L hip fracture, Parkinson's disease, dementia with poor safety awareness, and history of falls. The resident had unwitnessed falls on these dates: 10/22/16, 11/06/16, 11/23/16, 12/2/16, 01/25/17, 01/29/17, 03/28/17 (with head injury), and on 05/06/17. The interventions included on 3/18/17 Per resident preference, leave bathroom door open, do not close; 4/22/17 Landing mats to L and R side of bed. Progress notes dated 3/28/17 documented that R#34 was noted with a 3-4 cm hematoma to the top middle of head but denied pain to that area and the neuro checks were within normal limits. The progress note further documented that the resident was found sitting next to the opened bathroom door facing bed, and the resident stated that he was opening the damn bathroom door because those f closed it. It's not supposed to be closed and I fell . The resident also stated that he hit his head on the door. On 06/30/2017 at 8:41 AM observed R#34 in his wheelchair placed next to the nursing station. When looked into R#34's room there were no landing mats on the sides of the bed and the bathroom door was closed. Interviewed Staff#2, and according to her the resident's landing mats got wet and was removed to be cleaned or replaced but she needed to double check with maintenance. The bathroom door was opened when R#34 was placed back into bed and staff knew to keep door open. The resident started to wheel self around the nursing station and a staff intervened and brought R#34 back to bed. Went to observe R#34 in bed and noticed that the bathroom door was still closed with his wheelchair at the bedside. On 06/30/2017 at 9:28 AM interviewed Staff#3 and she provided that some interventions such as landing mats were resolved 6/5/2017 due to hindrance of level change and R#34 more likely to trip on it; wheelchair at bedside resolved 6/27/17 due to R#34 continually trying to walk around room to find it so to keep wheelchair at bedside; wearing glasses also resolved on 6/27 due to resident removing it. In progress notes Staff#3 wrote, Reviewed resident's fall CP and current interventions. Resolved interventions that were no longer appropriate for res. Discussed with Staff#3, that the bathroom door was left closed and that intervention was recommended when R#34 fell and hit his head. The facility failed to keep the bathroom door open which they knew if not implemented was very upsetting to R#34, and the risk for another fall.",2020-09-01
879,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2017-06-30,371,E,0,1,BF7Y11,"Based on observation and interview with staff member, the facility failed to ensure food was stored safely. Findings include: On 6/27/17 at 9:31 [NAME]M. a brief initial tour was done of the kitchen. Concurrent observation with the Food Service Manager (FSM) of the refrigerator found a half-filled tray of bowls with tapioca pudding stacked atop other trays with a label to use by 6/19/17. The tray directly under the top tray was full of bowls, the tray was not labeled. The FSM acknowledged the pudding had surpassed the used by date as well as the second tray was not labeled. The FSM removed the trays containing the tapioca pudding (the expired 1/2 full tray and the full try with no label) for disposal.",2020-09-01
880,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2019-10-04,600,D,1,1,842311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a facility reported incident, interview with resident and staff members, review of the facility's investigation and clinical record review, the facility failed to ensure a resident (Resident 44) was free from neglect, the failure to provide services necessary to avoid physical harm and emotional distress while showering of a vulnerable resident. Findings include: The facility submitted an Event Report to the State Agency regarding an allegation of neglect. The facility reported on 08/16/19, Resident (R)44 reported Certified Nurse Aide (CNA)5 left her alone in the shower for approximately 15 to 20 minutes. R44 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A record review found R44's admission Minimum Data Set with an assessment reference date of 06/22/19 notes the resident yielded a score of 13 (cognitively intact) when the Brief Interview for Mental Status was administered. R44 was also coded to require physical help in part of bathing activity with one-person physical assist. Further review found R44 requires extensive assist with one person physical assist for dressing and transfers (how the resident moves between surfaces including to or from: bed, chair, wheelchair, standing position, excludes to/from bath/toilet). R44 was coded as not being steady and only able to stabilize with human assistance for moving on and off the toilet and surface-to-surface transfer (transfer between bed, chair or wheelchair). The care plan for activities of daily living notes the following intervention for bathing/showering: The resident requires up to limited assist of (1) staff to provide bath/shower. Set up assist for upper and lower body bathing. Resident prefers to have supervision for entire shower to ensure safety. The initiation date of this intervention is documented as 05/15/19. On 09/30/19 at 11:00 AM an interview was conducted with R44. R44 reported CNA5 left her alone in the shower. R44 further reported CNA5 will keep an eye on her until she calls but this time, R44 called with no response. R44 stated CNA5 left her five times and was unable to get to the call light. Eventually another staff member, an Activity Staff (AS)78 entered the room and heard R44's call for assistance. R44 shared CNA5 continues to provide assistance, but does not assist with bathing/showers. On 10/02/19 at 03:36 PM the facility provided documentation of their investigation. The Grievance Form, dated 08/16/19 documents R44 complained CNA5 left her in the shower five times with one occasion of being left 15 to 20 minutes. R44 reported she was left for 20 minutes and the CNA did not return so she had to yell for help. Subsequently another staff member (AS78) responded and then called CNA5. Further review of the facility's investigation notes the resident's care plan for bathing/showering, R44 requires extensive assist of one staff to provide bath/shower as necessary and should not be left alone. A review of the facility staff interview with CNA5 on 08/16/19 was done. At this time CNA5 reported that she set-up R44 in the shower and did not leave her too long. CNA5 reported to facility staff that she went back to check on the resident 2 to 3 minutes later and found the resident had finished showering and was drying herself. CNA reportedly assisted R44 with transfer and helped the resident to dress. CNA5 informed the facility staff that R44 has been left during showers as she is able to bathe on her own, sits on the shower chair, the wheelchair is placed close to the shower chair and R44 will transfer herself. On 10/03/19 at 10:37 AM an interview was conducted with AS78. AS78 reported on the day of the event she recalls going into R44's room to visit her roommate. R44 thought AS78 was knocking on her door and called out. AS78 identified herself, knocked on the bathroom door and found R44 in the shower. R44 informed AS78 that she was waiting a long time, 20 minutes, for CNA5. R44 also communicated that she was done already and asked where was CNA5. AS78 found CNA5 in the hall charting. Inquired whether the call light was on, AS78 responded the call light rings at the nurses' station so if you are far from the station, you may not hear the alert. AS78 reported that residents should not be left unsupervised in the shower as the bathroom is dangerous and the residents are in the facility because they require help and supervision. On 10/03/19 at 01:19 PM a telephone interview was conducted with CNA5. CNA5 reported when R44 was admitted to the facility she required extensive assist but later got better and would tell CNA5 it is okay to leave her and come back. R44 also instructed CNA5 not to close the door so she can be heard calling when done. CNA5 reported on the date of the incident, AS78 informed her R44 was ready. CNA5 reported she was in the hall using the wall unit to catch up with charting. Inquired whether there were other incidences when R44 was left unsupervised during showers. CNA5 reported she would leave R44 alone while changing the resident's bed linen; however, this time she was farther away and could not hear R44 call her. CNA5 reported during the investigation she was placed on administrative leave and as a result of the investigation, was provided with education on following residents' care plan and instructions on the Kardex. CNA5 reported the facility does walking reports and reminds staff not to leave residents in the shower. Further queried whether she thought her action was neglectful. CNA5 responded, yes and added that she did not mean to. CNA5 also expressed remorse and wanting to apologize to R44. On 10/03/19 at 02:00 PM observation of R44's bathroom found there is no call light in the shower stall. The shower is in an alcove next to the toilet with a shower curtain across the opening. In R44's bathroom, the call light is to the left of the wall outside of the shower alcove (next to the toilet). Concurrent observation with Occupational Therapist (OT) confirmed there is no call light in the shower stall. The OT stated a call light in the shower alcove would be nice for independent residents to call for help.",2020-09-01
881,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2019-10-04,604,D,1,1,842311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interview, record review, review of policy, and review of Facility Reported Incident (FRI) 7641, the facility had past non-compliance; whereas, Resident (R) 2 was restrained to a wheelchair for the purpose of convenience, and not required to treat medical symptoms. Findings Include: According to the FRI 7641 (received from the facility) and record review, a staff member found R2 restrained to a wheelchair on 05/12/19 at 07:48 AM. R2 was sitting up, alert and smiling at that time. There was no harm to R2. Immediately after the staff was made aware of that restraint, it was removed and reported appropriately. A review of R2's medical record showed the following Diagnosis: [REDACTED]. On 09/30/19 at 10:00 AM, during survey, R2 was observed sitting up in a wheelchair using an upper body harness to support being upright. R2 was alert and appeared in no acute distress. R2's speech was not clear (baseline) and was not able to answer questions about the FRI 7641. R2 needed assistance with mobility and had a doctor's order which read; upper body harness while up in wheelchair during meals and activities to support upright positioning. A review of R2's care plan showed the following relative interventions: 1. For the upper body harness for positioning, 2. mobility, 3. falls, and 4. skin integrity. On 10/02/19 at 02:30 PM, the Regional Nurse Consultant (RNC) provided the full investigation notes for the FRI 7641. The notes showed evidence that the investigation was thorough. Evidence included interviewing other residents, obtaining written statements from employees, providing education/training/in-service on the prohibition of abuse and restraints, reviewing facility policy on Freedom from Abuse, Neglect, and Exploitation. A Performance Improvement Action Plan/Audit was also initiated and on-going to monitor for compliance. On 10/03/19 at 09:45 AM, Registered Nurse (RN) 75 was interviewed and asked about knowledge of FRI 7641 education/training/in-service. RN75 was able to recall FRI 7641 education/training/in-service on the prohibition of abuse and restraints. RN75 was also able to talk about the on-going monitoring for compliance.",2020-09-01
882,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2019-10-04,684,D,0,1,842311,"Based on observations, staff interviews, record review and review of the facility's policy and procedure, the facility failed to turn or reposition 1 of 5 residents to preserve the resident's skin integrity, Resident (R)22. This deficient practice puts R22 at risk for potential skin breakdown. Findings include: The annual Minimum Data Set (MDS) for R22 with an assessment reference date of 07/25/19 was reviewed, in Section B. Hearing, Speech and Vision, the facility coded R22 for no speech, rarely makes self understood, and rarely/never understands others. R22 is coded as totally dependent on staff (full staff performance every time during the observational period) for the following: bed mobility, transfer, dressing, eating, and toilet use. R22 requires extensive assist for personal hygiene (combing hair, brushing teeth, shaving). The resident has functional limitation (range of motion) on both sides of the upper and lower extremities. R22 has contractures of the right and left; hands, wrists, elbows, shoulders, and ankles. In Section M. Skin Conditions, R22 was identified to be at risk for developing pressure ulcers and has pressure reducing devices for chair and bed. R22 was observed in bed, positioned flat on his back on the following dates/times: 09/30/19 at 11:06 AM, 12:23 PM and 02:05 PM; 10/01/19 at 08:52 PM and 12:08 PM; and 10/02/2019 at 09:35 AM. During each of the observations R22 did not have an air mattress and/or device for repositioning (i.e. pillow, wedge) to alter R22's position. On 10/02/19 at 10:35 AM, interviewed both the Assistant Director of Nursing (ADON) and registered nurse (RN)80, inquired why R22's was not observed to be turned/repositioned as identified by the care plan. The ADON responded that R22 did not have any orders or task because R22 did not have a pressure ulcer. Inquired why would the facility wait until R22 developed a pressure ulcer. Both ADON and RN80 did not respond. Further inquired if the goal of turning/repositioning R22 was to preserve R22's skin integrity and prevent pressure injuries. Both ADON and RN80 did not respond. On 10/02/19 at 11:25 AM, R22 was observed repositioned facing the window. An interview was conducted with the assigned Certified Nurse Aide (CNA)9 on 10/02/19 at 01:02 PM, inquired what was the turning/repositioning schedule of R22. CNA9 replied that R22 is turned/repositioned when staff rounds and is documented in the CNA task report in the electronic medical record (EMR). CNA9 was agreeable to navigating and reviewing the EMR. CNA9 confirmed there were no task listed on the CNA task report to turn/reposition R22. CNA9 further confirmed there were no documentation in the EMR or other source that a record of the dates and times direct care staff turned/repositioned R22. Inquired with RN66, if there was documentation in the EMR or other source that documented the dates and times direct care staff turned/repositioned R22. RN66 navigated the EMR and confirmed that there was no documentation of staff turning/repositioning R22. A review of the facility's policy and procedure, Quality of Care Skin Integrity notes under the guidelines, A resident identified as at risk of developing PU/PIs will have individualized interventions implemented to attempt to prevent PU/PI from developing. Interventions will be monitored for effectiveness. The resident's care plan will reflect the interventions.",2020-09-01
883,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2019-10-04,689,D,0,1,842311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review (RR), the facility failed to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents for one of four residents (R) 62 selected for review. This deficient practice has the potential to put residents at high risk for injuries and/or harm. Findings Include: On 10/01/19 at 11:45 AM, observed certified nurse aide (CNA)25 pushing R62 who was in his wheelchair down the hallway towards the nurse's station in Banyan Lane. It was observed at one point, R62 came to an abrupt stop in his wheelchair and he jolted forward. Upon investigation it was revealed R62 had no shoes on, he was barefooted. It was also noted R62's wheelchair had no footrests. Thus, R62 was dragging his feet on the floor while CNA25 was pushing him in the wheelchair. When CNA25 was queried, he stated R62's feet got stuck on the floor causing R62 and the wheelchair he was pushing to come to an abrupt stop. CNA25 stated R62 doesn't use footrests and immediately started on their way. 10/02/19 at 08:40 AM, interview with Director of Nursing (DON) who stated she looked into the incident that occurred yesterday (10/01/19) with CNA25. DON concurred the incident happened and CNA25 confirmed it. DON stated she educated CNA25 about the use of footrest for the wheelchair during transport of residents. DON said they have started the process of re-educating staff on the safety of transporting residents in wheelchair and the use of footrest. 10/02/19 01:33 PM, RR showed R62 was admitted to facility on 05/31/19 with [DIAGNOSES REDACTED]. Nurse's progress notes dated 07/31/19 at 1901 showed R62 had a fall. It was documented Per 1:1 CNA she was pushing resident to the dining room when all of a sudden, resident falls forward and hit head on the floor. Per 1:1 CNA and another CNA, resident's feet got stucked. Noticed that resident does not have a footrest during transport, hence the intervention to apply footrest to prevent feet from getting stucked or creating friction during transport. R62 sustained a bruise to bridge of nose and redness to knees. 10/03/19 01:10 PM, interview with CNA25 who admitted he was pushing R62 to the dining room at around 11:45 AM for lunch on 10/01/19. CNA25 stated he understands R62's wheelchair should have had footrests. CNA25 stated he was re-educated on the safety of transporting residents on wheelchair with the use of footrests and agreed that there is potential for residents to get seriously injured if their feet get caught on the floor or the wheels of the wheelchair.",2020-09-01
884,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2019-10-04,812,F,0,1,842311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to label perishable foods with an expiration date and discard expired. On [DATE] at 09:45 AM, during the initial tour of the kitchen with staff member (SM) 77, observed a container of MARU-HI Brand Miso (Soybean Paste) and Minor's Beef Base in the walk in refrigerator with no label indicating the expiration date. Inquired with SM77 if the Maru-HI Brand Miso and Minor's Beef Base container should be labeled with an expiration date. SM77 responded that the Maru-HI Brand Miso and the Minor's Beef Base should have been labeled when opened and a date to discard 3 days after opening. On [DATE] at 10:04 AM, observed nine containers of individual Boost Vanilla pudding with an expiration date of 8 [DATE] stored in the second floor refrigerator used to store snacks for the residents on. SM77 responded that the Boost Vanilla pudding was in the refrigerator for consumption by the residents. SM77 promptly removed and disposed of the expired Boost Vanilla pudding.",2020-09-01
885,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2019-10-04,880,D,0,1,842311,"Based on observation, staff interview, and review of policy, the facility failed to clean the suction equipment/canister for one Resident (R) 34 of six residents reviewed. This deficient practice put the resident at risk for the development and transmission of communicable diseases and infections. Findings Include: During an observation of the suction equipment in R34's room, on 09/30/19 at 10:30 AM, the suction equipment/canister contained approximately 200cc of clear/yellow liquid. The same clear/yellow liquid was noted in the suction tubing as well. The resident was not in the room and there was no way to determine how long the contents had been there. Additionally, the canister was marked with the date 09/26/19. During an observation of the same suction equipment on the next day 10/01/19 at 08:45 AM, the clear/yellow liquid, which was previously noted in the cannister and tubing the prior day, remained the same. The date marked on the canister also remained the same 09/26/19. On 10/01/19 at 09:41 AM, Registered Nurse (RN) 75 was queried about the above findings. RN75 did not know how long the clear/yellow liquid had been there. RN75 further stated that the clear/yellow liquid should have been immediately disposed of and the suction tubing properly cleaned as per facility policy. A review of facility policy on Infection Prevention and Control Program (IPCP) stated the following: Purpose, The facility will establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy, the IPCP will include a system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases.",2020-09-01
886,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2018-10-12,600,D,1,1,7RR911,"> Based on record review, interview, review of the facility's policy and other documentation, the facility did not ensure that 1 of 32 residents (Resident (R) 40) in the sample, was free from neglect as the facility did not provide the required hourly checks for R40 who was a known elopement risk. This deficient practice had the potential to endanger the resident's health and safety, and affect the other 26 residents identified by the facility as being a high or at risk to wander. Findings Include: On 09/21/18 at 10:28 AM, during the review of the second abatement plan with the Nursing Home Administrator (NHA), the Director of Nursing (DON) and the Regional Nurse Manager (RNM), they were asked about a 6/17/18 clinical entry by registered nurse (RN) 1. This was the date R40 had eloped and was found in the town of Hilo, about three miles from the facility. Concurrent record review with the NHA, DON and RNM revealed that RN1's clinical entries for the 0900, 1000 and 1100 hours on 6/17/18 showed the resident was in the facility. RN1 documented her entries on the Medication Administration Record [REDACTED]. The NHA and DON affirmed RN1 had falsified her clinical documentation that R40 had been in the TV lounge that entire time, more specifically during 10:00-11:00 AM on the morning of his elopement on 6/17/18 . The NHA said it was, inaccurate documentation by RN1 and that RN1 had been written up for it. The facility also failed to include CNA1's account in their investigation, and failed to report RN1's falsification of R40's clinical record to the appropriate authorities, including the State Survey Agency (SA) (omitted in their FRI), Adult Protective Services (APS) and the Regulated Industries Complaint Office (RICO). Review of the facility's job description for a registered nurse noted an RN's duties included implementing/delivering the resident's plan of care, and, Ensure accurate documentation of all medical records and reporting forms. This was not done by RN1 as evidenced on the (MONTH) (YEAR) Medication Administration Record [REDACTED]. In addition, the facility's policy, Freedom From Abuse, Neglect and Exploitation Abuse states, 5.a. Neglect may be occurring, if the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them to the resident. There was a failure by the facility to identify, investigate and report this situation as an alleged violation of neglect by RN1. There also was a failure by the administrative staff to ensure their policy was enforced. This information that a licensed nurse failed to ensure for the safety of a resident and falsified her knowledge of his whereabouts was not part of their completed investigation.",2020-09-01
887,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2018-10-12,609,D,1,1,7RR911,"> Based on record review, interview, review of the facility's policy and other documentation, the facility did not report a registered nurse's (RN) failure to monitor a resident (Resident (R) 40) who eloped from the facility and, falsifying documentation of the resident's whereabouts. The facility further failed to report this situation involving RN1 to the State survey agency (SA), Adult Protective Services (APS) and/or the Regulated Industry Complaints Office (RICO). This deficient practice has the potential to affect the other 26 residents identified by the facility as a high or at risk to wander. Findings Include: The facility completed and sent their facility reported incident (FRI) to the State Survey Agency (SA) on 6/20/18. However, from the record reviews and interviews of various staff, it was found the administration failed to report RN1's falsification of her clinical entries regarding R40's whereabouts on the morning of 6/17/18. On 9/21/18 at 10:28 AM, during the review of the second abatement plan with the Nursing Home Administrator (NHA), the Director of Nursing (DON) and the Regional Nurse Manager (RNM), the NHA and DON verified that RN1 falsified her clinical documentation the morning R40 had eloped from the facility and was found in Hilo town. The NHA said it was, inaccurate documentation by RN1. The facility's policy, Freedom From Abuse, Neglect and Exploitation Abuse states, 5.a. Neglect may be occurring, if the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them to the resident. Yet, the facility failed to identify and report this situation as an alleged violation of neglect by a licensed nurse, and failed to report this information to the appropriate authorities, including the SA within five working days, and to APS and RICO. Thus, the facility failed to include caregiver neglect and as part of their investigation (refer to F600, F689).",2020-09-01
888,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2018-10-12,689,K,1,1,7RR911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview and a review of the facility's documentation, the facility failed to ensure each residents' risk for elopement/wandering was thoroughly evaluated/assessed, and failed to ensure adequate supervision was provided to their residents to prevent the elopements from occurring for four of 32 residents (Resident (R) 40, R63, R50 and R5) selected for review. As a result of this deficient practice, R40's safety was endangered when he eloped and was found about three miles from the facility on 6/17/18. R63's safety was endangered as he eloped and was found walking on the driveway on 9/16/18; R2's safety was endangered as he was found outside the facility's first floor entrance on 1/21/18, and, similarly for R50, who was found unsupervised outside the front office door on 9/9/2018. In addition, the facility failed to ensure their upgraded door alarm system was being checked on the weekends. R4, R63, R2 and R50 eloped or found a way out of the facility on a Sunday. Staff also failed to follow the residents' care plan interventions for monitoring their residents, and the cumulative effect of the deficient practices led to an ongoing situation where the non-compliance is likely to cause serious injury or harm to the 26 residents deemed at risk for wandering/elopement out of the total census of 84. Findings Include: 1) Record review found that resident (Resident (R) 40) was admitted to the facility in (MONTH) of (YEAR) with several diagnoses, including high blood pressure, [MEDICAL CONDITION], anxiety disorder and impaired physical mobility related to a history of a left [MEDICAL CONDITION]. R40 also had a care plan for his elopement risk/wandering related to his [MEDICAL CONDITION], impaired safety awareness and exit seeking behaviors. The interventions included monitoring and documenting any wandering behavior. During the survey, R40 was observed sitting in his wheelchair in his room or the Ohana 1 TV lounge area. He was able to self-propel himself around the unit and had a wander guard alarm bracelet on. On 9/19/18 at 1:11 PM, RN3, the unit manager, stated the resident could also walk, but preferred his wheelchair. Random observations found R40 to be alert when up in his wheelchair and able to move around freely on his unit. R40 was identified on a facility reported incident (FRI) as having eloped from the facility on Sunday, 6/17/18. Per the FRI, R40 was found that morning approximately three miles from the facility in downtown Hilo, by an off-duty certified nurse aide (CNA) 1. The facility's investigation noted R40 was last toileted around 9:30 AM and he stayed by the main TV lounge area. The charge nurse, registered nurse (RN) 1, documented the resident was in the facility specifically in the TV lounge area from 9:00-11:00 AM. However, it was revealed from an interview with CNA1 who found R40, that RN1's documentation of R40's whereabouts that morning had been falsified. The facility had not known that R40 was missing from their facility. On 9/19/18 at 2:40 PM, an interview with CNA1 was done. CNA1 stated she spotted R40 on Sunday, 6/17/18 in the downtown Hilo area while on her way to church. She recalled it was between 10:00-10:30 AM, when she passed R40 sitting in a wheelchair, unattended, by a nearby store. CNA1 recognized R40 and said, When I passed him, just how he sits and has a plaid [NAME]et, so when I turned around I called the facility and that's when I got to him. She said she spoke to RN2 (no longer at the facility), who asked her to stay with R40 until they could arrange to pick him up. CNA1 said when she found R40, he was pretty clear and asked how he got there along with the plate of food on his lap. R40 told her he used his wheelchair to come down the hill, using his brakes and there was grass on the wheels of his wheelchair. She said R40 was able to show her how he used the brakes on his wheelchair. CNA1 said R40 did not tell her about riding down the hill with a lady from the facility. But he did first say the lady with the red truck gave him the food. CNA1 stated she told the Assistant Administrator (AA) and the Director of Nursing (DON) that R40's version was not what RN2's 6/17/18 progress note stated. CNA1 told them R40 told her, I used my wheelchair, and showed how he used his brakes. RN2's progress note however, stated R40 indicated he had a ride in a truck and a woman bought him breakfast. But he also was confused upon his return to the facility around 11:30 AM, and could not state how he eloped from the building. CNA1 said she did not return to the facility with R40 since it was her day off. She verified although she was the first witness to see and speak with R40 that morning, her account of that day was not reflected in the progress notes nor in the facility's FRI or investigation. On 9/21/18 at 9:57 AM, CNA2 was interviewed. CNA2 said she was present when R40 returned to the facility around or after 11:00 AM on 6/17/18. She spoke to R40 while RN1 assessed him and recalled that R40 told her a lady gave him the plate of food on his lap. R40 also told her, went down the road. CNA2 said there was grass on his wheelchair tires and on his shoes. She recalled this because the administrator asked that it be cleaned up and she did it. CNA2 said R40 did not tell her that a lady gave him a ride down the hill. She said R40 is very fast in his wheelchair when he propels and, is always looking for a boat or his truck and will mention that. She said she is familar with R40 as she has cared for him. Record review revealed that RN1 was the day shift charge nurse on 6/17/18, which was Sunday, Father's Day. The facility had many visitors entering and exiting the facility using the Ohana 1 double door entrance. R40 resides on the Ohana 1 nursing floor. One of RN1's responsibility was to document/monitor R40 hourly as he was care planned to be at risk for wandering/elopement. Review of RN1's 6/17/18 clinical entries for the 0900, 1000 and 1100 hours showed R40 was in the facility. RN1 documented her entries on the Medication Administration Record [REDACTED]. On 9/21/18 at 8:35 AM, the Nursing Home Administrator (NHA) and DON verified that RN1 falsified her clinical documentation about where R40 was on the morning of his elopement on 6/17/18. The facility also failed to include CNA1's account in their investigation, and failed to ensure RN1's falsification of R40's clinical record was reported to the appropriate authorities, including the State Survey Agency (SA)'s (omitted in their FRI), Adult Protective Services (APS) and the Regulated Industries Complaint Office (RICO). 2) Even after the 6/17/18 elopement, the facility failed to thoroughly reassess residents deemed potentially at risk for elopement. On 9/19/18, the Assistant Administrator (AA) verified another elopement by R63 recently occurred on Sunday, 9/16/18. Record review revealed that on 9/16/18 at around 6:00 PM, R63 was found walking on the driveway outside of the facility. Prior to his elopement, R63 had been agitated and spoke about going home after being unable to contact a family member by phone. Then sometime after dinner, a CNA saw him through the second floor window and brought him into the facility. R63 was admitted in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. At the time, R63 did not have a wander guard placed. His care plan for elopement risk related to his [MEDICAL CONDITION] and history of wandering was developed after his 9/16/18 elopement. Yet, a resident with Alheimer's disease and a history of verbalizing wanting to go home had not been monitored for his whereabouts and safety on the day he eloped. 3) Further record review found a 9/9/18 1:41 PM nursing progress note whereby a licensed staff documented that R50 was found unsupervised and, out by the front door office. R50's record stated, Upon investigation, resident verbalized, 'I went there to get sunshine', asked how he opened it & stated 'I turn the door latch & the door open, I used to be maintenance worker before that's why I know all those'. Instructed resident to inform staff & the importance of being supervised because no office staff during weekends. Also offered alternatives to go outdoor garden. Resident verbalized understanding. Manager on duty aware. This event occurred on a Sunday. Record review found a 9/20/18 nursing progress note, which stated R50's physician authorized that R50 was allowed to go outside the premises of the facility unsupervised for relaxation and enjoyment, post incident. A 9/19/18 nursing entry found the resident was spoken to about safety concerns and staff were to periodically check him. Although the R50 verbalized his understanding, on 9/20/18, R50 had been left unsupervised, did open an alarmed door and exited to the front of the building. R50 resides on Ohana 1 and Ohana 2 (upstairs) is where the front office is. There also was a potential for other residents at risk for wandering/eloping to have gone out with R50, if they had been in the vicinity with him, with no staff present to prevent it. 4) In addition, review of an FRI for R2 revealed he had eloped on 1/21/18, Sunday morning at 3:25 AM. R2 was found outside of the facility standing at the first floor entrance, carrying his black bag. Staff redirected him back into the facility. R2 was also known to have a history of wandering and exit seeking behaviors. The facility did an audit of their elopement binders containing those residents identified to be high risk for elopement/exit seeking. Yet, there was no indication if the facility's alarm system had failed to alarm to notify staff that R2 had exited the facility when his elopement occurred, and similarly for R63, R50 and R40. 5) A review of the facility's door alarm system was done on 9/19/18 at 3:47 PM with the Environmental Services Director (ESD). As part of the facility's internal investigation as to how R40 had eloped, he said the staff knew R40 was in the TV room fronting the Ohana 1 double door entrance. He said he tested the doors at least 20 times, and found if someone walked in the middle of the doorway entrance, there was a brief moment of interrupting the signal such that the alarm would not trigger. The ESD stated 6/17/18 was a busy day per the visitor log with many people entering/exiting through the Ohana 1 doors. The ESD acknowledged that if R40 had exited through this, middle zone, R40 could have gone undetected as there was a potential his wander guard signal would not have triggered the alarm. The ESD stated, So if you test it every time with no one around, it works. So later I found out we had to change the frequency, but that's later. The ESD and his maintenance staff found that the frequencies from various signals emitted by other electronic devices affected their alarm system. The ESD said they, had to lower the frequency to pick up the wander guard transmitting signal. Yet, a review of the Daily Wander Guard Test from a 1/1/18 to 9/19/18 printout revealed there was no indication this was done. There also was missing information as to how his staff were testing/checking the alarms at specified door locations. Review of the printout also found that all of the weekend checks that were to be done, were all missing and not documented. Thus, on the day R40 eloped, Sunday, (MONTH) 17th, there was no documentation the Ohana 1 or Ohana 2 door alarms had been tested /checked. On 9/19/18 at 4:32 PM, the NHA was also interviewed with ESD. The NHA stated there was an upgrade to their system, but when they converted their data, they did not do a thorough review. The NHA said they also had no hard copies of their wander guard and/or door alarm checks. The ESD stated he relied on two maintenance staff to do the weekend door alarm checks, but he would input their results into their system on Monday mornings. The ESD said if his staff did not tell him that, it was broken, then he would enter, that everything is fine. On 9/19/18 at 5:52 PM, in response to how the facility could demonstate standardization of testing their alarm system, the NHA stated although the ESD inserviced his maintenance staff verbally, nothing was written. Further, on 9/20/18 at 8:50 AM, although the NHA produced another printout, Historical Meter Readings from 1/1/18 to 9/20/18, the documentation showed the Location of testing as either, pass, 2, pass/2, entry, and the Reading as 0, pass, 2. There was no notation of what the values/codes meant on the printout. In addition, it was found that Ohana 1's floor map showed approximately seven exit doors, which were not accounted for in the facility's overall alarm testing system. 6) On 9/20/18 at approximately 3:05 PM, the facility was notified of an immediate jeopardy (IJ) based on the investigations related to the residents' elopements. There also was an omission of pertinent information related to R40's elopement within the facility's FRI to the SA and their own investigation, which included the neglectful action by RN1 to monitor R40, and then falsifying the record about it. The NHA stated it was, inaccurate documentation by RN1 and that RN1 had been written up for it. This was reaffirmed on 9/21/18 at 10:28 AM which the NHA and DON verified RN1 falsified her documentation about R40 being in the TV lounge area at 10:00 AM on 6/17/18, when he was not. The IJ was abated on 9/21/18 at 12:12 PM with an acceptable Preformance Improvement Action Plan (PIAP). This included residents who were assessed to be at risk for wandering/elopement and whom had not been thoroughly evaluated. It also included the facility's door alarm system, for which the daily function checks of their wander monitoring system was not being documented. Substandard quality of care was identified with the I[NAME] As such, the SA returned to the facility from 10/10/18 through 10/12/18 to complete the extended survey. On 10/10/18 at 1:47 PM, the DON and NHA verified there had been no further elopements from their facility since the IJ abatement on 9/21/18. On 10/11/18 at 8:40 AM, the NHA presented an updated PIAP for the SA to review during the extended survey. The quality assurance performance improvement (QAPI) review was done with the NHA and DON on 10/12/18 at 9:10 AM. The NHA stated in review of their past elopements, there was a failure of their assessments and it was a systems error. The NHA explained after R2 eloped in (MONTH) (YEAR), although they had put in extra alarms at the doors, it was not loud enough so amplifiers were placed at the side door he got out from. The NHA presented further documentation showing all their residents were thoroughly re-assessed, that alarms were placed at every exit door, all staff were in-serviced on the implementation of their corrective measures, the falsification of documentation by RN1 was reported to the proper authorities, daily documentation to check the functionality of all exit doors alarms to be conducted each shift was to be implemented, a new out of pass procedure and education for residents/POAs was done and, a qualified technician was to conduct/document quarterly functionality checks of their alarm system. Further, the NHA stated an elopement is a never event and with the new corrective actions in place as of 9/24/18, the SA found it as a credible allegation of compliance (A[NAME]) and the scope and severity of the IJ was reduced to E, no actual harm with potential for more than minimal harm.",2020-09-01
889,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2018-10-12,842,D,1,1,7RR911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure the resident's medical record was accurately documented and contained an accurate representation of the actual experiences of the resident, including the care and services for 1 of 32 residents (Resident (R) 40) in the sample. Findings Include: A review of R40's care plan obtained on 9/21/18 showed he had a comprehensive care plan for elopement risk/wanderer related to his [DIAGNOSES REDACTED]. On 06/17/18, the day of his elopement per the FRI and on-site investigation, it was found that R40's clinical record did not contain an accurate and thorough account of what happened to the resident on the day he eloped. On 9/21/18 at 8:11 AM, the Assistant Administrator (AA) acknowledged this (refer to F689). In addition, through interviews conducted of the certified nurse aides (CNA), CNA1's encounter of finding and talking to R40 and CNA2's observation and conversation with R40 upon his return to the facility were not included, but included specific and relevant details of how R40 presented that day.",2020-09-01
890,YUKIO OKUTSU STATE VETERANS HOME,125058,1180 WAIANUENUE AVENUE,HILO,HI,96720,2019-11-15,689,G,1,0,ZUT111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, observation and record review (RR) the facility failed to prevent one Resident (R1) fall of a sample of seven. On 10/27/19, R1 fell off the bed while a Certified Nurse Assistant (CNA)1 was providing care. As a result of this deficient practice, R1 fractured his left hip, and required [MEDICATION NAME], an opioid medication for pain control. The [MEDICAL CONDITION] and pain could potentially effect R1's quality of life. Findings include: R1, a [AGE] year old was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 had a communication deficit and communicates with single words. He required assistance for ADL's (Activities of daily living, and was non ambulatory. Review of the facility's Office of Healthcare Assurance (OHCA) Event Report stated the following, On 10/27/19 at 02:05 PM, .CNA1 was attempting to change R1's brief and draw sheet and requested the resident to help turn himself to right side. In doing so, he rolled over bed onto the floor . R1 was transported to Hilo Medical Center (HMC) for x-rays and returned to the facility with a knee immobilizer in place and a new order for PRN (as needed) [MEDICATION NAME] for pain. The care plan was modified to two person total assist with ADL's. The x-ray report revealed, . resident had sustained a Left Femoral Neck fracture (break in the bone of the leg, just below the ball-shaped head that fits into the hip socket) .Director of Nursing (DON) and Staff Development Coordinator (SDC) held reenactment of scene with CNA that was providing care to resident when fall took place. Education provided on: safely repositioning resident prior to brief change by using draw sheet to pull resident closer to person prior to turning; obtain second staff member to assist with check and change and repositioning for safety if at all in doubt of resident's ability to assist . Review of an internal report number 4340 witnessed fall itnessed fall report dated 10/27/29 at 03:15 PM prepared by RN Supervisor dcumented: R1 received one person assist prior to fall. Day shift Licensed Nurse (LN) was notified at time of fall from day shift CN[NAME] Evening shift nurse coming on shift for report from day shift LN. Bed approximately three feet from floor and flat. Found resident lying on his left side on the right side of the bed closest to the window in a fetal position. Resident unable to verbalize description of fall. Review of the facility Fall Scene Investigation Tool included the following statement from CNA1 dated 10/27/19, While I was changing patient (R1), he was turned toward his window while I was putting his brief and new draw sheet. When it was time to turn back, he went more forward instead and he fell off his bed . Review of the Actions, Progress, and Resolution section of the facility's VHA issue brief (system report of fall incident) dated 11/04/19, also revealed the following statements: DON and SDC held reenactment scene with CNA that was providing care to resident when fall took place. Education provided on: Safely repositioning resident prior to brief change by using draw sheet to pull resident closer to person prior to turning . Review of 10/27/19 R1's Hilo Medical Center Emergency Physician (MD1) notes documented: This is a [AGE] year-old male with history of dementia who has one word nonverbal status . He has an impacted left femoral neck fracture. Due to his nonambulatory status he will not be a candidate for operative management. We will place him in a knee immobilizer so he does not flex his knee and thus flex his hip. I have given him a dose of [MEDICATION NAME] as he has had Tylenol for pain at the outside facility. I am going to recommend Tylenol first and [MEDICATION NAME] second for pain management for him. The patient was discharged back to the nursing home. Review of Progress Notes revealed R1 had ongoing pain after the fall. Entries included: 10/28/19 01:28 During perineal care (peri-care) at approximately 06:30 PM, CNA attempted to turn resident to his right side to change his brief when she observed resident with facial grimacing and moaning. CNA asked if he was in pain and resident nodded his head . 10/28/19 23:36 Denies any pain or discomfort however, during rounding and re-positioning, resident was observed with facial grimacing and soft moaning. 10/29/19 02:39 Denies pain. Reported some facial grimacing during incontinence care. 10/29/19 14:59 Resident noted to be in pain upon movement in bed by two-person assistance with ADL care. 10/29/19 23:32 Denies any pain or discomfort however, resident is observed groaning and guarding Left Lower Extremity (LLE) during peri-care and re-positioning. 10/30/19 01:22 .facial grimacing and other nonverbal cues of pain during bed mobility . 10/30/19 14:37 .Resident noted with facial grimacing and saying ow during rounds. Review of Medication Administration Records (MAR) revealed prior to the fall, R1 had an order in place dated 02/25/18 for [MEDICATION NAME] (Tylenol) tablet 325 mg (milligrams) every six hours as needed for mild pain not to exceed over three grams in 24 hours. The MAR from 10/01/19 through 10/26/19 revealed R1 did not need or receive any Tylenol for pain during that period of time. After the fall (10/27/19), a new order for pain medication was entered for [MEDICATION NAME] Capsule 5 mg. via pe[DEVICE] (tube in patient's stomach through the abdominal wall because of difficulty swallowing) every four hours needed for moderate to severe pain. The MAR further documents medication was administered for pain as below: 10/27/19 Tylenol 325 mg prior to transport to the hospital. 10/28/19 Tylenol 325 mg at 08:36 and 18:47. 10/29/19 Tylenol 325 mg at 01:01 and 18:30, and [MEDICATION NAME] at 11:46, 18:30, and 23:26. 10/30/19 Tylenol 325 mg at 10:00 and 19:42, and [MEDICATION NAME] at 06:48, 17:20, and 23:04. 10/31/19 Tylenol 325 mg at 06:45 and 18:10, and [MEDICATION NAME] at 03:39, and 13:34. 11/01/19 at 20:00, a new pain medication order was entered for [MEDICATION NAME] twice a day with the PRN as needed ([MEDICATION NAME] HCL tab 5 mg give 5 mg via [DEVICE] two times a day for PAIN.) R1 received the scheduled [MEDICATION NAME] twice a day 11/01/19 through 11/13/19. On 11/11/19 and 11/12/19 he required one additional PRN dose of [MEDICATION NAME], and on 11/13/19 R1 required two additional PRN doses of [MEDICATION NAME]. On 11/14/19 at 01:05 PM during an interview with the SDC and DON, the SDC said she reviewed the incident with the employee on her first day back to work. She said she provided education to CNA1 in the room with the resident in bed, after doing a reenactment of the fall. CNA1 roll played and described where she stood, where R1 was positioned in bed, and how he moved. When the SDC was asked what they determined the cause of the fall was, she said, positioning, he rolled over a little more than usual. He was more positioned on that side of the bed than when she usually works with him. SDC said the CNA1 was giving him (R1) cues so they would be coordinated with the turning procedure. The DON stated, We also identified during the reenactment that CNA1 should bring him closer to her first before moving. On 11/14/19 at 03:30 PM, observed that R1's bed had upper assist rails attached to help him with bed mobility/repositioning. At 03:35 PM observed CNA2 in R1's room preparing to provide care. CNA3 came to assist, and they provided peri-care and changed his brief. When R1 was rolled, he would grimace and groan loudly. He did this both times he was rolled to change his brief. When the two CNA's were asked if R1 groaned like that when they moved him prior to the fall, CNA2 said, No, he only does that after the fall. On 11/15/19 at 07:38 during an interview with R1's Physician (MD2), he said R1 had progressive dementia. When he came in, he had a significant mental health [DIAGNOSES REDACTED]. MD2 confirmed R1 had not been taking anything for pain prior to the fall .Surgery is not worth the risk, and treatment course is clear with comfort measures. The fracture, I expect will take three months to heal. There was sufficient evidence that the facility corrected noncompliance and is in substantial compliance at the time of the current survey for F-tag 689. Interventions and Findings include: 1. DON and SDC held reenactment of scene with CNA1. Education provided on: safely repositioning resident prior to brief change by using the draw sheet to pull resident closer to person prior to turning; obtain second staff member to assist with check and change and repositioning for safety if at all in doubt of resident's ability to assist . 2. RR revealed on 11/01/19 CNA1 completed the Competency Checklist titled, Moving a Resident in Bed. This competency included specific technique to move a resident safely with draw sheet utilizing one or two persons. 3. During interview with DON, discussed post event staff training. DON said she determined to retrain only the CNA involved in the event, as there were no other incidents or falls related to positioning. This was validated by RR of incident log. DON stated her decision was also because all CNA's are required to complete the mandatory Moving a Resident in Bed competency in orientation. RR confirmed all CNA's currently on staff had documentation of completing the competency. 4. On 10/28/19 R1's care plan was updated to reflect two persons assist with ADL's and incontinence care. 5. On 10/28/19, the CNA Kardex (task instructions) was updated to communicate to all CNA's the change of two persons assist for ADL's and incontinence care. 6. A new intervention included adding transfer bars to assist P1 with bed mobility and promote participation with care. RR revealed on 11/01/19 R1's POA (Power of Attorney) signed consent for the use of transfer bars. On 11/14/10, observation confirmed the bars were installed on R1's bed. 7. Ongoing staff huddles were held with all staff with a focus on safety, fall prevention and reporting any resident changes that might affect need for additional assistance. 8. On 11/14/19 observed brief change and peri-care provided by two CNA's according to R1's updated care plan. 9. All residents who were one-person assist were reevaluated for appropriate assessment, and emphasis in huddles to report resident changes that might require a change in assistance.",2020-09-01
891,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2019-02-01,578,E,0,1,NTP211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review (RR), the facility failed to provide documentation that residents or their representatives were given opportunities to formulate Advance Directives (AD) for three residents (R) 47, R72, and R78 of 31 residents selected for review. Findings Include: 1) On 01/30/2019 at 8:37 AM, RR for R78 showed no AD. On 01/30/2019 at 11:37 AM, Clinical Clerk (CC) 5 informed surveyor she was unable to locate an AD for R78. 2) R72 was recently admitted to the facility on [DATE]. Record review revealed R72 had a POLST, but no AD in the clinical hard chart. On 01/30/2019 at 8:57 AM, the Clinical Support Manager (CSM) stated the social worker, is responsible to follow up for advance directives on admission and/or with family. On 01/30/2019 at 9:03 AM, during a concurrent record review, the CSM confirmed the social worker only checked off the POLST but had no AD review/documentation on her initial assessment for R72. On 02/01/2019 at 12:02 PM, registered nurse (RN) 1 reviewed R72's durable power of attorney form and concurred it was not an AD for health care decisions, but for financial decisions only. 3) On 01/30/2019 at 1:06 PM, the RR on R47 found there was no AD. The facility's Acknowledgement form that R47 signed on admission had initialed with a check mark at, .7. I do not have a living will or Advance Directives and am interested in completing an Advance Directive . On 01/31/2019 at 11:04 AM interviewed the social worker coordinator (SWC) and inquired how she would be alerted that a resident at the facility was interested in developing an Advance Directive. The SWC stated that the admission clerk would alert social services and a social worker would then follow-up with the resident to get an AD done. The SWC was not aware of R47's request for AD on the facility's Acknowledgement form, as she just started in (MONTH) (YEAR) and R47 was admitted in (YEAR). On 02/01/2019 at 7:30 AM, interview with Clinical Support Manager (CSM) who confirmed the facility does not have a process for follow-up regarding AD. CSM stated they are working on a process and will have one soon.",2020-09-01
