cms_HI
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| Link | rowid | facility_name | facility_id | address | city | state | zip ▼ | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 846 | 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 | 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 include… | 2020-09-01 |
| 848 | 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 n… | 2020-09-01 |
| 849 | 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 | 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 | 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 | 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… | 2020-09-01 |
| 853 | 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 | 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 | 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 09:3… | 2020-09-01 |
| 856 | 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 hi… | 2020-09-01 |
| 857 | 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 | 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… | 2020-09-01 |
| 859 | 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 1… | 2020-09-01 |
| 860 | 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; 1/2… | 2020-09-01 |
| 861 | 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 … | 2020-09-01 |
| 862 | 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 docume… | 2020-09-01 |
| 863 | 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 hav… | 2020-09-01 |
| 864 | 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 compete… | 2020-09-01 |
| 865 | 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] Immuni… | 2020-09-01 |
| 866 | 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 licens… | 2020-09-01 |
| 867 | 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 (MON… | 2020-09-01 |
| 868 | 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 | 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 | 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 | 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 | 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 | 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 | 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 | 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 remi… | 2020-09-01 |
| 876 | 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 |
| 1181 | 1181 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2017-04-07 | 172 | F | 0 | 1 | 1ZFD11 | Based on interview and review of admission packets, the facility failed to ensure unlimited visiting hours for residents in the facility. During family interview for Resident #9, they stated that they can only visit up to 8:30 PM and then have to call to visit at other times. Admission information packets were obtained from Staff #1 for both the pediatric and adult residents. Both of these packets had it written visiting hours were 8:00 AM - 8:30 PM. Any other visiting arrangements would require the person/persons to call and make arrangements to visit outside of the stated visiting hours. Therefore the facility failed to provide unlimited visiting hours for the residents. | 2019-11-01 |
| 1182 | 1182 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2017-04-07 | 222 | D | 0 | 1 | 1ZFD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review the facility failed to document ongoing re-evaluation of the need for the restraint-like custom bed use for 1 of 13 residents ( R#2) in the Stage 2 resident sample. Findings include: 1) On 04/05/2017 at 2:59 PM while waiting for staff #21 to gather supplies for [MEDICAL CONDITION] care for resident(R) #2 it was noted that there was a large, wooden bed in the room. Staff #21 stated the bed was custom made for the resident. On 04/06/2017 at 12:49 PM met with staff #'s 1, 2 and 3 to discuss R#2's custom made bed. Upon interview Staff #2 stated that he had investigated getting a new bed for R#2 as the resident had broken the last bed. Staff #2 explained that R#2 was diagnosed at birth with intellectual disabilities (IID) and was too active for the standard hospital-type bed with bed rails available at the facility. Staff #2 stated that he called other hospitals to inquire if there was a bed made to keep an IID resident safe and not too restrictive. The other hospitals did not have any recommendations on beds that the resident could use to maintain safety with minimum restraints. Staff #2 stated that R#2 had very strong upper body strength , was able to roll around and pull himself up on his knees with a full height of 56 inches. Staff #2 stated that he did a web search for beds for adults who fall out of bed. He was able to find a manufacturer who made custom beds based on staff's specification. The facility ordered R#2's customized bed to protect the resident from falling out of bed and ensuring there were no rails or slats to prevent limb entrapment. The customized bed for R#2 had Plexiglas shutters with holes that close and lock into place instead of side rails with slats. Upon record review it was noted that there was a doctor's order to use the custom made bed on the monthly physician order [REDACTED].#2's Interdisciplinary Care Plan revealed that there was no discussion of how R#2's cu… | 2019-11-01 |
