cms_HI: 58

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.

This data as json, copyable

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