892,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2019-02-01,760,D,0,1,NTP211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to prepare and administer one medication for one resident (R) 4 of 31 residents selected for review. This deficient practice had the potential to cause the resident discomfort or jeopardizes his or her health and safety. Findings Include: On 01/31/2019 at 7:38 AM, Observation of Medication administration for R4 on Ilima Unit with Registered Nurse (RN) 6. R4 had the following medications: [REDACTED]. RN6 proceeded to crush all of R4's pills in a small clear plastic zip lock bag. RN6 was queried by surveyor if there was a physician's orders [REDACTED]. Surveyor questioned if all the pills were to be crushed, RN6 said yes. Surveyor queried RN6 if the Aspirin EC was to be crushed, RN6 thought for a moment and stated, No. 01/31/2019 at 7:45 AM, Interviews with DON and ADON who both confirmed that Aspirin EC 81 mg should not have been crushed.",2020-09-01
893,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2019-02-01,880,D,0,1,NTP211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and policy reviews the facility failed to ensure that policies and procedures for infection control measures implemented to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment were being followed. 1) Visitors entered the room (RM) without donning personal protective equipment (PPE) for one of 31 sampled residents, (R) 46 on contact precautions; and, 2) The facility failed to clean the suction equipment/canister for one of the eight residents (R) 68 reviewed. These deficient practices put the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: 1) Contact Precautions and PPE use On 01/30/2019 at 9:24 AM the electronic record review (RR) on R46 noted on the 12/31/18 monthly summary that R46 tested positive for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) to a left (L) ear wound, and was being treated with antibiotics via intramuscular (IM) injections and through his/her gastrostomy tube (GT) for 14 days. In addition, R46 was started on antibiotic ear drops to the L ear as the resident developed middle ear infection. On 01/31/2019 at 8:20 AM observed R46 being prepared for transport with certified nursing assistant (CNA) 6 wearing personal protective equipment (PPE) in the RM, and the spouse at the bedside without PPE on. The transport driver also walked into R46's RM without putting on PPE and the spouse assisted the transport driver in transferring R46 from the bed to the transport gurney. Both the spouse and transport driver left the RM with R46 on the gurney, walked through the common hallway and passed the activity/dining area to the transport van outside. Interviewed CNA6 about PPE use for visitors and she stated that the spouse normally wears PPE but didn't know why PPE not used on this date. Interviewed RN2, and she stated that R46 was transported to an acute care hospital to have GT changed. Shared observation with RN2 of spouse and transport driver not wearing PPE, with R46 on contact precautions [MEDICAL CONDITION]. RN2 stated that the spouse normally wears PPE, but didn't have an answer for the transport driver who was under contract for transportation. On 01/31/2019 at 10:16 AM R46 returned to the facility and observed CNA6 in R46's RM with PPE on, and the spouse entered the facility from outside with PPE on. The spouse was about to enter R46's RM but CNA6 stopped spouse at the door and stated that PPE needed to be changed. Interviewed the spouse who stated that PPE was not used when transported R46 earlier in the morning because just came to pick-up resident and didn't want to waste PPE. The spouse stated that instructions on PPE use was provided. Subsequently, observed that housekeeper (Hskpr) 8 walked into R46's RM without PPE on. The Hskpr8 delivered clean laundry and placed into R46's closet. Interviewed Hskpr8 and inquired if PPE used for residents on contact precaution. The Hskpr8 stated that he should use PPE for residents on contact precaution and would know by the contact precaution sign (smiley face picture) on the door. Pointed out that R46 had a smiley face picture on the door and PPE were in plastic drawers fronting the RM. The Hskpr8 was unaware that R46 was on contact precautions, and didn't notice smiley face sign as door was opened inward to the left of doorway. The Hskpr8 then put on PPE and delivered clean laundry to R46's roommate. On 01/31/2019 at 10:40 AM requested PPE policy and procedure for residents on contact precaution from unit manager (UM) 1. The facility's policy and procedure for Standard Precaution/Use of PPE, under the paragraph Personal Protective Equipment (PPE); a. Wear PPE when the nature of the anticipated resident interaction indicates that contact with blood or body fluids may occur. ; b. Prevent contamination of clothing and skin during the process of removing PPE. (see PPE removal procedure); c. Before leaving the resident's room or cubicle, remove and discard PPE. The facility's policy and procedure for Standard Precautions, with revision dates of 05/05/2008, and 12/15/2017 under the column for Room Signage, had comments, Use 'Happy Face' for non-[MEDICAL CONDITION] infections. Use 'Sad Face' for [MEDICAL CONDITION] or similar infections. Interviewed the director of nursing (DON) and shared above observations. The DON stated that all facility staff are aware that the smiley face picture on a resident's door means that the resident(s) are on contact precautions. The DON could not provide an answer for the contracted transport driver not wearing PPE but was aware that the spouse usually wore PPE. The facility did not a an infection prevention and control program that included a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that covered visitors, and other individuals providing services under a contractual arrangement. 2) Cleaning and Disinfection of Resident Care Equipment During an observation of the suction equipment in R68's room, on 01/29/2019 at 9:45 AM, the suction equipment/canister contained approximately 10 cc of white/brown liquid contents. The resident was not in the room and there was no way to determine how long the contents was in the canister. The canister was marked with the date 01/12/2019. During staff interview with the UM1 on 01/29/2019 at 9:53 AM, UM1 did not know how long the white/ brown contents was there. UM1 further acknowledged that the white/ brown contents should have been properly disposed of. After further inquiry with the DON on 01/30/2019 at 9:26 AM, she provided the policy on Reprocessing of Suction Machines, which stated - This facility will provide guidelines for the proper cleaning and disinfecting of reusable medical equipment after its use. Cleaning and disinfection; remove the used suction canister and empty any contents into the utility sink. Turn on water to thoroughly flush contents down the drain. This was not done.",2020-09-01
894,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2019-02-01,908,D,0,1,NTP211,"Based on observation, staff interview, and review of manufacturer's recommendation, the facility failed to perform routine maintenance and failed to keep preventative maintenance records for two out of two oxygen concentrators reviewed. This deficient practice put the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: During an observation on 01/30/2019 at 9:00 AM, resident (R)15 was noted to be receiving oxygen via an oxygen concentrator. Upon further observation of the oxygen concentrator, the cabinet filter was noted to be dirty containing lint and dust. For resident safety, R15 was briefly assessed and did not appear to be in any acute respiratory distress. During an interview with the Unit Manager (UM)1 on 01/30/2019 at 9:05 AM, UM1 stated that all routine maintenance for the oxygen concentrators were done by maintenance personnel. During an interview with the Maintenance Manager (Maint Mgr), on 1/30/2019 at 11:30 AM, Maint Mgr said that the facility was not aware of any routine maintenance, cleaning of the cabinet filter recommendation, and thus was not being done as per manufacturer's recommendation. Maint Mgr went on and said that he would immediately take care of this matter. A review of the instruction manual for the Devilbiss Oxygen Concentrator stated the following: Caring for your Devilbiss Oxygen Concentrator, Air Filter - the air filter should be cleaned at least once a week. As previously mentioned, the facility was not aware of this recommendation.",2020-09-01
895,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2018-03-09,580,D,0,1,JG6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews with staff, review of facility's policy and procedures and records, the facility failed to immediately report significant changes in the resident's weight on 3/3/18 and 3/5/18 to the resident's physician per regulation and facility's own policy. Findings include: A recertification survey was conducted on 3/6/18 to 3/9/18, and during this time review of the electronic health record reflected that resident whose admitting [DIAGNOSES REDACTED]. On 3/8/18 at 3:47 p.m. interviewed Staff #34 and asked when do you report a significant weight loss? Staff replied on Monday since the registered dietician does not work on Sunday when weights are taken. Staff #34 was asked what a significant weight loss is and replied three or more pounds. Requested from staff #166 on 3/9/18 at 7:52 a.m. facility's policies and procedures on weighing, assessments and reporting of changes of health status to resident's physician and received the documents at 8:40 a.m. The facility's policy and procedure on notification of changes in health status for residents was reviewed and states that the nurse will notify the physician of the changes on the shift the change occurs and document the notification. Review of resident's electronic medical record reflected that staff #34 initally notified resident's physician of the weight loss on 3/9/18 at 7:44 a.m., four days after resident had already lost 16.4 pounds, 6.11% of her weight. On 3/9/18 at 11:06 a.m. telephone interview with the physician who confirmed that he was notified of the weight loss on 3/8/18, three days after resident lost 16.4 pounds.",2020-09-01
896,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2018-03-09,584,D,0,1,JG6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to provide a clean and safe environment in 2 resident shower rooms. Findings include: On 03/06/18, while doing the initial tour on Weinberg Hall 1, observed that room [ROOM NUMBER]'s bathroom handheld shower head, the wall and floor tile had a black/gray substance. On 03/09/18 at 10:44 AM interviewed staff #110 and #130 who stated that they use cleaner 456 from ECO lab to clean the shower rooms. During that time it was noted that the hand held shower head and tile in shower room [ROOM NUMBER] continued to have the black substance on them. On 03/09/18 at 11:04 AM requested that staff #105 escort us as we toured the Weinberg Hall 1 resident and shower rooms. While in room [ROOM NUMBER] it was noted that there was black substance on the hand held shower head and the shower drain had what appeared to be a dark orange colored substance which staff #105 stated was rust. Staff #105 concurred that the wall and floor tile, hand held shower head and drain should be kept clean.",2020-09-01
897,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2018-03-09,655,D,0,1,JG6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to develop and implement a baseline care plan for Resident #153 (R#153) that would provide effective and person-centered care of the resident that includes the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders [REDACTED] Findings include: R#153 was admitted with a principal [DIAGNOSES REDACTED]. Observation on 03/07/18 at 10:39 [NAME]M. revealed resident on 3 liters of Oxygen (O2) with labored breathing. R#153 had just been turned. R#153 demonstrated using accessory muscles, labored breathing and appears anxious. Observation on 03/08/2018 at 07:33 [NAME]M. while R#153 receiving medications from nurse. R#153 still using accessory muscles to breathe. O2 nasal cannula on forehead. Nurse offered to assist her with correct placement of nasal cannula. R#153 initially refusing her medications and correct placement of 02 nasal cannula. R#153 appeared anxious with any activity or movement. Observation on 03/09/2018 at 11:34 [NAME]M. R#153 sleeping and appears comfortable. 03/09/2018 at 11:34 [NAME]M. Interview and concurrent record review with S#30 revealed that no baseline care plan in the facility was initiated for respiratory care. Further investigation revealed that hospice care plan had addressed R#153's respiratory status. Hospice care plan was not carried over within 48 hours of admission to promote continuity of care and communication among the nursing staff. R#153's admission [DIAGNOSES REDACTED].#153's treatments were not reflected in the facilities care plan.",2020-09-01
898,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2018-03-09,656,D,0,1,JG6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview the facility failed to develop and implement a comprehensive person-centered care plan for resident (R) #53 who receives [MEDICAL TREATMENT] service and has a permacath in her left jugular vein. Findings include: On 03/09/18 at 03:00 PM reviewed R#53's care plan (CP) for [MEDICAL TREATMENT] and noted that it stated Monitor AV shunt patency Q shift: Palpate for distal thrill; auscultate for a bruit; evaluate reports of pain, numbing/tingling; note extremity swelling distal to access. Avoid trauma to shunt; e.g., limit activity of extremity. Avoid taking BP or drawing blood samples in shunt extremity. Instruct resident not to sleep on side with shunt or carry packages, books etc. on affected extremity. It was noted that while reviewing R#53's [MEDICAL TREATMENT] Inter-facility Communication Sheet dated from (MONTH) 4, (YEAR) to (MONTH) 3, (YEAR) the facility nurses documented that R#53 had a permacath L IJ and at no time was an AV SHUNT checked off as the vascular access site for this resident. While reviewing the resident's record inquired with staff #88 if R#53 has a permacath or an AV shunt and he/she reviewed the resident's record and stated the information documented was a mistake and confirmed that R#53 has a permacath.",2020-09-01
899,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2018-03-09,700,E,0,1,JG6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, record review and staff interview the facility failed to assess the resident for risk of entrapment from bed rails, failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to use of bed rails for 6 of their residents (R# 12, 31, 53, 56, 82 and 84) . Findings include: On 03/06/18 upon initial tour of Weinberg Hall 1 it was noted that 6 residents (R# 12, 31, 53, 56, 82 and 84) had bed rails on their beds. On 03/08/18 at 08:58 AM requested Bed Rail Risk Assessment and Consent for Bed rail use for R# 12, 31, 53, 56, 82 and 84 from staff #72. Review of resident's Brief Interview for Mental Status (BIMS) from their Minimum Data Set (MDS) for R# 12, 31, 53, 56, 82 and 84 found that only R#53 had a BIMS of 15 and did not have a [DIAGNOSES REDACTED]. Interviewed staff #88 who confirmed that the facility does not have a Bed Rail Risk Assessment form being used and they also do not have a consent for bed rail use. Staff #88 was able to show the new Bed Rail Risk Assessment and Consent for Bed rail use form that was developed on 03/07/18. Staff #88 explained that the form is not in place as of yet and residents with bed rails do not have a risk assessment done and no consent for bed rail use. Staff #88 stated that they would look at residents records to search for documentation that risk assessments were done for each res before bed rails were used with them. Staff #72 stated that bedrails are on some of the beds and are not being used as one resident is paralyzed. Surveyor explained to staff #72 and staff #88 that there is no guarantee that the bed rails would not be used by staff who are not familiar with these residents. The bedrail is on the bed and anyone at anytime could raise them up putting a resident at risk for entrapment. Staff #88 concurred with this. Staff #88 was unable to produce any documentation for bedrail risk assessment for R# 12, 31, 53, 56, 82 and 84.",2020-09-01
900,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2018-03-09,761,D,0,1,JG6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to label in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the appropriate expiration date when applicable. Findings include On [DATE] at 10:17 [NAME]M. two medication carts and two med storage rooms were reviewed for proper labeling and storage. Review of the medication cart on Lehua Unit with staff #19 revealed a medication with an expired date of [DATE] for [MEDICATION NAME] 1 mg tab by mouth. Staff#19 confirmed that the medication should have been discarded on [DATE].",2020-09-01
901,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2018-03-09,812,E,0,1,JG6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to provide safe food handling practices to prevent the outbreak of foodborne illness. Findings include: 1) During the dining observation on 03/06/18 at 11:21 [NAME]M., three staff members were handling food trays in the dining area for approximately 12 residents. Staff #60 (S#60) was standing in between two residents and observed to be feeding one resident and prepping the tray for the other resident. No hand sanitization was done between prepping and feeding R#1 and R#2. S#60 then went to food trays in cart and obtained a tray for 3rd resident's food without hand sanitization. S#60 then prepped a straw for Res#4 and then a straw for Res#3. S#60 then disposed of a tray. S#60 obtained a tray for R#5 and took it to R#5. No hand sanitization was done. She then helped set up a napkin for R#5. S#60 then took dishes to dirties and emptied dishes. S#60 handled five resident trays without any hand sanitization. S#60 then pushed the lunch cart to hall and started passing trays out to Res #6 - in room [ROOM NUMBER] without hand washing or hand sanitization. S#60 touched the bed controls to set R#6 upright before serving R#6's tray. No hand sanitization was done after set up of R#6's tray. S#60 then passed room [ROOM NUMBER] or Res #7's tray without hand sanitization. Staff #60 passed room [ROOM NUMBER] or R#8's tray without hand sanitization. At this point, surveyor asked S#60 if she was forgetting something? S#60 stated to warm up? Surveyor then stated that she has not done hand sanitization since passing trays in dining area and hall, after 8 residents. She then proceeded to wash her hands. 2) On 03/08/18 observed lunch trayline at 11:10 AM. Prior to start of trayline food distribution the food temperatures were taken and recorded. As the trayline continued it was found that 2 food items (fish and rice) were replenished on the trayline and their temperatures were not taken. It was also observed that as staff #122 replenished the rice they dropped part of a dirty towel, which had been used earlier to wipe the counter, on the newly placed rice. Staff#122 was directed to throw out the rice by staff #81. As staff #122 replaced the rice again it was observed that they dropped a corner of part of the dirty towel onto the newly placed rice. After lunch trayline observation reviewed the (MONTH) (YEAR) Tray Line Temperature /Waste Log and found that the documentation was incomplete. Interviewed staff #122, who was working on 02/05/18, and had recorded some of the temperatures. Inquired why there were missing temperatures during lunch and they stated we were short staffed and then stated but that is not an excuse. Staff #81 confirmed that all temperatures were to have been documented for food cooked that day for lunch. 3) On 03/08/18, after observing trayline food distrubition, observed that the kitchen had a large rolling dish storing rack that had rust, as confirmed by staff #105, throughout on the parts that dishes rested on to dry. The kitchen also had a large rolling rack that stored metal storage containers and lids and again rust was confirmed to be on the rack by staff #105. Rust was also observed and confirmed by staff #105 on the cutting board storage racks. 4) During the dining observation on 03/06/18 at 12:11 PM Staff #117 was observed to rub his nose with his right hand then pick up the resident's drink cup to give the resident a sip of the liquid. Staff #117 then picked up residents spoon and fork with the right hand to give the resident a bite of food. Staff #117 did not sanitize hands after rubbing his nose before assisting the resident with the meal. On 3/08/18 at 9:35 [NAME]M. an interview was conducted with Staff #19 who provided the following inservice training documents for staff #117: Nurse Aide clinical skill competency; evaluation form; remedial education; and plan of correction. Upon review of the documents the following comments were revealed: A lot of tries, staff #117 miss to change gloves in between care, also forgets to use the sani-hands in between care, and needs to be reminded all the time. Review of the remedial education plan of correction dated 12/15/17 stated that Staff #117 needs improvement on infection control and that 1:1 education was done on the importance of proper hand hygiene and gloving to prevent the spread of infection. Staff #117 will be observed for consistency with sanitizing/ washing his hands properly. For example, after he touches anything dirty, between residents, before/ after changing gloves. Staff #117 will be re-evaluated on 3/15/18. The Hand hygiene policy was reviewed and states that hands must be washed thoroughly with soap and water or an alcohol based antiseptic handrubs when visibly soiled and before and after resident contact.",2020-09-01
902,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2018-03-09,842,D,0,1,JG6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to maintain accurate medical records on Resident #154 and #53. Findings include: 1) Interview on 3/06/2018 at 10:00 [NAME]M. R#154 stated there is an epidemic. My daughter and wife cannot come because of an epidemic. Record Review on 03/08/2018 at 09:44 [NAME]M. in the progress notes stated Stayed in bed today for scabies precaution. MD orders written on 03/01/2018 for Elmite 5% CN Cream. Apply topically on Thursday evening from neck to toes. Leave on for 12 hours. Shower off in [NAME]M. Repeat once on 03/08/2018. Diagnosis: [REDACTED].>Interview on 03/08/2018 with Staff #90. Staff #90 was asked how they record that they have showered a resident. A folder located in the shelf above the computer station with a flowsheet of ADL assistance and support was handed to surveyor. On further inquiry, it was missing the necessary documentation that stated that on 03/08/2018, a repeat application of Elmite 5% cream was applied and that it was left on for 12 hours and then showered off in [NAME]M. Interview with Staff#88 on 03/09/2018. Staff #88 stated that she did call the staff member who had completed the shower task and that the staff member did not document that she did it but she confirmed that she did do the shower task. It was explained to Staff #88 that because this was a very specific order that would stop the spread of transmission of scabies, documentation should have been demonstrated accurately. Policy and Procedure effective (YEAR) for Outbreak Investigation Protocol states in Step 8 In some situations, you may implement direct control measures to interrupt transmission or exposure. Cross Reference to F656 2) On 03/09/18 at 03:00 PM reviewed R#53's care plan (CP) for [MEDICAL TREATMENT] and noted that it stated Monitor AV shunt patency Q shift: Palpate for distal thrill; auscultate for a bruit; evaluate reports of pain, numbing/tingling; note extremity swelling distal to access. Avoid trauma to shunt; e.g., limit activity of extremity. Avoid taking BP or drawing blood samples in shunt extremity. Instruct resident not to sleep on side with shunt or carry packages, books etc. on affected extremity. It was noted that while reviewing R#53's [MEDICAL TREATMENT] Interfacility Communication Sheet dated from (MONTH) 4, (YEAR) to (MONTH) 3, (YEAR) the facility nurses documented that R#53 had a permacath L IJ and at no time was an AV SHUNT checked off as the vascular access site for this resident. Upon continued review of the [MEDICAL TREATMENT] Interfacility Communication Sheets it was noted that there was documentation missing. Of the 26 sheets only 13 noted who was transporting the resident to [MEDICAL TREATMENT], 16 noted the vascular access site, and only 11 of the 26 communication sheets documented the resident's [MEDICAL TREATMENT] weight. At no time did the facility communicate on the 26 [MEDICAL TREATMENT] Interfacility Communication Sheets dated from (MONTH) 4, (YEAR) to (MONTH) 3, (YEAR) the condition/complaints: that the resident was in or had. One nurse, on 1/16/18, however did use this box on the form to communicate with the [MEDICAL TREATMENT] center inquiring for copy of recent labs done and inquired if the resident need fluid restriction? Yes or no and How much ________ ml/day. 11 of these 26 communication sheets were not signed and dated by the facility nurse and 4 were not signed by the [MEDICAL TREATMENT] nurse. The [MEDICAL TREATMENT] facility failed to document 15 of the 26 times on resident's condition/complaints and failed to check off if the resident's Discharge was stable or unstable. While reviewing the resident's record inquired with staff #88 if R#53 has a permacath or an AV shunt and he/she reviewed the resident's record and stated that R#53 has a permacath. Interviewed staff #88 and inquired if [MEDICAL TREATMENT] Interfacility Communication Sheet dated from (MONTH) 4, (YEAR) to (MONTH) 3, (YEAR) are required to be completely filled out by facility staff and he/she stated yes and concurred that the documentation was incomplete.",2020-09-01
903,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2018-03-09,880,D,0,1,JG6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of facility policy staff #154 failed to follow proper hand hygiene procedures while performing a [DEVICE] dressing change for resident (R) #69. Findings include: On 3/8/17, in the afternoon, observed staff #154 perform a [DEVICE] dressing change with R#69 . Each of the 3 times staff #154 changed gloves during the procedure, hand hygiene was not done. Met with staff #88 afterwards who confirmed that all staff are to do proper hand hygiene while providing care for residents. Review of facility's Standard Precaution/Use of PPE policy found under PR[NAME]EDURE: 1. Perform Hand Hygiene f. After removing gloves. Staff #154 did not properly hand sanitize while peforming treatment to R#69.",2020-09-01
904,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2017-03-31,241,D,0,1,YHDP11,"Based on observation and staff interview the faciltiy failed to protect and promote the quality of life for one resident in the Stage 2 observation. Finding includes: On 3/30/2017 at 8:30 AM observed Resident #125 in bed with the privacy curtain drawn. Resident #125 could not be seen from the hallway. Staff #1 entered the resident's room and withdrew the privacy curtain so the resident was seen in bed from the hallway. Observed Resident #125 putting on her pants while in bed with no privacy provided. Staff #1 left the room and was immediately interviewed regarding the observation. Staff #1 shared, I understand, this is a dignity issue. The facility failed to treat the resident in a manner to promote quality of life.",2020-09-01
905,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2017-03-31,371,E,0,1,YHDP11,"Based on observations, policy reviews, and interviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Finding includes: 1) On 3/28/2017 at 8:07 AM a kitchen tour of the dry food pantry found the following: one plastic bin with individual serving size peanut butter cups with a used by date of 3/23/2017; one plastic bin of individual serving packets of lemon juice with a used by date of 3/23/2017; a cardboard box with jello powder bags with a used by date of 11/29/2016; a cardboard box of Krusteza blueberry muffin mixes with a use by date of 12/29/2016. An interview and observation of the expired foods was held with the Staff # 2 during the kitchen tour. Staff #2 looked at the above named foods and acknowledged that the food items should have been discarded. Expired foods should not be used beyond the used by date for food safety. 2) On 3/30/2017 at 11:10 PM a noon tray line food plating observation was done. The plating started at 11:10 AM and ended at 11:55 AM. Staff #2 shared the food is kept on the steam table for another 15 - 20 minutes in case a call comes from the floor for additional plates. A review of the tray line temperture log showed documentation for Cook and Hold temperatures already recorded for the noon meal. Staff #2 shared the Cook temp is when the food is in the pot, the Hold temp is just before plating when the food is on the steam table. Staff #2 was asked when the Hold temperature was taken and shared the hold temp was taken about 15 minutes before plating. There was no monitoring of food temperture during the entire plating observation. The facility policy titled, Food Temperature states: Temperatures are to be recorded and taken randomly throughout the meal service. Food safety requires monitoring of the temperature while food is on the steam table. 3) On 03/30/2017 at 11:10 AM during the noon tray line plating random Staff #5 and Staff #6 were observed. Staff #5 removed his gloves and failing to hand sanitize put on another pair of clean goves. At 11:44 AM observed random Staff #6 remove his gloves and failing to hand sanitize put on another pair of clean gloves. Staff #2 was asked the policy for hand sanitize between glove changes. Staff #2 stated the staff should hand sanitize before putting on clean gloves. The facility policy titled Infection Control Monitoring - Personal Hygiene states 8. Hands will be washed prior to food preparation and any activity that contaminates the hands. E. Before putting on gloves. Staff #2 stated the sinks to wash hands are nearby, it is not a problem to hand sanitize. Hand sanitizing between glove change is an infection control practice. 4) On 3/30/2017 at 11:55 AM observed in the dishwashing area of the kitchen a large fan mounted on the wall with dark brown dust visible between the fan grill. The fan was on and blowing towards a shelf of stored clean pans. Staff #2 agreed the fan was dirty and needed to be cleaned. Dust and dirt from the fan has the potential to contaminate kitchen equipment. 5) On 3/31/2017 at 7:47 AM found in a resident nourishment refrigerator on the floor was a juice container with no label and/or date. Confirmed with Staff #2 that the container was juice for resident use and should be labled and dated. Food handling risk includes foods stored on the unit left in the refrigerator beyond safe use by dates.",2020-09-01
906,PALOLO CHINESE HOME,125059,2459 10TH AVENUE,HONOLULU,HI,96816,2017-03-31,441,D,0,1,YHDP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to practice infection control prevention for one resident during the Stage 2 investigation. Finding includes: On 3/30/2016 at 8:30 AM observed Staff #5 walk into Res #125's room carrying a cloth personal bag and a black binder. Staff #5 placed her black binder on top of the resident's bed blankets. Staff #5 then picked up the black binder placed the binder into the cloth bag and placed the bag on the side of the resident's bed, below the bed. During the same observation period observed Res #125 sitting in a wheelchair. Staff #5 adjusted the resident's wheel chair footrest then stood and without hand sanitizing [MEDICATION NAME] back the resident's hair and combed the resident's pony tail. Immediately after the observation when Staff #5 exited the room the observation was discussed with Staff #5. Staff #5 stated, if an infection control risk I would not have put my folder on the bed, I wipe the folder down, I clean the binder if the resident has an infection. Later that day the observation was described to Staff #4 who agreed the folder should not have been placed on the resident's bed as an infection control practice. The faciltiy policy titled: Infection Control Policy & Procedure: Hand Washing states: 1. Hands must be washed thoroughly with soap and water when touching any object that is dirty. a. Before and after resident care i. After touching any soiled object or suface, clothing or tissue. Hand hygiene procedures by staff involved in direct resident contact is an infection control prevention practice.",2020-09-01
907,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-18,550,D,0,1,31RN11,"Based on observation and interview with staff member, the facility failed to ensure care was provided for residents with dignity and respect. Findings Include: On 04/15/19 at 12:10 PM an observation found four residents seated at a round table in preparation for lunch. Resident (R) 2 was seated in a reclined wheelchair with legs raised above the table height, preventing the resident from facing the table. R2 was placed to the left side of R23. The residents' meals were placed on the table and R23 independently ate the lunch. R2's feet were covered with a blanket; however, R2's feet were observed to be pointed toward R23's face (just below the chin). A second observation found the staff member feeding R23. R23's feet were pushed closer to R2 to create a space for the staff member to feed R2. On 04/15/19 at 12:40 PM, concurrent observation with Licensed Nurse (LN) 59 was done. LN59 asked the staff member to re-position R2's feet so that it was not placed toward R23's face.",2020-09-01
908,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-18,578,D,0,1,31RN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to ensure 1 of 3 sampled (Resident (R) 10) residents reviewed for advance directives was provided with the opportunity to formulate an advance directive. Findings Include: On [DATE] at 08:51 AM a record review found no documentation of an advance directive for Resident (R)10. A review of the resident's Admission Record notes CPR/Attempt Resuscitation. The resident's physician's orders [REDACTED]. On [DATE] at 10:44 AM an interview was conducted with the Director of Nursing (DON). The DON reported the facility will review a resident's code status annually if the resident does not have an advance directive. The review is done during the resident's interdisciplinary team meeting. The DON was agreeable to review R10's record for documentation related to advance directives, whether the resident was offered an opportunity to formulate an advance directive and declined or wanted the facility to assist in formulating an advance directive. On [DATE] at 10:18 AM, the DON reported documentation of an advance directive could not be found. The DON provided a progress note dated [DATE] (10:10 AM) documenting R10 was interviewed and informed the facility that a family member has the paperwork identifying R10's health care power of attorney. The facility contacted the family member who was agreeable to provide the documentation to the facility.",2020-09-01
909,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-18,640,D,0,1,31RN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure transmittal of a discharge summary was done within 14 days after completion. Findings Include: Resident (R) 1 was selected for review based on an overdue Minimum Data Set (MDS) record (over 120 days). On 04/16/19 at 01:57 PM a record review noted R1 was admitted to the facility on [DATE] and discharged on [DATE]. Further review found a discharge MDS which was coded as discharge assessment-return not anticipated. The electronic medical record documents the status of the MDS was completed. On 04/16/19 at 02:03 PM the MDS Coordinator was interviewed. The MDS Coordinator confirmed R1 was discharged on [DATE]; however, was unable to determine whether the discharge assessment was transmitted. The coordinator reported medical record staff transmits the MDS upon completion. An interview was done with medical record, Staff Member (SM) 81. SM81 was agreeable to follow up on the status of the MDS transmission. On 04/17/19 at 09:25 AM, SM81 reported the discharge MDS was not transmitted. SM81 provided a copy of the transmittal. The receipt documents the transmission was accepted on 04/16/19.",2020-09-01
910,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-18,655,D,0,1,31RN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with Staff (S)71, Director of Nursing, the facility failed to develop a care plan for Resident (R)201's prescribed psychiatric medications and a diuretic, medication that increases urination. The deficient practice resulted in a care plan that lacked the information needed to provide effective and person-centered care of this resident. Findings Include: On 04/16/19 at 10:53 AM R201 complained of swelling in her lower legs. It was observed that R201 wore support stockings. It was also observed that R201was sleepy during the day which R201 validated as side effects of her psychiatric medications. On 04/17/19 at 12:00 PM Review of R201's records reflected that R201 is diagnosed with [REDACTED]. Review of R201's care plan did not include the [MEDICATION NAME]-[MEDICATION NAME][MEDICATION NAME], Duloxetine, and [MEDICATION NAME] ordered by R201's physician. On 04/17/19 at 03:45 PM S71, the Director of Nursing reviewed R201's care plan and validated that the care plan did not include resident's prescribed [MEDICATION NAME] 60 mg by mouth, daily for fluid retention, [MEDICATION NAME] 1mg by mouth at bedtime for anxiety, Duloxetine 60mg by mouth, daily for depression, [MEDICATION NAME]-[MEDICATION NAME][MEDICATION NAME] 10 mg by mouth, daily for anxiety. S71 verbalized that she was aware that the facility is required to develop a baseline care plan that incorporates all R201's physician orders. S71 submitted an updated care plan for R201 for review after S71 was shown the deficient care plan.",2020-09-01
911,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-18,657,D,0,1,31RN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to ensure the care plan for residents with urinary tract infection [MEDICAL CONDITION] and dehydration were revised to identify interventions to prevent UTIs and dehydration. Findings Include: 1) Cross Reference to F690 and F692. R10 was sent to the emergency department (ED) on 03/07/19 in response to an episode of possible orthostatic [MEDICAL CONDITION]. The discharge summary notes R10 was clinically dehydrated and had a UTI. R10 was provided with IV fluids and sent back to the facility with antibiotics. The Director of Nursing (DON) confirmed R10's care plan was not revised to include interventions to prevent UTIs and dehydration. Subsequently, R10 had another episode of possible orthostatic [MEDICAL CONDITION] and was treated with antibiotics for UTI. 2) Cross Reference to F690. R15 has been diagnosed with [REDACTED]. Interview and concurrent record review with the DON found the facility did not revised R15's care plan to prevent further UTIs.",2020-09-01
912,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-18,689,D,0,1,31RN11,"Based on observation, staff interview, and review of policy, the facility failed to identify potential accident hazards for the following: 1. Laulima Unit; exit door was not secured, 2. Central Supply Closet on the Laulima Unit was not secured. As a result of this deficient practice, the facility put the safety and well-being of the residents at risk for accident hazards. Findings Include: 1. During an observation of the Laulima Nursing Unit on 04/15/19 at 11:05, an exit door which contained a door latch, was not engaged and thus the door was not secured. The exit door lead to an outside storage area. During staff interview with Charge Nurse (CN) 59 on 04/15/2019 at 11:06 AM, CN59 stated that the exit door should have been secured at all times. A second staff interview with Staff Member (SM) 34 on 04/15/19 at 11:10 PM revealed that a staff member forgot to engage the door latch when re-entering into the facility. SM34 immediately checked that the door latch was engaged and that the exit door was secured. 2. During an observation of the Laulima Nursing Unit on 04/15/19 at 02:18 PM, the Central Supply Closet which had a door lock, was not locked and thus the closet was not secured. The closet contained various cleaning supplies including Spray Cleanse, Powder, Lotion, Skin Cream which contained various hazardous ingredients. During staff interview with Certified Nurse Aide (CNA) 36 on 04/15/19 at 02:22 PM, CNA36 acknowledged that the closet should have been locked. CNA36 also revealed that the locks were not always secured in the locked position and anyone could turn the lock to open it, even without the key. A second staff interview with CN56 on 04/15/19 at 02:34 PM revealed that CN56 was not aware of the locks not always being secured and that anyone could turn the lock to open it, even without the key. During a follow up observation of the Central Supply Closet on 04/17/19 at 11:00 AM, it was noted that the doors were secured with a different combination padlock.",2020-09-01
913,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-18,690,D,0,1,31RN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with resident and staff members, the facility failed to ensure 2 of 5 residents (Residents (R) 10 and 15) sampled for urinary tract infection received the appropriate treatment and services to prevent urinary tract infections. Findings Include: 1) Cross Reference to F657, F692, and F881. R10 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. On 04/15/19 at 02:39 PM, R10 reported possibly having a urinary tract infection [MEDICAL CONDITION] and awaiting results of the tests. R10 was asked if he/she has fevers, the resident responded sometimes. R10 reported using incontinence briefs which staff members assist in changing. R10 did not report concern with having to wait a long time for incontinence care. A record review was done on the morning of 04/17/19. The quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/09/19 notes R10 is always incontinent of urine and bowel and requires extensive assistance with one person physical assist for toilet use (transferring on/off toilet; cleaning after elimination; changing pad; etc.). R10 also requires supervision while eating and drinking with one person physical assist. A review of the physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. every six hours for seven days for UTI) from 03/08/19 through 03/14/19. A progress note dated 03/07/19 documents R10 became unresponsive during a shower, staff members were unable to rouse the resident. R10 has a history of orthostatic [MEDICAL CONDITION] and staff were unable to obtain a blood pressure. R10 was placed on the floor with legs elevated and became alert. The physician was notified and ordered to send R10 to the emergency department (ED). The progress note indicates, R10 returned to the facility at approximately 03:45 PM with [DIAGNOSES REDACTED]. The discharge summary (dated 03/07/19) from the ED was reviewed. A urine culture was ordered and an IV was started. The result of the urinalysis (03/07/19 at 02:35 PM) found moderate amounts of leukocyte esterase and moderate amounts of bacteria. The diagnostic impression included: patient appears clinically dehydrated; patient has a UTI and started on Keflex; and no signs [MEDICAL CONDITION] or [MEDICAL CONDITION]. Further review found a progress note dated 04/11/19 which documents R10 had another unresponsive episode while seated in a shower chair. The episode lasted for approximately two to three minutes. The resident was assisted back to bed with legs elevated and awakened (talking). The resident's physician was notified and ordered a urinalysis. The physician ordered antibiotic, [MEDICATION NAME], 250 mg. twice a day for UTI with a start date of 04/15/19 prior to reviewing the results of the urinalysis. A review of the resident's care plan found no documentation of interventions for UTI prevention. R10's care plan was not revised following the two episodes which resulted in use of antibiotics to treat the resident for UTIs. On 04/17/19 at 10:44 AM an interview was conducted with the Director of Nursing (DON). The DON confirmed R10 had two episodes of orthostatic [MEDICAL CONDITION] while in the shower chair, the first episode (03/07/19) the resident was sent to ED and the second time (04/11/19), the resident refused to go to the ED. The DON further confirmed R10 was diagnosed with [REDACTED]. Inquired whether the facility has the lab report from the ED. The DON agreed to follow up on the results. The DON reported the facility treats UTIs if the culture is positive and the resident complains of dysuria, abdominal discomfort, confusion, or hypotensive episode. The DON clarified the physician ordered antibiotic ([MEDICATION NAME]) for R10 based on the previous orthostatic hypotensive episode in March; however, the facility is awaiting the results of the current urinalysis. A review of R10's care plan with the DON confirmed the facility did not revise the resident's care plan to develop interventions to prevent the development of UTIs. The DON noted interventions would include encouraging fluids, monitoring and reporting signs and symptoms of UTI, and providing peri-care/protective moisture barrier with each episode of incontinence. On 04/17/19 at 2:25 PM, the DON provided a copy of the ED report and reported the facility does not have the results of the urinalysis to identify whether R10 had any organisms in the urine. On 04/18/19 at 08:01 AM the DON provided a copy of R10's lab results. The results found >100,000 cfu/ml of mixed gram negative flora. The DON reported R10's physician was contacted and provided with the lab results. The DON reported R10 did not meet the criteria for a UTI. The prescribed antibiotic was discontinued on 04/17/19. 2) Cross Reference F657 and F881. R15 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A record review on 04/16/19 at 01:24 PM found an annual MDS with an ARD of 02/18/19 which notes R15 yielded a score of 1 (one) on the Brief Interview for Mental Status indicating a severe cognitive impairment. R15 was noted to be occasionally incontinent of bladder and frequently incontinent of bowel requiring extensive assist with one person physical assist for toilet use. Further review done on 04/17/19 at 11:38 AM found R15 received antibiotic treatment for [REDACTED]. There is documentation R15 was prescribed Bactrim for UTI on 02/20/19 with lab results of >100,000 cfu/ml of [DIAGNOSES REDACTED] pneumoniae. A subsequent lab result dated 03/04/19 notes >100,000 cfu/ml for mixed gram positive flora (no new orders). The resident was prescribed Bactrim for three days (start 04/03/19) for a UTI based on urinalysis result of large leukocyte esterase positive with few bacteria. The Bactrim was discontinued on 04/04/19. On 04/08/19 the lab results notes >100,000 cfu/ml of [DIAGNOSES REDACTED] pneumoniae and R10 was started on another antibiotic, [MEDICATION NAME]. R15 was prescribed [MEDICATION NAME] (500 mg. twice a day for seven days) for a UTI. The start date was 04/08/19 and the end date was 04/15/19. A review of the resident's care plan found no documentation of care plan revisions to develop interventions to prevent further UTIs. On 04/18/19 at 08:15 AM an interview and concurrent record review was done with the DON. The DON confirmed the results of the urinalysis for 02/20/19 included >100,000 cfu/ml of [DIAGNOSES REDACTED] pneumoniae with antibiotic treatment. The DON reported on 04/03/19 Bactrim was started and the antibiotic was changed to [MEDICATION NAME] as the organism found in the urine is resistant to Bactrim. The result of the culture found >100,000 cfu/ml of [DIAGNOSES REDACTED] pneumoniae. Queried the DON whether R15 met the facility's criteria for use of antibiotics to treat UTIs. The DON responded the resident was noted with frequent urination and positive culture. Further queried whether the DON was aware of where the bacteria, [DIAGNOSES REDACTED] pneumoniae originates from, the DON replied there is a need to discuss with the physician to determine how to prevent R15's recurrence of UTIs. The DON reported interventions to prevent UTIs may include encouragement of fluids, prompt voiding, and assisting with toilet use every two hours. The DON indicated an inservice for providing proper peri-care is scheduled for staff. The DON reported there is room for improvement to update/revised residents' care plans.",2020-09-01
914,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-18,692,D,0,1,31RN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff member, the facility failed to ensure Resident (R) 10 maintained proper hydration. Findings Include: Cross Reference to F657 and F690. R10 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A record review was done on the morning of 04/17/19. On 03/07/19, R10 became unresponsive during a shower and was sent to the Emergency Department (ED). A review of the ED discharge summary documents an impression of clinical dehydration and urinary tract infection [MEDICAL CONDITION]. R10 was provided with IV fluids and started on an antibiotic (Keflex) with no signs [MEDICAL CONDITION] or [MEDICAL CONDITION]. R10's quarterly Minimum Data Set (MDS) with assessment reference date of 02/09/19 R10 yielded a score of 15 (cognitively intact) with the Brief Interview for Mental Status. R10 was noted to require supervision while eating and drinking with one person physical assist. On 04/15/19 observation of the lunch meal found R10 eating in his/her room. R10 was eating and drinking independently. A review of the resident's care plan notes a focus area of poor fluid intake with an intervention of encouraging fluids during the day to promote voiding response. A review of the physician orders [REDACTED]. There was no documentation of a care plan revision following R10's ED visit on 03/07/19 to include maintaining hydration for this resident (i.e. fluid goals, monitoring of daily fluid intake, how to optimize fluid intake). A review of the Medication Administration Record [REDACTED]. There was no issue for the month of (MONTH) 2019. An interview and concurrent record review was conducted with the Director of Nursing (DON) on 04/17/19 at 10:44 AM. The DON confirmed R10 had an ED visit for dehydration and antibiotic treatment for [REDACTED]. Queried The DON regarding R10's fluid goal. The DON reported the facility has a weekly meeting with the RD to review the residents and it is encouraged to take 1500 cc of fluid per day. Further queried whether residents' daily fluid intake is monitored daily, the DON responded if a resident doesn't meet the 1,000 cc/day of fluid intake they are placed on alert charting. Inquired whether the software automatically generates an alert. The DON was further asked who is responsible to check residents' daily fluid intake. The DON replied adding up residents' fluid intake is not being done daily. The DON also confirmed R10's care plan was not updated following the ED visit on 03/07/19 to identify R10's fluid goals to prevent dehydration and UTIs. Concurrent review of the MAR indicated [REDACTED]. The DON was asked whether weekly monitoring for dehydration is sufficient for R10 who has a history of dehydration and UTIs. The DON acknowledged R10 needs to be monitored more closely for dehydration. On 04/17/19 at 01:59 PM a review of the Nutrition Risk assessment dated [DATE] was done. The Registered Dietitian (RD) notes R10 consumes an average of",2020-09-01
915,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-18,761,E,0,1,31RN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with staff member, the facility failed to ensure flu vaccine was discarded according to the expiration date. Findings Include: On 04/16/19 at 03:00 PM observation of the medication storage room was done with the assistance of Charge Nurse (CN) 24. Observation of the refrigerator found two boxes of [MEDICATION NAME] that were both labeled to discard after 03/18/19. The first box was sealed and contained 10 unused vials. The second box was opened with a label for (MONTH) (YEAR). There was one unused vial left in this box. CN24 stated the [MEDICATION NAME] will be discarded.",2020-09-01
916,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-18,812,F,0,1,31RN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and review of policy, the facility failed to store the following foods under sanitary conditions: 1. B-B-Q Sauce, 2. Guava Jelly, 3. Ice in the ice machine. Findings Include: 1. During observation of the kitchen on [DATE] at 10:20 AM, a bottle of NOH Hawaiian B-B-Q Sauce had a label which read - Use by [DATE]. Simultaneously during the above observation, Staff Member (SM) 55 was queried about the expired Use by date [DATE]. SM55 acknowledged that this item should have been discarded on [DATE] as indicated on the label. 2. During observation of the kitchen on [DATE] at 10:22 AM, a bottle of Guava Jelly had a label which read - Use by [DATE]. Simultaneously during the above observation, SM55 was queried about the expired Use by date [DATE]. SM55 acknowledged that this item should have been discarded on [DATE] as indicated on the label. A review of the facility policy on Food Storage read the following: Policy; Dry food must be stored under sanitary conditions . Procedure; Label with food name and the date when food was opened. Discard any unused left over food after 2 days. 3. During an observation of the kitchen/ice machine on [DATE] at 10:45 AM, a quart size Ziploc bag of food was noted under the ice in the ice machine. The bag appeared sealed and did not appear to have leaked any fluid. Simultaneously during the above observation, SM55 was queried about the bag of food. SM55 asked other employees about the food and later stated that the food in the Ziploc bag was fish. SM55 further stated that she had no awareness of this bag being stored in the ice and immediately removed it from the ice machine. SM55 also took further measures to ensure the ice machine would be cleaned. During a follow up observation of the kitchen/ice machine on [DATE] at 10:00 AM, the ice machine was noted to be out of service for cleaning and disinfection following facility procedure. A review of the facility policy on Ice Machines read the following: Purpose; To assure resident and staff safety in the use of ice machines . Policy; The following policy should be followed to reduce the likelihood of contamination of ice storage machines . Clean ice storage on a pre-set schedule.",2020-09-01