| 1183 | 1183 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2017-04-07 | 279 | D | 0 | 1 | 1ZFD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, staff interviews and observations, the facility failed to develop and implement quantifiable objectives for the highest level of functioning the resident may be expected to attain/maintain based on a comprehensive assessment and plan of care for 2 of 13 residents (R#16 & R#2) in the Stage 2 resident sample. Findings include: 1) On 04/05/2017 at 2:59 PM while waiting for staff #21 to gather supplies for [MEDICAL CONDITION] care for resident(R) #2 it was noted that there was a large, wooden bed in the room. Staff #21 stated the bed was custom made for the resident. On 04/06/2017 at 12:49 PM met with staff #'s 1, 2 and 3 to discuss R#2's custom made bed. Upon interview Staff #2 stated that he had investigated getting a new bed for R#2 as the resident had broken the last bed. Staff #2 explained that R#2 was diagnosed at birth with intellectual disabilities (IID) and was too active for the standard hospital-type bed with bed rails available at the facility. Staff #2 stated that he called other hospitals to inquire if there was a bed made to keep an IID resident safe and not too restrictive. The other hospitals did not have any recommendations on beds that the resident could use to maintain safety with minimum restraints. Staff #2 stated that R#2 had very strong upper body strength , was able to roll around and pull himself up on his knees with a full height of 56 inches. Staff #2 stated that he did a web search for beds for adults who fall out of bed. He was able to find a manufacturer who made custom beds based on individual specifications. The facility ordered R#2's customized bed to protect the resident from falling out of bed and ensuring there were no rails or slats to prevent limb entrapment. The customized bed for R#2 had Plexiglas shutters with holes that close and lock into place instead of side rails with slats. Upon record review it was noted that there was a doctor's order to use the custom made bed on … | 2019-11-01 |
| 1184 | 1184 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2017-04-07 | 431 | E | 0 | 1 | 1ZFD11 | Based on observations and staff interviews the facility failed to ensure that procedures for safe handling and secure storage for disposal of expired and/or discontinued medications were in coordination with the Pharmacist Consultant's recommendation. Finding include: On 04/05/2017 at 12:50 PM during interview of Staff#1 observed 8 plastic garbage bags (13-gallon size) full of medications on a utility cart in her office. According to Staff#1, the bags of expired and/or discontinued medications were to be taken to the Drug Enforcement Agency (DEA) in Honolulu for destruction as recommended by their Pharmacist Consultant (PC). The bags of medications were being kept in Staff#1's office until transported to the DEA office for disposal. Staff#1 stated, I have to be honest, I have been busy and this is maybe 5-6 weeks worth of expired/discontinued medications. The bags of medications were being kept in Staff#1's office because the door could be locked, and only Staff #1 and #3 had the office key. Staff #1 assumed responsibility for transporting the bags of medications to Honolulu in her personal vehicle and stated that she never heard of any regulation for medication disposal/destruction through the DEA and following the PC's instruction. Queried Staff#1 on the facility's policy and procedures (P&P), for medication disposal and she provided, Disposal of Discontinued or Expired Medications Procedure. Under the PR[NAME]EDURE paragraph .at a predetermined interval, typically once a month, these medications will be discarded using the following technique; the occlusive trash bag will have a large amount of paper product put into it; all liquid medication will be poured into the trash bag onto the paper product; any ointment or cream medication will be squeezed out of the container and the product will be added to the paper in the trash . Staff#1 stated that only non-narcotic medications were kept in her office and narcotics for disposal were kept in the locked compartment of the med cart until she is ready to transport al… | 2019-11-01 |
| 1185 | 1185 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2017-04-07 | 441 | F | 0 | 1 | 1ZFD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to implement and maintain an infection control program to prevent the spread of infection within the facility. Findings include: 1) On 04/04/2017 at 09:08 am while walking through resident #21's (Res #21) room there was a noticeable smell of urine. Res #21 was sitting up in her wheelchair next to her crib. Surveyor approached Res# 21 and greeted resident. Assessed Res #21 and could not tell if she was incontinent of urine. At 9:20 AM a CNA went into Res #21's room and changed her diaper. Resident's mattress was stripped and wiped down. On 04/05/2017 at 12:51 PM Res #21 was seen sitting up in her wheelchair in the dayroom with peers and staff. Resident did not smell of urine. Went into Res #21's room and there continued to be a noticeable smell of urine in the room. Smell of urine was found