cms_HI: 37

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
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