917,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-18,880,D,0,1,31RN11,"Based on observation, staff interview, and review of policy, the facility failed to maintain an infection prevention and control program to provide a sanitary environment for the following: 1. Resident (R) 25; facility failed to exchange the suction equipment/cannister and 2. Medication Cart; facility failed to remove a disposable medication cup that was stored in a container with powdery substance. Findings Include: 1) During an observation of the suction equipment in R25's room, on 04/15/2019 at 11:00 AM, the suction equipment/cannister contained approximately 100cc of white/brown liquid contents. The cannister was not marked with any date, and there was no way to tell when the content was collected and how long the suction equipment/cannister was in use. During staff interview with Certified Nurse's Aide (CNA) 73 on 04/15/2019 at 11:05 AM, CNA 73 did not know when the white/brown liquid contents was collected and did not know when the suction equipment/cannister was put in use. After staff interview with Charge Nurse (CN) 59 on 04/15/2019 at 11:10 AM, CN59 acknowledged that the liquid contents in the suction equipment/cannister should have been discarded and the suction cannister should have been marked with the date that it was put in to use. CN59 subsequently removed that suction cannister and said that it will be replaced with a new one. A review of the facility policy on Resident Equipment Sanitation read the following: Policy; Regency Pacific affiliated skilled nursing facilities will prevent the spread of potentially infectious agents through contaminated equipment by using appropriate and accepted sanitation procedures. Semi-Critical Items including but not limited to: thermometers, podiatry equipment and electric razors are devices that touch mucous membranes or non-intact skin and require meticulous cleaning and disinfection between use by different residents. 2) On 04/16/19 at 03:10 PM observed a clear plastic container on the medication cart which was labeled with a date of 03/16/19. The container stored white powdery substance in it with a plastic disposable medication cup nestled in the powder. Charge Nurse (CN) 24 confirmed this was thickener and was not clear whether the label reflected the disposal date or when the thickener was provided to the nursing staff. CN24 reported there is no resident on the unit who requires thickened liquids. CN24 was asked whether the medication cup is stored in the container, CN24 acknowledged storing the medication cup in the thickener is a risk for contamination.",2020-09-01
918,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-18,881,E,0,1,31RN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with S71, infection preventionist designate, the facility failed to follow their antibiotic stewardship critreria to support antibiotic use for Resident (R)48, Resident(R)10, and Resident(R)15. The deficient practice prevented antibiotics from being prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic-resistant organisms for this resident. Findings Include: 1) On 04/15/19 at 12:00 PM R48 observed at lunch, resident hygiene appropriate, no signs or symptoms of ongoing UTI, such as odor, urinary frequency or other behaviors suggestive of an ongoing UTI. On 04/16/19 at 09:57 AM Records reflect R48 continues [MEDICATION NAME] 500-125 mg p.o. BID for chronic UTI. Records also reflect that R48 is not care planned for UTI. On 04/16/19 at 12:42 PM during a meeting regarding infection control with S71, the infection preventionist designate, and Staff(S)40, the nursing home administrator. S71 clarified that R48 was not admitted with a UTI, and that the facility was not treating R48 for UTI but to prevent a UTI. On 04/17/19 at 03:27 PM Met with S71, who reiterated that R48 was not admitted to facility with UTI. S71 validated that she did not use antibiotic stewardship protocol when R48 was prescribed the antibiotic, [MEDICATION NAME] to prevent UTI, not for an actual infection. S71 said that she was new to the infection preventionist role and now understood the antibiotic stewardship protocol does not support the use of antibiotics in a preventive/[MEDICATION NAME] manner. S71 recalled that she was following the recommendations of the infectious disease specialist prior to R48's admission to facility. 2) Cross Reference to F690. Resident (R) 10 had an Emergency Department (ED) visit on 03/07/19 related to becoming unresponsive in the shower. R10 was discharged on antibiotic (Keflex) for a urinary tract infection [MEDICAL CONDITION]. The facility did not have the results of the urinalysis from the ED; however, R10 completed antibiotic treatment. On 04/11/19 R10 had a second episode of becoming unresponsive in the shower. The physician ordered a urinalysis and ordered antibiotic ([MEDICATION NAME]) to treat a UTI on 04/15/19. The Director of Nursing (DON) reported the facility received the results of the urinalysis on 04/16/19 which indicates R10 had >100,000 cfu/ml of mixed gram negative flora. The results were reported to R10's physician and the antibiotic treatment was discontinued on 04/17/19. The DON confirmed R10 did not meet the criteria for a UTI. R15 has been treated with antibiotics for UTIs on 02/20/19 (Bactrim), 04/03/19 (Bactrim), 04/08/19 ([MEDICATION NAME]) and 04/16/19 ([MEDICATION NAME]). The DON clarified R15 was started on antibiotic (Bactrim) on 04/03/19 prior to the results of the urinalysis. The Bactrim was discontinued on 04/04/19 as the organism was found to be Bactrim resistant. Subsequently, the antibiotic was changed to [MEDICATION NAME]. On 04/18/19 an interview was done with the DON. The DON is currently overseeing the infection prevention and control program. The records were reviewed for R10 and R15. The DON reported the facility follows the McGeer criteria for UTI. The DON also reported the facility's criteria includes symptoms as frequent urination, dysuria, confusion, abdominal discomfort, and a positive culture with greater than 100,000 cfu/ml organisms. The DON acknowledged R10 was treated with antibiotics for UTI when the criteria was not met. And R15 was provided an antibiotic prior to lab results which hand to be changed due to the organism's resistance to that specific antibiotic. The DON was unable to identify the source of the [DIAGNOSES REDACTED] pneumoniae to develop interventions to prevent UTIs. The DON was queried whether the facility is tracking and trending the frequency of UTIs (identified organisms and performing a root cause analysis). The DON reported she/he is in the process of studying to become an infection preventist and developing an antibiotic stewardship program.",2020-09-01
919,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2019-04-24,678,G,1,0,WTPW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews the facility failed to ensure basic life support was provided to one of three residents immediately according to the resident's requested code status signed in the POLST. Findings: Record review reflected documentation that the resident was found unresponsive, not breathing and appeared pale in the living room in a high back chair on (MONTH) 29, (YEAR). Time this occurred was not reflected in the medical record with the writer stating they last sighted the resident at approximately 10:30 AM, whom at the time requested to change the blanket. The Resident Care Manager (RCM) and the Director of Nursing (DON) were immediately notified. A nursing note in the progress notes dated [DATE] written at 04:01 PM stated Resident in DNR status. Contacted Power of Attorney (POA)[NAME]x1 no answer, called spouse no answer, left message to both numbers. Called POA again and no answer. Received call from POA (daughter) instructed that resident to be a Full Code and transport to the ER. CPR initiated immediately, 911 called, CPR continued until medics arrived and took over from nursing staff. The Hawaii EMS Report dated [DATE] had documented in the Narrative: DISPATCHED TO KAUAI CARE CENTER FOR A 79 YO MALE WITH CPR IN PROGRESS PER STAFF PAT HAD AN ADVANCE DIRECTIVE THAT DNR SO CPR INITIAL NOT STARTED UNTIL THEY SEEN A POLST STATING DAUGHTER WANTED EVERYTHING DONE. CPR STARTED ,[DATE] MINUTES LATER. The medical record contained an Advanced Directive dated [DATE]. On this Advanced Directive under Section 6. End-of-Life Decisions, Choice Not to Prolong Life is ticked off. Stated in this section is: I do not want my life to be prolonged if (i) I have an incurable and irreversible condition that will result in my death within a relatively short time, (ii) I become unconscious and, to a reasonable degree of medical uncertainty, I will not regain consciousness, or (iii) the likely risks and burdens of treatment would outweigh the expected benefits. In Section 7 of the Advanced Directive, Choice to receive nutrition and hydration is ticked off and states in this section: I do want my life prolonged by artificial nutrition and hydration. The medical record contained a POLST with a prepared date on it of [DATE] and signed by a physician on [DATE]. In section A (Cardiopulmonary Resuscitation (CPR)) of the POLST, Attempt Resuscitation/CPR was ticked off. In Section B (Medical Interventions) Full Treatment was ticked off. Full Treatment includes care described in Section [NAME] Use intubation, advanced airway interventions, mechanical ventilation, and defibrillation/cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care. The POLST was signed by legally authorized person (daughter) for the resident. In the medical record there was a physician order [REDACTED]. No documented conversation about change in code status with resident's legal representative or resident was found in the medical record. There was no care plan present in the medical record pertaining to code status for the resident. An interview with the Registered Nurse (RN) that was working that day was conducted on [DATE] at 10:30 AM. The RN stated she last saw the resident at about 10:30 AM on [DATE] and the resident was requesting a blanket. The RN stated the Certified Nurse Assistant (CNA) informed her that the resident was unresponsive, and the RN called for help and checked the physician order [REDACTED]. The RN stated the resident was unresponsive with no respirations or pulse and CPR was not commenced at that time. The RN stated they called the wife and daughter twice and there was no response from either one. The RN stated the daughter called back approximately ,[DATE] minutes later and stated to do CPR on him. The RN stated the resident was wheeled back to his room and placed in his bed, prior to daughter calling back. CPR commenced by facility staff and 911 was called. The distance was measured from the living room where resident was located to the resident's bed by maintenance and measured 154 feet. A progress note dated [DATE] by the DON stated the resident was pronounced at 12:27 PM on [DATE]. A Quality Assurance performance Improvement Committee Plan was commenced on the [DATE] in response to this incident to ensure in the future no discrepancies would be present in the medical record of any resident pertaining to resident's desired code status. It was identified on [DATE], that there were discrepancies between physician orders [REDACTED]. Director of Nursing Services (DNS) or designee will initiate POLST discussion upon admission/readmission, review existing POLST, or initiate a new one. In addition, the DNS or designee will assess if an ACHD has been completed, which should reflect the resident's wishes. Any conflicting information be addressed and documented. 2). POLST will be signed by resident, AHCPOA, or surrogate. 3). DNS or designee will place a copy of the POLST in the Medical Doctor (MD) box. 4). DNS or designee will contact MD for telephone confirmation of orders. 5). DNS/RCM will be notified to Un-queue orders. 6). DNS/RCM will check order against actual POLST. 7). Copy of signed POLST and Advanced Health Care Directives (AHCD) will be placed in the Disaster Binder at the nurses stations. 8). Medical Records (MR) will scan copy of signed POLST under documents in the Electronic Medical Record (EMR). 9). DNS or designee will be notified to supervise the POLST process when a resident makes a decision to change their POLST. 10). Once admission orders [REDACTED]. They must check the POLST orders against the Physician order [REDACTED]. MR will conduct admission order audit and check POLST against physician orders [REDACTED]. Orders will be reviewed at every morning meeting and confirmed that POLST and physician orders [REDACTED]. 13). DNS or designee will review the POLST, the physician order [REDACTED]. In addition, the ACHD will be included in the discussion if non is on file or any conflicting information that needs to be addressed. 14). DNS or designee will document information in the care conference notes. This is to include documentation follow up on AHCDs if pending or none, the resident's response to the discussion and a timeline of when the next follow will be and completion time. 15). When competing weekly order summaries, the DNS will review the POLST and physician orders [REDACTED]. 16). In-services will be conducted regarding these new processes. 17). The signed green POLST will be placed in front of each disaster binder after scanned by MR. 18). Green copy of POLST will be placed in MD box for signing. 19). Physician order [REDACTED]. 20). Progress note to be documented by nurse receiving information regarding code status, verbal orders to be confirmed with MD. 21). If POA/Legal representation to sign POLST, must have signed and activated AHCD or surrogacy. 22). If there is no AHCD, encouragement to be given to obtain resident's response , and timeline of process to be completed including follow-up. 23). Quarterly M[NAME]K Code Checklists implemented to identify opportunities for improvement. 24). Automated External Defibrillator (AED) systems in place. 25). Nursing to use Admissions Checklist to ensure resident's POLST/AHCD are reviewed and documented. 26). MR checklist to ensure code status orders are in place and copies of POLST/AHCD are readily available. 27). Admission Liaison to evaluate the residents POLST/AHCD status prior to or upon admission and provide nursing with the documentation to effectively initiate an appropriate discussion with the resident/representative (HCPOA or surrogate) confirm code status, and retrieve MD orders as necessary. 28). Admission's nurse to check off POLST/AHCD items appropriately on the admission checklist: adding in comments if needed for further follow up. 29). MR will utilize an admission's audit checklist to ensure code status order that hads been inputted into PCC matches the POLST. 30). Nursing shift report to review code status and changes to order. 31). Copies of the POLST will follow the resident when out of the facility. Documentation was obtained that all the above mentioned interventions were conducted and are ongoing. Mandatory in-services were conducted with all staff, including the attending physician, by a lawyer bought in by the facility to educate staff on the differences between an Advanced Health Care Directive and a POLST. Inservices will continue on an annual basis along with with being part of the orientation process for new staff. Observations and documentation reviews conducted during the abreviated survey reflected that the incident that occured was due to past non-compliance with no current non-compliance evident.",2020-09-01
920,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2017-05-19,156,E,0,1,YNNG11,"Based on interviews and observations the facility failed to post contact information for the State Long-Term Care Ombudsman in an accessible area. Findings include: On 05/18/2017 at 10:30 AM, interviewed the facility's Resident Council President and when asked if he knew where to find the State Long-Term Care Ombudsman's contact information, the reply was No. Staff#25 was asked where to find the information and the surveyor was shown to a glass enclosed bulletin board on the left wall when entering the facility from the main front door. Staff#25 had to point out the information because the Ombudsman contact information was partially obscured by the bulletin board door frame. The Resident Council President was called over to the bulletin board to find the Ombudsman information and it had to be pointed out to him also. The bulletin board for the facility's back unit also obscured the Ombudsman contact information by the bulletin board door frame. Also, both bulletin boards were placed near the entry/exit doors where it would be unsafe for residents to linger and read contact information for State regulatory and resident advocacy groups. The facility failed to post the State regulatory and resident advocacy groups contact information in a form and manner accessible to residents and resident representatives.",2020-09-01
921,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2017-05-19,225,D,0,1,YNNG11,"Based on record review and interview with staff member, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. Findings include: On 12/9/16 at 6:44 P.M. the facility transmitted an Event Report to the State Agency. The report documents on 12/9/16 at 0606, Resident #42 alleged when a request was made to have lotion applied, a Certified Nurse Aide (CNA) threw the lotion at her. The resident also reported the CNA was sassy. The facility initiated an investigation, identifying the two CNAs that were assigned on the night shift who provided care for Resident #42 on 12/9/16 (the day of the event). The two CNAs assigned to Resident #42 on 12/9/16 was Staff Member #66 and Staff Member #5. Subsequently a report was transmitted to the State Agency on 12/5/16 at 7:18 P.M. to provide notification that the investigation was completed. The facility concluded the allegation of abuse was not substantiated. The report also documented the CNAs involved were reassigned to another wing until the investigation was concluded. On the morning of 5/18/17 a request was made for the schedule of CNAs from 12/10/16 through 12/16/17. On 5/18/17 at 9:04 [NAME]M. an interview and concurrent review of the schedule was done with the DON. The DON reported Staff Members #66 and #5 both worked on the evening shift on 12/10/16 and 12/11/16 on the unit (Laulima) Resident #42 did not reside. Staff Member #66 worked during the evening shift on 12/13/16 on the Laulima unit. Both staff members worked on the night shift on 12/15/16, assigned to the Laulima unit. A review of the facility's policy and procedures entitled Abuse/Neglect/Misappropriation was provided by the facility (revised 6/2015). The procedure for protection includes the following: Protecting the resident from further harm means keeping the resident safe by: 1. Immediately suspend the alleged perpetrator On 5/18/17 at 1:00 P.M. an interview was conducted with the Administrator. The Administrator reported the two CNAs were immediately assigned to work on a different unit (Laulima) from the unit where the alleged victim resides as the resident was unable to clearly identify the perpetrator. The policy and procedure was reviewed with the Administrator to immediately suspend the alleged perpetrator and was queried why these CNAs were not suspended. The Administrator replied the resident was unable to identify the alleged perpetrator; therefore, the Administrator used discretion and had the CNAs assigned to another unit. Further queried is it the facility's policy to use discretion and allow the alleged perpetrators/CNAs to work with other residents. The Administrator acknowledged this is not the facility's policy. On 5/19/17 at 9:00 [NAME]M. the Administrator provided copies of two policies and procedures. The Administrator explained the Abuse Prevention Program policy (last updated 7/29/15) was the operational policy during the time of the event. This policy notes under Protection, prevent the resident from sustaining further harm means keeping the resident safe. The actions that might be implemented include: assuring the alleged perpetrator is kept away from the resident, having a trusted person stay with the resident, allowing the resident to stay in an area which he/she feels safe; and safeguarding the resident's property. The Administrator further reported the policy provided Abuse/Neglect/Misappropriation/Exploitation with revised date of 11/2016 was not received until 12/13/16; therefore, the facility followed their policy and procedure for protecting the resident by reassigning the staff members to another unit. However, the Administrator acknowledged that it is also important to ensure the safety of other residents during the time of the investigation. The facility failed to ensure the safety of the alleged victim and other residents of the facility while the investigation was in progress as the two CNAs continued to provide direct care to other residents during the evening and night shifts during the investigation period (12/9/16 through 12/15/16).",2020-09-01
922,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2017-05-19,252,D,0,1,YNNG11,"Based on observation and interview with staff member, the facility failed to promote a homelike environment for Residents #3, #4, #5, #13, #16 and #46. Findings include: On 5/17/17 at 11:45 [NAME]M. observed a staff member wheel Resident #27 into Room #3 to use the bathroom. Upon entering the room, Resident #13 was observed coming out from behind the privacy curtain for the toilet. Resident #27 resides in Room #7. The staff member assisted Resident #27 with using the toilet. Subsequent observation on 5/17/17 at 1:45 P.M. found the same staff member wheeling Resident #4 through Room #4 to use the restroom. Resident #3 resides in Room #3. On 5/18/17 at 1:47 P.M. ran interview was conducted with the Administrator. The Administrator was asked whether it is an acceptable practice for residents to use the restrooms of other residents. The Administrator replied this would depend on the urgency to use the restroom and the location of the resident. The aforementioned observation was shared with the Administrator, the Administrator acknowledged awareness of this practice and further stated the communal restroom for the residents is located at the backside of the atrium. The Administrator acknowledged residents' rooms are considered their homes and other residents passing through is likened to people entering your home to use the bathroom. The residents in Rooms #3 and #4 share a bathroom. The facility failed to promote a homelike environment for the residents residing in Rooms #3 and #4 by allowing other residents to traverse through their home to use their bathroom.",2020-09-01
923,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2017-05-19,371,E,0,1,YNNG11,"Based on observations and interviews the facility failed to ensure that food were properly stored to ensure safety. Findings include: On 05/16/17 during the initial kitchen tour at approximately 9:30 AM, observed that there were unlabeled food items stored in the refrigerator and freezer. In freezer #3 there was a bag of frozen french fry cut potatoes that was half used with no open or expiration dates, there were other frozen items that Staff#21 claimed were for personal use and not used for residents. In refrigerator#2 there were unlabeled squeeze bottles of ranch dressing and syrup with no expiration or open dates; opened containers of mayonnaise and grape jelly with no opened date; and a plastic container of chocolate syrup that expired in 2010. According to kitchen staff the chocolate syrup was for personal use and not for residents. In the walk-in refrigerator#4 a container of ranch dressing had an open date of 03/19/17 but no expiration date. The facility failed to keep track of when to discard perishable foods and dating, labeling all foods stored in the refrigerator and/or freezer.",2020-09-01
924,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2017-05-19,425,D,0,1,YNNG11,"Based on observation and interview the facility failed to ensure correct disposition of medications. Findings include: On 18 (MONTH) (YEAR), observation of the medication cart on the Lokahi unit, two bottles of Diocto (Docusate) 50mgs/5ml Liquid were found that had discard dates of 4/17 and 12/16. Interview with Staff #16 confirmed that these medications were in place on the medication cart past their discard dates. The facility failed to ensure the two bottles of Diocto Liquid were disposed of after their discard date.",2020-09-01
925,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2017-05-19,465,E,0,1,YNNG11,"Based on observation and interview, the facility failed to ensure it was providing a safe environment for residents, staff and the public. Findings include: During observation of the facility's environment on (MONTH) 16, (YEAR) during the initial tour, areas of the floor Laulima unit of the facility were buckling creating a trip hazard for residents, staff and the public. The areas of concern on the Laulima unit were located on the ramp outside of the Activities Director's office and on the ramp around the corner to the left. Residents who were self mobile, resided in this area. Other areas of concern were in front of the television in the main common area and an area outside of the meeting room before the dining room area. Self mobile residents on the Laulima area were exposed to these hazards, along with staff and public who visited the facility. Interview with Staff #24 confirmed these areas identified were a hazard in the facility to residents, staff and public who visited the facility.",2020-09-01
926,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2017-05-19,514,D,0,1,YNNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic and hard-copy medical record reviews and interviews, the facility failed to ensure accurate and complete documentation for 2 of 13 residents (R#41 & R#28) on the Stage 2 resident sample list. Findings include: 1) On 05/18/2017 at 1:45 PM, reviewed R#41's electronic medical record (EMR) as the resident was sampled for unnecessary medications. Documentation in the Nursing Notes, noted that on 05/05/17 the resident ate 100% of meals and supplement with staff assistance, and that R#41 was alert and pleasantly confused but cooperative with care. The POA (spouse) gave verbal consent for [MEDICAL CONDITION] medications [MEDICATION NAME]/[MEDICATION NAME] and verbalized understanding of uses/risks/benefits. Documentation on 5/10/17 noted that R#41 was very quiet today, no restlessness. Appears comfortable. The resident ate 25% of dinner and drank 240 cc supplement with staff assist. The PCP was in to talk with the family about plan of care and change of orders, the POA verbalized understanding and agreed. The new orders were to D/C [MEDICATION NAME], calcium D, [MEDICATION NAME], aspirin, [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] concentrate 0.125 cc PO Q 4 hrs scheduled, as resident was on hospice. Documentation on: 5/11/17 at 17:35 noted, [MEDICATION NAME] HN three times a day 120 ml for wt loss and poor appetite. Not available at this time. 5/12/2017 at 16:09 noted, [MEDICATION NAME] HN three times a day 120 ml for weight loss and poor appetite. Not available. 5/13/2017 at 09:34 [MEDICATION NAME] HN three times a day 120 ml for weight loss and poor appetite. supplement not available. 5/13/2017 at 12:58 [MEDICATION NAME] HN three times a day 120 ml for weight loss and poor appetite. supplement not available. 5/14/2017 at 11:22 [MEDICATION NAME] HN three times a day 120 ml for weight loss and poor appetite. na 5/14/2017 at 18:03 [MEDICATION NAME] HN three times a day 120 ml for weight loss and poor appetite. Two Cal not available. 5/15/2017 at 17:39 [MEDICATION NAME] HN three times a day 120 ml for weight loss and poor appetite. Unable to swallow. Risk for aspiration. On 5/19/2017 at 9:30 AM interviewed Staff#17 and queried whether R#41 was not provided any supplements as noted in the EMR because the facility did not have the ordered supplement. Staff#17 stated that the facility Dietitian made recommendation to the resident's primary care provider (PCP) and if supplement wasn't available the Dietitian would recommend closest that matched ordered supplement. Queried Staff#17 where staff would document that R#41 was provided substitute supplement if ordered supplement was not available. Later Staff#17 returned with documentation found in the certified nurse aides (CNA) EMR, Fluid Monitor, that R#41 began refusing fluids and supplement from 05/05/2017 and that the ordered supplement was always available. Staff#17 did not know why nursing staff documented that supplement was not available instead of resident refused supplement and/or could not swallow. When looking through R#41's hard-copy medical record noticed that fax to the physician dated 4/12/17 noted after Allergy: Two Cal 120 cc TID. Queried Staff#17 if R#41 was allergic to the supplement ordered and she responded that the supplement order was written on the wrong line, and that the resident had no allergy to the supplement. 2) On 05/19/2017 at 9:45 AM interviewed Staff#17 regarding R#28's 7/2016 TB result for the 2nd step and she had to go research as results were not in the EMR. Staff#17 returned and provided information that in 7/2016, R#28 had a 1-step TB test so the 2nd step was not needed. According to Staff#17, the nurse then mistakenly inputted 2 step TB test but annual TB tests are only 1 step. Also, R#28's immunization hard-copy consent had scanned date of 12/2016 but could not find in EMR, Staff#17 had no explanation. The facility failed to ensure that medical records were maintained with accurate and complete clinical information about each resident.",2020-09-01
927,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2018-06-29,689,E,0,1,RAWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview the facility failed to ensure that the resident environment remains free of accident hazards. The deficient practice left 17 residents housed on the unit access to toxic chemicals. The facility failed to ensure toxic chemicals were secured from residents' access. The relative risk to each resident housed in the unit is individual, but there were at least two groups whose level of cognitive impairment placed them at greater risk than residents that were assessed as cognitively intact. Findings include: During a tour of the laundry room on 06/28/18 09:59 AM with Staff (S) 24 it was observed that S24 accessed the room without a key. Upon entry to the room, there were four bottles of bleach stored on the lowest tier of a multi-tiered shelf. S24 was asked if the room is secured, to which S24 replied no. S24 was asked if residents on the Lokahi unit could access this room, to which S24 replied yes. S24 confirmed that the bottles marked bleach did in fact contain bleach. It was visually confirmed that the laundry room could be secured with key only access. S24 was asked if other laundry staff had a key to the laundry room to which he verbalized only he had a key to the laundry room. During an interview on 06/28/18 at 02:37 PM with S22 confirmed that all residents housed in the Lokahi unit could ambulate with either a walker or wheelchair. The Brief Interview for Mental Status (BIMS) is a standardized cognition test with the following categories; severe cognitive impairment, moderate cognitive impairment, and cognition intact. Record review of residents housed on the unit reflected that Resident's (R) 2, R13, R30, R40, R42, and R48 were assessed at severe cognitive impairment, R22, R31, R33, and R37 were assessed at moderate cognitive impairment, while the remaining seven residents housed on the unit were assessed at being cognitively intact. Based on record review and interview, the facility failed to ensure the resident environment remained free of accident hazards by serving food that was contaminated with toxic chemicals. Less than ten residents ingested brownies that were baked in an oven that contained a chemical cleaning agent. The deficient practice placed vulnerable residents at an increased risk for serious illness and/or injury. Findings include: Review of the incident report #6397 indicated on Saturday, 6/23/18 during a cooking activity with the residents, S31 baked brownies in the kitchen oven and was unaware that oven cleaner had been applied to the oven and had not been cleaned/ removed prior to baking the brownies. Once the kitchen staff returned to the kitchen and became aware that the brownies were placed in the oven for baking, the brownies were removed, covered and set aside by the kitchen staff, they were not discarded. The following morning on 6/24/18 different kitchen staff saw the covered brownies sitting on the counter and provided them to the residents as the morning snack. The brownies were given to several residents. As soon as the incident was discovered the kitchen staff reported to the Administrator, director of nursing services (DNS) and dietary manager. The poison control center was contacted. The medical director, family members, power of attorneys and guardians were all notified of the incident. The incident was reported to the office of healthcare assurance (OHCA) on 6/25/18 at 9:25 AM. Per recommendations of the poison control center all residents were placed on alert charting for 72 hours for signs and symptoms of physical distress: nausea, vomiting, abdominal pain, burning in the throat and diarrhea. S31, S11 and S35 were placed on suspension pending further investigation. The Administrator was interviewed on 06/26/18 at 11:00 AM and confirmed the documentation was an accurate account of the incident and the investigation was complete. During the survey investigation of the incident, several of the residents, one family member and staff were interviewed by the survey team. It was determined that less than 10 residents ingested the brownies that were exposed to the oven cleaner. No adverse actions or signs and symptoms of illness were reported by the residents/ guests who consumed the brownies nor were any residents treated in an acute health care facility for illness. Based on record review and interview the facility failed to ensure the resident's environment remains free from accident hazards for two Residents R46 who wandered out of the facility unsupervised on two occasions and R11 who wandered out of the facility unsupervised on one occasion . The deficient practice placed the residents at a high risk for injury. Findings include: Review of the first incident (report #4512) dated 08/06/17 stated that R46 had been found walking around another long term care facility located 0.2 miles away. The other facility called to report that R46 was wandering in their facility. Nursing staff had last seen the resident 10 minutes prior to the telephone report. R46 was brought back to the facility and the assessment revealed that she did not suffer any harm. The elopement evaluation was completed and the care plan was updated by the nursing staff to include the following interventions: Identity patterns of wandering; provide a quiet area for the resident; keep R46 supervised at all times and maintain as much consistency as possible in timing of activities of daily living (ADLs), caregivers and daily routine; monitor R46 behavior episodes to identify triggers, monitor triggers for wandering, walk alongside resident when she starts to wander or get agitated; provide structured activities, toileting, ambulation inside and outside and snacks. Review of the second incident (report #6290) revealed that on 05/08/18 R46 was found outside in the parking lot unsupervised. R46 was escorted back into the building without incident. R46 was confused and unable to state why she went outside by herself. The resident was assessed for pain and/ or injury, none noted. The resident has an elopement care plan with multiple interventions in place and has a history of wandering. An interview was conducted on 6/27/18 at approximately 10:00 AM with S1 and revealed that S1 observed R46 walking in the parking lot on 05/08/18 and appeared agitated and confused, she asked her where she was going and she stated that she didn't know. S31 escorted R46 back into the facility and reported to the charge nurse. Record review of the nursing notes dated 05/08/18 stated Resident was found outside in the parking lot and was brought back into the building. On 06/27/18 at approximately 10:30 AM R46 was observed to walk with a steady gait with a family member (F)1. During an interview with F1, he stated that although she is [AGE] years old, R46 is very active and walks very well. F1 confirmed he was aware of both incidents where she had wandered out of the facility and that she is at risk for wandering. Interdisciplinary team meeting notes stated new interventions were added to the care plan on 06/14/18 that included education to staff about keeping the outside gates locked. Reviewed care plan dated 06/14/18, noting the following interventions: Provide appropriate supervision for me and ensure I am closely monitored ensure exit door alarms are on please ensure I am being supervised and monitored at all times, as I tend to wander off into crowds or look for an exit. Reviewed elopement policy #SNCSP9 stated the elopement evaluation will be completed upon admission, readmission, an actual elopement During an interview on 06/27/18 at 2:46 PM with the director of nursing services (DNS) who confirmed R11 had eloped from the facility on 06/14/18 at 8:00 PM and was found sitting in the facility van out in the parking lot. DNS stated R11 was immediately escorted back into the facility and found without injuries at the time. DNS stated R11 was subsequently placed on elopement risk watch (safety checks every 15 minutes) by facility staff. Interview on 06/28/18 at 1:18 PM with S50 regarding R11's elopement from the facility on the evening of 06/14/18. S50 stated she was the licensed staff working with two or three certified nurse's aides (CNA's) but does not recall exactly how many CNA's there were that evening. S50 stated R11 was restless that evening and was usually ruminating about smoking or his dog. R11 wanted to sit in the breezeway and was therefore placed there. S50 stated she was monitoring R11 through the windows the whole time when another resident requested to use the bathroom. S50 said she assisted this other resident back to her room (room [ROOM NUMBER]) and toileted her. S50 said when she came back out with this other resident and placed her back into the recliner, S50 said she noticed R11 was gone. S50 stated she was the only staff at the nurse's station and day area at the time of the incident due to the CNA's were assisting other residents in their rooms at the time. S50 stated she immediately searched for R11 and found the Velcro stop sign on the side door detached. R11 was found in the facility van pretending to be driving. S50 stated she escorted R11 back into the facility and subsequent assessment found no injuries. S50 stated the incident occurred at approximately 7:45 PM. On 06/28/18 at approximately 2:20 PM, two surveyors proceeded to retrace R11's elopement path on the evening of 06/14/18. The surveyors started at the breezeway, entered a door into the unit then headed toward the side door next to room [ROOM NUMBER] that led to the outside parking lot. After removing the Velcro stop sign, the surveyors opened the door and the door alarm started chirping. Once outside, the surveyors noted no facility staff came to check who or what triggered the door alarm. The surveyors took notice of two gates, one swung open like a door and the other was a rolling gate. The door- like gate was closed by a latch in addition to having a chain latch. The rolling gate which was near a busy road had no closing latch and the additional chain latch was not applied. The surveyors were able to easily roll the gate open which led to the busy road behind it. On 06/28/18 at approximately 2:45 PM, the surveyors brought to the attention of facility administrator and maintenance director the unsecured rolling gate outside the facility side door. The maintenance director stated he was the person responsible for checking the latching of the gates and must have missed it. Discussed the seriousness of residents eloping from the facility and the potential for harm/injuries. Options were discussed to increase safety for residents in the facility. On 06/27/18 at 12:45 PM, record review of progress notes dated 06/14/18 at 9:26 PM reflects documentation by S50 regarding R11's elopement and subsequently found in facility van out in the parking lot. On 06/27/18 at 2:46 PM interview with DNS who provided the Event Report dated 06/18/18 concurred with documentation regarding R11's elopement incident on 06/14/18 at 8:00 PM.",2020-09-01
928,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2018-06-29,700,D,0,1,RAWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview and record review (RR) the facility failed to assess Resident (R) 17 for risk of entrapment from bed rails prior to installation, failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails. Findings Include On 06/26/18 at 01:16 PM while interviewing R17 noted that he had grab bars on his bed. Asked R17 about the grab bars and he stated that he was glad that they were on his bed, stated it makes it easier for him to move around in his bed especially when staff are assisting him with activities of daily living (ADL's) and cleaning him up. R17 stated that he rolled off his bed once this year when he did not have the grab bars on his bed. On 06/28/18 at 01:33 PM RR found that R17 fell on [DATE]. Per progress note, dated 3/27/18 and timed at 0305, in R17's electronic medical record (EMR), R17 was found sitting on the floor next to his bed with his blanket, denied hitting his head and no pain . Three staff assisted resident up off the floor. RR did not find the risk assessment or consent to use the bed rails for R17. Interviewed staff (S) 39 who confirmed that R17 did not have a current risk assessment or informed consent for bed rail use completed for this admission.",2020-09-01
929,KAUAI CARE CENTER,125061,9611 WAENA ROAD,WAIMEA,HI,96796,2018-06-29,761,D,0,1,RAWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure two inhalers had the opened on date and discard by dates written on pharmacy provided labels after these medications were opened. Findings Include On 06/28/18 at 10:05 AM while going through medication storage and looking through the medication cart on the Laulima unit with S50 found an inhaler, Stiolto Respimat, for R19 with sticker placed on the medication box which stated Discard after and an unidentified staff wrote the opened date of 6/1/18. When queried S50 stated this was an error and that the discard date of three months (after insertion of the cartridge into inhaler) should have been written there. A second inhaler was [MEDICATION NAME] Respimat 20 mcg/100 mcg which had a sticker with a blank opened and discard by date, instead R26's last name and open date of 06/10/18 was written in black ink directly on the inhaler. Review of facility policy Medication Administration did not find any procedures or guidelines on how the facility will label the opened on dates and discard by dates of medications such as inhalers.",2020-09-01
930,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2017-06-23,241,D,0,1,4C5I11,"Based on observation and staff interview, the facility failed to assist the resident to maintain and enhance a resident's self-worth and self-esteem as the resident was not afforded any assistance during dining for 1 of 27 residents (Resident #38) in the Stage 2 sample. Finding includes: Resident #38 was observed during the lunch dining service on 06/20/17 at 12:21 PM. The resident is blind, but able to grab bowls which his food was placed in. Although there were nurses and nurse aides in the dining room while this resident was eating, his food was spilling out from his mouth as he was hurriedly trying to eat. Thus, a large amount of chow fun noodles spilled out from his mouth onto his left lap. The resident was also using his fingers to dig into his food bowl to scoop the chow fun noodles into his mouth, creating the spillage. In addition, although other residents closer to the kitchen service window had green napkins, Res #38 had no napkin. Staff #2 was asked about Res #38 and she said he was supposed to have a napkin, and did not know why there were no other extra napkins. She then said, They are still washing, they never deliver yet like the green one like him, and pointed to a resident who had one. There also was no attempt to assist Res #38 by Staff #2 although she was aware of the food spillage. By the time Staff #2 obtained a napkin for the resident at 12:37 PM, the resident had picked at the noodles on his lap area and ate them using his fingers. Thereafter, the resident was seen licking his fingers over and over again which continued for at least another 10 minutes. On 06/22/17 at 8:41 AM, the Director of Nursing (DON) was made aware of the dining observation of Res #38 and that no staff member in the dining room had paid attention to him. She was told of how this resident ended up scooping up the spilled food from his pants to eat it, had no napkin, and thereafter licked his fingers over and over again. The facility failed to provide this resident with the assistance and services in order for him to have eaten his meal in a dignified manner with all the other residents and visitors.",2020-09-01
931,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2017-06-23,257,D,0,1,4C5I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interviews and a review of the facility's Health Insurance Benefit Agreement, also known as the provider agreement, the facility failed to ensure comfortable and safe temperature levels for their residents for facilities initially certified after (MONTH) 1, 1990 wherein they must maintain a temperature range of 71 to 81 degrees F (Fahrenheit). This facility was initially certified as a skilled nursing facility in the Medicare program under Title XVIII of the Social Security Act effective 6/7/2011. Findings include: During a resident interview on 6/20/17 with Res #73 at 11:24 AM, she stated her room temperature gets so hot. I have a fan, but that's it. It's rough, the summer months. This is how it works, you can buy your own AC and they'll install it for free. I don't have the money to buy an AC (air conditioner). She stated it got very hot mid-day and asked to check her room then. Another resident, Res #67 stated she could not go into her room during the day to sleep even if she wanted to rest because it's too hot. Another resident, Res #71 stated there was heat in general in the building. An environmental tour to check the facility's resident room temperatures was completed in the three buildings: Ilima, Makalapua and Mokihana, including the resident dining/activity areas on 6/22/17 with the facility's lead maintenance (Staff #3). Staff #3 stated between the use of the laser temperature gun and the digital thermometer, the digital thermometer is the more ambient temperature. Initial simultaneous readings to check for any significant difference or variance between the two devices was done by Staff #3 for the room temperatures obtained in various rooms of all three buildings. As it was determined there were only tenths of a degree of variance, the facility's ambient room temperatures were taken, read and confirmed using the digital thermometer handled by Staff #3 with direct surveyor observance during the walk through to obtain each building's ambient room temperatures. The following was recorded: Digital thermometer reading of the Ilima building on 6/22/17 at 1:49 PM: room [ROOM NUMBER]A was 84 degrees Fahrenheit (F). room [ROOM NUMBER] was 86 degrees F. During this walk through, Staff #3 stated they did not do routine nor random room temperature checks especially on really hot summer days. Staff #3 said if they had extra air conditioning (AC) units, they could install them free of charge. Otherwise, he stated the families would have to buy an AC unit. Staff #3 stated for Ilima rooms 9, 13 and 15, the families purchased the AC units, so those room were excluded from the temperature checks. Digital thermometer reading of the Makalapua Maka building on 6/22/17 at 2:54 PM: Rooms D4A, D4B and D4C were 86 degrees F. Rooms D5A and D5B were 85 degrees F. Room D2B was 86 degrees F. The main television for the D wing area was 85 degrees F. The Maka C unit showed the main television area to be 83 degrees F. Room C3 was 84 degrees. Room C1 was 85 degrees. Digital thermometer reading of the Mokihana Moki building on 6/22/17 at 3:12 PM: the Moki B wing main television area was 84 degrees F. Room B2A was 82 degrees F. Room B5 was 83 degrees F. Room B3 was 85 degrees F. The Moki rehab area at 3:16 PM was 82 degrees F. The conference room was 84 degrees F. Digital thermometer reading of the Ilima building on 6/22/17 at 3:21 PM: The main Ilima activity area fronting the entrance gate was 84 degrees F. The area by the door to enter the Ilima unit was 87 degrees. The area in front of the Ilima kitchen service window at 3:23 PM was 85 degrees F. room [ROOM NUMBER] was 83 degrees F. room [ROOM NUMBER] was 84 degrees F. Last, the measurement of the ambient temperature along the driveway outside of the Ilima building measured 87 degrees F on 6/22/17 at 3:28 PM. The facility failed to meet the requirement to provide comfortable and safe temperature levels, such that for facilities initially certified after (MONTH) 1, 1990 they must maintain a temperature range of 71 to 81 degrees F. None of the room temperatures taken by Staff #3 were found to be at or below 81 degrees F, and verified by this staff.",2020-09-01
932,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2017-06-23,431,D,0,1,4C5I11,"Based on record review and staff interview the facility failed to store it's refrigerated medications under proper temperature controls. Findings include: On 06/22/2017 at 2:03 PM A review of the facility's records of the temperature logs for the medication refrigerators, 3 total, showed a unit with 4 dates in (MONTH) (5th, 10th, 11th and 18th) (YEAR) with the temperature documented at 30 degrees Fahrenheit. On 4/5/2017 maintenance was notified but there was no documentation of the temperature rechecked for this refrigerator. On (MONTH) 10th, 11th and 18th of (YEAR) there was no documentation of the maintenance being notified and no documentation of the refrigerator temperature rechecked. On 04/20/2017 this same unit did not document a temperature for this refrigerator. On another unit it was noted that there was no temperature documention on 05/15/2017 and 06/10/17. Interview of staff #1 at that time confirmed that the temperatures were out of range and confirmed that there were missing temperatures that should have been logged. The facility failed to store it's refrigerated medications under proper temperature controls which could result in injury to the residents.",2020-09-01
933,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2018-09-07,578,E,0,1,OX9711,"Based on medical record reviews and interviews, the facility failed to ensure that 2 residents out of 27 residents were informed of the right to accept or refuse the right to formulate an advanced directive. Findings: 1. Resident # 37 was interviewed 09/06/2018 at 11:00 AM and stated no one from the facility had spoken to him about advanced directives. His Brief Interview for mental Status Score (BIMS) completed in (MONTH) (YEAR) was 15/15 under Section C - Cognitive Patterns in the Minimum Data Set assessment (MDS). During an interview with the Social Worker on 09/06/2018, an unsigned and unnotarized advanced directive was shown. The date on this document was 02/13/2018. There was no copy in the medical record and no documentation in the medical record to support this had been discussed with Resident #37. 2. A medical record review was conducted for Resident #58. No advanced directive was found and there was no documentation in the medical record to confirm that the information regarding advanced directives had been given to Resident #58. The Social Worker was interviewed on 09/06/2018 and they were unable to find any documentation in the medical record in regards to Resident # 58 being provided with information on advanced directives, and given the opportunity to either refuse or pursue an advanced directive.",2020-09-01
934,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2018-09-07,812,E,0,1,OX9711,"Based on observation and interview with staff members, the facility failed to store foods at acceptable parameters and staff member preparing food was not wearing a hair restraint. Findings include: On 09/05/18 at 10:25 AM observed Staff Member 10 (SM10) grilling hot dogs. The facility put up a tent and set up a grill outside for an activity. The staff member reported the grilling of hot dogs was a cooking activity for the residents; however, due to the weather the residents would not be coming out. Further observation found two packs of unheated hot dogs on a cart. The staff member was observed to pick up a pack of unheated hot dogs from the table to place in a metal pan. When the pack was lifted, liquid was dripping from the empty plastic wrapper that was still attached. The staff member placed the remaining hot dogs in one of three covered metal pans. The second pan contained hot dog buns and the third pan contained grilled hot dogs. The three pans were placed on the table. The staff member grilling the hot dogs was not wearing a hair restraint. An interview was conducted with the Assistant Food Service Director (AFSD). The observation of the staff member was shared with the AFSD. The AFSD reported the hot dog grilling is an activity for the residents. The activities department will request for supplies and the kitchen will prepare the supplies then the activities staff will pick up the supplies. The AFSD confirmed the staff member is required to wear a hair restraint while preparing food and the unheated hot dogs should be placed on an ice bath. The AFSD prepared a metal tray with ice and went to the office to obtain hair restraints for the staff member. At 10:35 AM, the AFSD went to the tent with a hair restraint for the staff member and a metal pan with ice to store the unheated hot dogs. A second observation found the unheated hot dogs on an ice bath and Staff Member 11 was placing the grilled hot dogs in a metal pan that was stored on the hot grill. The AFSD reported the temperature for the unheated hot dogs was 42 degrees.",2020-09-01