to be coming from the resident's crib. Crib appears neat except for the cloth snapped over the crib railing, this appears stained and smelled of urine. On 04/06/2017 at 7:11 AM met with Staff #24 and Staff #25 in Res #21's room and questioned them regarding the smell in the room. At first staff #24 did not recognize the smell and where the smell was coming from but staff #25 pointed to the crib net guard and stated it smelled like urine. Staff #24 stated that she would have maintenance come and take the crib net guard off and have it washed. On 04/06/2017 at 11:05 AM spoke with staff #9 and he stated that there is only one crib net guard and that he had recommended that extra be purchased to keep on hand when it is needed to change out and wash. This has not been done, there is no replacement to put onto the crib, it had to be sent out for special cleaning and that it will take one week to get the item back. On 04/06/2017 at 1:33 PM interviewed staff #1 and #3 about the crib net guard and was told that they are in the process of ordering another crib net guard as it was custom made and they were t… | 2019-11-01 |
| 1186 | 1186 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2017-04-07 | 516 | F | 0 | 1 | 1ZFD11 | Based on observation and interview the facility failed to keep the resident's clinical and personal records in a secure location. During observation of the nursing stations during the survey period of 04/04-07/2017 it was revealed that resident records were easily visible. These records contain both sensitive clinical information, along with resident-identifiable information. The nurse's station located down near the school area, was most of the time observed to have no staff member present in it. The resident records were located in an area, where anyone could pick them up and access any information contained in them without entering the nurse's station. The main nurse's station most of the time had a staff member in it, but there were times when no one was there and anyone could walk in and access information from resident records. On the morning of the 04/07/2017 at both nurses station the Kardex with sensitive resident information was observed to be placed on part of the nurses' station where anyone walking by could easily pick up and read. Interview with Staff #31 validated that the records and Kardex were left unsecured within easy reach of anyone walking past. The facility failed to keep resident records in a secure location protecting the resident's sensitive health information and resident-identifiable information. | 2019-11-01 |
| 1463 | 1463 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2016-02-10 | 241 | D | 0 | 1 | CNKR11 | Based on observation and staff interview, the facility failed to promote care in a manner to maintain or enhance the dignity for 1 (Resident #21) of 15 residents in the Stage 2 sample. Findings include: On 9/8/15 at 2:00 P.M. Resident #21 was observed to return to the facility from school, the resident was seated in a wheelchair and wearing an orange clothing protector which was saturated and glistening with liquid/fluid. The resident was transferred from the wheelchair to a mat on the floor by two staff members. He was prepared by staff members to be placed in the stander. Resident #21 was transferred to the stander by two staff members. While in the stander, a staff member brought paper wipes and placed it on the resident's stander. The staff member applied lotion to the resident's arms and would wipe his mouth intermittently with the paper wipes. Interview and a concurrent observation was done with an activity staff member at 3:00 P.M. The staff member acknowledged the resident's clothing protector was wet and reported the resident's clothing protector is changed often and he was on his way to be changed. | 2019-02-01 |
| 1464 | 1464 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2016-02-10 | 249 | C | 0 | 1 | CNKR11 | Based on a record review and staff interview the facility failed to have an Activity Director in their employment. Findings include: In a record review of LTC Key Personnel & Consultants (Form OHCA-12A) on 2/08/16, the Activities Director was listed as vacant. In an interview with the Interim Administrator on 2/09/16, he stated that we don't currently have an Activities Director but we are actively seeking one. Our previous director left on (MONTH) 28. He stated that they do have an activities person coming in once per week on Fridays until they can find a replacement. In an interview on 2/10/16 with the Quality Assurance Coordinator, she verified that we do not have an Activities director currently but we are looking. She stated that they do have a person who comes in on Fridays to do the paperwork. She further stated that the DON will do any monitoring and follow-up as needed. The nurses play a bigger role in activities. | 2019-02-01 |
