cms_HI: 847

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
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