935,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2018-09-07,880,D,0,1,OX9711,"Based on observation, staff interview and facility policy review, the facility failed to maintain appropriate infection control technique when performing a dressing change for Resident 37 (R37). Findings include: A Licensed Nurse (LN71) did a dressing change for R37 on the morning of 9/7/18 at 9:48 AM. LN71 was observed: Donned clean gloves; Removed R37's sock from his left foot; Used alcohol pads to clean off old tape adhesive from his left foot; Removed the soiled bandage from the wound on his left foot; and Placed clean gauze directly on the bedside table (which wasn't sanitized). With the same soiled gloves, LN71 continued: Poured normal saline on clean gauze (which was set directly on the bedside table) and wiped the wound; Placed ointment on wound; Placed a clean corn bandage around wound; Covered with clean gauze (which was set directly on the bedside table); Removed gloves, no hand sanitizing; Donned clean gloves; Placed sock back on his left foot. An interview of LN71 at 9:59 AM revealed her understanding that she should have removed her contaminated gloves and hand sanitized before donning clean gloves and proceeding with the clean supplies. A review of the facility policy for Using Gloves on the morning of 9/7/18 at 11:00 AM found staff should remove contaminated gloves, perform hand hygiene, and don clean gloves before proceeding with a clean procedure.",2020-09-01
936,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2018-09-07,925,F,0,1,OX9711,"Based on observations and staff interview, the facility failed to maintain an effective pest control program to control the fly (insect) population. Findings include: 1. Observation of the lunch meal on the morning of 9/4/18 at approximately 11:45 AM found several flies around the dining room on the Ilima unit. The flies were observed landing on various surfaces during the lunch meal. Although the flies were constantly around, there were increased numbers of flies during meal times. Some of the residents were not capable to moving their limbs independently to fan the flies away. Other residents were unable to react quickly enough to fan the flies away before they landed on their food or their bodies. Several flies were observed in the Mokihana unit while returning to the conference room. In the conference room, surveyors observed multiple flies. One fly would get swatted then two more would appear. During the survey period from 9/4/18 to 9/7/18, the conference room would have at least two flies present throughout each day. A meeting with three Resident Council members (R7, R18, R61) on the morning of 9/6/18 at 11:00 AM was conducted in the Activities area outside the Ilima area. There were multiple flies swarming around. The residents were asked about the flies. All three residents replied they recognize the facility has a lot of flies. The three residents stated it was difficult for the facility to manage since the Activities area is in an outdoor area. An interview of the Maintenance Supervisor on the afternoon of 9/5/18 at 3:40 PM revealed the facility kept a log to indicate where pests were found. The Maintenance Supervisor stated the facility had a contract with an exterminator who came monthly. The facility provided information in the log book to let the exterminator know where the problem areas were. 2. On 09/05/18 at 10:25 AM observation found a fly in the kitchen. Subsequent observation was done on the morning of 09/06/18. Observation found three flies in the kitchen. Concurrent observation and interview was conducted with Staff Member 11 (SM11). The staff member acknowledged there were flies in the kitchen and reported the facility has pest control prevention; however, it is difficult to control the flies as there are staff members and visitors that go in and out of the unit. There is a blower at the entrance to the unit that houses the kitchen. The staff member also reported there is a blower at the kitchen's back door. The staff member also reported there is a device that has blue lights to attract the flies and once the flies get dizzy they will become trapped on a sticky strip at the bottom of the box. During our conversation observed three flies enter the blue light box and only one fly was trapped in the box. 3. During a lunch meal observation of the Makalapua Assembly Area, on 09/05/18 @ 11:45 AM, several flies were noted to be flying while the residents were eating lunch. One fly landed on a resident's eating surface, and the resident was not aware. Another fly landed on the resident's head and didn't seem to have noticed.",2020-09-01
937,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2019-09-13,550,D,0,1,X09M11,"Based on observation, record review and interview, the facility failed to ensure the resident was assisted to eat in a dignified manner for one of 12 residents (Resident (R) 31) observed for dining in the Mokihana unit. This deficient practice has the potential to affect all residents who require feeding assistance. Findings Include: On 09/12/19 at 08:00 AM, Certified Nurse Aide (CNA) 87 was observed standing next to R31 to feed her. The overbed table was in front of the resident with the breakfast tray atop it. CNA87 scooped small portions of the pureed egg and oatmeal to feed the resident using a soft tipped spoon. R31's breakfast meal tray consisted of, pureed egg, oatmeal, egg toast blend, per CNA87. The tray also had orange juice, water and Ensure pudding. CNA87 said, I know the puree is not papaya. I don't know what this one, and pointed to the small cup of a beige food item. No papaya. So if none papaya, I have to make sure I ask kitchen. We always serve papaya. CNA87 was asked if she would want to know what she was feeding the resident prior to, and she nodded yes. Yet, CNA87 did not know what one item was and that there was no pureed papaya, although it was on the diet card. CNA87 continued to feed R31, using a small soft tipped spoon. However, CNA87 stood next to R31's left shoulder facing the same direction as the resident. Thus, when CNA87 scooped the food from the tray, she had to crook her right elbow at an odd angle to get the spoon to the resident's mouth. The State Survey Agency (SA) asked CNA87 about her method of feeding the resident. CNA87 said, No, I just stand up like this, usually I supposed to sit down. R31 has swallowing and chewing difficulties and CNA's feeding technique did not allow CNA87 to clearly look at the resident to monitor for potential aspiration. On 09/12/19 at 08:09 AM, with RN19 present at R31's bedside, she said to CNA87, Next time bring chair over here and then make like this way and then feed. RN19 said they were staffed this morning with herself and CNA87, but a transporter, a CNA came to help serve the residents their foods. RN19 said it was always one charge nurse and one CNA, and other administrative staff would come over to bring the food and assist. A review of the CNA position description revealed an essential function was to provide residents with meal assistance, which included verifying the diet cards and assisting with the meals. R31 requires staff assistance for eating. On 09/12/19 at 08:27 AM, the Director of Nursing (DON) and the Chief Nursing Officer (CNO) were informed of the way CNA87 was observed feeding R31. The DON stated because R31's bed, is pretty high, and they (staff) have to be at the resident's height, which is a standing height, . The facility's, Dignity: Feeding Residents and Patients form did not mention whether staff should sit to feed a resident. However, the RN on duty told CNA87 to bring a chair over to sit and assist with the feeding, and to reposition herself in order to feed and observe the resident better since R31 is at risk for aspiration. The facility is responsible for providing care to residents in a manner that helps promote quality of life. This includes respecting a resident with dignity during dining. The manner in which R31 was observed to be fed was not a dignified nor safe approach for her based on her comprehensive care plan.",2020-09-01
938,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2019-09-13,578,E,0,1,X09M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record Review (RR) and interview, the facility failed to have a process in place to establish, maintain, and implement written policies and procedures regarding the resident's right to formulate an Advance Directive (AD) for four of 16 residents (Residents (R) 15, 28, 43, and 165) selected for review. This deficient practice had the potential to affect all residents' capability to formulate an AD. Findings Include: 1 ) On 09/11/19 at 03:00 PM, RR reflected R15 was admitted to facility on 11/27/15 with the following Diagnoses: [REDACTED]. No AD noted on file for R15. On 09/18/19, Administrator provided copies of documentation regarding AD for R15. The documentation is as follows: Care Conference Summary dated 11/14/18, Clinical Notes Report by Social Services dated 12/27/18, Clinical Notes Report by Social Services dated 04/05/19, Care Conference Summary dated 05/15/19, and Care Conference Summary dated 08/14/19. Review of the aforementioned documents found no mention of providing resident and/or his or her representative(s) information and education regarding AD, only that the facility is here to assist and support. 2 ) On 09/12/19 at 01:39 PM, RR showed R43 was admitted to facility on 08/01/18 with [DIAGNOSES REDACTED]. RR reflected no AD for R43. On 09/18/19, Administrator provided copies of documentation regarding AD for R43. These included: Clinical Notes Report by Social Services dated 09/06/18, Care Conference Summary dated 01/02/19, Care Conference Summary dated 04/03/19, Clinical Notes Report by Social Services dated 06/21/19, Clinical Notes Report by Social Services dated 07/08/19, Care Conference Summary dated 07/17/19, Clinical Notes Report by Social Services dated 09/04/19, and Clinical Notes Report by Social Services dated 09/06/19. None of the documentation mentioned above showed that AD information and education were given to the resident and/or his or her representative(s). 3) During a RR for R28, no AD was found. A Physicians Order for Life Sustaining Treatment (POLST) states do not attempt resuscitation (DNAR) with limited interventions. Requested copy of the AD and AD Policy from the facility administrator. Clinical notes dated 01/28/19 were received and reviewed. R28's family member (FM) assumes all responsibilities and serves as surrogate for R28. FM declines assistance with updating POLST and in agreement that all forms are current. Clinical notes dated 04/19/19, 07/25/19 and 09/11/19 revealed no documentation that R28's FM was provided education about an AD or offered assistance to formulate one. The documentation is in regard to the POLST. 4) During a RR for R165, no AD was found. The POLST states DNAR. The Facility admission packet was reviewed at Section 4. Advance Health Care Directive and POLST. There was an initial at, provided a copy of the Resident's advance health care directive to the Community. Durable Power of Attorney found. Family member of R165 named as power of attorney (POA) dated 07/28/06. Requested copy of the AD for R165 and AD Policy from the facility administrator. Documentation received and reviewed for R165. Durable General Power of Attorney, provided for R165 page 3, at #11. states, consent to medical treatments: to have exclusive authority to give consent for such medical treatment to be administered, . No AD found for R165 or documentation that the facility provided the information (brochure, etc.) to the POA and offered to develop an AD to the PO[NAME] During an interview with the Social Worker (SW)1 on 09/13/19 at 11:35 AM, stated that she meets with the resident or representative to go over the admission paperwork. I show the resident or representative the form (AD) and ask if they have ever filled one out and offer to make a new one for them. If they don't have one and don't want to develop one I give them the handout. I help them complete the other section which states at what point they want treatment to stop. If they don't want an AD we follow up every three months at the Interdisciplinary Team Meeting (IDT). If there is a surrogate we offer the same information. Most of the time they decline.",2020-09-01
939,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2019-09-13,584,D,0,1,X09M11,"Based on observation, record review, interview and facility policy review, the facility did not ensure a resident's report and investigation about her missing personal property was completed and/or resolved for one of one residents (Resident (RR) 57) selected for review. This deficient practice has the potential to affect any other resident who reports missing personal property to the facility staff. Findings Include: On 09/11/19 at 08:48 AM, during an interview with R57, she said she reported her money (cash) was missing. R57 said she told this to a staff person approximately two months ago. R57 said the amount was $15.00 which she had put into a small red cloth bag and hung it on a statute in her room. She was planning on giving this money to the church, but then it went missing. R57 could not recall whom she told this to, but said, No one ever came back to me about it. R57 has consistently scored a 15 on her Brief Interview for Mental Status (BIMS) from her (MONTH) 2019 assessment for cognition and recall to her most quarterly review of 08/26/19. She has a care plan for risk for confusion and alteration in mood and behavior related to . fixation including . money, . and the interventions state, Assist in locating missing items and provide reassurance. (R57) at times will state has missing items or missing money that is not accurate, . (R57) will either decline or accept this assistance . During episodes of fixation of money and/or funds, provide support as requested and as needed by (R57). On 09/12/19 at 08:53 AM, an interview with the Social Services Director (SSD) was done. The SSD verified upon query that R57 had three $5.00 bills totaling $15.00 which were reported missing. The SSD stated on 04/29/19 when she visited R57, the resident declined their offer to accept the $15.00 and although they have talked to the resident, the SSD said R57, won't take the money. Review of the facility's policy, Theft and Loss Program, (effective date 01/01/2010) stated, Policy: It is the policy of this facility that all responsible efforts shall be undertaken to safeguard resident property against theft and loss . 11. After investigation, if the lost/stolen item has not been located, the Administrator and Social Services will decide on a final resolution to the report. 12. Social Services will complete the report form with recommendations and forward it to the Administrator for review and signature. The SSD produced the theft report form related to R57's missing money and a concurrent review was done with her. It was found this Loss of Personal Property Report, (not dated) had a follow-up date on it as 04/29/19 by the SSD about R57's missing money as described by R57. However, the report was incomplete as portions were left blank, unsigned/undated, and there was no documentation it had been forwarded to the Administrator with his recommendation to refund R57 her missing $15.00. On 09/12/19 at 10:54 AM, R57 was sitting at a dining table in the Makalapua building visiting a friend and having a snack. When the resident was asked whether any staff, including the SSD followed up about the missing $15.00, she said, No. R57 also said she did not remember ever telling staff that she did not want the money returned. She said, The statute is right in front of me, and I look at it every day. She said she is reminded about it whenever she looked at the statute and that it still bothered her. R57 said, Of course, I want to give it to the church! and shook her head. For R57, she has not received any confirmation or resolution about her missing money. The facility failed to ensure R57 was provided resolution of this matter as the specific theft report form was incomplete.",2020-09-01
940,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2019-09-13,684,D,0,1,X09M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review (RR), the facility failed to assure the Power of Attorney (POA-authority to act for another person) of one of one residents (Resident (R) 16) sampled, was notified after R16 fell three times in a 24 hour period. R16 was receiving hospice (end of life care) services during that time, but the facility retains primary responsibility for the notification of PO[NAME] As a result of this deficient practice there is the potential that important issues/events affecting hospice residents may not be communicated to their POA or Resident Representative. Findings include: RR revealed R16 was a [AGE] year old who had a [DIAGNOSES REDACTED]. He had severe cognitive impairment, and was unable to make decisions for himself. R16's family member (FM) was his designated PO[NAME] R16 was admitted to the facility on [DATE] and was receiving Hospice services until discharged from Hospice on 07/27/19 after showing significant improvement of his medical condition. During the time he was receiving Hospice services, R16 had three documented falls with no injury, 07/04/19 at 12:30 AM, 07/04/19 at 04:55 AM, and 07/05/19 at 12:23 AM. There was lack of documentation that R16's POA had been notified by either Hospice or the facility. RR of the facility internal Incident Reports revealed the following documentation: 07/04/19 12:30 AM : Notification of responsible party .Name: per Hospice they'll take care of it. 07/04/19 04:55 AM : Notification of responsible party .Name: per Hospice they'll take care if it. 07/05/19 12:23 AM : Notification of responsible party Box is checked, but there is no documentation who was notified. On 09/11/19 at 01:22 PM during a phone interview with R16's POA, inquired if he had been notified by Hospice or the facility that R16 fell three times in July. POA replied, No, I was not aware of that. On 09/13/19 at 10:22 AM during an interview with the Director of Nursing (DON), reviewed documentation of R16's three falls. The DON stated, We did not notify (POA), because Hospice told us to stop calling the families. Hospice said they need to be the ones that contact the family. They (Hospice) did not want us to notify them anymore, and said they are the main contact. They gave us an in-service, and at that time told us not to call the families, and that they would do it. Queried if there was a policy or language in the contract that delineates that responsibility, and the DON said, I don't think so. A discussion regarding the overall responsibility of the facility for coordination of care, communication with the POAs, and monitoring of Hospice services was done. The facility did not follow their own policy. Review of the facility's policy titled, Falls Program directs facility staff to, Upon an event of a fall or near fall, the nurse will . Notify POA of fall and findings. The facility had a contractual agreement with a certified hospice provider to provide services at the facility. The agreement states, Hospice desires to provide hospice services to eligible Nursing Home residents in coordination with the management and staff of Nursing Home . The contract also states, services to be performed cooperatively by hospice and nursing home with, Joint responsibility and will, mutually establish policies and protocols for the care of the Hospice patient. There was no language in the hospice agreement regarding communication with POA's in this situation.",2020-09-01
941,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2019-09-13,689,G,0,1,X09M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review, the facility failed to use a two-person assist to transfer a resident while using the hoyer lift (a mechanical floor lift and assistive device) for one resident (Resident (R) 31) selected for review. As a result, R31 sustained a significant head injury to the back of her head, which was a large hematoma (collection of blood from damage to a larger blood vessel) measuring 8 centimeters (cm) in length x 7 cm in width x 1 cm in depth and a laceration. The facility's investigation also did not determine why R31 was showered so early on the morning of 04/20/19 by the only certified nurse aide (CNA) 25 working the night shift. There was no documentation of CNA25's task performed as well. This deficient practice, including the lack of adequate supervision of CNA25 by the charge nurse that night, was a contributing factor for R31 sustaining serious injury and harm. This deficient practice also has the potential to cause serious harm to other residents residing in the facility, as the facility failed to complete their in-service education/training for hoyer lifts after the accident, and failed to monitor ADL activity/care provided to the residents during the night shift. Findings Include: Resident (R) 31 is an [AGE] year old resident who has a [DIAGNOSES REDACTED]. She was non-verbal, observed primarily in bed, and required staff assistance with her activities of daily living (ADLs). A family interview was done on 09/11/19 at 04:45 PM, and during the interview with R31's Family Member (FM), it was revealed that R31 had fallen out of a transfer lift sustaining a head injury. The FM said R31 was taken to the hospital emergency department for evaluation and treatment. The FM also found out for R31's showers, it was 3:30-4:00 in the morning and that was the night shift and they had been doing that for I don't know how long up until the incident anyway. Then they stopped after what happened. The FM said after R31's accident, the facility said they wanted to switch R31's showers to bed baths, but the family declined and told them to continue with the showers, but not that early in the morning. The FM further said her understanding of R31's fall from the hoyer lift was because, the attachments weren't attached properly. The FM said according to the nurses, she was told, their protocol is that it should be two people. They told me this. The FM said it was the older hoyer lift which was used on the morning of 04/20/19. Review of R31's Minimum Data Set (MDS) (MONTH) quarterly review with a 04/25/19 observation end date showed she requires a two person physical assist for bed mobility, transfer and toilet use. R31's comprehensive care plan at risk for falls and self-care deficit related to her Alzheimer's dementia and non-ambulatory status noted, . fall from Hoyer lift; CTs negative for injury; Staff re-educated for proper technique for Hoyer lift. Review of a 04/24/19 change in condition clinical entry revealed the resident was seen for, . the following acute problem of: f/up (follow-up s/p (status [REDACTED]. The resident sustained [REDACTED]. She was sent to the ER for further evaluation due to a large occipital hematoma . Further review found the following: 1) The mechanical lifts, including the hoyer lift, was a two person assist to ensure safe transfer of a resident. CNA25 had received in-service education on the use of a mechanical lift prior to the 04/20/19 accident. This was verified by the Director of Nursing (DON) on 09/13/19 at approximately 12:10 PM, when she produced CNA25's 12 hour inservice education sheet. The DON confirmed CNA25 received this training on 04/08/19, which was included in their topic, Safety & Body Mechanics. Yet, it was found that CNA25 did not follow this basic safety protocol, and by performing a single person assist/transfer of R31 from a shower chair to her bed, caused serious injury to the resident. The facility's protocol for the use of the hoyer (Tempo) lift for transferring R31 on the early morning of 04/20/19 was to have been a two person assist. This was further verified by Registered Nurse (RN) 11, during her telephone interview on 09/12/19 at 01:58 PM. RN11 stated, For the hoyer lifts, should be two people. However, this protocol was breached and not followed by CNA25. In addition, a lack of adequate supervision by RN11, who was the charge nurse on the night shift of 04/19/19 to 04/20/19, enabled CNA25 to perform an unsafe procedure using a mechanical lift, which in the end, caused a serious head injury to R31 from a drop/fall from the hoyer lift. 2) The FM interview revealed R31 was given an early morning shower on 04/20/19 and that, it was 3:30-4:00 in the morning and that was the night shift . Review of CNA25's witness statement found two versions, both dated 04/20/19 at 04:15 AM. One version revealed CNA25 completed R31's shower, brought the resident back to her room, . while transferring the 2 upper attachment came off, the resident fell down with shower chair on the floor with hard impact to the head, noticed moderate bright red on the floor. I called charge nurse to come and assist. CNA25's second version stated, .The resident was still in the shower chair and was able to do transfer using the hoyer lift. I set everything up, while transferring in the middle of lifting her up both upper attachment of the sling slipped off, I wasn't able to catch her, things happen so fast. the resident end up falling in the shower chair and hit her head by the shower chair. Immediately call the charge nurse. During the DON's interview on 09/13/19 at 08:21 AM, she said as part of their fall prevention review, including a fall with injury, it involved looking at the root cause of the fall and communicating it back to her staff to prevent future falls. The DON was then queried if she asked CNA25 about one of the primary antecedent factors as a probable root cause, which was why the aide showered R31 by herself early that morning. The DON replied, We felt this particular staff needed further training. We felt the use of the hoyer lift needed to be trained on. We could see this as a factor. We would report it as a near miss. However, review of CNA25's employee performance appraisal of 04/05/19 showed she exceeded expectations, including assisting residents with transfers and met expectations for the use of assistive devices, including a mechanical lift. The DON said the CNA's second version was probably written, to clear some things up. However, the DON did not have a clear response regarding which version accurately depicted the events and cause of injury to R31. The DON stated, a thorough investigation had been done and multiple people helped her investigate this accident. The DON did say CNA25 explained it to her and that the shower chair was on the floor. After this statement, the DON was unable to provide any further response about the discrepancies in the two written statements submitted by CNA25. At the end of her interview, the DON said she would look at providing more information from others who conducted the investigation with her. On 09/13/19 at 10:35 AM, the DON stated she did not have any additional documentation regarding this investigation. The facility leadership failed to thoroughly investigate CNA25's unsafe use of an assistive device, her decision to shower the resident by herself, and failed to review the lack of documentation by the CN[NAME] (Of note, the State Survey Agency (SA) attempted to contact CNA25 and left two telephone messages, but to no avail. The facility was also asked to assist in contacting this CNA as well, but to no avail. Thus, the SA was unable to obtain a direct interview with her to further clarify the events leading up to R31's drop or fall from the hoyer lift with the resulting head injury.) 3) There was a lack of adequate supervision by the charge nurse, RN11, during the night shift of 04/19/19 into the morning of 04/20/19. During a telephone interview of RN11 on 09/12/19 at 01:58 PM, she said she was not aware of CNA25's whereabouts when the accident occurred. RN11 confirmed CNA25 was her only CNA staffed on the Mokihana unit that night and did not know CNA25 had taken R31 for an early morning shower. RN11 had been orienting a new nurse and CNA25 did not communicate that she was going to shower and transfer R31 by herself using the hoyer lift. RN11 said as the charge nurse, she was responsible to know what was happening on the unit, including oversight of CNA25's actions. RN11 was not sure if the resident had, made a mess or had to shower her right away, as the reason for the early morning shower. RN11 said again, I know it's supposed to be two staff assist for the hoyer lift. She said, I told (CNA25) it has to be two staff assist next time with me or whoever is the charge nurse. RN11 was queried if the hoyer lift was done with a two person assist, would this accident have been preventable, and she replied, Yeah. R31 was showered early in the morning with no documented reason or knowledge as to why CNA25 was doing the shower and sole transfer. RN11 was asked if other residents were being showered in the early morning. RN11 said some of the other residents were receiving early morning showers, and was aware the CNAs would do these early morning showers. RN11 said she thought they should be documenting these early showers, but was unsure and stated, I know they do the showers, but it could be to help out the day, but I don't know. RN11 said she worked with CNA25 after the accident but was uncertain whether CNA25 continued to shower residents early in the morning since she worked in the other buildings. 4) The facility's fall protocol stated the root cause analysis or drill down method was used to determine how/why a fall occurred. However, for R31's accident, one primary antecedent factor which preceded the accident was her early morning shower. Although the resident's daily shower schedule for 04/19/19 was requested, the Chief Nursing Officer (CNO) on 09/12/19 at 11:32 AM said per their DON, they did not have the daily shower schedule when R31 fell , because it changes so often. The CNO was asked why her daily shower schedule would not have been kept as part of the facility's falls review/drill down method, to determine: 1) why such an early morning shower that resulted in a fall with injury occurred, and 2) why the CNA did it unsupervised and without the required two person assist. The CNO replied, sometimes if they're soiled they might. The CNO was asked again whether this was even reviewed, and the CNO stated she would check for a shower schedule during the time of the accident. This was not produced to the S[NAME] 5) The facility's investigation failed to determine if the correct standard sling and type was used by CNA25 during R31's transfer. The DON verified it was the Tempo lift used on 04/20/19. Although she produced the facility's policy, Mechanical Lift, Policy No. , it had no effective date on it. The policy did state there were different types of slings with a color to match a size and if it was a transfer or bathing sling. The product description in Fig. 2 also showed the different sling profiles used with the Tempo lift. Yet, although CNA25 stated in both written versions that both upper attachments slipped/came off during the resident's transfer, the type of sling used and/or why the attachments came undone, was not investigated by the facility in determining how the accident occurred. 6) The facility failed to look at CNA25's documentation for 04/20/19, the morning of the accident. CNA25 failed to document the 04/20/19 early morning shower for R31. The shower entries showed a shower entry on 04/20/19 at 01:01 PM, which was after R31 returned from the hospital at 10:18 AM. The other shower entry was on the night of 04/19/19 and documented at 10:45 PM. There was no other shower entry for the early morning shower done before the accident happened or why it was given. This discrepancy and lack of clinical documentation by CNA25 was not investigated by the facility. During an interview with CNA8 on 09/12/19 at 03:24 PM, she reviewed the ADL Verification Worksheet and said for 04/20/19, the 4/2 meant total assist with one person. CNA8 noticed the two shower entries and said if the resident was showered, although it may not be the real time of the shower, you have to put it in before the end of your shift. The shower entry of 04/19/19 at 10:45 PM may have been CNA25's entry, but then it meant it was documented before the shower was even given on the early morning of 04/20/19. Per CNA8, for the other shower entry, she said it was already, the day shift entry of the on-coming morning shift. 7) Record review also found CNA25 was counseled on 06/28/19 for using the hoyer lift by herself. CNA25's Employee Performance Improvement Plan (EPIP) stated the employee will use the hoyer lift with two staff assistance. Yet, her EPIP, dated more than two months after the accident, was found to be incomplete and invalid as it lacked the signatures and dates of CNA25, the supervisor, the human resources director and a witness. Although the DON said she counseled CNA25, she did not follow-up to check if CNA25 followed the hoyer lift protocol after she completed the initial one to one in-service with her on 04/26/19. The EPIP's Follow-Up Dates & Results, was also blank and incomplete. 8) The facility failed to ensure after this accident, that all staff, including the Registered Nurse (RN) 11, who was the charge nurse on the 04/20/19 night shift, received the in-service education/training on the use of the hoyer lift. Of the approximate 21 licensed staff and 35 CNAs, only 12 other staff were in-serviced. Thus, approximately 1/5 or 21% of the nursing staff completed the 04/23/19 in-service education on Transfers. In addition, the DON verified during her interview that she did not look at CNA25's lack of documentation and thus, did not provide any in-service education about inaccurate/incomplete documentation. The cumulative review found R31's head injury was avoidable based on the aforementioned findings. The facility leadership failed to thoroughly investigate how the accident occurred, and failed to implement measures to ensure residents who required transfers with mechanical lifts would be properly cared for. There also was a failure to ensure that adequate supervision and staffing needs were satisfactorily met, as no follow-up monitoring or documentation was provided to demonstrate what was done to prevent similar accidents from occurring by facility leadership. Cross-reference to findings at F725 and F726.",2020-09-01
942,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2019-09-13,725,G,0,1,X09M11,"Based on observation, record review and interview, the facility failed to ensure there was sufficient nursing staff to provide adequate supervision and care to prevent a potentially avoidable accident for one resident (Resident (R) 31). This deficient practice, including the lack of adequate supervision of CNA25 by the charge nurse that night, was a contributing factor for R31 sustaining serious injury and harm. This deficient practice also has the potential to cause serious harm to other residents residing in the facility, as the facility failed to complete their in-service education/training for hoyer lifts after the accident, and failed to monitor ADL activity/care provided to the residents during the night shift. In addition, another resident (R57) stated the facility lacked the staff to meet her toileting needs, and the resident council voiced there was not enough staff for the number of residents in the facility because of long wait times for assistance. This deficient practice had the potential to affect all residents residing in the facility. As such, the facility failed to ensure their staffing satisfactorily met the needs, care and services for their residents in order to have them maintain their highest practicable physical and psychosocial well-being. Findings Include: 1) There was a lack of nursing oversight and staffing for the Mokihana unit on 04/20/19. This lack of adequate supervision by the charge nurse, RN11, was revealed based on her telephone interview on 09/12/19 at 01:58 PM. RN11 stated that she was not aware of CNA25's whereabouts when R31's head injury occurred from a drop/fall from the hoyer lift. RN11 was the assigned charge nurse on the Mokihana unit on the night shift of 04/19/19 into 04/20/19. RN11 confirmed CNA25 was her only CNA staffed on the Mokihana unit that night and did not know CNA25 had taken R31 for an early morning shower. RN11 said as the charge nurse, she was responsible to know what was happening on the unit, including oversight of CNA25's actions. Because she did not know where or what CNA25 was doing, this was a contributing factor for R31 sustaining her head injury. By this lack of oversight of CNA25, it allowed CNA25 to perform a task (the early morning shower of R31) using the hoyer lift by herself and unsafely transfer R31. Further, RN11 was not sure if the resident had, made a mess or had to shower her right away, as the reason for the early morning shower. There was no documentation found as to why CNA25 showered R31 that early in the morning. As to the appropriate use of the hoyer lift, RN11 stated, I know it's supposed to be two staff assist for the hoyer lift. She said, I told (CNA25) it has to be two staff assist next time with me or whoever is the charge nurse. RN11 was queried if the hoyer lift was done with a two person assist, would this accident have been preventable, and she replied, Yeah. 2) RN11 also said some of the other residents were receiving early morning showers, and was aware the CNAs would do these early morning showers. RN11 said she thought they should be documenting these early showers, but was unsure and stated, I know they do the showers, but it could be to help out the day, but I don't know. Yet, the facility's investigation of R31's accident did not include any inquiries or documentation of why an early morning shower was given to R31, or whether this was a practice by the night shift staff that was on-going, but unreported and undocumented. 3) RN11 stated for their night shift staffing in the Mokihana unit where R31 resides, they were staffed with one nurse and one CN[NAME] She said the Mokihana charge nurse was also responsible for the care of the residents in the next building (Makalapua or Maka). RN11 said she went to the Maka unit whenever she got called to assess a resident. She said sometimes it would be an hour or so, depending on a resident's condition. RN11 said if she left Mokihana to go to Maka, it would leave the Mokihana residents with only one CN[NAME] The Maka unit too, would be without a licensed staff once she would return to Mokihana. RN11 affirmed the staffing currently remains the same, and did not change after the 04/20/19 accident involving R31. RN11 stated the Ilima building/unit had their own nurse, and that nurse did not need to travel between the buildings. RN11 said she could not remember how many times she had to go to the Maka unit since the (MONTH) incident. RN11 was asked if this was a safe practice to leave the Mokihana residents (or Maka residents) unattended and with one CNA, and she replied she did not think so. Of note, the daily staffing schedule showed the Maka unit was staffed with two night shift CNAs; however, on 04/25/19, the work schedule shows CNA25 worked the night shift on both the Mokihana and Maka units, which would have left one CNA in both buildings/units. 4) The potential for harm for the residents in Mokihana and Maka still exists since the facility failed to investigate and determine after R31's accident, if the night shift had been or still may be performing early morning resident showers, as well as one person assist transfers using the hoyer lift, instead of the required two. Given the current staffing in the Mokihana and Maka buildings/units, if there was a need to use the hoyer lift, the Mokihana unit may not always have this capability, based on RN11's account of covering both buildings at any given time. On 09/13/19 at 10:32 AM, the DON produced the CNA in-service training log for CNA25 on the topic of transfers. The DON said, it was verbal, and said she went over the hoyer lift in-service. DON verified she did not do any post incident monitoring or follow-up of CNA25 to show that staff were providing safe care using the hoyer lift. The DON verified she did not complete the staff in-service education/training on the hoyer lift and two person assist. The facility failed to show what was done to ensure the safety of all residents was being monitored for those who required the use of a mechanical lift for transfers. There was no documentation or evidence provided by the facility to show they performed any monitoring, such as on-site audits of staff involved in the accident and/or of other nursing staff. The facility also failed to determine whether their staffing sufficiently met the needs of the residents. During the DON's interview on 09/13/19 at 08:21 AM, she verified their staffing pattern did not change. She said only one nurse covers Mokihana and Maka for the night shift. The nurses worked a 12 hour shift, but the CNAs did not. She said the CNAs would switch out from the different buildings to help cover, but again, there was no documentation to show the allocation of staff, time and resources to verify their staffing was adequate to ensure the residents' needs were being met. Cross-reference to findings at F689 and F726. 5) On 09/11/19 at 08:52 AM, a follow-up interview was done with R57. She initially stated on the initial tour that the facility's staff took a while to answer her call light or toilet her when she needed to go. She said it happened on every shift. This interview revealed that R57 felt the facility has a lot of staff around, but they all busy. The longest I waited was 20 minutes. When I want to use the bathroom, I just call, call, call and nobody comes you know. R57 said it happens frequently, and sometimes, more than half an hour. I can't wait so I stand up, but I'm afraid you know. She reiterated that the wait time was usually was 20 minutes before staff could toilet her and it was, anytime. She said even though they toilet her every two hours, she, can't wait inbetween. I ring the bell at the bed and takes 20 minutes, sometimes longer. They have to hurry up, and sometimes the urine comes out, not much, just drops when I cannot hold. 6) During the Resident Council interview with the President and Vice President on 09/12/19 at 10:29 AM, the President stated that sometimes there were not enough staff for all of the residents in the facility. The President stated, During these times several of the call lights are going on and the staff try to get to those residents but it takes a long time. As the president I alert the nurse if there is a resident who fell , or if someone needs help immediately. It isn't during any specific period of time during the day or night it happens at different times.",2020-09-01
943,"HALE KUPUNA HERITAGE HOME, LLC",125062,4297A OMAO ROAD,KOLOA,HI,96756,2019-09-13,758,D,0,1,X09M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record Review (RR) for one of five Residents (R) reviewed R34 was prescribed an anti-anxiety medication as needed (PRN) for greater than two weeks. This deficient practice with the lack of monitoring has the potential of having detrimental side effects for the resident by not keeping her free from unnecessary medications. Findings Include: Minimum data set (MDS) quarterly review dated 07/19/19 was reviewed for R34. She is diagnosed with [REDACTED]. Section V care area assessment was coded for mood and [MEDICAL CONDITION] drug use. Orders reviewed dated 07/26/19: Monitor behavior every (Q) shift for [MEDICATION NAME] (an anti-anxiety) use two times daily (BID). For [MEDICATION NAME] use. Behavior: Picking at skin with tweezers. Monitor Side effects: Dizziness, drowsiness, lethargy, apnea. Medication Administration Record, [REDACTED] 1. Starting 08/13/19, [MEDICATION NAME] 0.5 milligram (mg) tablet, give 1 tablet via gastrostomy tube ([DEVICE]) as needed two times continue for 2 weeks. Pharmacy notes reviewed: Medication regimen review (MRR) dated 10/22/18 reviewed. PRN [MEDICAL CONDITION] orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the PRN order. Please consider. There were no new orders for the PRN anti-anxiety. MRR for following dates reviewed: 03/16/19, 05/15/19, 06/11/19, 07/91/19, 08/07/19, no new suggestions. Behavior team rounds notes dated 09/06/19 reviewed: Medications include [MEDICATION NAME] (an anti-anxiety) 0.5 mg prn BID via [DEVICE]; [MEDICATION NAME] 10 mg via [DEVICE] prn headache; [MEDICATION NAME] 5 mg via [DEVICE]. PRN at bedtime. Resident is doing well on prn [MEDICATION NAME] with other medications. Next evaluation recommended in 3 months. No changes. During an interview with Registered Nurse (RN)54 on 09/13/19 at 1:00 PM, she stated that R34 is on [MEDICATION NAME] PRN, adding that R34 takes the medication twice per day even though it is ordered PRN. She agreed that the medication order is longer than two weeks and will follow up with the MD for a new order. Normally the MD will review the pharmacist recommendations and follow up with the orders. R34 behavior rounds were changed from monthly rounds to quarterly rounds.",2020-09-01
944,15 CRAIGSIDE,125063,15 CRAIGSIDE PLACE,HONOLULU,HI,96817,2019-10-11,689,D,0,1,5T9H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with facility staff, the facility failed to identify an accident risk to avoid an accident while wheeling/pushing a resident in the wheelchair without foot rests for one (Resident 14) of one residents sampled for accident hazards Findings include: Resident (R)14 was admitted to the facility on [DATE] from an acute facility. R14's [DIAGNOSES REDACTED]. On 10/09/19 during lunch observation, R14 was found to self-propel in a wheelchair (utilizing his/her feet) away from the table and had to be redirected by staff back to the table for lunch, three times before the resident's meal arrived. On 10/09/19 at 01:30 PM observed the resident in the hallway with Certified Nurse Aide(CNA)1. There were no foot rests on the resident's wheelchair, the CNA began to push the resident, then stopped and stated he/she would get R14's foot rests. The foot rests were retrieved from the resident's room, applied and R14 was wheeled (pushed) from the hall to the dining room. On 10/09/19 at 01:54 PM observed Staff Member (SM)1 wheeling R14 back to his/her room. There were no foot rests applied to the wheelchair, R14 had to lift his/her feet to prevent it from dragging on the ground. The resident's feet were barely off the ground. On 10/10/19 at 11:45 AM observed CNA2 pushing R14 from the resident's room to the dining area. The foot rests were not applied and the resident had to hold up his/her feet for the duration of the ride. CNA2 was asked whether R14 has foot rests, the CNA replied the foot rests are not applied as the resident wants to propel himself/herself about the unit. A record review found a quarterly Minimum Data Set with an assessment reference date of 08/05/19. R14 yielded a score of zero (severe cognitive impairment) upon administration of the Brief Interview for Mental Status. The resident was coded with signs and symptoms of [MEDICAL CONDITION] (fluctuating behavior, inattention, disorganized thinking and altered level of consciousness). R14 was also noted to have range of motion impairment of both lower extremities. A review of the care plan provided by the facility on the morning of 10/11/19 notes R14 is at risk for fall and injuries due to impaired safety judgment and generalized weakness (extensive to total assist with mobility). Also noted, R14 uses the wheelchair as the main mode of locomotion, he/she is able to wheel in the hallway with general supervision. R14 is documented to receive routine antipsychotic medication ([MEDICATION NAME]). Further review found a Care Plan Update Sheet which notes an additional entry dated 10/09/19 with the following intervention: If staff is wheeling resident from resident's room to around dining area, foot rest is not needed as resident is able to propel but resident may need assistance in direction. If resident uses his/her feet as a brake to stop the wheelchair, staff will stop wheeling and ask resident what he/she would like to do. The update was recorded by the Director of Nursing (DON) on 10/11/19 at 08:24 AM after initial observations and interviews were done. On 10/11/19 at 09:52 AM an interview was conducted with the Physical Therapist (PT). The PT confirmed he/she is familiar with R14 and concurrent observation of the resident's wheelchair found the foot rests were not affixed to the chair. The PT reported the foot rests are not placed on the wheelchair to allow R14 to be mobile. The PT demonstrated that with the foot rest applied, the foot rests can snap back and hit the resident's feet/legs while he/she is self-propelling. The PT was asked about staff members pushing the resident in the wheelchair without placing his/her feet on the foot rests. The PT reported R14 has a tendency to drop his/her feet down and for safety purposes foot rests are indicated.",2020-09-01
945,15 CRAIGSIDE,125063,15 CRAIGSIDE PLACE,HONOLULU,HI,96817,2019-10-11,755,D,0,1,5T9H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with staff members, the facility failed to control and account for controlled drugs while awaiting disposal, as evidenced by accurate documentation of medications placed in the locked drawer for disposal; multiple nurses having access to controlled drugs stored in a locked drawer; and a system to account for controlled medication disposal in sufficient detail to enable accurate reconciliation to prevent drug diversion. Findings include: On 10/10/19 at 12:05 PM, inspected the medication storage room with Registered Nurse (RN)1. Observation of the locked controlled drugs found a discrepancy between the list of medications and the actual medications. There were five medications in the drawer; however, only four were listed. An open bottle of [MEDICATION NAME] HCL 100 mg/ 5 ml for Resident (R)13 was not documented on the Medication to be Discarded log. RN1 confirmed that the [MEDICATION NAME] was not documented on the log. Although RN1 did not place the [MEDICATION NAME] in the locker drawer, upon discovery of the undocumented medication, RN1 made an entry dated 10/10/19 with R13's name, type of medication, number of units remaining (11.4 ml) and initialed the entry. RN1 did not measure the [MEDICATION NAME] prior to documenting the units remaining. Inquired about the process of discarding medication. RN1 responded medications that are removed from the medication cart, are then listed on the Medications to be Discarded log. Medications are stored for a week in the locked drawer, with disposal scheduled every Friday. The responsibility for discarding medications are rotated between the three shifts. The RN1 was asked who has access to the locked drawer, RN1 responded multiple staff have access to the drawer. During a day, there are up to five nursing staff that have access to the drawer (two medication nurses during the day shift; two medication nurses during the evening shift; and one mediation nurse during the night shift). The Director of Nursing confirmed that there are multiple staff that have access to the locked drawer. Further review of the Medication to be Discarded log for controlled drugs found there is no documentation of the time the drug was placed in the locked drawer. Also, there is no initial verification by another nurse to attest how many units/tablets remain when it is placed in the locked drawer for disposal purposes. Additionally, there is no way to identify who and when staff accessed the drawer.",2020-09-01
946,15 CRAIGSIDE,125063,15 CRAIGSIDE PLACE,HONOLULU,HI,96817,2019-10-11,812,D,0,1,5T9H11,"Based on observation, inquiry with staff, and policy review, the facility failed to follow their protocol/procedure; where a kitchen staff member, (KSM)1, failed to wear a hair restraint while in the kitchen. As a result of this deficient practice, the facility put the residents at risk for food contamination. Findings include: During a walk through of the kitchen on 10/09/19 at 08:35 AM, KSM1 was observed not wearing any hair restraint (such as a hat, or hair net) while being in the kitchen. When asked the reason why a hair restraint was not being used, KSM1 stated that he/she just came in recently from outside. The Kitchen Manager (KMgr), who accompanied the walk through, was queried about the above finding. KMgr acknowledged that KSM1 should have been wearing a hair restraint while being in the kitchen. KMgr also stated that it was in their Dining Protocols to wear hair restraints (such as a hat, or hair net). A review of facility's policy on Dining Protocols stated the following: Personal Hygiene; Dining Services personnel are to wear appropriate clothing including hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens, and unwrapped single-service and single-use articles.",2020-09-01
947,15 CRAIGSIDE,125063,15 CRAIGSIDE PLACE,HONOLULU,HI,96817,2018-10-26,921,E,0,1,O0MU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, review of facility policy, and review of manufacturer recommendations, the facility failed to properly store three of five Soft-Fall Bedside Mats (mats) reviewed. As a result of this deficient practice, the facility put the safety and well-being of not only the residents, but the public and the staff at risk for accidents/tripping/falls. Findings Include: During an observation of 16 resident rooms (201A to 208B) on 10/25/18 at 10:30 AM, there were a total of 5 mats being used in these rooms. Two mats were properly placed along both sides of the bed in room [ROOM NUMBER]B, as per manufacturer's instructions. However, a total of 3 mats, 1 mat for each room; 205B, 206B, and 207A, were not properly stored away, as per manufacturer's instruction. These mats were stored away either by leaning up against the wall or leaning up against a cabinet. These mats had the potential to end up on the floor, and thus, creating a risk for accidents/tripping/falls, etc. During staff interview with Registered Nurse (RN) 1, on 10/25/18 at 01:30 PM, RN1 acknowledged that all mats assigned to residents were being stored away, when not in use, by leaning up against the wall. RN1 was not aware of the manufacturer's recommendation for properly storing these mats. During discussion with the Administrator (Admin) on 10/25/18 at 1:50 PM, Admin reviewed the manufacturer instructions which stated The one-piece mat is sized to fit under the bed for storage. Admin acknowledged that storing the mats by leaning it against the wall or cabinet had the potential for it to end up on the floor and creating a risk for accidents/tripping/falls.",2020-09-01
948,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2020-01-27,554,D,0,1,Q4UO11,"Based on observation, record review, interview with resident and staff members, and a review of the facility's policy and procedures, the facility failed to ensure the right to self-administer medications were exercised only when the interdisciplinary team determined this practice is clinically appropriate for one resident (Resident 397) in the active sample. Findings include: Cross Reference to F755 and F842. Resident (R)397 was observed with medications left for him/her to self-administer on the bedside tray. Record review and interview with staff members found there is no documentation that R397 was assessed by an interdisciplinary team to determine he/she has the ability to exercise his/her right to self-administer medications safely and it is clinically appropriate. Also, the facility did not follow their policy and procedures for self-administration of medications by a resident.",2020-09-01