| 1465 | 1465 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2016-02-10 | 253 | D | 0 | 1 | CNKR11 | Based on observations and staff interview the facility failed to keep resident care equipment properly cleaned for 1 resident (R# 22) of 15 residents in the Stage II sample, potentially contributing to spread of disease-causing organisms. In an observation on 2/08/16 of residents in the learning center at the facility, (R) #22's wheel chair had positioning devices (pads) that were obviously soiled. When brought to the teachers attention, she stated yes, we should have someone change those. In an observation on 2/10/16 of residents in the teaching area, it was noted that (R) #22's wheel chair had soiled positioning devices. When the activities aid was asked if these are changed, she stated usually someone changes them if they look dirty. | 2019-02-01 |
| 1466 | 1466 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2016-02-10 | 323 | D | 0 | 1 | CNKR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and interview with staff members, the facility failed to ensure 1 (Resident #23) of 15 residents in the active case sample resided in an environment that remains free of accident hazards as possible. Findings include: Resident (R) #23 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 2/09/16 at 8:43 A.M. (R) #23 was observed asleep in the crib. The resident was laying on her right side with her left leg over the right. (R) #23's lower leg (just below the knee) was sticking through the bar of the crib. At 8:45 A.M. a concurrent observation was made with the Director of Nursing (DON). During the observation, (R) #23 was observed to stiffen both legs, pressing her left calf to the bar of the crib. The DON repositioned the resident to her back and the resident turned to lay on her left side. The DON reported that the facility has tried applying a netting around the crib; however, the resident will pull it down. On 2/09/16 at 11:34 A.M. (R) #23 was observed sitting in her wheelchair. There was a dark semi-circle mark to her right shin. Concurrent observation and interview with the Licensed Nurse (LN) was done at 11:34 A.M. The LN reported the resident had a bruise to her shin and thought the resident got the bruise from trying to stand. The LN acknowledged the resident liked to put her legs through the bars of the crib. The LN also reported in the past a netting was tried but discontinued as the resident liked to play peek-a-boo and the concern was the netting would get pulled around the resident's neck. Subsequent observations on the afternoon of 2/09/16 found the resident asleep with her feet sticking out of the bars as she was laying across the width of the crib. On 2/10/16 at 8:16 A.M., (R) #23 was asleep on her back with no extremities sticking through the bars. A record review was done on 2/09/16 at 1:00 P.M. and the morning of 2/10/16. A review of the Interdisci… | 2019-02-01 |
| 1467 | 1467 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2016-02-10 | 441 | F | 0 | 1 | CNKR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with staff members, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment. Findings include: 1) On 2/08/16 at 2:55 P.M. a staff member was observed wearing personal protective equipment (PPE) which included a gown and gloves. The staff member grabbed a bag from a resident's wheelchair and removed the contents. The staff member did not remove the gloves, instead removed another pair of gloves from the box and donned them over the existing pair. The staff member went on to assist in preparing a resident for the standing device. On 2/10/16 at 10:45 A.M. an interview was done with the Director of Nursing (DON). The DON reported staff members are taught to hand sanitize before donning gloves and to change gloves between tasks and between residents. The observation was shared with the DON, the DON acknowledged the staff member needed to remove the gloves, sanitize hands, and don a new pair of gloves. 2) On 2/10/16 at 9:40 A.M. an interview was conducted with the Infection Control Designee (ICD). The facility contracts an infection control specialist. The ICD reported facility staff submit reports regarding infections and the ICD will collect the data and present the information at the Quality Assurance (QA) committee meetings. The ICD reported there was an increase in urinary tract infections (UTI), the organisms identified included ESBL, [DIAGNOSES REDACTED] and one resident with e.coli. The ICD identified the population of the facility are developing neurogenic bladder and are requiring straight catherterization. Inquired what staff member is responsible for analyzing the information and developing a plan of action to prevent further infections. The ICD identified the DON is doing the follow up for the UTIs. Further queried whether the ICD does surveillance for proper hand hygiene and/or the use of aseptic techniques during the straight catherterization … | 2019-02-01 |
| 1798 | 1798 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2015-05-06 | 309 | D | 0 | 1 | 3QRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and record review, the facility did not provide the services to attain or maintain the highest practicable physical, mental, and psychosocial well-being when alternative activities were not provided for 1 resident of the stage 2 sample whom was on activity precautions and isolated in his room. Findings Include: Observations throughout the day on 5/04/2015 of Resident #1 included: At 8:30 A.M. he was in his room lying in a custom made wooden bed with Plexiglas sides and slide locks. At 9:30 A.M. he was in his bed awake, up on his knees, and swinging his arms. At 11:25 A.M. he was in his bed, up on his knees, rocking back and forth. At 12:30 P.M. he was in his bed lying down with his eyes closed. At 3:15 P.M. the resident was out of his bed, dressed, and in his wheel chair located inside of his room In observations on 05/05/2015: At 7:50 A.M. resident #1 was observed in his custom made bed, sleeping with all doors shut and secured with slide locks. At 8:08 A.M. he was observed lying in bed with his eyes open, moving around. At 8:36 A.M. CNA #1 was observed performed morning care for Resident #1. CNA #1 stated, yesterday we got him up late at 3:00 P.M., usually when he goes to school we get him up at 6 A.M Today we are going to get him up now. At 10:02 A.M. Resident #1 was observed in his room watching TV in his wheelchair. At 10:25 A.M. he was observed sitting in his room watching TV in his wheelchair In an Interview with Licensed Nurse #2 on 05/05/2015 at 8:55 A.M. when asked about activities for Resident #1, she stated he has a gait trainer but because he is on precautions and needs to stay in his room he won't use his gait trainer today. She stated that he will have Passive Range of Motion (PROM) twice per day in his room with activities staff. In an Interview with Licensed Nurse #2 on 05/05/2015 10:38 A.M., when asked how long Resident #1 stays in his bed, she stated that he is usually out of bed all … | 2018-02-01 |
| 1799 | 1799 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2015-05-06 | 431 | D | 0 | 1 | 3QRZ11 | Based on observation, staff interview, and package insert review, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, including appropriate accessory and cautionary instructions and the expiration date. Findings include: A tour of the medication storage room was done with the the Charge Nurse (CN) on 5/4/15 at 8:05 A.M. Inside the refrigerator was an opened vial of Tuberculin Purified Protein Derivative (PPD, brand name Tubersol) dated 3/16/15 upon opening. After checking with another staff, the CN stated that the PPD solution is only good for 30 days after opening and should have been discarded. Review of the package insert for the PPD noted a vial of Tubersol, which has been entered and in use for 30 days should be discarded. | 2018-02-01 |
| 1800 | 1800 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2015-05-06 | 441 | E | 0 | 1 | 3QRZ11 | Based on observations, staff interview, and policy review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. Findings include: 1). On 5/5/15 at 9:30 A.M., an observation was made of Housekeeping Staff #2 cleaning the apartment bathroom. A staff member was observed using gloves while cleaning the bathroom and removing trash from the 2 trash receptacles. No observation was made of staff removing gloves, wash or hand sanitize prior to opening the door. Interview was done with the Infection Control Coordinator on 5/5/15 at 10:35 A.M. The Infection Control Coordinator acknowledged that staff should have removed dirty gloves, wash or sanitize hands before opening the door. Review of the facility's Handwashing Policy noted hands must be washed thoroughly with soap and water when visibly soiled. If running water and soap is not immediately available; hand antisepsis may be accomplished with alcohol-based sanitizer (if hands are not visible soiled) after removing gloves. 2). An observation on the afternoon of 5/4/15 found a Housekeeper, #1, cleaning the apartment trash cans. The Housekeeper #1 had blue gloves on when he removed the filled trash can liner and tied it up. Using the same gloves, he re-lined the trash with a clean trash liner. Without removing his gloves and washing/sanitizing his hands, the Housekeeper #1 opened the door to the apartment and left. 3). During an observation on 5/04/15 of morning hygiene care of Resident #2, the CNA/Activities staff member was brushing Resident #2 's hair. Resident #2 motioned that she needed suctioning of her trachea at which time the CNA grabbed the suction hose, took off the trachea cap, and suctioned without changing gloves and sanitizing her hands. 4). An observation made on 5/05/2015 of Licensed Nurse #1 who was completing Resident #1's care which included: dressing, and changing his attends. After completing… | 2018-02-01 |
| 2061 | 2061 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2013-03-14 | 278 | D | 0 | 1 | D8QM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interview, the facility did not ensure the Minimum Data Set accurately assessed the resident's medications for 2 of (Resident #21 and #12) 10 residents' medications reviewed in the Stage 2 sample. Findings include: 1) Record review on the afternoon of 3/13/13 was done for Resident #21. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/22/13 was done. Under Section NO410, there was no coding for the use of the diuretic ([MEDICATION NAME] or [MEDICATION NAME]). Interview with the MDS Coordinator on 3/13/13 at 1:35 P.M. and concurrent review of the MDS acknowledged the error and the use of the diuretic ([MEDICATION NAME]) should have been coded. 2) Record review for Resident #12 found a March 2013 physician's orders [REDACTED]. Review of the quarterly MDS with ARD of 10/2/12 noted in Section N. the resident was not coded for use of diuretic. Interview and concurrent chart review with the MDS Coordinator was done on 3/13/13 at 2:10 P.M. confirmed the [MEDICATION NAME] was not coded and should have been coded as a diuretic. | 2017-06-01 |