949,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2020-01-27,584,D,0,1,Q4UO11,"Based on observation and interview with resident and staff members, the facility failed to meet 4 residents(R)198, R6, R200 and R248's accommodations and preferences in several areas to maintain independence. Findings include: 1) In an interview on 01/22/23 at 0143 PM, R 198 stated that on the first day I was here, outside of my door, one of the higher ups was talking to a CNA in a loud, scolding manner in Illocano. R198 overhead the conversation and stated out loud that's okay I'm done. R198 commented, they should not be scolding someone who was helping me so loud outside my door in Illocano. The CNA was helping me and the higher up wanted her to come out and help another person. 2) In an interview on 01/24/20 at 11:38 PM, R198 stated last night while my daughter and her daughter's friend was visiting, my daughter noted a swirl of ants by the sink. R198 stated that she has seen ants from the first day. Surveyor, went to look at the sink area where R198 was referring to and observed two ants crawling near the sink area. The nurse manager was notified. 3. During an observation in R6's room on 01/23/20 at 11:47 AM, noted the bed rails with rust and dark smudges. 4. During an initial tour in R248's room on 01/22/20 at 01:16 PM, noted a wall clock in line of the residents view with a cracked cover and taped together with transparent tape. 5) On 01/23/20 at 01:20 PM, Resident (R)200 attended the Resident Council interview. R200 reported when he/she was first admitted to the facility, he/she was in a double room and had a roommate. R200 wanted to rest; however, the roommate's television volume was too loud, keeping him/her awake. R200 asked a staff member to request the roommate turn the volume down. R200 fell asleep only to be awakened by the loud television. R200 went back to sleep then at approximately 02:00 AM the roommate's son came to watch football and they were speaking loud, as well as, the television volume was too loud. R200 asked the roommate to be quiet. Later R200's roommate had a visitor at 08:00 AM, they were so loud R200 could not rest and by night time R200 yelled so an aide came to see what was happening. R200 informed the aide that the roommate was asked to lower the volume. The roommate reportedly called R200 stupid and a dumb ass. R200 stated that she felt nervous and expressed his/her concern to staff member. The facility then transferred R200 into a new room.",2020-09-01
950,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2020-01-27,585,D,1,0,Q4UO11,"> Based on interviews and record review (RR), the facility failed to make prompt efforts to resolve three of three grievances that had been filed with the Office of Healthcare Assurance (OCHA), intake #[AGE]58, #[AGE]64, and #[AGE]95. The facility did not acknowledge one written complaint, one verbal request to speak with a manager, and did not internally identify the other complaint as a concern or grievance. As a result of this deficient practice the complainants had unresolved or delayed response to their concerns. This deficient practice potentially puts all residents/representatives at risk that their concerns/grievances, may not be acknowledged, and prompt efforts would not be made to resolve them. In addition, facility failed to provide enough evidence that it maintained the results of all grievance decisions for the required three-year period. Findings include: 1) Intake #[AGE]64, anonymous resident (R) - A complaint was received at OCHA on 02/11/19. The complainant's family member had a fall while at the facility resulting in a skin tear. The complainant stated, I requested a report of the fall on numerous occasions up until R was discharged . The complainant went on to say, The last time I requested the report, I was told by a nurse at the facility it would be sent to my house and this never occurred. RR of progress notes revealed the following entry dated 12/09/19 by Registered Nurse (RN)50, Family is looking to talk with Nurse Manager regarding fall on 11/15/19. RN Manager notified by email. On 01/24/20 at 02:00 PM, during an interview with the Nurse Manager (NM6), reviewed the progress note requesting that she follow up with R's family about the fall. The NM6 stated, Email? I can't recall anything. We send email straight through Vision (the computer system used by RN's). During the interview, NM6 reviewed her email history and stated, I'm not able to go back that far. NM6 could no longer view emails from this date. NM said, I do not recall this incident or the email that someone wanted to speak with me. Inquired if RN50 was still at the facility, and NM6 said he no longer worked there. RR revealed this issue was not logged on the 2018 or 2019 Grievance or concern log. 2) Intake #[AGE]58, anonymous R - A written letter of complaint was received at OCHA on 01/15/19 from the Power of Attorney (POA) for R, who had been at the facility. The Complainant letter stated, I wrote to the CEO (Chief Executive Officer) . on November 20, 2018 about the rash but never got a response. A copy of that letter is enclosed. On 0[DATE] at 02:00 PM, during an interview with the Administrator (ADM) and the Assistant Administrator (AST ADM), asked what the process was if a complaint went directly to the CEO, whose office is not located on site. ADM said, He would send the complaint to the me for follow up. When asked if this should be logged as a grievance, the ADM replied, Yes. The current ADM was not employed at the facility at the time the letter, but the AST ADM was the ADM at that time. The AST ADM did not recall any letter of complaint brought to her attention, and said, The CEO would pass the letter/grievance on to the administrator of the facility for further follow up. That's our process. On 0[DATE] at 04:30 PM during a phone interview, the Complainant confirmed that he did not get a response to his from the CEO or the facility. On 01/24/20 at 03:15 PM during a phone interview with the CEO, he stated, If I receive a phone call or letter of complaint, I forward the information or letter to the Administrator of the facility involved. I email the information and often drop it off in person. Inquired if a log is kept of the complaints that came through the office, and he replied, I note it on my calendar to remind me to follow up, but that is not kept. There is not a specific log. Surveyor was asked if the letter was sent certified. On Follow up interview with complainant, he said the letter was sent by regular mail. On 0[DATE] at 10:00 AM, during an interview with the Social Service Manager (SSM), she said if a complaint went to the CEO, they would let her know. Inquired if a letter would be considered a grievance, and she replied. Yes. SSW added that it should be entered on the grievance log. RR revealed this complaint was not entered on either the grievance log or concern log. 3) Intake #[AGE]95, anonymous R - Family member filed a complaint with OHCA and expressed concerns regarding her sister's discharge. Complainant said she was informed on [DATE] that her sister's Medicare coverage would end 12/31/19 and needed to leave the facility 01/01/20, instead of 01/07/20. The complainant wrote. I was unable to get a conference to discuss my sisters' condition to help me with placement. She did not understand why PT services were not going to be continued. Complainant also did not understand why the Case Manager from Caresift, who was trying to find placement for her sister was asking questions about her sister's condition and type of care she would need when discharged . The complainant was not comfortable answering the questions and felt some of the information they had was not accurate. Caresift was under the impression she used a cane. I don't believe that and can't give them the information they need. Complainant letter stated, I finally was able to get a meeting scheduled for 12/30/19 at 02:30 PM. We had been working with SW1, but she went on vacation. On 0[DATE] at 01:00 PM. during an interview with SW1, she said. I started working with R and her sister, and then went on vacation. SW1 said when she left, they were still deciding if R would go home with her sister or need placement. SW1 said she connected them with a Case Manager at CareSift, and then went on vacation. When inquired how CareSift gets information on the resident's status and capabilities, she said they sometimes ask for PT/OT (physical therapy and occupational therapy) notes so they can see what level they are at. They also talk to the guest and sometimes come and watch them in therapy. The SSM took over after I left. I know they did have a meeting to discuss. When I came back, she was being discharged the next day. On 01/24/20 at 03:00 PM, during an interview with SSM, discussed the meeting held with R's sister regarding concerns about discharge and PT services. SSM said PT was present at that meeting and explained why R no longer qualified and what the current status was. SSM said we had connected her with Caresift, but they found another place. Asked SSW why this issue had not been logged as a concern or grievance as complainant had requested a meeting specifically to discuss concerns. SSW replied, I felt everything was resolved at the meeting. Queried if there was documentation of the meeting, and SSM replied, There should be, but there is not. Discussed a different Grievance that was logged for R200, that was very similar in nature to R's. Asked SSM why R200's concern was logged as a grievance, and not R's. SSW said. R220's had been brought to SW1's attention and she spoke to the guest, who didn't agree that OT was ending. If someone doesn't agree with the discharge process and it's brought up to us, we initially go in, and talk and find out specifics. We'll investigate it and talk to the manager. They usually communicate back to the guest. The Manager would connect with PT/OT. The SW should be going back in and validate that follow up has been done. If not resolved, will revisit and make them aware of ombudsman and outside agencies to contact. The Business office keeps track of issue notices and provides information on how to appeal. I may not know if an appeal is being done. 4) Reviewed the facility policy titled Grievance Procedure, dated 10/15/17. The policy states, The community investigates all grievances and complaints filed with the community. A Grievance is defined as any and all complaints requiring investigation and follow-up to the person making the complaint; issues previously addressed but which continue to be a concern; . Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of the staff or other residents/guests and other concerns regarding their LTC (long term care) community stay. The policy procedures included the following statements: 1. The designated Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances through to conclusions; leading any necessary investigations . 2. Upon admission, residents/guests are provided with written information on how to file a grievance or complain.Grievances and /or complaints may be submitted orally or in writing. Written complaints or grievances should be signed by the resident/guest or the person filing the grievance or complaint on behalf of the resident/guest . 3. Should a staff member be the recipient of a complaint voiced by a resident/guest, a resident/guest's representative, or another interested party ., every attempt should be made to see if the issue can be resolved at that time. If not, then assist the resident/guest, or person acting in the resident/guest's behalf, to file a written complaint with the community. Resident /Guest Grievance/complaint forms are available at community specific locations and in the Social Services office. The Grievance/Complaint form also includes contact information of independent entities with whom grievances may be filed. 4. All complaints and/or grievances must be brought to the attention of the Administrator, Social Services Department and involved manager on the next business day. 7. The Resident/guest Grievance/Complaint Investigation Report Form must be filed with the administrator with 5 working days of the receipt of the grievance or complaint. 8. The resident/guest, or person acting in behalf of the resident/guest, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 10 working days of filing of the grievance or complaint . 12. The community will maintain evidence demonstrating the result of grievances for a period of no less than 3 years from the issuance of the grievance decision. 5) On 0[DATE] at 02:00 PM during an interview with the ADM and AST. ADM asked who the designated Grievance official was. ADM said, The Social Services Manager, is the point person for complaints. Inquired what is considered a grievance versus a concern. ADM replied, It's the goal to get back to the individual who has the concern and resolve it within [AGE] hours from when it comes to our attention. We immediately get back to guest. We do the correct follow up and investigation. We want to be proactive and talk about them (the concerns) in the Stand-up meetings every day. We discuss ongoing concerns at the morning meeting. We discuss and report any grievance at Quality Meeting every month, note any patterns, and will discuss opportunities. Asked ADM if the process described for identifying a grievance versus concern was written in the Grievance policy, and the ADM said, No, but that is our practice, and everyone is aware of it. 6) On 0[DATE] at 10:30 AM during an interview with the Social Services Manager (SSM) inquired if she was the Designated Grievance Official referenced in the policy. She explained her role was to coordinate the complaints, and when grievances occur, they conduct investigation and involve the clinical managers as needed. She said. The Social Worker (SW) is usually the one that gets the complaints. If a staff member gets one, they will notify the SW. We bring it to the supervisor, SW or Director of the area. It happens immediately. We try to resolve issues when they occur. If they want to take it further, or guest wants to do something more official, that's when we make it a Grievance. SSM said the complaint could be verbally or written (form referenced in the policy). I will track on the Grievance form what follow up is done. Inquired how Residents/representatives get the grievance form to complete. SSM stated, Staff will sometimes give them the form to complete. SSW was asked if there were other grievances for the year, as the number was very low. She said, There is a separate tracking log for concerns. We try to resolve immediately. If unable to resolve goes to grievance. If it is a grievance, the DON is made aware immediately and include AST ADM if needs attention. Inquired if ADM receives a complaint or letter sent directly to them or CEO, what would the process would be. SSM said, If it requires follow up, they will bring it to our attention for follow up, and it will be put on the grievance log. SSM said there is nothing in writing that states what a concern is versus a grievance. 7) The admission packet provided to all residents/representatives includes a flyer titled, Guests Rights Grievance Procedure, included the statement If you believe your rights have been violate contact: The Grievance Official or the Administrator .at ([AGE]8-547-[AGE]00). There is no name for the Grievance Official or direct extension. When [PHONE NUMBER] was called, there is no listing to relate to the Grievance Official or the Administrator but offers a general mailbox which has the recording: The extension [AGE]01 is not available. The admission packet also includes a copy of the Guest Grievance/Complaint Form which includes the statement, Please fill out, date, and sign this report and submit to the Grievance Officer or designee. There is no indication on the form who the Grievance Officer is to submit the form to. The Admission packet includes a telephone directory but does not identify anyone as the Grievance Officer. 8) Review of the POS [REDACTED]. The position description Essential Functions number 3 states, Will meet with all guest on respective caseload regularly. Maintains a complaint/issues log. Prepares a report monthly for the Administrator from the log including all follow up to issues. 9) RR of Grievance and Concern logs RR of Grievance/Complaint Log from June 2019 through December 2019 revealed five grievances. Due to the small number, requested the logs for the past three years, 2017, 2018, and 2019. There were no additional grievances logged for 2019. RR of Grievance/Complaint Log for 2018 revealed a total of six for the year. Two in April, and four in March. August 2019 Concern log revealed a concern entered on 08/03/19 for R 201. Resolution/Date documented, 08/06: Unresolved. Although this concern is documented as unresolved, it is not documented on the Grievance log. There is no documentation that this was escalated to the grievance level for further investigation as the process was described by the SSM, ADM and AST ADM. On 0[DATE] at 01:00 PM during an interview with the SSM, inquired about the documentation provided. SSM said. The grievances for 2017 were probably logged as concerns. Discussed there are not clear direction, or policy statements to identify what is a grievance and what is a concern. The staff is also not consistently assisting guests and families to fill out the form to ensure the issue is forwarded to be investigated timely.",2020-09-01
951,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2020-01-27,604,D,0,1,Q4UO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to ensure 1 of 2 sampled residents were free from the use of physical restraints. The facility failed to assess/recognize the use of a bedside tray, locked wheelchair, and staff placing both hands on the resident's shoulders as restricting Resident (R)449's movement, as well as, assessing the resident's ability to easily move the table or release the wheelchair lock to allow movement. Therefore, a plan of care was not developed to provide parameters for use of physical restraints and there is no documentation identifying the medical symptom being treated with a physician's orders [REDACTED]. The use of physical restraints may also impact the resident's psychosocial well-being. Findings include: A record review documented R449 was admitted on [DATE], [DIAGNOSES REDACTED]. Review of R449's baseline care plan documented the resident is at high risk for falls related to impulsivity. #1 Impulsive self-propelling to rooms/hallways getting up)-->redirect guest calmly, re approach, stay 1 arm length away for safety, remind guest of RUE (Right Upper Extremity) being NWB (Non Weight Bearing) .redirect guest calmly and stay 1 arm's length away for safety. The baseline care plan did not identify or address the use of a physical restraint. A review of the Behavior Monitoring Sheet on 01/22/20, Day shift, revealed staff documented N/A for interventions, outcomes, and side effects regarding R449's behavior for combative behavior, impulsive behavior, and swearing. On 01/22/20 at 10:05 AM, observed R449 seated in a wheelchair at the nursing station. Staff informed this surveyor to exercise caution when interacting with R449 due to his/her history of behavioral issues (hitting staff, verbal aggression, and impulsivity). Staff explained that R449 is at the nursing station with staff, because if R449 is left in the room, he/she will attempt to stand and will fall. Observed R449 stand-up from his/her wheelchair, R449's movements were not obstructed. R449 stood and attempted to walk before being verbally redirected by staff. On 01/22/20 at 12:57 PM, observed R449 near the 3rd floor nursing station, seated in his/her wheelchair. A bedside table was placed directly in front of R449's wheelchair. R449 was not engaged in mealtime or any activity, there was nothing placed on the tabletop. Observed unit staff attending to another resident's needs; toileting, meal distribution/assistance, and medications/treatment. At 01:20 PM, observed R449 attempt to back away his/her wheelchair from the bedside table, however, he/she was unable to move the wheelchair due to the wheels being locked. Unable to move the wheelchair, R449 then attempted multiple times to unlock the wheelchair, but was unsuccessful. Finally, R449 attempted (three times) to push the bedside table away, unsuccessfully, to stand. R449 could not stand and freely move due to the bedside table that was placed directly in-front of R449's wheelchair. R449 then partially stood up, using the wheelchair as a support and attempted to move his/her left leg out from in between the wheelchair and the bedside table when certified nurse aide (CNA)5 became aware of the situation. Subsequent observation on 01/22/20 at 01:45 PM (approximately 45 minutes later), Certified Curse Aide (CNA)5 noticed R449 was attempting to stand, CNA6 was notified of the situation. CNA5 and CNA6 discussed that they were both not finished with another resident's tasks and were unable to supervise R449. CNA5 and CNA6 discussed possible taking R449 to physical therapy watching R449 while they completed their work. Observed CNA5 unlocked R449's wheelchair and wheel R449 away from the table. CNA5 continued to speak with CNA6, while R449 continued to attempt to stand again. In response to R449's attempts to stand, CNA5 placed his/her hands on both of R449's shoulders, physically preventing R449 from standing and verbally told R449 You have to sit down, you cannot go walking right now and did not remove his/her hands from R449's shoulders. As a result of CNA5 placing both hands on R449's shoulders, R449 was unable to attempt to stand and remained seated in his/her wheelchair. CNA5 addressed this surveyor stating, R449 requires a lot of attention because he/she is always trying to stand/walk because he/she wants to go home and can be combative. CNA5 stated R449 becomes mad when he/she cannot do what he/she wants. CNA5 further described, R449 is hard to watch . especially at certain times because other residents need help also, but R449 is always trying to stand and leave. CNA5 failed to identify the placement of a bedside table directly in front of R449's wheelchair, along with R449's inability to unlock the wheelchair, and placing his/her hands on R449's shoulders restricted R449 from freely moving and acted as a form of physical restraint for staff convenience. Approximately 15 minutes later, observed a physical therapy staff interacting with R449 as unit staff attended to other resident's needs. On 01/23/20 at 09:57 AM, observed unit staff assisting other residents. R449 was seated in his/her wheelchair at the counter of the nursing station watching Korean basketball on a computer screen. R449 was able to stand up from his/her wheelchair and attempting to walk away from his/her wheelchair. Contract staff seated at the nursing station noticed R449 standing and proceeded to intervene to maintain R449's safety from falling. After the contracted staff was able to ensure R449's safety, he/she alerted unit staff of the situation. On 01/27/20 at 11:18 AM, inquired with Nurse Manager (NM)4 regarding the observation of the bedside table (empty tabletop) placed directly in front of R449's wheelchair, locked wheelchair wheels, and CNA5 placing both hands on R449's shoulder, which prohibited R449 from freely moving. NM4 verbally identified the combination of placing the bedside table in front of R449 and the locked wheelchair, which he/she was unable to unlock and freely move away from the table is a form of physical restraint. NM also confirmed that when staff placed both hands on R449's shoulders restricting the resident from standing is a physical restraint. NM4 verified R449 did not have a medical [DIAGNOSES REDACTED].",2020-09-01
952,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2020-01-27,656,D,0,1,Q4UO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and record review, the facility failed to ensure care plan interventions to maintain a safe environment for Resident (R)16 was implemented as evidenced by chairs obstructing the walkway in R16's room. As a result of this deficiency, R16 is at an increased risk of falls and injury. A second resident, R248's care plan did not include information pertinent to the resident's [DIAGNOSES REDACTED]. The care plan did not include goals, objectives and measurable outcomes to address the resident's risk for bleeding related to the [DIAGNOSES REDACTED]. The deficient practice places R248 at an increased risk of injury. Findings include: 1) Cross-Reference to F689 Record review documented R16 was admitted on [DATE] with [DIAGNOSES REDACTED]. R16's fall risk assessment documented a high risk of falls (score=18). Review of the care plan documented R16 has a history of falls at home prior to admission within the last month. Interventions include, keep areas free of obstruction to reduce the risk of falls or injury. On 01/22/20 at 09:30 AM, observed R16 sitting at the edge of the bed facing the window. R16 reported that he/she does walk to the restroom at times without assistance. There was a single chair placed with the back of the chair up against the wall under the window. When asked about the placement of the chair, the resident stated that it was hard to get around the chair, but he/she will try to. On 01/27/20 at 10:00 AM, observed R16 resting in bed. There were 2 chairs on the left side of the bed near the foot of the bed, against the wall. A large wedge to reposition R16 was placed on top of and hung off the side of the chair. The minimal space and the placement of the chairs decreased R16's walkway to approximately 1.5 feet. Certified nursing assistant (CNA)8 confirmed R16 does not always call staff for help and has been found ambulating by himself/herself. At approximately 11:52 AM, observed the room set-up with Nurse Manager (NM)4. NM4 confirmed the placement of the chairs and large positioning wedge was a fall risk hazard and obstructed R16's walkway to create an unsafe environment. 2) R248 is an [AGE] year-old female admitted on [DATE] with a [DIAGNOSES REDACTED]. During an interview with R248 on 01/22/20 at 01:42 PM stated that she came in due to bleeding from the varices, and that she has [MEDICAL CONDITION]. Electronic medical record (EMR) reviewed. R248 diagnosed with [REDACTED]. R248 care plan dated 01/13/20 reviewed. Current problems include chronic urinary tract infection, personal preferences, short term memory problem, nutrition risk related to overweight, and risk for dehydration. No interventions included bleeding precautions related to [MEDICAL CONDITION] varices and history of GI bleeding. During an interview with Registered Nurse (RN)25 on 01/27/20 at 11:29 AM stated that the care plan is created when the guest gets admitted . It is based on the [DIAGNOSES REDACTED]. The Interdisciplinary team (IDT) update it with problems that the resident wishes to do. Care Planning policy reviewed, Med pass inc, 01/01/2010. Purpose. The plan of care will be developed based on the Social Service (SS) assessment and history and will guide the SS and IDT staff in helping the resident to achieve and maintain his/ her maximum potential. The care plan should be developed no later than seven (7) days following the completion of the comprehensive assessment. During an interview with the minimum data set (MDS) coordinator on 01/27/20 at 01:17 PM, stated, her care plan is not being done, the nurses should be monitoring it and charting on it. I've got the nurses notes, and R248 was admitted for acute [MEDICAL CONDITION] related to [MEDICAL CONDITION] varices with bleeding. The nursing staff should be monitoring her and charting on it.",2020-09-01
953,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2020-01-27,677,D,0,1,Q4UO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to meet the resident(R)198, Resident #198's necessary services to maintain grooming, and personal and oral hygiene. Findings include: R198 was admitted on [DATE] for post-surgical rehabilitation. 1) Interview on 01/22/20 at 01:23 PM with R198, they haven't given me a bath and no offer. So, I have been kind of wiping myself down. I learned how to wipe myself from another facility. It's hard for me to reach down to my feet and legs and I can do my hands and face with the cleanser. On 01/23/20 at 08:42 AM during an interview, R198 stated that she has not been offered to shower or sponge bath and she would like to have that offered. Spoke to nurse manager (NM)5 and she said, I will check on that. R198's hair look disheveled and uncombed. Record Review (RR) on 01/23/20 showed documentation on 01/23/20 entered at 0731 PM by NM5 stating, during morning rounds, R198 was offered to get ready for the day and change her clothing. R198 stated that she wanted to just change her gown. R198 stated she asked for shorts so she could cover her back side but never received shorts. Staff encouraged R198 to wear her personal clothing. Later in the morning, R198 was offered by CNA to have a shower; however, R198 said she would prefer her body to just be wiped down in the bed and for it to be done after her therapy was completed in the afternoon. Further RR of Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. The MDS, Section F Preferences for customary routine and activities shows R198's preference to choose the clothes she wears is very important. R198's preference to choose between a tub bath, shower, bed bath or sponge bath is somewhat important. It is also documented that it is very important for R198 to have books, newspapers and magazines to read. R198's Brief interview for mental status (BIMS) is 15. Queried with R198 on 01/23/20 at 12:30 PM about R198 declining to shower in the am. R198 stated that she did not refuse. She had already wiped herself down and did tell the staff that she would like to get a wipe down after she gets her therapy.",2020-09-01
954,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2020-01-27,689,D,0,1,Q4UO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and record review, the facility failed to ensure Resident (R)16's room remains free of accident hazards as evidenced by two separate observations of R16's room in which movable chairs obstructed R16's path to the bathroom, creating a hazardous environment. As a result of this deficiency, R16 is at an increased risk of falls with the potential for resulting in harm. Findings include: Cross-Reference to F656 Record review documented R16 was admitted on [DATE] with [DIAGNOSES REDACTED]. R16's fall risk assessment documented a high risk of falls (score=18). Review of the care plan documented R16 has a history of falls at home prior to this admission within the last month. Interventions include, keep areas free of obstruction to reduce the risk of falls or injury. R16 shares a room with another resident and his/her bed was located nearest to the window. On 01/22/20 at 09:30 AM, observed R16 sitting at the edge of the bed facing the window. R16 reported that he/she does walk to the restroom at times without assistance. A chair was placed under the window facing R16's bed. The chair was in the area that R16 would use to ambulate out of bed and there was only approximately 18 inches between R16's bed and the chair. R16 confirmed although the movable chair was a hazard, he/she would still attempt to ambulate to the bathroom by his/herself if needed. On 01/27/20 at 10:00 AM, observed R16 resting in bed. There were 2 chairs placed on the left side of the bed near the foot of the bed, against the wall. A large wedge to reposition R16 was placed on top of the chair and was hanging off the side of the chair. The minimal space and the placement of the chairs decreased R16's walkway to approximately 1.5 feet. Certified nursing assistant (CNA)8 confirmed R16 does not always call staff for help and has been found ambulating by himself/herself. At approximately 11:52 AM, observed the room set-up with Nurse Manager (NM)4. NM4 confirmed the placement of the chairs and large positioning wedge was a fall risk hazard and obstructed R16's walkway to create an unsafe environment.",2020-09-01
955,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2020-01-27,755,D,0,1,Q4UO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview with staff and resident, and a review of the facility's policy and procedures, the facility failed to ensure administration of medications were administered under the supervision of a nurse. The facility also failed to ensure a record for controlled drugs are maintained. Findings include: 1) Cross Reference F554 and F842. On 01/22/20 at 08:10 AM during a screening of residents, Resident (R)397 was awake and seated on the side of the bed. R397's bedside tray was observed with a small plastic cup with seven pills in it and a small cup of water. R397 was asked about the pills in the cup. R397 reported the medications are left as he/she does not like taking medications and it is taken when he/she is ready. On 01/22/20 at 10:25 AM a resident interview was conducted with R397. R397 answered questions appropriately; however, later appeared irritable and the interview was discontinued. R397 was focused on familial issues with his/her children. On 01/23/20 at 10:52 AM and 01/24/20 at 08:16 AM a record review was done for R397. R397 was admitted to the facility on [DATE]. The admission [DIAGNOSES REDACTED]. A review of the physician orders found the following scheduled medications for 08:00 AM: Renal tab (one tab); [MEDICATION NAME] 400 mg (400 mg for [DIAGNOSES REDACTED]); Eliquis 2.5 tablet (2.5 mg for [DIAGNOSES REDACTED]); calcium acetate 667 mg (three capsules for end stage [MEDICAL CONDITION]); [MEDICATION NAME] ER 50 mg (two times daily for blood pressure); [MEDICATION NAME] 100 mg (three times a week for pain); and [MEDICATION NAME] 800 mg (three times daily for end stage [MEDICAL CONDITION]). There was no physician order for [REDACTED].>Further review found no documentation R397 was assessed for abilities to self-administer medications. Also, there was no documentation of a baseline plan of care to address the interventions for self-administration of medications. On 01/23/20 at 10:00 AM an interview was conducted with Registered Nurse (RN)5. RN5 confirmed he/she is the nurse that administers R397's medication. RN5 reported the medications are left with the resident as he/she is alert and does not like the staff to watch him/her take the medications (resident gets upset when the RN stands there while he/she takes the medication). The RN has instructed the resident to call when he/she completes taking all the medication. Inquired how the RN ensures the resident took all the medication, the RN replied he/she will check on the resident once in a while. The RN also reported R397 sometimes gets upset when you return to check. Further queried how long do you wait before going back. RN5 responded, he/she moves to the next resident and closely monitors R397. The RN was asked how the facility determines whether a resident can self-administer his/her own medications, who makes the determination. RN5 replied residents that are alert x4 can administer their own medication; however, still requires supervision and needs to be checked. Lastly asked the RN how nurses are notified of which residents have been identified as competent to self-administer medications. The RN responded sometimes there is a paper assessment. On 01/24/20 at 10:10 AM an interview and concurrent record review was conducted with Nurse Manager (NM)5. The observation of the morning of 01/22/20 of R397 with the medication cup filled with seven pills left on the bedside try was shared with NM5. Inquired whether R397 was assessed for self-administration of medication. The NM responded the resident was not assessed; however, it may be possible that the nurses did the assessment. A request was made to review the assessment, the NM was unable to find an assessment in the electronic health record. A review of the physician's order and the Medication Administration Record [REDACTED]. NM5 confirmed the nurses are supposed to watch the guest (resident take the medication). On 01/24/20 at 10:52 AM the NM provided copies of the physician's orders and MAR. On 01/21/20 at 10:00 AM, the facility provided a copy of the policy and procedure for Medication Administration, Self-Administration by Resident. The policy notes the following: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe, and the medications are appropriate and safe for self-administration. The procedures include an assessment by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process. Also, a skill assessment is conducted to determine the resident's abilities. The results of the assessment are recorded in the Medication Self-Administration Assessment which is placed in the resident's medical record. 2) On 01/23/20 at 09:59 AM a review of the medication cart with RN5 found the reconciliation of controlled medications were accurate. The RN provided a folder containing Narcotic Count Sign in Sheet from 01/01/20 to 01/23/20. The sign in sheet requires two staff initials daily for every shift (in-coming and out-going) with three shifts per day. The following entries were missing a second initial to attest the accuracy of the narcotic count: 01/03/20 at 1430, off-going staff; 01/05/20 at 0630, on-coming staff; 01/05/20 at 1430, off-going staff; 01/19/20 at 1430, on-gong staff; 01/19/20 at 2230, off-going staff; and 01/21/20 at 2230, off-going staff. RN5 confirmed the missing signatures.",2020-09-01
956,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2020-01-27,842,D,0,1,Q4UO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately document information in four resident records (Resident (R)38, R74, R97 and R397). The deficient practice had the potential to place the residents at an increased risk for safety and illness. Findings include: 1) Electronic Medical Record (EMR) for R38 reviewed. The transfer/ discharge summary (scanned copy), box sent to the ombudsman was not checked and the date was left blank. When a copy of the Guest discharge/ transfer notice dated 12/27/19 was received from the Director of Nursing (DON) and reviewed noted the box was checked and the date written in black pen. On 01/24/20 at 03:07 PM the DON was showed the scanned copy of the form in the EMR was blank. 2) EMR for R74 reviewed. R74 has a [DIAGNOSES REDACTED]. The medication order states: [MEDICATION NAME] Regular (R) Unit (U)-100 Insulin; 100 unit/milliliter (ml) injection solution (ml) Intramuscularly (IM). The route of administration should state Subcutaneous (SQ) instead of Intramuscularly. 3) EMR reviewed for R97. The transfer/ discharge summary (scanned copy), box sent to the ombudsman was not checked and the date was left blank. When a copy of the guest discharge/ transfer notice dated 12/27/19 was received from the Director of Nursing (DON) and reviewed noted the box was checked and the date written in black pen. On 01/24/20 at 03:07 PM the DON was showed the scanned copy of the form in the EMR was blank. 4) Cross Reference to F755 and F554. Resident (R)397 was observed on the morning of 01/22/20 with a medication cup of seven pills in it. On 01/24/20 a record review and interview were done with Nurse Manager (NM)5. A review of the resident's health records with NM5 found R397 has orders for seven medications at 08:00 AM and the Medication Administration Record [REDACTED]. The NM confirmed R397 was not determined to safely self-administer medications. The NM also confirmed the nurses are supposed to observe residents taking their medications.",2020-09-01
957,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2020-01-27,880,D,0,1,Q4UO11,"Based on observations and staff interviews, the facility failed to ensure a reusable shared patient care equipment, blood pressure cuff, was properly disinfected before and after use for Resident (R)449 to prevent the possible spread of infection. As a result of this deficient practice, residents on the third floor could potentially be at an increased risk of acquiring an infection from reusable shared patient care equipment. Findings include: On 01/23/20 at 08:58 AM, observed registered Nurse (RN)4 apply the blood pressure (BP) cuff to Resident (R)449's arm. RN4 was observed not to disinfect the BP cuff prior to removing it from R449's room. After exiting the room, RN4 immediately plugged the BP machine in the hallway, walked away, and proceeded onto the next task without disinfecting the BP cuff. Inquired with RN4 regarding disinfecting the BP cuff. RN4 confirmed the BP cuff is used for multiple residents and he/she forgot to disinfect the BP machine/cuff prior to using the equipment for R449 and before leaving the BP machine in the hallway for use on another resident. On 01/27/20 at 10:20 AM, inquired with Infection Control Preventionist (ICP)1 and Nurse Manager (NM)6 regarding the observation made on 01/23/20 at 08:58 AM. ICP1 and NM6 both confirmed the BP machine and cuff should have been disinfected with the Super Sani Cloth-Germicidal (purple top) wipes prior to removing the BP machine and cuff from R449's room to prevent the possible spread of infection.",2020-09-01
958,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2018-11-02,558,D,0,1,66XK11,"Based on observation and resident interview, the facility failed to accommodate one resident's, R208, needs. Findings Include: Observation and interview of R208 on the morning of 10/31/2018 at 10:14 AM found him lying in bed. He stated he was uncomfortable in his bed since he's 6'4. The facility provided him with a standard twin sized bed despite his stature. His legs were curled up and he barely fit in the bed. When R208 extended his legs out, his legs extended past the end of the bed and hung over. An interview of the Nurse Manager on 11/02/2018 at 11:21 AM found she was unaware that R208 was uncomfortable in his bed. She stated R208 never informed her of his discomfort in his small bed. The Nurse Manager stated the facility's bariatric beds were all taken. She further noted R208 was not interested in moving rooms as he enjoyed the view from his current room. The Nurse Manager did verify his tall stature and confirmed he did not fit in the twin sized bed comfortably.",2020-09-01
959,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2018-11-02,578,E,0,1,66XK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility did not ensure 8 of a sample size of 48 residents (Residents 50, 91, 156, 157, 307, 308, 313, and 316) were informed of the right to formulate an advance directive. The facility failed to document the residents' right to execute their advance directives were reviewed and for residents without an advance directives, were provided with information and assistance to execute an advance directive. Findings include: On 10/31/2018 at 8:43 AM a record review was done for Resident (R)156. R156 was admitted to the facility on [DATE] following a hospitalization . The review found no documentation of an advance directive or whether the resident wanted to formulate an advance directive. On 10/31/2018 at 7:34 AM a record review was done for Resident (R)157. On 10/13/2018, R157 was admitted to the facility from an acute facility. The review found no documentation of an advance directive or whether the resident wanted to formulate an advance directive. An interview was conducted with the Social Services Manager (SSM) and Social Worker on 10/31/2018 at 1:43 PM. Queried what is the facility's process regarding advance directives. The staff members reported advance directives are reviewed upon admission then the admission staff member will inform social services whether the resident has an advance directive and if the resident would like to formulate an advance directive. The staff members were agreeable to review R156's and R157's record and provide documentation related to advance directive and provide a copy of the facility's policy and procedures. On 10/31/18 at 2:43 PM the SSM reported the residents' assigned social worker failed to document information regarding advance directives for R156 and R157. The SSM provided a copy of R156's POLST (Provider's Orders for Life-Sustaining Treatment). The POLST was prepared on 10/30/2018. A review of the policy and procedures for advanced directives notes the following: Social Services Director and/or the Facility Designee review Advanced Directives with the guest and responsible party when appropriate. Required documentation that the information related to the Guest Self-Determination Act has been presented to the family and then kept on file. The procedure also includes for Guests that have not executed an advance directive are asked if they would like to formulate an advance directive. On 10/30/2018 at 2:04 PM, a record review was done for Resident (R) 50. In particular, the admission notes were reviewed which found no documentation of an advance directive or whether the resident wanted to formulate one. On 10/31/2018 at 1:49 PM, further record review was done for R50 which found no follow up documentation of an advance directive or whether the resident wanted to formulate an advance directive. On 10/31/2018 9:20AM a record review found no documentation of a POLST or advanced directive for Resident (R)91, R307, R308 and 313. There was no documentation that advanced directives had been discussed or whether the resident wanted to formulate one. On 11/01/2018 9:16 AM a record review found a POLST, but no advance directive for R316. There was no documentation that advanced directives had been discussed or whether the resident wanted to formulate one.",2020-09-01
960,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2018-11-02,640,D,0,1,66XK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to ensure the required Minimum Data Set (MDS) assessments were encoded and transmitted within 14 (fourteen) days for 2 of 3 sampled residents (Residents 369 and 470). Findings include: 1) Resident (R)369 was admitted to the facility on [DATE]. R369 was discharged from the facility on 09/07/2018. A discharge assessment with an assessment reference date (ARD) of 09/07/2018 was completed, indicating the resident was discharged with no return anticipated. There was no record of the transmission. On the morning of 11/01/2018 at 10:05 AM an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC reported the transmission was successful. A request was made to review documentation the transmission was successful. On 11/02/2018 at 7:37 AM, MDSC provided documentation from their facility's software which documented R369's assessment was batched and submitted on 09/19/2018 with an accepted status. A request was made to review validation report from Centers for Medicare and Medicaid Services (CMS). On 11/02/2018 at 8:58 AM, interview and review of the final validation reports were done with the MDSC. The MDSC confirmed the submission of the discharge assessment was late, more than 14 days after the signature of completion (Z0500B). 2) Resident (R)470 was admitted to the facility on [DATE]. A significant change assessment with an ARD of 08/30/2018 was done by the facility. The documentation submitted by the MDSC on 11/02/2018 at 7:37 AM documents the submission was accepted. The MDSC reported R470's assessment was batched on 09/19/2018. A request was made to review the CMS report. On 11/02/2018 at 8:58 AM, an interview and review of the final validation reports were done with MDSC. The MDSC confirmed the submission was late, more than 14 days after the signature of completion.",2020-09-01
961,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2018-11-02,686,G,0,1,66XK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review (RR), the facility failed to implement a physician order [REDACTED]. Because of this deficient practice R91 developed a Stage 3 pressure ulcer on the medial aspect of her right knee. This deficient practice has the potential to affect other residents who are at risk for developing pressure ulcers. Findings Include: Resident (R)91 is a [AGE] year-old female who had a right hip hemiarthroplasty (replacement of a joint) following a fall that resulted in a right [MEDICAL CONDITION]. She was admitted to the facility on [DATE] for skilled rehabilitation. On 09/25/2018 R91 was transferred to Kuakini after she had increased pain, and internal rotation of the right hip. R91 was diagnosed and treated for [REDACTED]. Review of the Care Plan Report revealed R91 was at risk for altered skin integrity and had poor skin turgor. Staff were directed to keep knee immobilizer in place at all times as identified to be at risk-(D/C'd 10/24/18), and pain-at risk for immobility/friction/sheer. Review of the Kardex directed staff to use a hip abductor (foam pillow designed for post-operative positioning) and leave the knee brace on at all times. During an interview with the Unit Nurse Manager on 10/31/2018, she stated, the immobilizer would be taken off for bathing and checking CSM (circulation, sensation, and motion). On 10/23/2018 R91 had an outside appointment to see MD1. RR of the Consultation Request form that came back to the facility with R91 revealed new written orders from MD1: Discontinue knee brace, continue hip precautions. MD2 signed that the Consultation Request form was reviewed on 10/23/1018. During an Interview on 11/02/2018 at 1:20 PM, the Unit Nurse Manager stated, When the Consultation Request comes back, we put it in the binder and then MD2 signs when he reviewed it. The RN who gets the form reviews it, implements the orders, changes the Care Plan, and Kardex. They also communicate changes in report. RR of Clinical Notes include the following entries: 10/24/2018 entered at 1:59 AM by RN1. Guest returned from appointment with ORTHO. Consultation request left in MD communication book for review. carried out physician orders. will continue P[NAME] (plan of care). Physician orders: Discontinue Knee Brace. Continue hip precautions. 10/24/2018 entered at 1:44 PM by RN2. Guest cont (sic) reposition in bed abductor pillow on as indicated. Guest immobilizer on as indicated. 10/25/2018 entered at 2:33 PM by RN3, Brace to (sic) applied. 10/27/2018 entered at 2:27 PM by RN4, Immobilizer to be worn at all times. 10/28/2018 entered at 1:11 PM by RN4, Immobilizer to be worn at all times. 10/28/2018 entered by 11:31 PM by RN5, Guest found to have area of non blanchable redness measured 6x3.5 cm and open area measured 2x1cm. 10/29/2018 entered at 7:05 AM by RN5, Family member notified of new pressure ulcer wound found to right knee MD2 updated. RR of MD2 Progress note dated 10/29/2018 documented: Patient seen today for concerns about [MEDICAL CONDITION] on the right medial knee. Skin: Right medial knee with open [MEDICAL CONDITION] with central eschar. Review of Kardex revealed it was updated 10/31/2018 to reflect R91 no longer using knee immobilizer. At 11/02/2018 at 1:07 PM conducted a record review and interview with the Chief Nursing Officer (CNO), Director of Nursing (DON) and the Unit Nurse Manager. The CNO explained when the Care Plan is updated to reflect new orders or changes, this computer system does not time stamp or automatically date the revisions to the care plan, so we can't tell who or when the revision to discontinue the knee brace was added to the Care Plan. The Unit Nurse Manager stated, When the new orders were received, the RN should update the Treatment Administration Record (TAR), change the Kardex, and Care plan. It was confirmed the TAR was updated 10/24/2018 at 2:00 AM, and the Kardex was updated 10/31/2018. The CNO, DON, and Unit Manager confirmed the order to discontinue the immobilizer was written on 10/23/2018, but the doctor's order was never carried out. The resident continued to have the immobilizer on until 10/28/2018. As a result, the resident developed a Stage 3 pressure ulcer.",2020-09-01
962,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2018-11-02,700,D,0,1,66XK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide documentation that the risks and benefits for the use of bedrails were reviewed with Resident (R) 91 and R307, or their representative. The facility must maintain evidence that it has provided sufficient information so that the resident or resident respresentative could make an informed decision. Findings Include: Record review revealed three Consent for bedrail forms that were incomplete and did not have documentation the risks and benefits were reviewed with the resident or resident's representative. Resident (R) 91, had two consent forms for the use of bedrails for two admissions dated 09/14/2018, and 09/26/2018. Both forms were signed by the resident's representative, but were incomplete and did not indicate the risks and benefits were reviewed. R307 admitted on [DATE] had a consent for use of bedrails signed, but was incomplete, and did not have documentation the risks and benefits of the bedrail were reviewed with R307.",2020-09-01
963,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2018-11-02,921,D,0,1,66XK11,"Based on observations, staff interview, and review of policy, the facility failed to properly store two out of 15 oxygen cylinders (O2 tanks) in the appropriate storage rack. As a result of this deficient practice, the facility put the safety and well-being of the residents, staff, as well as the public at risk for accident hazards. Findings Include: 1. During an observation of the oxygen storage room, on the 5th floor, two freestanding O2 tanks were not properly stored in the designated storage rack. With these freestanding O2 tanks not being properly stored, there was a possibility of them falling over and causing accident hazards. On 10/30/2018 at 10:07 AM, RN6 was interviewed about the facility procedure to store O2 tanks. RN6 stated that O2 tanks should have been stored in the storage rack. RN6 acknowledged that the two freestanding O2 tanks, mentioned earlier, were not properly stored in the storage rack. RN6 subsequently placed the two freestanding O2 tanks in the appropriate storage rack. A review of facility policy, titled Oxygen Cylinder Storage, stated All freestanding cylinders shall be stored in a rack, on a cart, in a portable cylinder holder, in a gas cylinder storage cabinet, or secured with a chain to protect them.",2020-09-01