| 2062 | 2062 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2013-03-14 | 279 | E | 0 | 1 | D8QM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and staff interviews, the facility did not develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 9 (Residents #2, #5, #12, #14, #15, #16, #21, #22, and #27) of 15 sampled resident with care plan review of the 22 residents included in Stage 2 sample. Findings include: Review of unnecessary medications found that residents receiving antibiotics, diuretics, insulin, and [MEDICAL CONDITION] medications ([MEDICATION NAME] and [MEDICATION NAME]) did not have comprehensive care plans that was based on the assessment of the resident's conditions, risks, needs, and behavior; was consistent with the resident's therapeutic goals; considered the need to monitor for effectiveness based on therapeutic goals and for the emergence or presence of adverse consequences; and revised as needed to address medication-related issues. 1) Record review was done for Resident #27 on the morning of 3/13/13. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review found physician orders [REDACTED]. No care plan could be found for this resident on insulin, monitoring for signs and symptoms of hypo/[MEDICAL CONDITION], actions to be taken for any reactions. 2) Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. The resident was also receiving [MEDICATION NAME] N 27 units sq at 0600; [MEDICATION NAME] N 20 units sq at 1700; [MEDICATION NAME] R sq bid per sliding scale. Interview with licensed nurse on 3/13/13 at 11:30 A.M. revealed blood sugar testing done twice a day at 9 AM and 9 PM. The resident will occasionally receive insulin depending on the results of the random blood glucose. Review of the MAR indicated [REDACTED]. Record review could not find a c… | 2017-06-01 |
| 2063 | 2063 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2013-03-14 | 280 | D | 0 | 1 | D8QM11 | Based on observation, staff interview and record review, the facility failed to periodically review and revise 1 (Resident #16) of 3 care plans reviewed of the Stage 2 sample residents for physical restraints. Findings include: Cross to F279. Resident #16 was observed during the survey to be seated in a wheelchair with seat belts affixed while seated. The resident was also observed to ambulate with the assistance of a walker. Review of the quarterly Minimum Data Set with assessment reference date of 2/25/13 notes trunk restraint coded as used daily. Review of the resident's care plan found that there was no care plan revision to address continued evaluation of the effectiveness of the restraint, indication of when or how to use the restraint, or reduction of use. | 2017-06-01 |
| 2064 | 2064 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2013-03-14 | 520 | E | 0 | 1 | D8QM11 | Based on interview with staff, the facility failed to ensure the quality assessment and assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Findings include: Interview with the QAA Coordinator/Administrator was conducted on 3/14/13 at 9:30 A.M. to discuss quality deficiencies related to development of care plans and care plan revision. The coordinator reported that the facility identified care plans as an area for improvement following a comparative survey conducted by the Regional Office last year. In response, the facility implemented a plan of action to review all the residents' care plans to ensure plans were individualized and revised as indicated. The Coordinator reported the team spent months reviewing and revising all the care plans to ensure the plans were individualized and addressed all the residents' challenges with the goal to maintain or improve the residents' status. The Coordinator was queried regarding how the action plan was monitored to ensure continued efficacy of the systemic changes. The Coordinator reported that the action plan was not monitored. | 2017-06-01 |
| 2384 | 2384 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2012-04-02 | 241 | D | 0 | 1 | RE4Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility did not ensure that the it must 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 his or her individuality. Findings include: 1) At 8:45 A.M. on the initial tour of the facility observation by two surveyors noted a Respiratory Therapist (RT#1) walking into a room occupied by an adult without knocking or acknowledging entry into the resident's room. 2) On 3/29/12 observation from 1:45 through 2:05 P.M. an RT #2 was observed walking into 3 resident rooms including rooms [ROOM NUMBERS] without knocking or acknowledging entry into the rooms. The resident were in their rooms at the time. 3) Observation on 3/30/12 at 7:45 A.M. found three staff members enter room [ROOM NUMBER] without knocking or announcing themselves. Also observed one staff member enter room [ROOM NUMBER] without knocking or announcing him/herself. Another staff member entered room [ROOM NUMBER] and was observed to knock. Interview done with the Administrator on 4/2/12 at 1:00 P.M., the Administrator reported that staff should announce or knock before entering a resident's room which would be dependent on whether the resident is aware of staff member entering. | 2016-06-01 |