964,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2017-11-17,246,D,0,1,BPWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, and record reviews the facility staff failed to reasonably accommodate a resident's needs and preferences to maintain unassisted functioning for 1 of 24 residents (R#1) on the Stage 2 Resident Sample List. Findings include: On 11/16/2017 at 8:50 [NAME]M., R#1 called this surveyor to bedside to complain about how his/her breakfast tray was delivered and placed on the overbed table, 4 feet away near the foot of the bed. The resident stated, I went to the bathroom at 7:45 AM and nothing was said that my breakfast had arrived. The resident was semi-awake and waiting for breakfast and noticed the breakfast tray at approximately 8:30 AM when he/she raised the bed. The resident stated, I cant use my left hand, my left hand won't extend and I can't reach. I can't peel the skin of the oranges and the skin was left on. The resident also requested two butters but was given only one and couldn't eat the orange. Resident #1 further stated, The nurse came at 8:35 AM, I hate to be [***] y but it is uncalled for. The nurse had warmed-up the breakfast then but the resident stated don't want to eat already, and that it was probably cold. Interviewed Staff #13 and informed her of the situation (as described above), and she stated that she would look into it. Record Review on 11/16/2017 at 9:05 [NAME]M. revealed R#1 was admitted on [DATE] for arthritis due to bacteria and a septic left shoulder, dehydration, weakness and difficulty walking. The residents care plans (CP) included, The resident has a self care deficit and assistance is required with activities of daily living performance and functional mobility related to weakness, and impaired mobility; and, Nutrition risk due to limited mobility with cutting up foods. On 11/17/2017 at 11:28, interviewed Staff #154 and inquired about protocol for meal tray delivery. Staff#154 stated, Once it comes to the corner, dietary starts to help deliver trays with or without a CNA present. We try and do this if the resident is prepped to eat, then we can help. The facility staff failed to provide accommodations for R#1 to eat independently in his/her room by not ensuring that the overbed table that held the meal tray was within reach, based on the residents left upper extremity disabilities.",2020-09-01
965,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2017-11-17,279,D,0,1,BPWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical record reviews (EMR) and staff interviews, the facility failed to develop a comprehensive care plan that included rationale for deciding whether to proceed with care planning in the use of insulin for 1 of 24 residents (R#526), on the Stage 2 Sample Resident List. Findings include: On 11/16/2017 at 10:19 AM reviewed R#526's EMR, as the resident was sampled for unnecessary medications. The current physician orders [REDACTED]. The resident's care plans (CP) included, At risk for bleeding and easy bruising R/t aspirin and [MEDICATION NAME] (d/c 11/12) status [REDACTED]. The resident's Medication Administration Record [REDACTED] [MEDICATION NAME] 40 mg/0.4 ml SQ syringe order date: 11/07/17 ; Discontinued 11/08/17 [MEDICATION NAME] 100 unit/ml (3 ml) SQ insulin pen (24 U) insulin pen one time daily starting 11/07/17 Order Date: 11/07/17, ICD-10 : type 2 diabetes mellitus w/o complications, sliding scale insulin: Blood sugar is [MEDICATION NAME] 100 unit/ml SQ (7 U) insulin pen (ML) SQ three times daily starting 1/07/17; discontinued: 11/08/17; Notes: Hold and notify MD with Blood sugar [MEDICATION NAME] 100 unit/ml subcutaneous (10 units) insulin pen (ML) SQ three times daily starting 11/08/17; discontinued 11/15/17; Notes: Hold and notify MD with Blood Sugar The resident experienced low BS readings on: 11/13/17 at 17:00, BS 71 mg/dl ; and 11/15/17 at 17:00, BS 60 mg/dl. The resident's initial intake dated 11/07/17 included the CP, Functional/ADL Decline/Goal: Improve functional decline to prior status. A concurrent EMR review with Staff#65 was done to verify if there were any other CPs. Staff#65 mentioned that the facility had 14 days to complete assessments for the CP, but the initial intake CP usually included the resident's [DIAGNOSES REDACTED]. Staff#65 stated that Staff#49 would answer questions regarding CP for insulin use, as the facility utilized different tools to communicate and that CNA's referred to each resident's Kardex. On 11/16/2017 at 2:01 PM reviewed R#526's EMR concurrently with Staff#26. Staff#26 pulled up the Kardex for R#526 which had written on it, Inform RN immediately re: S/S of hypo/[MEDICAL CONDITION]: excessive sweating, hunger, thirst, confusion, lethargy . According to Staff#26, a CP was not done for insulin use and the facility was still within the 21 days timeframe to complete a comprehensive CP. Staff#26 also stated that the resident's [DIAGNOSES REDACTED]. On 11/16/17 the CP, Risk for hypo or hyperglycemic reactions d/t insulin dependent type 2 diabetes, was completed after surveyor inquiry. The CP interventions included: administer insulins and antidiabetic medications as ordered; dietitian consult as needed for diabetic diet education; Monitor wt's as ordered. Notify MD and RD of sig wt changes; Observe for and report S/S of [DIAGNOSES REDACTED]; shakiness, nervousness, irritability, clamminess, confusion, dizziness, rapid heartbeat and breathing; and Accucchecks TID. Inquired of Staff#26 if R#526 had a dietary assessment completed and she was unable to find one in the EMR. The facility did not do a comprehensive assessment nor CP intermediate steps to manage blood sugar levels with R#526's [DIAGNOSES REDACTED].",2020-09-01
966,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2017-11-17,323,D,0,1,BPWC11,"Based on observation and staff interview the facility failed to provide an environment as free from accident hazards as is possible for 1 of 25 residents (R) #535 from the Stage 2 resident sample list. Findings include: On 11/13/2017 at 10:31 AM while making observations in R#535's room it was noted that there was a a reddish-brown fixed matter on the resident's metal bed rail. At this time asked Staff #38 to come into R# 535's room to look at what was on the resident's bed rail. Staff#38 tried to wipe it off but it would not come off of the metal bed rail. When asked what she thought it was she stated I don't know. On 11/15/2017 at 2:43 PM went to R# 535's room with Staff #79 to have her look at the metal bed rail. When asked what she thought was on the bed rail, she stated that it had rust on it. The rust was about half a nickel in size and on the part of the bed rail that the resident could grab. The facility failed to provide an environment as free from accident hazards as is possible for R#535, as what appeared to be rust on the resident's bed rail could either cut/puncture the skin if the resident were to grab or rub against the metal bed rail.",2020-09-01
967,CLARENCE TC CHING VILLAS AT ST FRANCIS,125064,2230 LILIHA STREET,HON,HI,96817,2017-11-17,329,D,0,1,BPWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and electronic medical record (EMR) review, the facility failed to ensure 1 of 5 residents (R#133) sampled for unnecessary drugs, had a drug regimen that was managed and monitored. Findings include: On 11/16/2017 at 2:00 P.M. the EMR review for R#133 found that the resident was prescribed: [MEDICATION NAME] 50 mg tablet (12.5) mg four times a day by mouth; and [MEDICATION NAME] 10 mg tablet two times a day by mouth. The care plan (CP) described Name has verbal behavioral symptoms directed at others; swatting/swinging arm/pushing, resistive with care, hollering/yelling/yelling at staff, severe agitation, combative and uncooperative with care. The CP goal was that, number of verbal incidents will be decreased over the next 90 days, as evidenced on behavior tracking. The CP interventions included: two persons as needed with increased agitation; administer med as ordered; approach guest in calm manner; respond in a calm voice; maintain eye contact; remove from area if name is verbally abusive to others; activity therapist, ensure hearing aides are in place during care; gently remind name that screaming/cursing is not appropriate; Monitor pattern of behavior (time of day, precipitating factors, specific staff or situations. The CP for [MEDICAL CONDITION] drugs for behavioral symptoms included interventions of: Monitor for severe agitation; anxiety; depression; combative & resistive to care; screaming/hollering/yelling at staff associated with [MEDICAL CONDITION] secondary to metabolic encephalitis. On 11/17/17, R#133 EMR review found two progress notes written on 11/07/2017 with documentation, Guest follows commands, pleasant with care. With occasional yelling and screaming when spoken to with no aggressive behavior towards staff noted. From about 0645 am to 0730 am, guest was talking loud. Sounding irritable and upset, swore several times[***]to nurses aide providing assistance. Upon review of R#133's Behavioral Monitor sheet, there was no reference of any behavior on 11/07/17. On 11/17/2017 at 11:33: [NAME]M. interviewed Staff #13 regarding R#133 behavior monitoring and documentation. Staff#13 went through the progress notes and behavior monitor sheets on the 7th and the 13th of November, (YEAR). Staff#13 stated the notes and the behavior monitor sheet does not match, there is a different nurse that signed off and a different nurse that did the note. It appears that the nurse monitored it but it is not jiving with the actual log so this is an area to work on. The facility staff did not monitor R#133's pattern of behaviors by not utilizing the behavioral monitoring sheet to track those behaviors.",2020-09-01
968,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2020-02-07,550,D,0,1,PXY311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with residents, the facility failed to promote care for residents in a manner that enhances each resident's dignity as evidenced by providing a resident's meal on a plastic bag during dining; a staff member talking about the resident in the resident's presence; and a resident with an uncovered catheter bag in the presence of other residents. Findings include: 1) On [DATE] at 12:00 PM observed residents consuming lunch in the dining room. CNA1 was observed to bring R18's tray to the table. The CNA was heard stating she would check, the CNA was observed to remove the plate cover and engaged in conversation with the resident. R18 could be heard saying, that he/she told them one hundred times, CNA1 then gave R18 the bowl of fruit then placed the lunch tray on the counter. R18 was asked what happened to his/her lunch, R18 replied that she/he asked for a tuna sandwich and was given egg salad. Later CNA1 was observed to bring a tuna sandwich which was cut into four pieces in a plastic bag to the resident. The CNA tore open the plastic bag and placed it on the resident's placemat. R18 ate his/her sandwich out of the plastic bag. On 02/05/20 at 11:30 AM an interview was conducted with four resident council representatives. The observation during the lunch meal was shared with the residents. Three of the four residents reported they would have preferred for the sandwich to be served on a plate. 2) Cross Reference F6[AGE]. On [DATE] at 10:15 AM, R40 was observed with Registered Nurse (RN)1 pushing the resident in the wheelchair. The RN reported the two cups on the resident's bedside table were thrown out. As RN1 continued pushing R40 in the wheelchair, RN1 added that R40 has been refusing to take his/her medication and has been temperamental so they are going to have a meeting. 3) A record review documented Resident (R)41 was admitted on [DATE], diagnosed with [REDACTED]. At the time of the survey (2/4- 7/20), R41 had just recently completed a round of oral [MEDICAL CONDITION] treatment. R41 currently has a Foley catheter and an ostomy bag. Review of R41's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/29/19 documented R41's Brief Interview for Mental Status (BI[CONDITION]) score was 1, indicating severe cognitive impairment. R41 requires the use of a mechanical lift and is totally dependent on staff for all transfer needs and requires a 2+ person physical assist, 1 person physical assist for locomotion in a wheelchair (unable to wheel self). R41's speech is unclear (slurred or mumbled words), sometimes able to understand (responds adequately to simple, direct communication only) of expressed ideas and wants (verbal and non-verbal), and rarely/never able to understand verbal content. On 02/05/20 at 09:21 AM, observed R41 participating in morning exercise and his catheter bag was not covered. The catheter bag was filled with approximately 220 milliliters of light yellow urine. More than 10 other residents were a part of the morning exercise group, along with 2 activity staff. Certified nurse assistant (CNA)8 and Licensed Nurse (LN)10 confirmed the catheter bag should have been covered to maintain R41's dignity.",2020-09-01
969,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2020-02-07,575,B,0,1,PXY311,"Based on resident interview and observation, the facility failed to ensure posting of the names, addresses (mailing and email) and telephone numbers of all pertinent State agencies and advocacy group (State Survey Agency, adult protective services, resident advocacy groups, home and community based services, and the Medicaid Fraud Control Unit in a form and manner which is accessible and understandable to residents and/or resident representatives. Findings include: On 02/05/20 at 11:30 AM the resident council interview was conducted with four residents. The residents were asked whether they know where the ombudsman contact information is posted. None of the participating residents were aware of the posting. Observation on [DATE] found a posting located across the kitchen in the hall which provided information of the contact information for the long-term care ombudsman. Although this information was posted, the posting was placed high on the board which would make it difficult for some residents to see if they are seated in a wheelchair. Another posting was found in the lobby of the facility. The posting included the long-term care ombudsman information; however, this information was also placed high on the board which would make it difficult for residents to see if they are seated in a wheelchair. Further observations found postings of resident rights in the resident's rooms. The placement of the postings was inconsistent, some rooms had the posting next to the wash basin and other rooms had the posting above the paper towel dispenser (too high for the residents to see if they are in a wheelchair). Overall the residents were not aware of the required postings and where the postings are located. And the observation found no posting for the adult protective services, resident advocacy groups, home and community-based services, and the Medicaid Fraud Control Unit.",2020-09-01
970,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2020-02-07,577,B,0,1,PXY311,"Based on resident interview and observation, the facility failed to ensure the results of the State inspection is readily accessible (residents wanting to examine the survey results do not have to ask to see them). Findings include: On 02/05/20 at 11:30 AM the resident council interview was conducted with four residents. All the residents reported they are not aware that the results of the State inspection are available for their review. On [DATE] observation found a binder with the results of the State inspection (recertification and complaint surveys) was located atop the counter at the reception desk. The height of the countertop would require a person to be able to stand to see the binder; however, there is a limited population of residents who would have the ability to stand to see and retrieve the binder. Overall, residents were not aware of the location/availability of the State survey results and the results were placed in a location where the residents would have to ask for the binder to review the survey results.",2020-09-01
971,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2020-02-07,641,D,0,1,PXY311,"Based on record review and interview with staff member, the facility failed to ensure a resident's assessment accurately reflected the resident's status. Findings include: A record review was done on [DATE] at 01:24 PM found a quarterly Minimum Data Set (MDS) with an assessment reference date of 12/02/19 notes in Section J. Health Conditions, Resident (R)24 was documented with two or more falls since admission with one fall with major injury (bone fracture, joint dislocation, closed head injuries with altered consciousness, subdural hematoma). Further review of the progress notes found no documentation of a fall with injury. An interview and concurrent record review was done with the Minimum Data Set Coordinator (MDSC)1 on [DATE] at 03:52 PM. MDSC1 reported this was an inaccurate assessment and the facility will be submitting a correction.",2020-09-01
972,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2020-02-07,658,D,0,1,PXY311,"Based on observation and staff interviews, the facility failed to provide services according to accepted standard of clinical practice as evidence by residual medication residue on a pill splitter stored in a medication cart on the Lehua Wing. As a result of this deficient practice, residents on the Lehua Kona wing are at risk of potential harmful drug residue transfer. Findings include: On [DATE] at 08:40 AM, conducted an inspection of the medication cart located on the Lehua Wing, with Licensed Nurse (LN)1. Observed a pill splitter with medication residue. The residue consisted of both powder and small clumps of white and yellow pieces. Inquired with LN1 regarding practices of cleaning the pill splitter. LN1 stated that he/she did not know how to properly clean the pill splitter and proceeded to wipe the pill splitter with an alcohol wipe. LN1 also acknowledged that he/she has not cleaned the pill splitter after use. The Administrator confirmed pill splitters should be cleaned with soap and water after each use to avoid inadvertent harmful drug residue transfer.",2020-09-01
973,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2020-02-07,684,D,0,1,PXY311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff members, the facility failed to ensure residents received treatment and care needed in accordance with their comprehensive person-centered care plan to meet the resident's highest practicable physical well-being. Resident (R)40 has been non-compliant with taking medications and completing [MEDICAL TREATMENT] treatments, there is no evidence that based on a root cause analysis (assessment) for R40's refusals, the care plan was revised to develop interventions to address R40's noncompliance with medications and [MEDICAL TREATMENT] treatment. Findings include: Cross Reference F550. On [DATE] at 09:30 AM during initial screening of the residents, Resident (R)40 was observed sitting up at bedside. The bedside tray was placed in front of the resident, there were two small disposable plastic containers, each containing tan/brown colored substance in it with a spoon stuck into the substance. The resident was asked what that was, R40 responded he/she doesn't know what that is as he/she just got up. Later Certified Nurse Aide (CNA)2 entered the resident's room, the CNA was asked what was in the cups, the CNA responded it looked like pudding and applesauce. The CNA reportedly was going to provide morning care and dress R40. Registered Nurse (RN)1 was observed entering the room with the CNA. The door was closed. At 10:15 AM, the door was opened and found the CNA taking out the laundry. RN1 was pushing R40 in the wheelchair. Inquired what was in the two containers, RN1 replied it was applesauce and pudding which was placed on the resident's bedside tray as the resident was refusing to take medication. The RN stated the applesauce and pudding were prepared should the resident agree to take his/her medications. While strolling the resident out of the room, RN1 stated R40 has been refusing to take his/her medications and has been temperamental so the facility will schedule a meeting. A record review was done on the afternoon of [DATE] and morning of 02/07/20. R40 was originally admitted to the facility on [DATE] and was discharged to an acute hospital. R40 was discharged from the acute hospital and readmitted to the facility on [DATE]. R40's [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. R40 has 12 medications scheduled for administration at 06:00 AM. In addition, there is an order for [REDACTED]. A review of the MAR for the month of January 2020 found documentation of R40's refusal of medications. R40 refused medications on the following days: 01/01/20 (refusal of one medication); 01/02/20 (refusal of 8 medications); 01/03/20 (refusal of one medication); 01/04/20 (refusal of 2 medications); 01/07/20 (refusal of 11 medications); [DATE] and 0[DATE] (refusal of 3 medications); 01/12/20 (refusal of one medication); 01/14/20 (refusal of four medications); 01/16/20 (refusal of two medications); 01/17/20 (refusal of one medication); 01/18/20 (refusal of two medications); 01/20/20 (refusal of 8 medications); 01/22/20 (refusal of 7 medications); 0[DATE] (refusal of one medication); 01/25/20 (refusal of seven medications); 0[DATE] (refusal of 11 medications); 01/28/20 (refusal of two medications); 01/29/20 (refusal of 8 medications); 01/30/20 (refusal of 9 medications); and 01/31/20 (refusal of 3 medications). R40 refused medications on 18 of the 31 days in January. A progress note dated 01/31/20 documents resident's refusal of 08:00 PM medications stating, they are too big and too much. The resident was also noted as saying Please, don't call me sister. The review for February 2020 found R40 refused all morning medications on 02/01/20, 02/03/20, [DATE] and 02/05/20. The progress notes from [DATE] through 02/07/20 were reviewed. On 12/29/20, R40 was sent to emergency from the [MEDICAL TREATMENT] entity due to complaints of chest pain and anxiety. R40 returned to the facility. On 01/24/20, R40 went on an overnight pass for a family funeral. On 0[DATE], R40 refused to go to [MEDICAL TREATMENT]. There is documentation of R40 not completing [MEDICAL TREATMENT] treatment on 01/29/20, 01/31/10, 02/03/20, and 02/05/20. The physician met with the resident on 02/05/20 to discuss the resident's noncompliance with medication and [MEDICAL TREATMENT] treatments (build-up of toxins which could lead [MEDICAL CONDITION]). R40 refused treatment on 02/07/20. At this time social services and the nurse met with the resident to educate R40 on the risks and benefits of the noncompliance. On [DATE] at 11:23 AM an interview was conducted with the Director of Nursing (DON). The DON reported she spoke to RN1 regarding leaving the pudding and applesauce at the resident's bedside would appear that the resident's medications were left at bedside. In regard to the resident's refusal of taking medications, the DON responded, when resident's refuse the nurses should wait and approach the resident at another time. The DON also shared that he/she was able to get R40 to take the medications by sitting and talking with the resident. Inquired whether approaches were developed to address the resident's refusals including interventions to take the time and visit with the resident during the medication administration. On the morning of 02/07/20, the MDS Coordinator (MDSC)1 reported a meeting with the family had been scheduled for 02/12/20 (Wednesday). Inquired whether the [MEDICAL TREATMENT] entity will participate in the meeting, the MDSC1 responded, they will be invited.",2020-09-01
974,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2020-02-07,758,E,0,1,PXY311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to accurately monitor, assess, and document behaviors for use of [MEDICAL CONDITION] medications for 3 of 7 residents (R27, R124 & R125) sampled for unnecessary medications; and, ensure as needed (PRN) orders for [MEDICAL CONDITION] medication are only used when the medications are necessary and the PRN use of a [MEDICAL CONDITION] medication is limited to 14 days (unless a rationale for continued use is provided) for R124. In addition, the facility failed to implement R124's care plan to document behavior episodes to identify triggers. Findings include: 1) On [DATE] at 09:04 AM, RR showed R27 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses: [REDACTED]. R27 was on the following medications: [REDACTED]. On [DATE] at 09:40 AM, interview attempt with R27 revealed resident was in a foul mood. R27 was observed to be irritable and yelled at surveyor, stating I am not in a good mood, what do you want? After surveyor stated his name and where he was from, R27 told surveyor to Get Out! Subsequent attempts to interview R27 resulted in similar outcomes. On 02/07/20 at 10:05 AM, RR of R27's Behavioral Monitoring Sheets for the month of January and up to February 6, 2020, staff documented 0 behaviors daily. R27 was on [MEDICATION NAME] 25 milligram (mg) by mouth twice a day for depression, [MEDICATION NAME] XL 5mg by mouth twice a day for anxiety, [MEDICATION NAME] XL 300mg by mouth daily for depression. R27's physician ordered Behavioral Monitoring for [MEDICAL CONDITION] medication use. RR of R27's care plan under interventions reflected the following: Monitor for behaviors as evidenced by calling out, swearing, hallucinations. Document number of times behavior occurs. On 02/07/20 at 09:09 AM, interviewed the Director of Nursing (DON) and Minimum Data Set Coordinator (MDSC) 1, both concurred there is a lack of accurate documentation by the facility staff regarding behavior monitoring of residents who are on [MEDICAL CONDITION] medications including R27. DON stated facility staff see residents' behaviors daily, and think no change from previous day, not realizing that the behavior is not the norm and needs to be accurately documented. Both DON and MDSC1 stated facility staff need more education and training on how to document specific or target behaviors for residents who are on [MEDICAL CONDITION] medications. 2) Resident (R)124 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. On [DATE] at 08:38 AM a record review found a physician's orders [REDACTED]. The start date was 01/14/20, the end date was documented as indefinite. A review of the Medication Administration Review (MAR) documents administration of [MEDICATION NAME] on 02/03/20 at 07:43 AM. There were no indicators of anxiety documented in the behavior monitoring log for anxiety. A review of the resident's progress notes found no documentation R124 was exhibiting anxiety or the need for administration of the [MEDICATION NAME]. A review of R124's care plan found the following goal, I at times request for my anti-anxiety medication for episodes of anxiety. I am at risk for side effects to medication. The interventions include the following: non-pharmacological interventions - 1:1 interaction, re-direct, nature strolls, soft music or comfort food; monitor and record my anxiety episodes and document per facility protocol; monitor for behavior episodes to identify triggers (consider location, time of day, persons involved and situation); monitor for side effects; psych medication review per facility protocol/process; review medication; and evaluate the use of anti-anxiety medication for gradual dose reduction. On [DATE] at 11:10 AM an interview and concurrent record review was done with the Director of Nursing (DON). The DON stated PRN orders for [MEDICAL CONDITION] medication should not exceed 14 days. The DON confirmed the order for [MEDICATION NAME] exceeded 14 days and would further review the record whether the physician documented a clinical rationale for continuation of the PRN order. Concurrent record review with the DON found no documentation of a progress note or documentation in the MAR indicated [REDACTED]. Also, inquired whether there are parameters to determine when the anti-anxiety med was needed (i.e. administering anti-anxiety med after non-pharmacological interventions are tried). The DON was agreeable to further review R124's medical record for the following: rationale for prescribing anti-anxiety medication for more than 14 days and documentation of the anxiety episode which warranted the PRN anti-anxiety med (administered 02/03/20). On [DATE] at 03:55 PM, the DON confirmed there was no documentation for R124 of a clinical rationale by the physician for prescribing the anti-anxiety med PRN order indefinitely (greater than 14 days), and no documentation of the anxiety episode prior to the administration of the anti-anxiety medication. 2) R125 was admitted to the facility on [DATE] with the following admission Diagnoses: [REDACTED]. On 02/05/20 at 09:44 AM a record review was done. A review of the physician's orders [REDACTED]. The PRN prescription for [MEDICATION NAME] had a start date of 01/31/10 with an indefinite order. A review of the MAR found PRN administration of [MEDICATION NAME] on the following days: 02/02/20 at 06:00 PM; 02/03/20 at 09:35 AM; [DATE] at 03:30 PM; 02/05/20 at 01:35 PM; and [DATE] at 08:10 AM. On [DATE] at 11:15 AM an interview was conducted with the DON. The DON confirmed the PRN order for [MEDICATION NAME] had an end date of indefinite. The DON acknowledged the regulation for [MEDICAL CONDITION] PRN orders of 14 days and stated the PRN order should have had an end date of [DATE]. The DON found a pharmacy recommendation to the physician to review the PRN order. The notification from the pharmacist was dated 02/02/20; however, the physician did not provide a response.",2020-09-01
975,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2020-02-07,880,E,0,1,PXY311,"Based on observations, staff interviews and policy and procedures (P&P) review, the facility's infection prevention and control program (IPCP) failed to maintain standard precautions for safe handling of equipment or items that are likely contaminated with infectious body fluids, as well as cleaning and disinfecting or sterilizing of potentially contaminated equipment. As a result of this deficiency, residents are at an increased risk of development and transmission of communicable diseases and infections. Findings Include: 1) On [DATE] at 11:45 AM observed RN2 perform a blood glucose test on R176 using a multi-use glucometer. After reading the results, RN2 wiped the glucometer with a paper towel that had hand sanitizer gel on it. RN2 walked back to the unit's med cart and placed the glucometer on the top of the cart. RN2 then went into the unit's activity/dining room to help pass out lunch trays, came out of activity/dining room, went down the hall with a tray, came back to the med cart, grabbed the glucometer from the top of the med cart, and placed it into the top drawer of the cart. Inquired of RN2 on the facility's P&P for sanitizing the glucometer after use. RN2 stated that sani-cloth from the red top container was used to wipe the glucometer before and after use. There was no red top sani-cloth container in the vicinity of the med cart, and inquired where the red top container was located. RN2 stated that the red top container was kept in the medication supply room adjacent to the unit's nursing station, and that the glucometer was taken into the med room and sanitized. Shared above observations with RN2, and that did not observe her taking the glucometer into the med room. RN2 insisted that the glucometer was sanitized and that may have missed observation because she moves around quickly. Explained to RN2 that followed her from R176's rm to the med cart, sat right by med cart to specifically observe how glucometer was to be sanitized, and did not observe RN2 take glucometer from med cart into the med room. On 02/07/20 at 10:00 AM provided above observations during meeting with the director of nursing (DON) and administrator (ADM). The DON stated that red topped sani-cloth containers are kept in each med cart drawer to sanitize the glucometer, and that nurses shouldn't have to go into the med room to sanitize the glucometer. 2) On [DATE] at 08:14 AM, observed RN10 taking Resident (R)35 blood pressure with a manual blood pressure cuff in preparation to administer Lorasartan 100 mg. After obtaining R35's blood pressure, staff then placed the blood pressure cuff on the resident's bed. RN10 took the manual blood pressure cuff that was draped over the right side of the medication cart, took it into R35's room, used the manual blood pressure cuff on R35, placed the blood pressure cuff on the bed, administered meds, exited the room, placed the blood pressure cuff back on to the medication cart, and proceeded to provide care for another resident. RN10 did not disinfect the blood pressure cuff before taking the blood pressure cuff into the room, while in the room, or before placing the cuff back onto the medication cart. The area of the medication cart where the unsanitizied blood pressure cuff was placed was not disinfected also. RN10 confirmed the blood pressure cuff should be sanitized with the red wipes (Medline Micro-Kill+ wipes). There were no container of Medline Micro-Kill+ wipes on or in the medication cart utilized by RN10. Further inspection of the entire facility on [DATE] at 09:30 AM, observed only two containers of Medline Micro-Kill+ wipes readily available for staff use located on: 1 of 4 medication carts in the facility on the Ka Maka unit; near the sink of one nursing station used by the Kamakau Wing and the Lehua Kona Wing. On 02/07/20 at 08:45 AM, during review of the facility's Infection Control Program, the infection preventionist (IP), stated the blood pressure cuff should have been disinfected prior to leaving the residents room with the red wipes. 3) Multiple observation throughout the entire survey ([DATE] at 09:42 AM through 02/07/20 at 09:40 AM), observed two resident's ((R)17 and R37)) urinals were placed in the resident's trash bin for storage. The urinals were placed in a manner in which the handheld portion to the urinal rested on the lip and on the inner portion of the trash bin. The trash bins were stored on the ground near each resident's bed. R17's and R37's trash bin contained various trash including but not limited to: used gloves; tissues used to wipe the resident's mouth and blow his nose, paper towels; and food wrappers. On 02/07/20 at 09:00 AM, inquired of the facility's IP on where urinals should be kept. The IP stated the resident's urinals should be stored on the side of the resident's bed frame and not in the resident's trash bin. A document provided by the facility, Legacy Hilo Rehabilitation & Nursing Center Survey Reminder. (revised 07/10/19) documented Infection Control Issues.Place bed pans & toilet hats in the resident's night stand (bottom drawer). The IP staff also stated the facility conducted Infection Control rounds which monitored the labeling and appropriate storage of urinals, but could not produce documentation of completed Infection Control Rounds sheet upon request. At approximately 10:50 AM, RN15 provided a different facility document Infection Control Focus Rounds Resident Rooms which was conducted on [DATE] at 02:30 PM, however, this document did not include monitoring of the appropriate storage of resident urinals. 4) On 02/07/20, requested appropriate policies and procedure, to which RN15 provided Care and maintenance of protective clothing document, which states protective clothing should be inspected for cleanliness and working order; used during spraying operations; thoroughly washed, rinsed, dried in an airy environment; washed at the end of each day's spraying operation (if spraying is done on two or more days in a row); removed and placed for laundering; and changed if heavily soiled. On 02/07/20 at 09:45 AM, upon inspection of the dirty laundry room located on the Lehua Kona and Na Maka wings, observed a yellow, heavy-duty reusable apron, with a shoelace used to secure the apron around the user's neck and a pair of black rubber gloves hanging in the dirty laundry room, were visibly soiled. Certified nurse assistant (CNA)8 stated the apron and gloves were used by staff when rinsing soiled linen from residents rooms. Upon inspection of the equipment, CNA8 acknowledged the presence of unknown residue on both sides of the apron. Further inquiry with various staff (2 CNAs, 2 housekeepers, and the Housekeeping Manager) from the Na Maka and Lehua Kona wings confirmed staff does not sanitize/clean the equipment, is unaware of the procedure to sanitize/clean the equipment. The Housekeeping Manager confirmed the apron and gloves in questions has not been sent through the laundry services to be sanitized/cleaned. Various staff further acknowledged and confirmed the exterior of rubber boots (used when showering residents) are not sanitized/cleaned after use, including incidents in which the boots are in contact with fecal matter.",2020-09-01
976,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-02-08,558,D,0,1,GKXE11,"Based on observation, interview and record review (RR), the facility failed to ensure one resident (R)73 had communication equipment accessible to call for immediate help when needed. As a result of this deficient practice, R73 was not able to call for assistance when he needed it Findings Include: RR revealed R73 is wheelchair/bed bound. Review of R73's care plan includes: 1. I have ADL self-care performance deficit and /or limited physical mobility. I require total assist by (1) staff for locomotion using wheelchair. 2. Be sure my call light is within reach and encourage me to use it for assistance when needed. I need prompt response to all requests for assistance. On 02/06/19 at 09:55AM, observed R73 in wheelchair located next to the bed. R73 was grimacing. Asked if had pain, and R73 replied, Yes, I need go back to bed. Asked if had called for assistance, and R73 stated, I can't do that if I don't have the call light. Observed call light was not available to R73. Certified Nursing Assistant (CNA)5 was located, who obtained assistance to put R73 in bed. Observation made that the call light was placed within reach to R73 after he was settled in bed. During interview R73, asked if there were other times the call light was not available to him, and he replied, Yes, it happens a lot. I know they are busy, and forget sometimes. The accommodation of R73's needs is essential and includes ensuring the call system is readily available if immediate assistance is needed. R73 was unable to call for assistance when he was in pain and needed to return to bed.",2020-09-01
977,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-02-08,578,D,0,1,GKXE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR) and interviews the facility failed to maintain a current, accurate Advanced Directive (AD) for Resident's (R)1 and R69. As a result of this deficient practice, there is potential that the wishes for healthcare for R1and R69 may not be honored at the end of life. During a RR on 02/05/19 at 02:53 PM no advanced healthcare directives or healthcare decision surrogate form was found. R69's medical record contained only a physician order [REDACTED].>On 02/06/19 a copy of the advanced healthcare directives was requested from the facility administration. A copy of the petition for appointntment of a guardian for R69 was received. The petition appoints a guardian for R69 and is not specific for health care decisions and is not an advanced healthcare directive. On 06/07/2017 a POLST was completed by Resident (R)1, who marked she wanted a defined trial period of artificial trial nutrition by tube, with written Goal: 2 weeks w/goal to be able to eat again by mouth. On 09/20/2017 R1 completed the Hawaii Advance Health Care Directive (AD) and selected the End of life decision, I want to stop or withhold medical treatment that would prolong my life. Artificial Nutrition and Hydration section was not marked and therefore must be withheld or withdrawn in accordance with the choice made to not prolong life. On 02/07/2019 at 03:38PM during interview with Admissions Coordinator (AC) regarding discrepancy in R1's wishes in the POLST and AD. AC stated I spoke with her (R1) regarding her wishes. She (R1) told me didn't understand what was being said when the AD was presented to her at the hospital. I explained it to her and she verbalized wanted tube feeding. We did correct it with the doctor and patient today. The facility must ensure that advance care planning documents are reviewed for accuracy to reflect resident's wishes. I not, the resident's wishes may not be honored at the end of life.",2020-09-01
978,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-02-08,584,D,0,1,GKXE11,"Based on interview the facility failed to maintain comfortable sound levels. Another Resident (R)24 reportedly yells at night disturbing R)64 and R144. Findings include: During an initial tour of the Kona section of the facility on 02/05/19 at 10:00 AM noted R24 was sleeping in his room. During an interview with R64 on 02/05/19 at 11:57 AM said the neighbor over there, pointing to the room to the left (R24's room) he pounds on the wall and makes a lot of noise at night. R64 is alert and oriented to person place and time. During an observation on 02/06/19 at 12:30 PM noted R24 was sleeping in his room, did not get up to go to the dining room for lunch or sit up and eat lunch in his room. During an interview with R177's husband (F)1 on 02/06/19 at 10:30 AM stated when I come visit my wife here at night there's a lot of noise coming from down the hall, there's a guy yelling and carrying on. During an interview with RN2 on 02/07/19 at 09:00 AM stated that R24 is very restless at times and makes noise when he wants attention. He usually sleeps a lot during the day and is awake at night. That's when he gets loud.",2020-09-01
979,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-02-08,636,D,0,1,GKXE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews (RR) the facility failed to develop comprehensive care plans for 2 of 35 residents (R)19, to provide appropriate care and services for the use of oxygen (O2); and, R23 for behaviors, and precautions for extended-spectrum B-lactamase (ESBL)-producing Escherichia (E)-coli colonization. Findings Include: 1) On 02/05/19 at 12:13 PM during initial pool interviews, observed R19 lying in bed with labored breathing, wearing nasal cannula (NC) and motioned to daughter that air not coming out of O2 tubing. A nurse was alerted and maintenance supply staff immediately changed the O2 tubing. The daughter held the durable power of attorney (DPOA) for R19, and stated that the resident was declining with shortness of breath (SOB) increasing. The daughter found a kink in the tubing and stated reason why R19 couldn't feel O2 through the NC. On 02/08/19 at 07:38 AM, R19's RR in progress notes dated 2/6/2019 documented, Lung sounds clear in upper bases with coarse crackles in bases, 02 was 87% on 2.5L and resident complained of SOB. The facility's medical director gave new orders for antibiotic treatment for [REDACTED]. On 02/08/19 at 08:48 AM interviewed licensed practical nurse (LPN)1 as unable to find R19's physician orders [REDACTED]. LPN1 provided that the PO was written for R19 to have, O2 24/7 when ambulating or toileting. Inquired how staff knew how many liters of O2 should be administered to R19, and LPN1 was unable to provide information. LPN1 stated that R19 refused to use O2 on this date (02/08/19) because feeling cold and O2 saturation was at 96% room air. On 02/08/19 at 08:55 AM interviewed the minimum data set coordinator (MDS-C) and she could not find PO for O2 in discontinued orders as well. The MDS-C found that R19 first used O2 in (MONTH) (YEAR) once as noted in progress notes. The MDS-C stated that she will get PO from the MD and care plan today. 02/08/19 at 09:34 AM further RR on R19 found that the quarterly MDS dated [DATE] had, No for O2; and, the most recent MDS for significant change dated 11/20/18 had, Yes for O2. Under progress notes dated 10/22/2018, a physician note was written, Portable oxygen as needed for SOB available for OOP with responsible party. Start date: 10/23/18 POA requested and approved by MD. Progress notes dated 11/18/2018 by registered nurse (RN)3 noted upon R19's return from the ER for possible aspiration, Communicated that residents vitals taken upon return were as follows: BP 160/82; HR 80; RR 22; oral temp. 96.8. Resident was not on oxygen and was sating at 80% RA, I placed him on 2L NC and within 5 minutes 02 saturations was at 97% on 2L NC. Progress notes dated 12/28/18 by registered nurse (RN)4 as she sent R19 to ER to be assessed for continued vomiting of clear, mucous looking emesis.He is currently on 02 @ 3 liters continuously. The facility failed to assess R19's use of oxygen and ensure a written PO for the use of O2 when completing an annual comprehensive assessment and for a significant change in the resident's status. 2) On 02/05/19 at 11:28 AM interviewed R23 as part of initial pool sample and observed that R23 had a irritable demeanor and answered dignity question with, If they treat me bad, I tell them off. On 02/07/19 at 10:40 AM R23's RR found on a Physician Communication note on 01/28/19 that Resident is refusing his scheduled 1400 med .refused five times during the shift with swearing, yelling & stating to 'throw it in the trash can'. In the progress notes section behavior notes on: 09/26/18, Verbal aggression, abuse towards CNA staff. Resident swearing at her 'You F*** Filipino, you don't know what you doing.' Continued to verbally belittle CNA The outcome noted that R23 had calmed down and eventually allowed care and accepted as needed (PRN) [MEDICATION NAME] 5 mg and [MEDICATION NAME] 600 mg; 04/24/2018, Aide reported that res was inappropriately name calling the aide. He repeatedly called her dirty rat and used swear words at the aide. The outcome was that social services to speak to R23 and to agree to behavioral contract with MD and DON notified; and, 04/21/2018 Resident threw fork out the door nearly hitting the LN on duty. Outcome: Resident will be placed on alert for behaviors and social services will have him sign a behavior contract. On 02/07/19 at 02:54 PM interviewed social services assistant (SSA) and she provided R23's behavioral contract signed copy on 4/21/2018 . agree to comply with all of the rules and expectations of being a resident at facility. Inquired of SSA if R23 had any other behavioral contract and/or social services counseling and she could not find any documentation. Inquired if R23 was referred for psych consult and SSA needed to check with the receptionist as she scheduled those appointments. Inquired about CP to address R23's behaviors/mood and SSA stated that the licensed social worker (LSW) was responsible for developing CPs and the behavior/mood component for MDS. The LSW came to the facility in the evening to review residents' brief interview on mental status (BIMS), patient health questionnaire to rule out depression, initial psychosocial history and discharge plan, and stand-up meeting minutes. The SSA further stated that nurses fill out a comment and concern form as needed and provide to social services so that the LSW can address behaviors/moods. On 02/07/19 at 03:39 PM interviewed licensed practical nurse (LPN)1 and inquired if R23 had behavior monitoring logs based on behaviors exhibited. There was no behavior monitoring for R23 because the resident was not prescribed any [MEDICAL CONDITION], but R23 was on alert charting for behaviors. The LPN1 stated that she had no problems with R23 and that resident only acts out with certain nurses and aides, I feel that it's just his personality to be grumpy. Inquired if nursing staff follow any behavior CP for R23, and LPN1 could not find one. The facility failed to identify behaviors that R23 exhibited and provide further assessments for psychosocial well-being.",2020-09-01
980,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-02-08,656,D,0,1,GKXE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews (RR) the facility failed to develop a comprehensive care plan (CP) for one of 35 residents (R)23 sampled, with the [DIAGNOSES REDACTED]. Findings Include: On 02/05/19 at 11:20 AM RR found that R23 was currently receiving intravenous antibiotics for UTI. A urinalysis lab report dated 1/27/2019 had urine culture results of positive for ESBL E-coli and antibiotics sensitivity results attached. On 02/07/19 at 09:49 AM observed in the medication storage room two 50 ml IV bags labeled with R23's name, for the antibiotic Ertapenem Sodium 1000 mg dose, to be administered at 20 mg/ml; 50 ml over 30 min daily intravenously for ESBL E.COLI for 10 days. Inquired of licensed practical nurse (LPN)1 if R23 was on any precautions due to ESBL E-coli UTI, and she wasn't sure if R23's urinalysis (UA) came back positive with that results. LPN1 did RR on R23 and found the UA lab results with ESBL E-coli positive dated 01/27/19 and date stamped [DATE]. There were physician orders [REDACTED]. On 02/07/19 at 10:54 AM registered nurse (RN)5 reported that spoke with the facility's medical director (Med Dir), and R23 not in isolation because has past history of ESBL E-coli so will always have, and no need for any kind of extra precaution. There was no CP for ESBL E.coli colonization and/or treatment by IV antibiotics. The CP, I have occasional episodes of bladder incontinence, had a goal to remain free from skin breakdown due to incontinence and brief use through the review date; I will show no s/sx of urinary infection through review date; and, I will maintain dignity and privacy r/t incontinence through next review. On 02/07/19 at 11:39 AM interviewed certified nursing assistant (CNA) 6 as she came out of R23's room. Inquired if CNA6 emptied R23's urinal, as observed earlier that urinal was filled with approximately a cup of urine. The CNA6 stated that LPN1 just emptied R23's urinal that was hanging on the rubbish can at bedside. The CNA6 stated that standard precautions were used when providing care to R23. On 02/07/19 at 12:40 PM telephone conference with the facility's Med Dir revealed that the facility's policy was to review case-by-case of individuals suspected to have infection with a multiple drug resistant organism (MDRO) to determine the need for contact precautions. The current standards of practice is that contact precautions are not necessary for residents colonized with MDRO, and that staff are to use standard precautions with all residents. The Med Dir was aware of R23's UA culture results and stated that the UTI was not R23's site of infection, because the resident is colonized with ESBL the UA results will always be positive for that organism. The Med Dir acknowledged some changes to the facility's standard precaution policy and procedures (P&P), for MDROs will be made. The facility provided the P&P for [MEDICAL CONDITION], and under the paragraph for Standard Precautions; .3. Masks are not recommended for routine use in caring for residents with MDRO infection or colonization except as indicated by Standard Precautions when there is a risk of splashing body fluids. Under the paragraph, Environmental Precautions; .2. For residents with colonization or infection with MDROs, non-critical resident-care items will be dedicated for individual use or decontaminated prior to use with another resident. The facility failed to develop a comprehensive CP for R23 being colonized with ESBL E-coli to attain his highest practicable well being, and prevent avoidable MDRO spread in handling of urinal.",2020-09-01
981,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-02-08,657,D,0,1,GKXE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update the care plan for two residents (R) and R71. R33 did not receive passive range of motion services to prevent further decline in mobility and R71 was at a greater risk for additional falls. Findings Include: 2) During an interview with RN3 on 02/06/19 at 10:21 AM R33 doesn't have contractures, but is really stiff. She's not receiving physical therapy (PT) since she's on Hospice. During an interview with the Hospice Nurse on 02/07/19 at 09:19 AM. Passive Range of Motion (PROM) is being done by me. R33 was more stiff before and wasn't able to bend her arms or her legs and now she can bend them a little more. Hospice services are being coordinated by myself. Review of medical Diagnosis: [REDACTED]. Minimum Data Set (MDS) Significant change dated 06/27/18 section G (Functional Status) with the following: Bed mobiity: Extensive assistance. Transfers: Extensive assistance. Dressing; Extensive assistance Eating: Supervision. Toileting: Extensive assistance. Bathing: Total dependence. Most recent quarterly dated 12/17/18 section G with the following: Bed Mobility: Extensive assistance. Transfers: Total dependence. Dressing: Total dependence. Eating: Total dependence. Toileting: Total dependence. During an observation on 02/07/19 at 09:45 AM R33 is sitting up in her wheelchair (W/C) at nurses station. Care plan quarterly review dated 01/04/19 reviewed: 1. I have ADL self-care performance deficit and/or limited physical mobility r/t Cognitive impairment, dementia, weakness, impaired functional mobility Gradual decline in function is expected as my terminal illness progress. Goals not updated: I will maintain current level of function through the review date. No interventions for PROM exercises. 2. I am at risk for falls. Last review date: 03/07/07 Encourage me to participate in activities that promote exercise, physical strengthening and improved mobility. (Resident is coded as total dependence on most recent quarterly MDS dated [DATE]). 2) Review of care plan revealed R71 was at risk for falls, with actual unwitnessed/no injury falls occurring on 01/01/19 and 01/05/19. R71's chart was labeled with sticker, High fall risk. Review of fall meeting notes for R71 dated 01/07/19 revealed the following: 1/1/19 .attempted to pick up item off the ground . & slid off of the WC (wheelchair) This was deemed to be an isolated event with the resident attempting to retrieve a food item on the floor. Interventions included: floor mats put in place, and Resident placed on q 15-minute checks. 1/5/19 . resident found by staff member lying on the floor . Potential interventions: Review of previous fall meeting minutes by nurse in charge of falls-reflects that the resident verbalized that she does not want any chair or bed mat alarms d/t increased noise levels & outright refusal. RR of Fall Risk Evaluation dated 01/05/19 recorded, Balance problem while standing/walking/needs safety reminders . Change in gait pattern when walking ., Unsafe ambulation/transfer/impulsive. Occupational therapy (OT) screening complete 01/11/19 with notes, Recommended to nursing for bed/wc (wheelchair) alarms for fall prevention. On 01/12/19, R71 admitted to acute care hospital for unrelated medical issue and readmitted back to facility on 01/16/19. 01/17/19 progress notes revealed, .OT screened R71 after fall on 1/1 and 1/5 and recommended bed and wheelchair alarms. Spoke with POA (Power of Attorney) this AM and got the okay for alarms. Bed and wheelchair alarms added to R71's care plan as interventions to prevent additional falls. On 02/06/19 at 04:36 PM, Interviewed Director of Nursing (DON) on facility process post fall. DON stated, We start follow up right away. The RN checks out the environment . A form is completed for rehab (rehabilitation-PT/OT) referral. I'm notified and the next day interview Resident if able, and staff. We have a fall meeting to review the care plan and add interventions if needed. 02/07/19 at 03:00 PM Interview and RR with Rehabilitation Director (RD). Discussed OT recommendation for alarms. RD responded, That's a nursing intervention and measure and usually they would follow up with that and put on right away. 02/07/19 at 03:10 PM during interview with DON reviewed care plan and time line. DON stated, after the first fall, we implemented basic monitoring which is every 15-minute checks. After the second fall, noticed a change in her safety awareness was poor, and she was beginning to get up and doesn't realize she needs assistance. We try not do verbal consents to use alarms and like to talk to family directly. Asked if family was notified after each fall and DON replied, Yes. Inquired if alarms was discussed with family when notified after each fall, and DON stated, No. Usually wouldn't wait to implement routine measures such as alarms. When she (R71) was more alert, she expressed the noise was irritable to her. Asked when that conversation occurred, and DON replied, back in (YEAR). Asked if would do anything differently, and DON replied, I would approach it quicker with what interventions could do. R71 had two falls on 01/01/19 and 01/05/19. The post fall assessment on 01/05/19 noted a change in her safety awareness and impulsivity. There was a delay in revising her care plan and implementing nursing measures to prevent further falls which put R71 at risk of injury.",2020-09-01
982,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-02-08,697,D,0,1,GKXE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interviews and Record review (RR) the facility failed to ensure adequate pain management was provided to one resident (R)73 of a sample size of two residents. As a result of this deficient practice it has a potential for R73 to be at risk of unnecessary pain and not attaining his highest level of physical and psychological well-being. Findings Include: RR revealed R73 admitted to facility 12/27/19 with [DIAGNOSES REDACTED]. Physician (MD) order was [MEDICATION NAME] HCL 50. Give 50 mg by mouth four times a day oral related to pain. Scheduled time of administration was 09:00AM, 09:00PM, 01:00AM, 05:00AM. RR of the Pain Evaluation (V13.3) admission form completed by nursing staff, dated 12/30/18 assessed R73's pain to be daily, almost constantly, and limited day-day activities because of pain. Documentation indicates R73 felt his pain was controlled, and there was No complaint of pain in between pain medications. R73 determined his acceptable level of pain (0-10) was 6. RR of R73's care plan revealed pain was identified as a focus and documents: I have pain r/t Chronic joint pain. Interventions included: 1. Anticipate my need for pain relief and respond immediately to any complaint of pain. 2. I am able to: (call for assistance when in pain, ask for medication, tell you how much pain I am experiencing .) 3. Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience in pain. 4. Provide my family and I education about pain and options available for pain management. Discuss and record preferences. Request made for documentation R73 and family had been educated about pain/options available for pain management, and discussion regarding preferences. Facility was unable to produce documentation. Medication Administration Record [REDACTED]. Nursing assessed R73's pain level prior to administration of each scheduled pain medication (four times a day) for a total of 120 times that R73's pain was assessed when administering pain medication. There were 68 out of the 120 times that R73's pain level was above his acceptable level (6). MAR revealed R73 did not receive six scheduled doses of [MEDICATION NAME] 50 mg. the following times: 02/03/19 01:00AM, 05:00AM and 02/04/19 09:00AM, 09:00PM, 01:00AM, 05:00AM. Medication administration notes included: 02/03/19 11:23AM Waiting for it to arrive from Pramerica 02/03/19 10:11PM Waiting for delivery from pharmacy 02/04/19 02:31AM prescription has no refills. Will alert the Doctor and request for pain medication for resident. 02/04/19 06:24AM prescription does not have a refill. Put a prescription in Dr's consult book for her to sign 02/04/19 08:53AM [MEDICATION NAME] is n/a (not available). Will follow up with pharmacy. MAR does not have evidence R73's pain was assessed during the timeframe his pain medication was not available. Occupational Therapy Daily treatment note dated 02/04/19 documents R73 received Electrical stimulation therapy to decrease stiffness and pain . with good tolerance . Nursing documented R73 slept 5 hours of sleep on the night of 02/03/19 and 02/04/19, which was normal for him. On 02/06/19 09:55 AM Surveyor observed R73 in wheel chair next to his bed grimacing. Asked if he had pain, and R73 replied, Yes, I need go back to bed. Asked if had called for assistance, and R73 stated, I can't do that if I don't have the call light. Observed call light was not available to R73. Surveyor saw CNA across the hall and informed her R73 needed assistance. On 02/07/19 08:25 AM during interview with R73, he appeared uncomfortable. Asked if in pain, and R73 replied yes. Stated pain was a 9 or 10. Asked if he had received anything for pain, and R73 replied, at 5 AM. Next dose was due at 09:00 AM. Asked R73 if he had made anyone aware his pain wasn't controlled, and he replied, I did tell the doctor it (pain medication) wasn't working. On 02/07/19 at 10:15 AM interviewed LN2 about R73's pain. Registered Nurse (RN)2 stated, R73 always has pain in his joints. I'm always here to give him his 9AM dose of [MEDICATION NAME]. When asked if RN2 felt his pain was controlled, she replied, He doesn't express need for more pain meds. RN2 stated that after a PRN (as needed) medication is administered, the electronic medical record (EMR) system triggers staff to do a reassessment of pain (numeric value) to be documented in the MAR, but if the medication is scheduled (i.e. four times a day), the system does not trigger a reassessment. Nursing staff must document reassessment of pain in the progress notes. Nursing staff also are directed to document pain once a shift in the MAR. Asked RN2 if there are specific times this is done, and RN2 stated, No, it just needs to be done once a shift. This pain assessment is not specifically correlated to monitor the effectiveness of the medication. During interview with RN5, she confirmed EMR does not trigger a reassessment of pain on a scheduled medication, and that nursing would have to document the pain reassessment in the progress notes. The documentation of pain assessment/reassessment lacked standardization. The EMR potentially contributed to this, but facility policy also was not reflective of current practice. Documentation of reassessment of pain for medication effectiveness could be found consistently only on PRN medications. Nursing failed to monitor, identify a trend and report to the physician that R73's established pain goal was not being met. In addition, the nursing staff did not anticipate R73's needs and follow up timely to obtain a new prescription from MD to ensure medication was immediately available if needed. R73 was put at unnecessary risk for inadequate treatment of [REDACTED]. Cross reference tag 558 Based on observation, interview and record review (RR), the facility failed to ensure one resident (R)73 of two sampled residents selected for review had communication equipment accessible to call for immediate help when needed. As a result of this deficient practice, R73 was not able to call for assistance when he needed it.",2020-09-01
983,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-02-08,740,D,0,1,GKXE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews (RR) the facility failed to recognize and thoroughly address the psychosocial needs for one of 35 residents sampled and provide behavioral health care services. Findings Include: On 02/05/19 at 11:28 AM interviewed R23 as part of initial pool sample and observed that R23 had a irritable demeanor and answered dignity question with, If they treat me bad, I tell them off. On 02/07/19 at 10:40 AM R23's RR found on a Physician Communication note on 01/28/19 that Resident is refusing his scheduled 1400 med .refused five times during the shift with swearing, yelling & stating to 'throw it in the trash can'. Also, RR found in the progress notes section behavior notes on: 09/26/18, Verbal aggression, abuse towards CNA staff. Resident swearing at her 'You F*** Filipino, you don't know what you doing.' Continued to verbally belittle CNA The outcome noted that R23 had calmed down and eventually allowed care and accepted as needed (PRN) [MEDICATION NAME] 5 mg and [MEDICATION NAME] 600 mg; 04/24/2018, Aide reported that res was inappropriately name calling the aide. He repeatedly called her dirty rat and used swear words at the aide. The outcome was that social services to speak to R23 and to agree to behavioral contract with MD and DON notified; and, 04/21/2018 Resident threw fork out the door nearly hitting the LN on duty. Outcome: Resident will be placed on alert for behaviors and social services will have him sign a behavior contract. On 02/07/19 at 02:54 PM interviewed social services assistant (SSA) and she provided R23's behavioral contract signed copy on 4/21/2018 . agree to comply with all of the rules and expectations of being a resident at facility. Inquired of SSA if R23 had any other behavioral contract and/or social services counseling and she could not find any documentation. Inquired if R23 was referred for psych consult and SSA needed to check with the receptionist as she scheduled those appointments. The licensed social worker (LSW) worked only during the evening shift, and reviewed residents' brief interview on mental status (BIMS), patient health questionnaire (PHQ) -9, to rule out depression, initial psychosocial history and discharge plan, and stand-up meeting minutes. The SSA further stated that nurses fill out a comment and concern form as needed and provide to social services so that that the LSW can address behaviors/moods. The SSA stated that she didn't have a problem with R23, and that the LSW was responsible for developing CPs and for behavior/mood component in the MDS. The SSA provided R23's initial psychosocial history and discharge plan on admitted [DATE]. Discharge plans then was to home within 20 days. There were no involved family/significant other to provide support. Inquired of SSA if R23 had any visitors, and she stated that no one visits R23. The resident's brother was the next of kin contact, but SSA stated that brother never visited. The summary included that R23 had nine children, never married, and prior to admission lived alone. Admission to the facility was for R23 to receive rehab services, and was bedridden. The LSW e-signed the document on 04/01/17. The SSA conducted the PHQ-9 depression screening tool for R23 on 01/24/19, with results of minimal depression, and the LSW e-signed on 01/25/19. Inquired if the LSW counseled R23 and/or conducted further assessments and the SSA could not provide any documentation. On 02/07/19 at 03:39 PM interviewed licensed practical nurse (LPN)1 and inquired if R23 had behavior monitoring logs based on behaviors exhibited. There was no behavior monitoring for R23 because the resident was not prescribed any [MEDICAL CONDITION], but R23 was on alert charting for behaviors. The LPN1 stated that she had no problems with R23 and that resident only acts out with certain nurses and aides, I feel that it's just his personality to be grumpy. Inquired if nursing staff follow any behavior CP for R23, and LPN1 could not find one. The facility did not provide behavioral health care and services that involved an interdisciplinary approach to care, with qualified staff that demonstrate the competencies and skills necessary to provide appropriate services to R23.",2020-09-01
984,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-02-08,757,D,0,1,GKXE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review (RR), and interviews, the facility failed to ensure that one (R25) resident did not receive unnecessary medication. As a result of this deficient practice, R25 received additional doses of medication. Findings Include: R25 had a history of [REDACTED]. She was receiving [MEDICATION NAME] for her anxiety disorder. Monthly medication reviews (MMR) of R25's medication regimen are required. The facility uses an offsite pharmacy (PharMerica) as consultants to do the MMR. The MMR is done to identify any potentially unnecessary medications, ensure there is a rational for the medication, and recommend tapering when clinically indicated to prevent any potential adverse consequences. The MMR process at the facility is the Pharmacist (P) documents recommendations for consideration for the Physician (MD) and faxes the report to the facility. A communication follow-up form is utilized that includes P's recommendations. The MD reviews the recommendations and documents comments and adjusts orders if needed. RR of the faxed PharmMerica MMR dated 12/30/18 was marked as a Medium Priority. The content of the report included, Per nursing notes, resident was seen by psych consult (sic) this month. Her [MEDICATION NAME] dose was adjusted. Will be sending recommendation for re-review of curren (sic) [MEDICATION NAME] order as she is now on scheduled and PRN dosing . RR of PharmMerica Medication Regimen Review follow-up communication form was initiated by P1 on 12/30/18. Documentation included: R25 had her [MEDICATION NAME] dose changed from 0.25mg PO (by mouth) Q 12H (every 12 hours) PRN (as needed) for anxiety to 0.25mg PO BID (twice a day) scheduled and 0.5mg PO Q24h PRN. I just wanted to verify this is the new dose for her. I was unable to find the original psych consult report scanned into the chart, however per your progress notes it seems that she was just supposes to be changed to just be on 0.5mg PO QHS secondary to anxiety at bedtime only. I am not sure she was supposed to be on scheduled [MEDICATION NAME] as well. In addition to your progress note, you also wrote a prescription for 0.5mg PO QHS PRN only around that same time. MD1 wrote the following comments in the Physician Response Section dated 01/06/19: her only active order should be for [MEDICATION NAME] 0.5 mg p.o. q hs prn. I spoke with RN2 today at 1430 to fix this order. An additional report (Review of Medication Review Report) is generated to assist MD1 in reviewing all active orders. RR of report dated 01/02/19 for R25, revealed active order of [MEDICATION NAME] Tablet 0.25 mg by mouth two times a day related to anxiety disorder ., and [MEDICATION NAME] Tablet 0.5 mg by mouth every 24 hours as needed to Anxiety disorder QHS (every night at bedtime) PRN (as needed). MD crossed out the scheduled order two times a day and wrote the comment, incorrect. I never ordered this. Spoke with RN2 to d/c (discontinue) it. There is no date or time documented when MD1 reviewed this report. RR of Physician order [REDACTED]. There was no order written at that time to D/C the scheduled [MEDICATION NAME] twice a day order. RR of MD progress notes dated 01/04/19 and electronically signed at 05:44PM include: Patient seen due to being requested to review pharmacy recommendation regarding her [MEDICATION NAME] order . She is getting 0.25 milligrams [MEDICATION NAME] p.o. b.i.d. scheduled and [MEDICATION NAME] 0.5 milligrams p.o. Q 24 hours prn. Plan note: spoke with RN2 to remove the [MEDICATION NAME] 0.25 milligrams po bid scheduled order. made notations to remove outdated/completed orders On 02/07/19 at 02:10 PM conducted interview with MD1 to review the MMR and medication regimen of R25. MD1 stated, I told RN2 to discontinue the scheduled [MEDICATION NAME] order. She (R25) was supposed to be on prn only at night. On 02/07/19 at 02:30PM conducted interview with RN2. Reviewed R25's medication orders and process for verbal orders. RN2 said, MD1 did give me a verbal order and I guess I misunderstood her. When I became aware of the discrepancy I checked the computer and it had already been changed. On 02/07/19 at 04:1OPM during interview with DON, discussed R25's medication orders. DON stated, I am aware of the error. MD1 said she told RN2 to discontinue the bid order (for [MEDICATION NAME]). Asked DON the process for verbal orders, and DON stated, if a verbal order is given, the MD will follow up by writing the order. MD1 wrote other orders to DC a different medication, so not sure why she didn't write the one to discontinue the [MEDICATION NAME]. Asked how orders are put into the system to activate, and DON stated, the RN puts the order in. Reviewed facility policy titled Medication Orders dated (MONTH) 2014. The policy statement for verbal orders included, Verbal orders shall only be given in an emergency or when attending is not immediately available to write or sign the order. Policy directs staff as follows: The individual receiving the verbal order will read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed, and the practitioner will review and countersign verbal orders during his or her next visit. On 02/05/19 at 08:14 conducted telephone interview with P2 regarding R25's medication orders. R2 stated, Yes, I see both medications were active, and R25 did receive both at the same time. MAR indicated [REDACTED]. Reviewed dosage of administered medications with P2, who said, order is within therapeutic range. RR of Behavioral monitoring documentation while R25 received both the scheduled dose and as prn oder. There were no documented negative effects of the additional doses recieved. A verbal order was given by the MD in a situation that was not an emergency. MD1 did not follow up with a written order, and RN2 did not validate the order per facility policy. In addition, the facility failed to respond timely to a recommendation the pharmacist made during the MMR. As a result, there was a delay in correcting the order and R25 received unnecessary doses of her antianxiety medication. This had the potential for adverse consequences and interfered with the plan to taper R25's medication to avoid unnecessary medication.",2020-09-01
985,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-02-08,880,D,0,1,GKXE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow infection control procedures ensuring hand hygiene procedures were followed by Registered Nurse (RN)3 during direct resident contact during a dressing change for R33. RN3 did not sanitize/ wash hands in between changing dirty gloves to clean gloves. The facility also failed to have criteria-based assessment tools for and identification of an infection and did not develop written protocols on antibiotic prescribing as part of their antibiotic stewardship program (ASP). As a result of this deficiency, an infection may not be identified timely, and treatment of [REDACTED]. 1. During a dressing change on 02/07/19 at 09:04 AM with R33, RN3 sanitized hands, donned gloves, removed the old kerlix and gauze dressing to the bilateral lower arms and left leg skin tear. RN3 cleaned the exposed area with normal saline dried with the gauze then removed dirty gloves then applied the clean gloves. RN3 proceeded to dress and wrap the dressing/ kerlix dressing. She did not sanitize or wash hands when changing gloves. Legacy Hilo Hand hygiene policy number IPC102 reviewed. Policy: washing hands with water and either plain soap or soap/ detergent containing an antiseptic agent or thoroughly applying an alcohol-based hand rub. Before and after changing a dressing; after handling soiled dressings; after removing gloves or aprons. During an interview with RN3 on 02/07/19 at 10:00 AM reviewed the steps during the dressing change and confirmed that she missed sanitizing the hands between the glove change. 2.Findings Include: On 02/08/19 at 09:44 AM Interviewed Staff development Coordinator (RN3), who was covering for the Infection Preventionist (IP). Asked how staff were educated to identify a potential infection and what process was in place to communicate a potential infection to appropriate individuals. RN3 stated, All nursing staff are taught in orientation. RN3 said, if a resident has a fever, dysuria or other symptoms, they will notify the doctor by filling out a communication form and send a copy to the IP. We have a log to track lab results from there. Asked if staff utilized a standardized tool to identify infections, and RN3 replied, No. Inquired if a copy of reportable communicable diseases was available, but RN3 was not able to find a copy. Surveyor and RN3 reviewed facility policy titled, Infection Report & Tracking/Surveillance with revision date of 01/14/19. Policy directs staff to complete the infection report . when identifying symptoms of resident's illness. Asked RN3 if they utilized the infection report, and she replied, I'm not aware of that, we use the communication report. Facility policy also states, Communicable diseases are reported to the appropriate County Health Department in accordance with State regulations. Reviewed the Antibiotic Stewardship program with revised date of 01/14/19 with RN3. The document included the following, The facility may consider obtaining an infectious disease physician consultant to provide guidelines for developing protocols. The facility did not have written protocols for antibiotic prescribing in place. On 02/08/19 at 10:22AM Surveyor and RN3 interviewed RN2 to inquire if she was aware of whom and when to report communicable diseases to, or if a list of reportable diseases was available on the nursing unit. RN2, replied, I know to report [MEDICAL CONDITION] ([MEDICAL CONDITION], a bacterial infection) but not aware of any list of communicable diseases. We use the communication form to let the MD know or call them. The copy goes to the IP. We implement additional precautions if needed. On 02/08/19 at 10:00 aphone interview conducted with Infection Preventionist (IP) with R3 present. When asked if criteria were used by staff to identify an infection, IP stated, I think I have McGeer's (criteria-based tools for common infections) on my computer. Asked IP if he had a copy of reportable diseases, or if staff have one available to them for reference, but IP was unable to provide information immediately here to locate the list. Staff did not use evidence-based criteria for identification of a potential infection, so rely on each RN's assessment and independent judgement to trigger reporting and follow up for a potential infection. This may result delay to implement treatment measures and prevention precautions. It is imperative that the facility have a list of reportable diseases immediately available for reference to report to Public Health Departments in a timely manner so communicable diseases can be monitored.",2020-09-01
986,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2018-03-16,550,D,1,0,0RMI11,"> Based on resident interviews, the facility failed to treat residents with respect and dignity in an environment that promotes their quality of life. Findings include: 1) On 3/16/18 at 8:32 [NAME]M. during the resident council meeting, four residents reported staff members often speak in the non-dominant language of the facility to one another while in their rooms and in the common areas. One resident reported this occurs on different shifts. 2) On 11/1/17, Resident #137 registered a complaint with the State Agency. The resident reported she was in the company of visitors in the lounge when a Certified Nurse Aide (CNA) walked up to her and started to say, how many times a day did you .at this point the resident reported she stopped the CNA as she was sure he was going to ask how many times she urinated or had a bowel movement. Resident #137 reported she was aware that the CNA was completing his shift and needed this information. She met the staff member in the hallway and told him five and one, the he stated aloud you made shi-shi five times and dodo once.",2020-09-01
987,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2018-03-16,697,D,1,0,0RMI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview with resident and staff members, the facility failed to ensure pain management was provided for 2 (Residents #78 and #137) of 3 residents sampled in accordance with the physician orders [REDACTED]. Findings include: 1) On 3/13/18 at 12:26 P.M. an interview was conducted with Resident #78. The resident reported that she has pain to her right hip. Inquired whether she is provided with medication, she responded she is given medication for pain but sometimes it helps but sometimes it is not effective. A record review done on 3/15/18 at 8:15 [NAME]M. notes Resident #78 was re-admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. Further review found a physician's note dated 3/7/18 documenting Resident #78 was readmitted to the facility following hospitalization for a [MEDICAL CONDITION] related to a fall on the night of 2/7/18. On 3/15/18 at 1:43 P.M. a review of the physician's orders [REDACTED]. give 2.5 mg. by mouth every 24 hours as needed for sleep agent (monitor sleep patterns document # of hours of sleep); [MEDICATION NAME] tablet, give 10 mg. by mouth one time a day related to major [MEDICAL CONDITION]; [MEDICATION NAME] tablet 5-325 mg. ([MEDICATION NAME]-[MEDICATION NAME]), give one tablet by mouth every 4 hours as needed for moderate pain, pain rate 1-5 related to fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing and give 2 tablets by mouth every 4 hours as needed for severe pain. The resident's care plan was reviewed. The facility developed a care plan with the following goal, I will not have an interruption in normal activities due to pain through the next review date. The care plan was initiated and revised on 3/4/18 with target date of 6/6/18. Interventions included pharmacological and non-pharmacological interventions. A review of the Medication Administration Record [REDACTED]. one tablet for moderate pain (pain rate of 1-5) was administered on the following dates with pain levels greater than 5: 3/5/18 (pain level =7), 3/6/18 (pain level =7), 3/7/18 (pain level = 8), 3/10/18 (pain level = 9), 3/12/18 (pain level = 7) and 3/15/18 (pain level = 6). All administrations were documented as effective; however, there is no documentation of efficacy of medication on 3/15/18. Resident #78 was provided with two tablets of [MEDICATION NAME] Tablet 5-325 mg. on 3/7/18 at 2012; 3/8/18 at 1627; 3/9/18 at 0223 and 1810; 3/10/18 at 1515 and 2300; 3/11/18 at 1310; 3/12/18 at 1810; 3/13/18 at 1418; and 3/14/18 at 1457. All administrations were documented as effective. Further review noted on 3/7/18 the resident had a pain level of 5; however, was provided with 2 tablets of [MEDICATION NAME] Tablet 5-325 mg. The dosage was noted to be effective. On 3/18/18 at 2:35 P.M. an interview was done with Staff Member #139. The staff member confirmed Resident #78 was not provided with the physician prescribed medication to manage the resident's pain levels. 2) A complaint was registered by Resident #137 on 11/1/17. The complaint investigation was done during the recertification survey. The resident reported her pain was not being managed. On 3/14/18 at 11:45 [NAME]M. and 3/16/18 at 9:15 [NAME]M. a record review was done for Resident #137. Resident #137 was admitted to the facility on [DATE] and discharged on [DATE]. The [DIAGNOSES REDACTED]. A review of the resident's admission Minimum Data Set with assessment reference date of 10/5/17 found in Section J0100. Pain, the resident received scheduled pain medication and prn (pro ro nata/as needed) pain medication. The resident was also noted to have experienced pain in the last five days with a pain intensity of 5. The facility developed a care plan to address the resident's pain related to status [REDACTED]. The care plan included pharmacological and non-pharmacological interventions. A review of the physician's orders [REDACTED]. by mouth three times a day for pain related to primary [MEDICAL CONDITION] presence of left artificial should pain (0700, 1400 and 2100); [MEDICATION NAME] HCI 10 mg. tablet every four hours as needed for severe pain; [MEDICATION NAME] HCI 5 mg. tablet every four hours as needed for moderate pain related to [MEDICAL CONDITION] and presence of left artificial shoulder; [MEDICATION NAME] tablet 500 mg. give one tablet at bedtime for pain related to primary [MEDICAL CONDITION] presence of left artificial shoulder; and [MEDICATION NAME] capsule 75 mg. at bedtime for pain related to primary [MEDICAL CONDITION], left artificial shoulder. A review of the resident's Medication Administration Record [REDACTED]. The review found parameters for prn medications, moderate vs. severe pain, were not defined. The prn medication for moderate pain (5 mg. [MEDICATION NAME] every 4 hours) was provided for reported pain levels from 3 to 8. And the prn medication for severe pain (10 mg. [MEDICATION NAME] every 4 hours) was provided for reported pain levels from 3 to 10. The routine medications for pain, [MEDICATION NAME] (75 mg. at bedtime), [MEDICATION NAME] (500 mg. at bedtime), [MEDICATION NAME] (975 mg. three times a day) and [MEDICATION NAME] ER (10 mg. twice a day) were administered as ordered. There is documentation in the MAR for administration of prn [MEDICATION NAME] 5 mg. for moderate pain which was ineffective on the following dates: 3/1/18 at 1459 (pain level = 6); 3/4/18 at 0906 (pain level of 4); 3/10/18 at 1322 (pain level of 5); and 3/12/18 at 1209 (pain level = 3). Also noted administration of [MEDICATION NAME] 10 mg. for severe pain that was ineffective on the following dates: 3/10/18 at 1941 (pain level = 10) and 3/11/18 at 0824 (pain level = 3). On 3/16/18 at 10:09 [NAME]M. an interview and review of the physician's orders [REDACTED].#87. The staff member confirmed the orders did not contain parameters/pain levels for the administration of prn medications for moderate to severe pain. The staff member acknowledged the resident was also on routine medications to control the pain. Queried the staff member regarding pain levels for severe pain, the staff member responded a level of 7 to 10 would indicate severe pain.",2020-09-01
988,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2018-05-22,567,E,1,0,HEVY11,"> Based on review of the personal trust fund account records and interview with staff members, the facility failed to ensure a system is in place to safeguard against misappropriation of resident's funds for 1 of 3 residents (Resident 140) and the residents with existing trust accounts in (MONTH) (YEAR). Findings include: 1. On the morning of 5/22/2018 a review of the residents' trust account was done. A review of the bank account (Client Trust Account) for the period beginning 4/1/2018 and end date of 4/30/2018. Interview and concurrent review of the statement was done with the Staff #10 and Staff #9, a request was made for receipts/invoices/deposit slips to document the transfer of funds posted on 4/2/2018 in the amount of $5,452.40 and a second transfer posted on 4/6/2018 in the amount of $29,196.40. Also requested the documents related to withdrawals on 4/9/2018 of $859.00 and 4/18/2018 of $890.00. On 5/23/2018 the facility provided the documents (i.e. deposit, withdrawal slips, cost share) to document the transfer of the funds on 4/2/2018 and 4/6/2018 to the operations account. On 5/24/2018 at 11:10 AM, the facility provided documents regarding the withdrawal for $855.00. Staff #10 reported, they were unable to account for $4.00 related to this withdrawal. The staff member reported the facility was unable to find the documents (invoices, receipts, withdrawal slips) for the withdrawal on 4/18/2018 of $890.00. 2. A complaint was filed with the State Agency (SA) regarding the discharge of Resident 140 (R140). The complainant alleged facility staff members withdrew money from the resident's trust account to purchase a money card (approximately one hundred dollars) to pay for his transportation. The complainant further reported a staff member went to purchase the money card on the day of the discharge. R140 was discharged from the facility on 9/8/2017 to a hotel approximately 86 to 112 miles away from the facility. The resident was transported to the hotel via commercial transportation. The facility reportedly used R140's funds to purchase a card to pay for the transportation. On 5/22/2018 at 12:51 PM, the facility confirmed R140 had a trust fund and provided copies of the transaction history. A review of the Trust - Transaction History dated 1/1/2016 through 4/30/2018 was done with Staff #9. The review found documentation of the first deposit to the trust fund on 5/24/2017 in the amount of $1,360.00. Further review found a debit (withdrawal) of $100.00, personal cash 9/8/2017. A request was made for documentation that the resident requested the cash and that the resident received the money. On 6/23/2018 at 2:22 PM, Staff #9 reported the resident's supporting documentation for the withdrawal of a hundred dollars could not be located. 3. On the morning of 5/24/2018 a review of Resident 19's (R19) quarterly trust fund report for (MONTH) (YEAR) to (MONTH) (YEAR) noted a cash withdrawal of $100.00 on 1/31/2018 (posting date). A request was made to review the resident's authorization for the withdrawal. A review of the Resident Trust Disbursement Authorization documents a request for a cash withdrawal from the resident's trust account on 1/29/2018 to pay his sister. The facility staff person signed as the party disbursing the money. On the bottom there was a handwritten note documenting, witnessed: with a signature of the staff member. There was no documentation by the sister or the resident of receipt of the $100.00 in cash. Concurrent review of the Trust Statement and Resident Trust Disbursement Authorization was done with Staff #9. The staff member acknowledged the signature of the Responsible Party/Title was not signed and although the resident signed to request the cash, there was no documentation that the resident or his sister received the money. A review of the facility's policy and procedure entitled Resident Trust Fund was provided by the facility on 5/23/2018 at 11:00 AM. A review of the policy and procedure was done with Staff #9, the staff member acknowledged the policy and procedure did not have a process for ensuring receipt of money or checks (written to cash) was received by the attended recipient.",2020-09-01
989,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2018-05-22,569,D,1,0,HEVY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on personal funds trust record review and interview with staff members, the facility failed to ensure within 30 days of discharge, eviction or death, the facility conveyed the resident's personal funds and a final accounting to the individual or probate jurisdiction administering the resident's estate for 2 of 10 residents in the sample selection (Residents 138 and 140) Findings include: 1. A complaint was registered with the State Agency (SA) regarding the discharge of Resident 140 (R140). The complainant alleges the facility staff used approximately a hundred dollars to purchase a money card to pay for the resident's transportation. R140 was discharged from the facility on 9/8/2017. On 5/22/2018 at 12:51 PM the facility provided documentation related to R140's trust fund. A review of a document entitled Trust - Transaction History for 1/16/2016 through 5/31/2018 found notation dated 11/20/2017 to close trust acct-trf to SNF, the amount of debit was $326.47 which would leave the resident with a 0 (zero) closing balance. Another document entitled Transaction History by Effective Date for 1/1/2016 through 5/31/2018 notes the resident's total for (MONTH) (YEAR) showed a balance of $54.53. The document entitled A/R Aging by Service Date for (MONTH) (YEAR) documents R140 was discharged on [DATE] and there was a balance of $54.53 in the trust account. On 5/22/18 at 12:51 PM review of the documentation provided by the facility was done with Staff #9. The staff member was queried regarding the discrepancy of the zero-balance documented on the Trust - Transaction History and the documentation of the resident having a balance of $54.53. The staff member acknowledged the discrepancy between the two statements and was agreeable to research the records for supporting documentation. On 3/23/2018 at 2:22 PM the staff member reported R140's trust fund documents (receipts/withdrawal request, etc.) cannot be located to record the resident's trust fund was closed and whether the resident was reimbursed the $54.53. 2. Resident 138 (R138) was discharged from the facility on 1/27/2018. The Trust - Transaction History provided by the facility on 5/22/2018 at 12:51 PM found posting dated 12/31/2017 noting the resident had a balance of $5.04. Staff #9 documented a check for the balance was being sent on 5/22/2018. The SM confirmed the resident's trust account was not conveyed within 30 days of discharge.",2020-09-01
990,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2018-05-22,624,G,1,0,HEVY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, medical record reviews and interviews the facility failed to provide sufficient preparation and orientation to Resident 140 (R140) to ensure a safe and orderly discharge from the facility. Findings Include: On 04/30/2018 the State Agency received a complaint with concern that R140 had been discharged from the facility on 09/08/2018 in an unsafe manner. On 09/08/2017 R140 was discharged at 05:30PM to Manago Hotel. According to Google maps, Manago Hotel is located 86.7 miles from the facility and is estimated at being a 1 hour and 48 minute drive from the facility. Manago Hotel was established in 1917 and still maintains the original building as the functioning hotel. Surveyors visited the Manago Hotel on 05/08/2018. The building is the original wooden structure that consists of various narrow ramps that incline upwards or downwards as well as many steep staircases between the different levels. There are no elevators in the building. One of the hotel workers was interviewed on 05/08/2018. They recalled R140 arriving at the hotel that evening at approximately 07:30 PM in a vehicle driven by a LYFT driver. The hotel worker stated, he was very lethargic, unable to walk on his own and one of his feet was purple, but she could not remember which one. She stated that R140 did not fully understand why he was coming to the hotel from Hilo. He was unable to exit the vehicle himself. He was assisted by the LYFT driver and the hotel manager into the wheelchair that had been sent with him along with boxes of his belongings. The hotel worker stated they offered him food, but he did not respond so they gave him a sandwich. She also stated that a reservation had been made that day by the facility for one night and that no plans for payment had been made. She also stated that R140 had no identification, credit card/s or money on him, or any documentation from the facility. She stated it was evident he was unable to care for himself or mobilize independently, so the LYFT driver called EMS to take him to the local hospital. On 05/08/2018/, surveyors went to the local hospital where R140 was taken to review his medical record. The physician who completed an assessment of R140 in the Emergency department on 09/08/2017 documented in the medical record of R140 that he was a poor historian, unable to give details of his medical history, and inform them what medications he was currently taking. The hospital physician contacted the facility physician who informed him that he had a psychiatric evaluation that determined that he had capacity to make his own decisions. He demanded discharge, and stated he wanted to go to this Hotel. According to this physician, nursing discharge managers told her that he had a source of income, and a place to stay at this hotel. She did recently workup the foot pain, with an MRI for osteo[DIAGNOSES REDACTED] which was negative for osteo[DIAGNOSES REDACTED]. The physician had also documented that the previous care home had refused to have him back. The EMS report dated 09/08/2017 had documented Pt relates being transported from Legacy Hilo Rehabilitation and Nursing Center via Lyft driver to Manago Hotel with all his belongings. Pt relates Legacy Rehab center told pt that they had set up a room for him to live in and seek treatment for [REDACTED]. Pt and hotel staff were unaware of the situation, hotel staff then activated 911. Upon EMS arrival pt complaining of bilateral foot pain. Lyft driver then tried to contact Legacy Rehab Center with no success. HPD was contacted for possible abandonment case. On 09/08/2017 a Registered Nurse in the Emergency Department had documented in the medical record of R140, I was able to speak with the physician who had been caring for him at the skilled nursing facility. The patient has apparently been refusing all of his medications for the past 4-6 weeks. He has been violent with the staff there, injured other residents, and assaulted nursing aides with his cane. He had a psychiatric evaluation that determined that he had capacity to make his own decisions. He demanded discharge, and stated he wanted to go to this Hotel. Documentation for Admission History and Physical in the medical record dated 09/09/2017 stated that R140 's presenting chief complaint was Altered mental status. Further documentation stated He was evaluated by psychiatry and thought to have at least moderate dementia and lacked capacity. On 09/09/2017 a psychiatry consult note was documented in R140 ' s medical record at the hospital. The documentation stated, Insight is poor. Judgment is poor On Cognitive exam, the patient is Oriented x 1 only. He does not know where he is or what kind of place he is in. He cannot give the date, or year. Cannot name the president or the governor. assessment: The patient is significantly demented. He is unable to perform ADLs, manage finances or care for himself. DX: Dementia, severe. In my opinion, he lacks capacity to make medical decisions. R140 was admitted to inpatient medical-surgical with a [DIAGNOSES REDACTED]. Case management had documentation in the medical record of R140 throughout his admission at the hospital until appropriate placement was found for him. On 09/11/2017 it was documented, patient discharged from Legacy and sent to Kona in a taxi to Manago Hotel. Per Manago there was no reservation for patient. Patient was confused upon arrival and sent to hospital. Patient shares he was living at Regency for a long time. He verbalizes he does not know why he had to leave, patient shared, I don't know why they sent me to Manago Hotel, why didn ' t they send me home? The hospital made requests to the facility on ,[DATE] for R140's medical records with follow up phone calls daily. Documentation on 09/13/2017, DON spoke again to Legacy owner who consulted with his lawyer re: case. Per lawyer recommendation, if currently treating MD feels patient does not have capacity and a note documenting as such is provided to Legacy then to benefit the patient discharge planning, records will then be able to be shared. Owner requests once documentation completed to please forward to his email for review and he will forward it to his facility with instructions to forward records as requested. Spoke to hospitalist who agrees presently patient does not have capacity and records will be most beneficial for pt care. On 09/14/2017 fax was received from facility to hospital that included admission record, discharge summary and admission History and Physical for R140's stay at the facility. On 09/15/2017 it was documented in the case management notes that the owner of the facility had been informed of what had been received so far at the hospital and notified him that the case manager (CM) had called medical records requesting additional information. Further documentation stated, No faxes or return calls from Legacy Medical records department so far today, called again this afternoon, no answer, left a VM at 13:30 requesting again the psych evaluation conducted by psychiatrist, SW notes, CM notes and nurses notes for the last week leading up to pt discharge. On 09/18/2017, CM had documented, called direct line for Legacy, rang unanswered, unable to leave VM, rang approximately a dozen times and went straight to off hook signal. Attempted again with same result . On 09/19/2017 CM had documented, call to Legacy to follow up. No answer, was able to leave a VM requesting return call. Called Legacy direct line, transferred to SW, confirmed her direct line. Per SW patient left facility AMA, however records received so far include a discharge summary. Inquired SW re:d/c summary which instructs patient to follow up with PCP in a week, asked if she knew who patient PCP was, as it was not listed in d/c information and if a post d/c appointment had been made for him prior to leaving. Per SW patient PCP is a Nurse Practitioner (NP). CM asked if pt PCP was located in Kona or Hilo, she shared PCP in Hilo. Inquired again, if pt was discharged knowingly to Kona, is it regular practice to not assist patient with establishing primary care in the area patient is discharging to? SW then directed CM to follow up with facility DON, as she was present during pt discharge, direct contact number obtained. The Legacy DON was called and a VM requesting a return call. CM called Legacy medical records to state they were still awaiting requested records and requested again psych evaluation completed by psychiatrist noting R140 to have capacity. CM also requested a return phone call if the requested records could not be found. CM asked medical record staff at Legacy if a patient leaves AMA at their facility as SW believes patient was, if there was an AMA form signed by patient. If so they would like a copy of the AMA form. The requested documentation was received on 09/19/2017. Also documented on 09/19/2017 by the CM was that R140 arrived at the hospital with no ID, insurance cards, bank cards, cash and no medications. On 09/21/2017, CM documented in the R140's medical record, received copy of patient current ICF L[NAME] 1147. 1147 indicates patient has noted impairment of vision and hearing, has a problem with both short term and long term memory, needs supervision and/or assistance with feeding, has difficulty communicating his needs or wants, is disoriented and/or disruptive, aggressive and/or abusive, requires minimal/standby assist with transferring, able to walk with minimal assistance, ambulates with a device but unsteady and subject to falls, patient is continent of bowel with cues, incontinent of urine at least once a day, unable to bathe without total assistance and patient requires physical assistance for dressing and personal grooming on a regular basis. On 09/22/2017, CM documented in R140's medical record, discussion with Corporate and strong feelings from Medial staff confirming that patient discharge from Legacy was unsafe and put a vulnerable, demented elder at risk, it is recommended that an APS report be filed. On 09/29/2017, CM documented in R140's medical record that patient was under the protection of APS and they will be managing his finances and assist with safe discharge. an order for [REDACTED]. R140 was discharged from the hospital to another Long Term Care facility on the Big Island. The discharge summary from the hospital dated 02/28/2018 had documented , 76 yo M h/o HTN, DM, who was brought to the ER due to confusion. Please see H&P for details of his presentation, but in short, he had been deemed competent and discharged from Legacy SNF, send to Manago hotel by Lyft. As they did not have vacancy, and as the patient has dementia he was sent to the ER. During his prolonged hospital stay, there have been no acute medical issues besides situational [MEDICAL CONDITION]. He does not have capacity to make medical decisions for himself and has little to no insight into his circumstances. He is overall surly and stubborn, not agreeing to physical examination, and only answering few and simple questions. On 05/10/2018 the Manago Hotel manager was interviewed via a telephone interview. The Manager stated staff #11 called on the same day R140 arrived to make a reservation for one night. They did request on a room on the second floor. The manager stated a credit card number was given for the reservation along with an email address. The email address was rejected and they could not verify the reservation at the hotel. The manager stated when R140 arrived at the hotel at approximately 07:30 PM that evening, he stated there was major problems with his leg, it appeared black and looked like his foot was dead and he had no ID on him. There was a wheelchair and several boxes of belongings that had accompanied R140 to the hotel. The hotel manager stated R140 was confused and did not know what was going on and he was unable to do anything for himself. The hotel manager went onto to say that the facility had not communicated the needs of R140 to them. The hotel manager stated they attempted to call facility with no success. The hotel manager and the LYFT driver assisted R140 into the wheelchair. The hotel gave R140 a sandwich to eat and the LYFT driver called EMS for R140 as the hotel was unable to accommodate his needs. The hotel manager stated, To someone in his condition and just being dumped. On 05/10/2018 the LYFT driver was interview via a telephone interview. The LYFT driver stated late on the afternoon of 09/08/2017 he received a transfer request from Legacy from a woman (whom he could not recall the name of) for a resident to go to Kona. He went onto say when he arrived at the facility and that a staff member met him with the resident in a wheelchair and 2-3 boxes of the resident's personal belongings. The driver stated, the woman running the show had other people to help load him in the car. The LYFT driver stated he asked the facility staff if the resident had been fed and toileted and the staff responded with a yes. He said he asked the staff if there was any paperwork for the hotel, and the staff responded there was not, and that the hotel was expecting him, and everything was taken care of. The LYFT driver went onto say as he was leaving the parking lot of the facility, R140 stated to him if they are not home you will have to take me back and the driver asked what he meant, he replied you taking me to my family. The driver stated he informed R140 he was taking him to the Manago Hotel and resident insisted he was taking him to see his family. The driver stated he went and asked female staff member where he was going, and the staff replied that he was not going to family and that he was just confused. The female staff had one of the other staff go and talk to R140 and the driver once again requested paperwork but there was none. The driver stated they arrived at the hotel 2 1/2 hours later and it was dark and raining. The hotel manager met them and stated he had a reservation but no funds to pay for the hotel. R140 had no credit card, ID or money on him, stated he was unable to care for himself and he appeared to be wheelchair bound. The driver stated he called EMS for R140 and also called Police for elderly abandonment. EMS arrived and took R140 to local hospital. The LYFT driver stated he made several calls to the facility asking for on duty manager, but no one called back. The driver stated, I felt that person was put in car for me to take him 100 miles plus as far away as possible. The driver also stated, The result was a dangerous situation for an elderly person for dumping this elderly person at hotel. He was a nice little guy. On 05/10/2018 the facility physician was interviewed. The physician stated R140 was constantly stating he wanted to leave to go to a place in Kona, but staff were unable to find this place. Staff then informed physician that he wanted to go to Manago Hotel. The physician stated her role in discharging residents was to ensure they were stable, have a PCP in place, home help if needed and to write up discharge summary. The physician stated R140 was a higher risk due to his status and that it was not a well-planned discharge. The physician went onto to state we have to allow people to make bad decisions as part of their rights. The physician stated she was informed R140 called a taxi himself and the DON informed her that he was demanding to leave, and everything was in place. The physician did not remember who the PCP was for R140. The physician was asked if he was demanding to leave why didn't they do an Against Medical Advice (AMA) and she responded, Making AMA causes insurance issues. The physician was asked if she thought it was a safe discharge and she responded by saying she felt she was misled about the circumstances and does not feel she was told the full story and if she knew what she knows now then, she would not regard it as a safe discharge. On 05/10/2018, staff #5 was interviewed. She stated the week before R140 left that he got nasty, calling her names. Staff #5 stated she did not have anything to do with R140's discharge but recalls he refused to sign discharge paperwork and that he was given Crisis Access telephone number and contact for a PCP. Staff #5 stated it was a planned discharge and the facility conducts discharge meetings for residents with upcoming discharges. When staff #5 was asked who was responsible for completing discharge summary, she replied it was the nurse completing the discharge to do so and continued to state she had nothing to do with his discharge. Staff #5 was asked why her digital signature was on all of the discharge summary items in the electronic medical record (EMR). She stated whoever opens the note and closes the note, it locks with their name. Staff #5 was asked if it was a planned discharge, why did it occur at 05:30 PM and she responded she got word of the discharge at 05:00 PM, that an aid took R140 to the front door and he got in a taxi. Staff #5 returned a little while after interview to state she had helped the RN with the discharge and believed he had been given medications at discharge. On 05/11/2018 the social worker (SW) was interviewed. The SW stated for those residents planning to return to the community, discharge planning commences on admission for them. The SW stated he remembered R140 coming to the facility around (MONTH) (YEAR) and had expressed desire to be discharged back into the community or an adult foster home. The SW stated that he had been informed that R140 was demanding to be discharged on [DATE] and that the notes had stated R140 had ambulated using a forward wheel walker (FWW) to the front door that day. The SW was asked if he thought it had been a safe discharge for R140 and he responded No. Medical record review or R140's record was conducted on 05/09/2018. The Minimum Data Assessment (MDS) completed on admission, had documented that R140 had a BIMS (Brief Interview for Mental Status) score of 6 out of 15. A score of 0-7 is indicative of a person being severely cognitively impaired. Documentation dated 08/17/2017 in R140's care plan stated that pre-discharge plan to be established with patient and caregivers and to be revised a week before resident is discharged . This never occurred. Staff #5 had documented on the 09/08/2017 in R140's EMR, Resident declined to sign d/c summary & inventory sheet prior to d/c today. Resident continues with inappropriate verbal and attempted inappropriate physical behaviors up until departure today w/o remorse. Resident did however leave this facility ambulatory w/FWW in stable condition. No documentation could be found in the medical record to support that discharge planning had occurred during his stay at the facility.",2020-09-01