| 2385 | 2385 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2012-04-02 | 371 | D | 0 | 1 | RE4Z11 | Based on observation and staff interview the facility failed to ensure that tube feeding formula stored in the refrigerator was properly labeled to eliminate food safety hazards. Findings include: On 3/29/12 during the initial tour, looked inside the refrigerator where the facility stores residents' prescribed tube feeding formulas. Observed gallon sized plastic containers filled with formula, each container was labeled with name, contents, date and time prepared and stored on the lower shelf of the refrigerator Also, observed the following: a pint-sized plastic container filled with formula on the top shelf that was labeled with the resident's name with no date and time and two baby bottles filled with formula stored on the refrigerator door, labeled with the residents' names only. On 3/30/12 at approximately 10:00 A.M. while observing med pass, the licensed staff went to the refrigerator for the resident's tube-feeding formula that was stored in a baby bottle with the resident's name. Inquired of the staff member how she/he knew when the formula was prepared. According to the licensed staff, the night shift staff prepares tube feeding formula for each resident every 24 hours and the formula is stored in gallon-sized plastic containers. The staff will pour formula into a baby bottle labeled with the resident's name and place it in front of the gallon-sized plastic container for the resident's next tube feeding. Validated information with the Charge Nurse (CN), and he/she stated that the baby bottles with the resident's name is kept in front of gallon container, so that staff know that formula in baby bottle from gallon size container with date and time. Concurrent observation with the CN, inquired of formula in pint-sized container on top shelf that was labeled with name only and of the two baby bottles filled with formula stored on refrigerator door. The CN did not have an answer, but later informed surveyor, that the formula in the pint-sized container without date and time was discarded. During an interview w… | 2016-06-01 |
| 2386 | 2386 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2012-04-02 | 441 | D | 0 | 1 | RE4Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not ensure that it implemented its Infection Control Program to provide a safe and sanitary environment as evidenced by a nurse not cleaning hands, changing gloves and using clean equipment. Findings include: Observation by two nurse surveyors during medication pass on the morning of 3/30/12 had a licensed nurse providing treatments and medication to a pediatric resident. Procedures observed included tracheostomy care and suctioning, gastrostomy care, and administration of medication through [DEVICE]. Observation noted that while providing care to the resident the suction tube fell on the floor with the tip of the tube hitting the floor. The licensed nurse picked up the tubing and without cleaning the tip, reinserted the tube back into the canister. There was another instance where after suctioning the resident and covering the end of the tubing, the covered tubing fell on the floor. Observation by the two surveyors noted that the licensed nurse's gloved hand touched the floor when she picked up the tubing and the nurse did not clean her hands or change the gloves. Thirdly, the licensed nurse did not clean her hands or change gloves between the three procedures of tracheostomy care, cleaning of the gastrostomy site, and administering the medications via [DEVICE]. Interview with the Registered Nurse charged with Infection Control issues at the facility on the morning of 4/2/12 confirmed that hands should be washed/cleaned and gloves changed between the different procedures. Secondly, when the tubing tip fell on the floor, the nurse should have wiped the tip of the tubing or changed the tube before putting the tube in the canister. Thirdly, when the licensed nurse picked up the equipment that fell on the floor she should have changed her gloves. | 2016-06-01 |