991,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2018-05-22,658,D,1,0,HEVY11,"> F658 Based on medical record review and staff interviews that facility failed to ensure professional standards of quality were adhered to in documentation in the medical record and by not providing services outlined in the care plan for R140. Findings include: Cross Referenced with F 624 Medical record review or R140's record was conducted on 05/09/2018. Documentation dated 08/17/2017 in R140's care plan stated that a pre-discharge plan was to be established with patient and caregivers and to be revised a week before resident is discharged . There was no supporting documentation in R140's medical record to reflect this had occurred. Staff #5 had documented on the 09/08/2017 in R140's EMR, Resident declined to sign d/c summary & inventory sheet prior to d/c today. Resident continues with inappropriate verbal and attempted inappropriate physical behaviors up until departure today w/o remorse. Resident did however leave this facility ambulatory w/FWW in stable condition. The information in this documentation conflicts with information from the hotel manager at where R140 arrived later the evening of his discharge from the facility, the LYFT driver who transported the resident to the hotel and information obtained from the medical record at the hospital where the resident was taken later the evening of his discharge from the facility. On 05/10/2017, Staff #5 and the facility physician were both interviewed and made statements that discharge planning occurs at the facility through discharge meetings. Staff #5 stated that discharge planning had been discussed for R140 in morning meetings. No documentation reflected any discharge planning had occurred in the EMR of R140 or in the minutes of the morning meeting. The SW was interviewed on 05/11/2017 who also stated it was practice of the facility to conduct discharge planning for those residents planning to be discharged back into the community.",2020-09-01
992,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2018-05-22,689,G,1,0,HEVY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview with staff members, the facility failed to ensure 2 (Resident 69 & Resident 141) of 3 sampled residents were free from accident hazards. Findings include: 1) On 4/27/2018 an anonymous caller filed a complaint with the State Agency (SA) reporting Resident 69 (R69) had a fall which resulted in a [MEDICAL CONDITION]. At the time of the fall, the facility reportedly did not have a nurse to watch the falls. R69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review done on 5/9/2018 at 12:15 PM noting R69 was heard yelling for help on 4/24/2018 at about 2:25 PM. The resident was found on the bathroom floor. The resident reported she had a fall after using the toilet and requested the paramedics to be called. At 6:15 PM the paramedics picked up R69. R69 was admitted to the acute hospital. Subsequent progress note documents the facility was informed R69 passed on 5/2/2018. Further record review found a quarterly Minimum Data Set (MDS) with an assessment reference date of 2/19/2018 documenting R69 yielded a score of 13 (cognitively intact) when the Brief Interview for Mental Status was conducted. In Section [NAME] Functional Status, R69 requires limited assistance with One-person physical assist for toilet use (how resident uses the toilet, transfers on/off toilet) and was coded to be always continent of bowel and bladder. The resident was also noted to be not steady while moving on and off the toilet, only able to stabilize with staff assistance. A review of Section N. Medications notes R69 received antidepressants and hypnotics during the last 7 (seven) days and opioid in the last six days. In Section O. Special Treatments, Procedures and Programs, R69 was noted to receive [MEDICAL TREATMENT]. On 5/21/2018 at 11:58 AM, R69's medical record was reviewed at the acute hospital with the assistance of the Quality Manager. On the afternoon of 5/21/2018, copies of the ED notes, nursing progress notes and death summary was obtained from the hospital. A CT scan of the pelvis was done on 4/24/2018 at 7:26 PM. The impression included displaced [MEDICAL CONDITION] iliac wing, fractures of the right pubis and superior pubic ramus, and moderate free fluid within the pelvis. An x-ray was done on 4/24/2018 at 7:32 PM. The impression was fractures of the right pubis and right superior pubic ramus. A chest x-ray was done on 4/24/2018 at 7:34 PM. The results found cardiomegaly and mild vascular congestion with suspect of small right pleural effusion. R69 was admitted to the hospital. The progress note of 4/25/2018 at 3:55 AM documents R69's was not well controlled and she was asking for pain medication approximately every hour. Subsequent nursing note of 4/25/2018 at 7:25 PM documents the pain control was the main issue during the shift. R69 received [MEDICAL TREATMENT] on 4/26/2018, 4/27/2018, and 4/28/2018. The nurse's note for 4/29/2018 documents R69 was lethargic with decreased respiratory rate, [MEDICATION NAME] was administered. At 4:30 PM, R69 was agitated and [MEDICATION NAME] was administered for agitation. The documentation of 5/1/2018 at 2:37 PM documents pain control was still an issue and R69 lets pills sit in her mouth or chews them, even when prompted to drink water. At 9:17 PM R69 took medications that were crushed with jello. On 5/2/2018 at 12:28, the nursing assistant notified the nurse it was difficult to get a blood pressure on patient during vital sign check. The nurse arrived to assess R69, R69 took her last breath, unarousable to sternal rub, no heart beat and pulse. At 12:29 AM the physician confirmed R69's death. A review of the Death Summary notes the immediate cause of death, pelvic fracture as a result of dementia with end stage [MEDICAL CONDITION] and [MEDICAL CONDITION] as contributory causes. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]., one tablet three times a day related to diabetes mellitus with foot ulcer (start date of 3/15/2018); [MEDICATION NAME] capsule, 15 mg, by mouth at bedtime related to [MEDICAL CONDITION] (start date 11/13/2017); and [MEDICATION NAME] Tablet 5-325 mg., one tablet by mouth every 8 hours as need for breakthrough pain related to diabetes mellitus with foot ulcer (start date 3/14/2018). On 5/22/2018 at 8:24 AM an interview was conducted with the resident's daughter. The daughter reported her parent missed two [MEDICAL TREATMENT] treatments, went to [MEDICAL TREATMENT] and fell upon return from [MEDICAL TREATMENT]. The resident's daughter further shared that her parent did not know what happened and while hospitalized was not talking as much. The daughter reported her parent had difficulty with transferring as her parent had a stroke and is unable to use one side of her body. Inquired whether the resident had a previous fall, the daughter replied that she was not aware of other falls. A review of the care plan provided by the facility was done on 5/22/2018 at 11:12 AM. The care plan for activities of daily living notes R69 uses the toilet with limited to extensive assist of one staff member and requires extensive assist of one staff member for all transfers. A care plan was developed for falls, noting the resident is at risk for fall related to the following: chronic medical condition; [MEDICAL CONDITION], Stage 5; right side weakness; falls risk score of 17 (high); history of falls; and weakness/deconditioning. Also documented is on 3/22/2018 at midnight here was a change in elevation, unwitnessed. Further review on the afternoon of 5/22/18 found a progress noted dated 3/23/2018 at 6:21 AM which documents R69 was on alert charting for status [REDACTED]. The resident approached the nurse's station requesting a dressing for bleeding to her left upper arm at approximately 0000 (midnight). The resident reported to the staff member that while attempting to transfer from the toilet back the wheelchair, she slipped and landed with her butt on the toilet seat twice. The resident acknowledged she is aware that she needs to call for help and was apologetic for not doing so. Subsequent entry dated 3/23/18 at 9:36 AM documents the resident reported she transferred herself, lost balance and fell . The resident reported that she able to care for herself without staff assistance and did not need to speak to staff concerning the need for transfer assistance. The staff member reminded R69 that safety is the primary concern. The staff member documented to continue with care plan presently in place. Further review could not find documentation of a root cause analysis following the first fall and there was no revision to the care plan. On 5/22/2018 at 11:16 AM, concurrent record review and interview was done with Staff #8. The staff member reported the facility had a falls nurse to review residents falls and identify risks. A request was made to the staff member to find documentation in the record of a progress note regarding possible factors that contributed to the resident's fall and whether the facility revised the resident's care plan to prevent future falls. The staff member confirmed there was no documentation in the electronic record of a root cause analysis related to the fall in (MONTH) (YEAR) or a care plan revision based on an assessment. On 5/22/2018 at 2:05 PM an interview was conducted with the Administrator and Director of Nursing (DON). Information related to the resident's non-compliance with [MEDICAL TREATMENT] before the falls and the resident fell while independently using the toilet despite the identified need for limited to extensive assist for toilet use were shared with the staff members. The DON acknowledged the resident's history contributed to the situation by refusing [MEDICAL TREATMENT] and was terminal with confusion which placed her at risk for falls. The DON also acknowledged that the resident was transferring to the toilet without calling for assistance which also contributed to the risk for falls. The DON stated the resident may have benefited from being monitored more closely. The Administrator reported that a pattern or trend surrounding the falls were indicated and the fall nurse should have assessed the fall and prepared an incident report. 2) On 05/21/2018 the State Agency received an anonymous complaint with concern that Resident 141 (R141) eloped. The complainant reported on 04/22/2018, R141 was found outside of the facility in the parking lot. R141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of the facility found the front entrance to the facility automatically opens and closes when the sensor is triggered. There is a reception counter in the front which is staffed by one person. There are other doors in the facility which chimes when opened and closed. On 05/10/0218 at 1:30 PM R141 was observed out of bed, the resident's room is near the nurse's station (the first room next to the nurse's station). The bed was placed in a low position and a candy cane rail was up. R141 was found in the activities room with other residents. The resident was seated in a wheelchair at the table manipulating small rectangular blocks. On 05/21/ at 10:20 PM, R141 was observed in the large activity room playing BINGO with the assistance of another resident. There was a wheelchair alarm attached to the back of the chair. Subsequent observation at 11:00 AM and 11:25 AM found R141 was participating in BINGO. An observation at 1:30 PM found R141 in the activities putting the blocks back into the box and subsequently at 2:15 PM the resident was observed in the small activity room folding small bath towels. On 05/22/2018 at 2:08 PM and 2:55 PM, R141 was observed in his room, seated in the wheelchair looking at a newspaper. Observation on 05/23/2018 at 11:05 PM, R141 was seated at a table in the courtyard with other residents. He was folding towels while other residents engaged in individual activities. At 12:51 PM the resident was in the dining room, he had finished his lunch On 05/24/2018, R141 was in his room visiting with his son. The resident's son reported it was his father's birthday and later the family will have a celebration lunch with R141. The resident's son comes to visit his father and states his father can walk in his room for short distances independently. At 9:10 AM, R141 was observed to wheel himself out of his room, the staff member at the nurse's station saw the resident emerge from his room and approached the resident. The staff member asked a Certified Nurse Aide (CNA) to take the resident for a walk around the unit. The CNA wheeled R141 around the unit and then took him to the activities room. At 1:01 PM, the resident was observed to be parked in his wheelchair by the nurse's station. On the afternoon of 05/21/2018 a record review was done. R141 was admitted to the facility from home. A review of the resident's admission Minimum Data Set with assessment reference date of 03/23/2018 notes R141 yielded a score of 3 (severe cognitive impairment) when the Brief Interview for Mental Status was administered. In Section E. Behavior, R141 was not coded to have indicators for [MEDICAL CONDITION], behavioral symptoms, rejection of care, and wandering. R141 was noted to require extensive assistance with one-person physical assist for bed mobility and transfer, locomotion on and off unit did not occur and mobility devices included a wheelchair. The resident was not coded to have functional limitation in range of motion of the upper and lower extremities. A review of the progress notes found no documentation of R141's elopement/wandering to the parking lot. There was no care plan to address resident's elopement/wandering. Interviews were conducted with R141's direct care staff members on the afternoon of 05/21/2018. At 2:10 PM, Staff #1 was not aware R141 eloped from the facility. At 2:12 PM, the Activities Director (AD) stated she was not aware of R141 exiting the facility. The AD reported R141 can propel himself in the wheelchair; however, he is always engaged in activities. An interview was done with Staff #2, the staff member reported R141 can stand and ambulate and can propel his wheelchair if he wants to do it. Upon query, the staff member responded that she is not aware of R141 wheeling himself out of the building. At 2:20 PM, Staff #3 was interviewed. The staff member reported R141 can stand but not independently and requires close supervision. The staff member was not aware of an incident of the resident leaving the building. At 2:20 PM, Staff Member #4 stated R141 has never left the building but tries to go down the hall to look outside (the door by the therapy room). An interview was done with Staff #5 at 2:25 PM. The staff member reported having knowledge of R141 being found at the front door and was not sure when this occurred; however, the resident did not exit the facility and was escorted back to his unit. The staff member further reported R141 wants to check on his car in the garage. The staff member shared that most of the time there is a staff member at the reception counter at the front door; however, there may be times when the reception counter is not staffed. The staff member reported the front door is locked at 8:00 PM and opened at 7:00 AM and the staff watch the resident and work together. The staff member stated it was Staff #6 who found R141 at the front door. Staff #6 was observed standing at the reception counter with Staff # 5. The staff member was asked about finding the resident at the front door. The staff member reported she did not remember this incident, Staff #5 insisted Staff #6 found R141 at the door. Again, the staff member could not recall this incident. Subsequently, on 05/22/2018, Staff #5 stated thinking back, it was not Staff #6 that found R141 at the door, it was Staff #7 and this staff member is on leave. Staff #5 reported she learned about the incident during a stand up meeting and reiterated, the resident did not leave the building. The staff member further reported the resident can propel himself for a short distance and has not been identified as a wanderer. On 05/21/2018 at 2:45 PM an interview and concurrent record review was done with Staff #8. The staff member confirmed there was no documentation in the progress notes related to elopement or finding the resident at the front door of the facility. The staff member has no knowledge of the incident; however, stated if the interdisciplinary team members were aware of this incident, an assessment and care plan would be developed. On 05/24/2018 at 8:45 AM an interview was conducted with R141's son. The son reported his father is doing good at the facility, he has not had any falls. Inquired whether the facility notified him of any significant event related to his father. Inquired what notifications has he received from the facility, he replied the facility called him when his father's bed sore healed. The resident's son also showed the surveyor a bandage on his father's knee and explained the facility's process for labeling the sore. The resident's son was asked whether his father wanders, the son reported his father likes to stand up and wants to go and check on his car. A review of the standup minutes found no documentation of R141 eloping or managing to independently propel himself to the front entrance of the facility. Interview was done with Staff #7 on 05/25/2018 at 8:50 AM. This is the staff member that was identified by Staff #5 to have witnessed R141 at the front entrance of the facility. Staff #7 responded that she did not find R141 at the front entrance of the facility, she further reported that she has not observed R141 off the facility units. The staff member is able to identify R141.",2020-09-01
993,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2018-05-22,919,E,1,0,HEVY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, the facility failed to ensure an operating call system was available to all beds that were able to accommodate residents for 7 out 100 beds. Findings include: On 04/30/2018 an anonymous complaint was made to the State Agency that call lights at the resident's bedsides were not in working order. On 05/21/2018, this surveyor conducted a test of call bells in the facility. Seven out of the one hundred were found to be not fully operational. There were located in room [ROOM NUMBER] by bed closest to the window, room [ROOM NUMBER] by the bed closest to the door, room [ROOM NUMBER] by the bed closest to the window, room [ROOM NUMBER] by the only bed in room, room [ROOM NUMBER] by the bed closest to the window, room [ROOM NUMBER] by the bed closest to the window and in room [ROOM NUMBER] by the only bed in the room.",2020-09-01
994,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-05-31,600,J,1,0,96M311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews and observation the facility failed to ensure R8 was being protected from further verbal abuse from R11 after an incident on (MONTH) 13, 2019 where R11 was verbally abusive and aggressive towards R8 endangering R8 of psychosocial harm. Findings include: Complaint On 05/16/19 an anonymous complaint was filed with the State Survey Agency (SSA) reporting that R8 had been verbally abused and threatened by R11 and the facility had failed to put in place interventions to protect R8 from further verbal abuse and threats from R11. Event Report 1) On 05/15/19 at 06:19 PM, the facility transmitted an Event Report (ER) to the State Survey Agency (SSA) regarding an allegation of resident to resident abuse. The allegation involved Resident R11, the alleged perpetrator and R8, alleged victim. On 05/13/19 at approximately 06:20 PM, R8 stated that he wanted to go home. At this time R11 (who was seated approximately 7 feet away from R8) stated Go on and cry, you [***] ing Crybaby, that's why your mom doesn't want you. Registered Nurse (RN)1 intervened with a verbal warning to R11. R11 responded in a raised voice, I don't give a [***] about him he's a [***] ing Jap piece of[***] RN1 wheeled R11 away from the nurses' station, as well as, the other residents who were present. On the way to her room, R11 continued screaming, I don't give a [***] , you [***] ing jap piece of[***] I'll kill you. R11 began raising her voice to the RN, stating, [***] you you cunt, don't tell me what to do. R11 was taken to her room and continued to yell profanities at RN1. 2) On 05/17/2019 at 07:20 PM the facility transmitted a completed report on the incident of verbal abuse (resident to resident) that occurred on 05/13/19. The report stated that the ombudsman had been contacted and informed the facility to assess the two residents in regard to their ongoing relationship: if R8 wanted R11 relocated to the other side of the building; if R8 felt verbally abused; and whether they felt the need to contact Adult Protective Services (APS) to make a formal report. The facility asked both R8 and R11 if they wanted to make a report to APS and both residents verbalized they did not. The completed report went on to to say that R11's care plan had been updated to reflect that she may use vulgar language when speaking to each other, use of racial slurs & demeaning phrases at times: staff to approach (R11) in a calm manner & re-approach at a later time if agitated or uncooperative; do not take what (R11) may say out of anger or irritation personal as this is a way that she lets her feelings out. R8's care plan was updated to reflect that he & his female friend speaks w/ vulgar language, racial slurs, & demeaning phrases - they have been speaking that way to each for the past 3 - 4 years: separate the two pals if it seems to get out of hand: at times he may get upset & feel lonely & state that he wants to go home: he likes to talk story w/ the staff using profanity & staff may use profanity back at him. Investigation 3) On (MONTH) 28, 2019 a review of R8 and R11's medical records was conducted. R11's medical record listed admission [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. 4) Some of the admission [DIAGNOSES REDACTED].; Presence of Cerebrospinal Fluid Drainage Device; Hypertension; Dementia without Behavioral Disturbance; and Presence of Prosthetic Heart Valve. 5) Further review of R8's medical record on 05/28/2019 had documented in the Kardex under Behavior/Mood Allow my female friend to speak to me with vulgar language, racial slurs and demeaning phrases. This is the way we speak to each other for the past 3-4 years. I don't get offended by what she says. If it seems that its getting out of hand, please separate us. 6) Further review of R11's medical record on 05/28/19 had documented in the Kardex under Behavior/Mood Allow my male friend and I to speak to each other with vulgar language, racial slurs and demeaning phrases. This is the way we speak to each other for the past 3-4 years. I don't get offended by what he says. If it seems that its getting out of hand, please separate us. 7) A phone interview was conducted with R8's attending physician on 05/30/19 at 10:50 AM. This physician has been R8's attending physician since the resident's admission in (MONTH) (YEAR). The physician stated R8 has poor ability to comprehend and understand what is being said to him, R8 is able to understand simple commands, answer simple questions with simple replies and that R8 functions at the level of a 5-6 year old. 8) After the incident on 05/13/19 at approximately 06:20 PM, the facility had determined that corrective action would be to move R11 to another room, away from the alleged victim. The move did not occur and reasons varied from one of the residents was asleep, and there were not enough staff available to move R11. It was also reported that R11 and R8 were in agreement not to make a room change. 9) Lunch time dining observation was made by two surveyors on 05/28/19 who observed R8 and R11 seated at the same table. Interviews with Certified Nursing Assistant (CNA) and Registered Nurse (RN)1 on 05/28/19 validated that R8 and R11 have continued to be seated at the same table for all meals since the incident on the evening of 05/13/19. On the afternoon of 05/28/19, R8 and R11 were observed by two surveyors sitting side by side outside of the nurses station. No one was present to supervise their interactions. 10) Interviews conducted on 05/28/19 with CNA and RN, and then on 05/29/19 with the Minimum Data Set Coordinator (MDSC), RN2, SSA, DON, and Administrator all confirmed the incident that occurred on the evening of 05/13/19 was an occurrence of resident to resident verbal abuse. The facility did not provide any documentation or evidence that corrective action was taken to separate the alleged perpetrator away from the alleged victim. During an interview with CNA on 05/28/19, she stated that R8 had once told her that R11 is mean, she is just mean, and I friend, so just taking it. Interviews with both the CNA and RN1 on 05/28/2019 stated that they had never heard R8 swear, use racial slurs or berate anyone. RN1 stated R8 has the mentality of a ten year old boy and someone needs to advocate for him. RN1 went onto to say the nurse who witnessed and diffused the incident was trying her best to advocate for the residents and ensure the residents were safe and the correct reporting procedures were being followed. 11) On the morning of 05/28/19, R11 was interviewed and she admitted to the use of bad words towards R8 and is aware this is not okay. R11 was more concerned that she was not being allowed visitation with her boyfriend that she wants to marry. R8 was interviewed on 05/28/2019 and stated he feels sad when R11 uses bad words towards him. When R8 was asked what abuse was he replied I don't know. R8 was interviewed again on both 05/29/19 and 05/30/19 and asked what abuse was, both times R8's response was I don't know. 12) On 05/29/19 a phone interview with the legal guardian/mother of R8 was conducted. She stated she had been notified of the incident on the evening of 05/13/19. She expressed her concern that R8 continues to sit at the same table for meals with R11 and is often left sitting beside R11. She states she has witnessed while visiting R8, R11 being bossy and swearing towards R8 and also behaving in this manner to other residents and staff. She also expressed her distress that the facility continues to allow this to occur as her family does not and has never used swear words in their home. 13) Observations were done by two surveyors of R8 interacting in activities on 05/29/19, 05/30/19, and 05/31/19. During these observations it was observed that R8 would repeat anything that was being said twice. This occurred during each observation. During observation and conversation with R8 during these times, R8 would repeatedly state I wanna go home. At no time did the two surveyors during observation, interview or conversation with R8 hear R8 use any profanity. 14) During interviews with all the staff noted in point (10), they were able to articulate what abuse is, the different types of abuse and the need to separate the perpetrator from the victim to avoid further incidents of abuse occurring to prevent any harm occurring. Interviews conducted on 05/29/19 with MDSC, Administrator, and MD who all acknowledged that the incident that occurred on the evening of 05/13/19 was verbal abuse, stated that updates to the Kardex reflected the resident's choices and preferences and further corrective action was not required as that is the way they always talk to each other, and talking that way was a local culture thing. The failure to take corrective action to protect R8 from further verbal abuse from R11 may result in serious psychosocial harm to R8. All residents in the facility are at risk of psychosocial harm from the behaviors and language used by R11. In addition, R11's behavior puts her at risk as another resident may take offense which may result in an altercation/abuse (physical/verbal).",2020-09-01
995,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-05-31,607,F,1,0,96M311,"> Based on review of the facility's policy and procedures, record review, and interview with staff members, the facility failed to implement written policies related to abuse prevention, investigation of abuse/neglect allegation, protecting residents during the investigation and ensuring the protection of other residents in the facility. Therefore, demonstrating a failure in the facility's system to implement their policies and procedures. Although verbal abuse was confirmed, the facility included in both the residents' corrective action to allow them to continue to verbally abuse one another by allowing them to use vulgar language, racial slurs, and demeaning phrases. Finding include: 1) Cross Reference to F740 and F610. On 05/13/19 at approximately 06:20 PM, Resident (R)11 became verbally abusive to R8. A review of R11's record found the use of antianxiety and antidepressant medications. A review of the care plan found the following interventions: identify and remove triggers for anxiety and depression from the environment and to remove R11 when she begins to use profanity; however, the facility did not identify the resident's triggers for anxiety or depression that may have prevented the situation from escalating. Also, the facility did not identify how R11 behaviorally expresses her anxiety/depression. The facility also determined immediate corrective action was to move R11 to another room, away from the alleged victim. This was not done, the reported reasons varied from one of the residents was asleep and there were not enough staff available to move R11. Also, it was reported the residents were in agreement to not make a room change. On 05/29/19, the facility provided a copy of the policy and procedure entitled Abuse Prevention Program with an effective date of 06/12/18. A review of the policy and procedure found under the investigation section, After the investigative phase is complete, action to correct the reasonable cause and prevent further reoccurrence is required. 2) Cross Reference to F610. A review of the facility's policy and procedures provided by the facility on 05/29/19 does not identify a staff member that is responsible for abuse/neglect investigation. Further review of the policy, notes data collection is done which would include: answering the questions of who, what, when, where and how; interviewing the resident involved; interviewing witnesses; and upon completion of the investigation, taking corrective action to correct the reasonable cause and prevent further reoccurrence. The facility did not provide documentation of the interviews that were conducted and failed to implement the corrective action of moving R11's room away from R8. The facility also documented in the Kardex to allow R11 and R8 to be verbally abusive to one another. 3) Cross Reference to F610. The facility did not ensure protection of R8, alleged victim during the investigation. The progress note of 05/14/19 at 12:55 AM documents room change for R11 in the morning. Although the decision was to relocate R11's room away from R8, this was not done. Also, the progress note dated 05/14/19 documents R11 and R8 were interviewed by the Social Services Assistant (SSA) and Administrator together. It is documented the residents held hands, forgave one another, and stated they are good friends. The residents also did not want a report to be made to Adult Protective Services. On 05/29/19 at 11:15 AM an interview was conducted with the SS[NAME] The SSA reported, she and the Administrator interviewed R8 on the morning of 05/14/19 to inquire whether R8 felt safe. R8 confirmed that he felt safe and was later asked if he wanted R11 to join the meeting. R8 was agreeable. R11 was also agreeable to meet. The two residents were then interviewed together. The SSA reported at this time R8 (alleged victim) apologized to R11 (alleged perpetrator) and informed her that he doesn't like when she says things like that. The Administrator also reportedly asked the residents if they felt it was verbal abuse and at this time they apologized to one another. The facility's policy and procedure notes under the section entitled, Protection, to prevent the resident from sustaining further harm means keeping the resident safe. Also included, assuring the alleged perpetrator is kept away from the resident and other residents.",2020-09-01
996,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-05-31,608,F,1,0,96M311,"> Based on a review of the facility's policy and procedures and interview with staff members, the facility failed to ensure their policy and procedure included the procedures of reporting a suspected crime with the mandated timeframe (the facility will report immediately, but not later than 2 hours after forming the suspicion, if the event caused serious bodily injury or not later than 24 hours if the events that caused the suspicion do not result in serious bodily injury). Findings include: On 05/29/19, the facility provided the policy and procedure entitled Abuse Prevention Program. The effective date of the policy and procedure was 06/12/18. A review of the policy and procedure found no documentation for reporting of crimes against a resident which includes the mandated timeframe. On 05/30/19 at 08:30 AM, the facility provided further documents related to abuse/neglect policy and procedures. There was no authentication of review and acceptance of these documents as the facility's policy and procedures. The Administrator confirmed these documents were not a part of the facility's policy and procedures during the time of the alleged abuse allegation and investigation. On 05/31/19 at 11:15 AM, an interview was conducted with the Administrator. The Administrator was asked whether the current policy and procedure included the reporting of a suspected crime with the mandated timeframe. The Administrator responded she was not sure whether the additional documents provided on 05/30/19 included this information.",2020-09-01
997,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-05-31,610,F,1,0,96M311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview with staff members, the facility failed to ensure all alleged violations are thoroughly investigated (including interviews with the alleged perpetrator, alleged victim, and witnesses) and as a result of the investigative findings, take appropriate corrective action to ensure the safety of the alleged victim, as well as, the other residents of the facility and prevent reoccurrence. Findings include: 1) On 05/15/19 at 06:19 PM, the facility transmitted an Event Report (ER) to the State Survey Agency (SSA) regarding an allegation of resident to resident abuse. The allegation involved Resident (R)11, the alleged perpetrator and R8, alleged victim. On 05/13/19 at approximately 06:20 PM, R8 stated that he wanted to go home. At this time R11 (who was seated approximately 7 feet away from R8) stated Go on and cry, you [***] ing Crybaby, that's why your mom doesn't want you. Registered Nurse (RN)1 intervened with a verbal warning to R11. R11 responded in a raised voice, I don't give a [***] about him he's a [***] ing Jap piece of[***] RN1 wheeled R11 away from the nurses' station as well as the other residents who were present. On the way to her room, R11 continued screaming, I don't give a [***] , you [***] ing jap piece of[***] I'll kill you. R11 began raising her voice to the RN, stating, [***] you you cunt, don't tell me what to do. R11 was taken to her room and continued to yell profanities at RN1. On 05/29/19 at 11:00 AM, the survey team requested documentation of the facility's investigation. The facility provided handwritten statements from the two Certified Nurse Aides (CNA) that were assigned to the unit on the day of the event. The review found no documentation of interviews with possible witnesses, staff members, residents, and visitors that may have been present. Also, there is no documentation of an interview conducted with the residents to ascertain what had happened on 05/13/19. The facility interviewed both residents together. A progress note for 05/14/19 at 03:18 PM documents the Social Services Assistant (SSA) and Administrator met with the residents together. R11 reported feeling safe with the other resident and both residents agreed that they are good friends and love each other. The residents held hands and forgave each other. On 05/29/19 at 03:25 PM an interview was conducted with the Administrator. Inquired who is responsible for investigating allegations of abuse/neglect. The Administrator reported, she is the lead and the interdisciplinary team (IDT) participates in the investigation. Inquired whether the written statements from the CNAs without interviews were sufficient and whether the IDT interviewed other possible witnesses (other residents, staff members). The Administrator responded, the IDT could've asked more questions and was not sure whether there were other residents present at the time of the event. Further queried whether the IDT determined abuse had occurred, the Administrator confirmed verbal abuse had occurred and that's why a report was made to the SS[NAME] The Administrator stated that she is responsible and documents the findings of the interdisciplinary team's investigation. 2) On the morning of 05/28/19 a record review found a care plan for R11 which was not revised to address the resident's behaviors exhibited on 05/13/19 or for prevention of further verbal abuse. A review of R11's Kardex found the following under Behavior/Mood: Allow my male friend and I to speak to each other with vulgar language, racial slurs and demeaning phrases. This is the way we speak to each other for the past 3-4 years. I don't get offended by what he says. If it seems that its getting out of hand, please separate us. On the morning of 05/30/19 an interview was done with the Minimum Data Set Coordinator (MDSC). Inquired how are care plans and the Kardex updated. The MDSC responded, the IDT will provide input. The MDSC also reported this is how the residents speak to one another and maybe the wording needs to be adjusted and remove the word allow residents to speak to one another with vulgar language, racial slurs and demeaning phrases. On 05/29/19 at 02:08 PM an interview was conducted with the Director of Nursing (DON). The DON confirmed verbal abuse occurred. Further queried regarding what corrective actions were taken by the facility. The DON responded the plan was to move R11's room away from R8; however, this did not occur as the residents did not want a room change. The facility also provided an inservice to staff members. On 05/29/19 at 03:25 PM an interview was conducted with the Administrator. The Administrator confirmed she was contacted on the day of the event and the decision was to move R11 to another room, away from R8. The Administrator recalled one of the residents were asleep (not sure which one) so the room change was not done and later in the interview, the Administrator stated she was informed by RN1 there was not enough staff to make the move the room change. However, the resident was not moved the following day and a move did not occur . In regard to revision of R11's care plan and the directive in the Kardex, the Administrator responded there are some residents that speak with profanity and both residents were crying during the interview. Further queried how does this behavior affect the other residents in the facility, the Administrator reported R11 requires reeducation and staff members can remove R11 but removing R11 can be isolation (mental abuse). On 05/29/19 at 05:29 PM an interview was conducted with the Medical Director (MD). The MD confirmed he reviewed the investigative documentation. The MD reported the residents' care plans were updated to reflect the residents relationship and reflects the residents' personal preferences. The MD further reported abuse is not evident and the alternative of separating these residents would severe their relationship. The MD further explained if R8 did not capacity, this event would be abuse; however, R8 has capacity and it is his right to use the language they have been using.",2020-09-01
998,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-05-31,740,D,1,0,96M311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and interview with staff members, the facility failed to ensure a resident diagnosed with [REDACTED]. The facility failed to identify a resident's triggers for anxiety and depression to prevent escalation of behaviors and failed to implement the resident's care plan which may have prevented verbal abuse from occurring. Findings include: Resident (R)11 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Observation on 05/28/19 at 10:56 AM found R11 participating in group activity, BINGO. R11 was seated at the front table with activity staff. R11 was later observed at lunch, she was seated at the dining table with R8. On 05/30/19 at 10:00 AM, R11 was not seated next to R8 while she participated in Pokeno. At 01:00 PM, R11 was observed in the small activity room participating in the celebration of residents' birthdays. R11 was not seated next to R8. At 02:45 to 02:55 PM, R11 was observed in the small activity room participating in BINGO. R8 was observed to be echolalic, repeating the numbers being called by the activity staff. He would repeat the called out BINGO number twice. R8 was also observed to giggle when R11 would make comments. During these observations, R11 was not observed to use profanity, make racial slurs or demeaning remarks. A record review done on 05/28/19 at 10:15 AM found R11 has physician orders [REDACTED]. The orders also include to monitor for anxiety (verbalizations of anxiety and see behavior note) and monitor for signs of depression (tearfulness/crying; flat affect; and see behavior note). A review of the Medication Administration Record [REDACTED]. The dates included: 04/05/19 at 07:50 PM; 04/06/19 at 07:50 PM; 04/08/19 at 08:59 PM; 04/0919 at 09:31 PM; 04/13/19 at 08:00 PM; 04/14/19 at 08:00 PM; 04/15/19 at 07:40 PM; 04/16/19 at 08:00 PM; 04/19/19 at 09:12 PM; 04/20/19 at 11:30 PM; 04/21/19 at 08:14 PM; 04/22/19 at 07:21 PM; 04/23/19 at 07:22 PM; 04/25/19 at 07:30 PM; 04/26/19 at 07:56 PM; 04/27/19 at 07:57 PM; and 04/28/19 at 07:56 PM. A review of the corresponding monitoring of anxiety found no documentation R11 verbalized feelings of anxiety. A review of the progress notes found no documentation of a behavior note. A review of the MAR from 05/01/19 through 05/29/19 found R11 was administered the prn of [MEDICATION NAME] 25 of the 29 days. A review of the corresponding monitoring for anxiety found no documentation in the MAR indicated [REDACTED]. Further review done on the morning of 05/30/19 found a consult by the adult mental health clinic dated 12/10/18 noting R11 was seen in the clinic for [MEDICAL CONDITION] medication check. At this time the facility's physician was tapering the use of [MEDICATION NAME]; however, R11 reported that she is more anxious at night and would like to take the whole tablet at bedtime rather than half a tablet twice a day. The recommendation was to change [MEDICATION NAME] to 0.5 mg. prn at QHS and to continue duloxetine (60 mg daily) and [MEDICATION NAME] ER (37.5 mg daily). A record review done on the afternoon of 05/28/19 found a quarterly Minimum Data Set (MDS) with an assessment reference date of 05/01/19 documenting R11 achieved a score of 10 (moderate cognitive impairment) when the Brief Interview for Mental Status was administered. The result of the Resident Mood Interview was unremarkable and there were no indicators for [MEDICAL CONDITION]. R11 exhibited verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) on one to three days during the assessment period. There was no rejection of care or wandering. R11 requires extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. R11 has a care plan which focuses on her [DIAGNOSES REDACTED]. Also, R11 has episodes of using profanity towards staff and other residents (11/25/17). Interventions include usage of prn of [MEDICATION NAME]; identify and remove triggers for my anxiety and depression from my environment; when profanity is used the resident is to be removed from the situation and spoken to calmly in a quiet area; and respond to concerns related to mood and anxiety levels, encouraging the resident to talk about concerns, practice deep breathing techniques, and allow me an opportunity to regain control over myself to encourage healthy coping habits before offering a prn. Another focus area is the use of antianxiety and antidepressant medication for the treatment of [REDACTED]. The interventions include monitoring for side effects of medication, review psych medication per facility protocol, review target moods/behaviors, and medication effectiveness per facility protocol. The resident's Kardex notes under Mood/Behavior, Allow my male friend and I to speak to each other with vulgar language, racial slurs and demeaning phrases. This is the way we speak to each other for the past 3-4 years. I don't get offended by what he says. If it seems that its getting out of hand, please separate us. There was no documentation of a care plan revision to address possible triggers which would lead to a reoccurrence of verbal abuse. Further review found documentation of an incident between R11 and a discharged female resident on 11/26/17. R11 was on alert charting related to presentation of a nose bleed. The progress note for 11/26/17 at 11:11 PM notes an altercation between the two female residents. R11 was slapped on her left cheek by the female resident following verbal altercation. An interview was conducted with the Minimum Data Set Coordinator (MDSC) on the morning of 05/29/19. The MDSC reported R11 will call R8 names and swear; however, this behavior goes both ways. The MDSC stated sometimes R8 will start it with R11. R8 will often yell for people to shut up, will swear ([***] you) and repetitively state that he wants to go home. On 05/29/19 at 11:15 AM an interview was conducted with the Social Services Assistant (SSA). The SSA was asked what are the triggers for R11. The SSA responded that she did not know and deferred to the MDSC. On 05/29/19 at 03:25 PM an interview and concurrent review of R11's care plan was done with the Administrator. The Administrator reported R11's care plan was not implemented at the time of the event, as the staff member did not remove R11 as she began to swear. The Administrator also confirmed the facility did not identify R11's triggers for anxiety and depression.",2020-09-01
999,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2019-05-31,835,F,1,0,96M311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview with staff members and review of the facility's policy and procedures, the facility failed to administer in a manner to effectively and efficiently utilize its resources to attain or maintain the highest physical, mental, and psychosocial well-being of each resident. The administration failed to implement their policy and procedures for abuse and neglect. The facility did not ensure the safety/well-being of the alleged victim during the investigation (resident room change was not done, residents were interviewed together during the investigation process), did not have documentation that a thorough investigation was completed (interviews were not conducted with the residents involved, witnesses and potential witnesses), and did not develop an appropriate corrective action in response to their findings (the plan was to allow residents to continue being verbally abusive to one another). Therefore, demonstrating a system failure. Findings include: Cross Reference to F600, F607, F608 and F610. On 05/31/19 at 11:15 AM an interview was conducted with the Administrator. The Administrator reported investigations are conducted by the interdisciplinary team. The Administrator was asked who is responsible for ensuring a thorough investigation was completed. The Administrator confirmed she is responsible for the investigations. Further queried whether the facility's policy and procedure includes the reporting of a crime with the mandated time frames. The Administrator replied she was not sure if this was included in the documents provided on 05/30/19 at 08:30 AM which she obtained online. The documents provided were entitled: Abuse and Neglect-Clinical Protocol and Abuse Investigation and Reporting. These documents were revised (MONTH) (YEAR). On 05/29/19 at 03:25 PM another interview was conducted with the Administrator. The Administrator confirmed a thorough investigation regarding the alleged abuse was not done, the interdisciplinary team could've asked more questions and followed up with interviews with possible witnesses of the event. The Administrator also confirmed the decision was made to move R11's room away from R8; however, the Administrator confirmed this was not done, either due to one of the residents falling asleep or there was not enough staff to make the move. The progress note of 05/14/19 at 12:13 PM by the Administrator notes on 05/14/19 both residents verbalized not wanting to make a formal report to adult protective services, did not want room changes to occur and R8 stated he did not feel abused. The progress note by the Social Services Assistant (SSA) documents she and the Administrator interviewed the residents together. The facility's corrective action as evidenced by the documentation in both residents' Kardex and care plan did not ensure an appropriate corrective action was implemented. On 05/29/19 at 03:25 PM, the interview with the Administrator found confirmation abuse occurred. The Administrator reported verbal abuse occurred; therefore, a report was made to the State Survey Agency. Although the verbal abuse consisted of R11 swearing and name calling ([***] ing crybaby), racial slurs (Jap piece of[***], and demeaning remarks (Go on and cry, you [***] ing crybaby, that's why your mom doesn't want you), the correction was to allow these residents to speak to one another with vulgar language, racial slurs and demeaning phrases as this is the way we speak to one another. And if it gets out of hand, please separate us. Based on record review, interview with staff members and review of the facility's policy and procedures, the facility failed to administer in a manner to effectively and efficiently utilize its resources to attain or maintain the highest physical, mental, and psychosocial well-being of each resident. The administration failed to implement their policy and procedures for abuse and neglect. The facility did not ensure the safety/well-being of the alleged victim during the investigation, did not have documentation that a thorough investigation was completed, and did not develop an appropriate corrective action in response to their findings. Therefore, demonstrating a system failure. Findings include: Cross Reference to F607 and F610. On 05/31/19 at 11:15 AM an interview was conducted with the Administrator. The Administrator reported the investigation is conducted by the interdisciplinary team. The Administrator was asked who is responsible for abuse/neglect investigations, the Administrator confirmed she is responsible for the investigations.",2020-09-01
1000,LEGACY HILO REHABILITATION & NURSING CENTER,125065,563 KAUMANA DRIVE,HILO,HI,96720,2018-07-11,552,D,1,0,89PG11,"> Based on staff interview and record review, the facility failed to provide, to Resident 1 (R1) and/or the representative, a right to participate in the decision to receive further emergency medical treatment following an episode of lethargy which prompted a call to 911. As a result of this deficient practice, R1 was not taken to an emergency room , and was signed out against medical advice (AMA). Findings Include: Cross Reference F 580 - Notify of Changes. On 07/10/18 at 09:49 AM, an anonymous complaint was called in. The complainant reported that while R1 was on an outing he displayed behaviors which warranted a call to 911 police. On 07/10/18 at 02:36 PM, during an interview with the Director of Nursing (DON), an inquiry was done on the event involving R1. DON reported that R1 was on an activities/fishing trip accompanied by facility personnel. On 07/09/18 at 11:30 AM, DON received a phone call from the Activities Director (AD) saying that the resident was acting lethargic. DON inquired if R1 was awake and talking and if 911/ambulance/Emergency Medical Service (EMS) was called. AD said that R1 was awake with eyes closed, EMS was called and on their way. DON instructed the AD to give R1 a sternal rub in which the DON reported being able to hear R1 respond verbally. After EMS arrival and assessment, DON determined that R1 was at baseline. At this point, EMS asked if R1 should be taken to the emergency room for further medical treatment. DON again determined that R1 was at baseline and did not need further medical treatment. DON instructed AD to sign the AMA form refusing any further treatment. R1 was immediately brought back to the facility. During a review of R1's medical record, R1's sister was listed as the responsible party, substitute decision maker, and emergency contact number one. There was no record that showed any contact was made, with this person, at the time or after the above event. On 07/11/18 at 10:49 AM, another interview was conducted with the DON. Queried whether the EMS report was obtained, the DON replied the report was not obtained. DON also acknowledged that R1 did not have decisional capacity and that R1's sister, who was listed as the responsible party, substitute decision maker, was not contacted to participate in the decision making.",2020-09-01