| 2787 | 2787 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2011-01-20 | 441 | E | 0 | 1 | 66EG11 | Based on observation, the facility did not ensure that the Infection Control Program was designed to ensure staff implemented methods to help prevent the development and transmission of disease and infection. Findings include: A. On the morning of 1/18/11, observation of a dressing change revealed staff did not: 1) provide a barrier between dressings, supplies and the resident's bed, 2) did not change gloves between the removal of soiled dressings and before implementing treatment and, 3) changed the dressing to a gastrostomy (GT) site before a tracheostomy site. 1. The licensed nurse (LN) was assisted by a Certified Nurse Aide (CNA) who positioned the resident during treatment. The dressing removed from around the GT site by the LN was soiled with brown-red drainage. After placing the soiled dressing on a napkin, the LN picked up a cotton-tipped applicator, applied a 22 gauge around the tip of the applicator then swabbed the skin area surrounding the tube. The LN did not change gloves after removing the soiled dressings. 2. After dressing the GT site, the LN proceeded to remove the dressing from the tracheostomy site. When asked, the nurse stated she usually did the tracheostomy site before the GT site. 3. The nurse placed a pair of scissors and an unopened pack of dressing directly onto the resident's bed linen and used the items when doing the dressings. B. Observation of medication pass and medication administration via GT during the morning of 1/19/11 revealed staff did not implement measures to prevent transmission of infection and disease as gloves were not changed prior covering the tip of an open syringe and shaking the syringe of medication and, staff did not clean his/her stethoscope before placing it around their neck after placing the stethoscope on the resident's bed. 1. After pouring medication, the LN placed the cup holding the syringes filled with liquid and crushed medication on a surface at the side of the resident's bed. 2. The LN then used his/her gloved hands to pull the curtains closed, low… | 2015-07-01 |
| 2788 | 2788 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2011-01-20 | 514 | D | 0 | 1 | 66EG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure a monthly physician's order contained accurate documentation for 1 of 9 residents (Resident #5) in the active case sample. Finding includes: Resident #5 was admitted in July 2010 with [DIAGNOSES REDACTED]. During observation and short conversations with the resident on 1/18/11 through 1/20/11, the resident was found to be alert, oriented and able to comprehend/understand what was said. The resident could speak when his/[MEDICAL CONDITION] was deflated, although his/her speech was soft and/or slurred. The resident communicated his/her needs and made decisions when he/she interacted with the nursing and respiratory therapy staff on observation. The record review revealed the resident's current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/10 and a significant change MDS with an ARD of 9/28/10, noted the resident remained independent in his/her decision making and achieved a Brief Interview for Mental Status (BIMS) summary score of 15 on the current MDS. However, a 7/16/10 physician order for [REDACTED]. On 1/20/11 at 12:20 P.M., the MDS Coordinator reviewed the January 2011 physician order sheet and stated the order for the use of [REDACTED]. She stated this resident was alert and oriented, used various electronic devices such as an iPad, iPod, computer, etc., and confirmed this adult resident did not have immature cognitive development nor slept in a crib. The MDS Coordinator also stated it was the resident's request to use the bilateral upper half side rails while he/she was in bed. | 2015-07-01 |
| 2789 | 2789 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2011-01-20 | 466 | F | 0 | 1 | 66EG11 | Based on observation, staff interview and review of the facility's policies and procedures, the facility's established procedures did not ensure that water was available to essential areas when there was a loss of normal water supply as 1) the facility's policies did not identify a consistent amount of water needed per person and, 2) the policies did not contain a method to calculate the amount of potable and non-potable water to be available in an emergency. Finding includes: Observation on 1/18/11 revealed a storage room next to the dirty utility room that contained bottles of 5 gallons of water. On 1/18/2011, the Food Service Manager (FSM) stated she and the Administrator had previously discussed the amount of water necessary was one-half gallon. Interview with the FSM and Plant Operations Manager (POM) on 1/19/2011 confirmed water was stored in that storage room and that food, water and other liquid nutrition was available in another storage area. The amount calculated as adequate was for 7 days. They stated that in addition to the stored food and water, containers of water were filled throughout the facility in the event of an emergency. An interview with the Clinical Operations Officer revealed the facility also had a pool of water available for use during an emergency. Interview with the POM revealed the pool's capacity was 2000 gallons of water. Review of the facility's policies and procedures identified water sources that included a 75 gallon water heater and 5 gallon containers of water available within the unit and the administration building. One policy stated the amount of water necessary per person was 67 ounces, while another identified 1 gallon of water as the necessary amount. The written policies however, did not identify a formula to calculate the amount of water needed per person and did not identify sources for non-potable water. The Administrator stated the facility was in communication with a State wide task force and was working with them on the amounts necessary. | 2015-07-01 |
| 2790 | 2790 | KULANA MALAMA | 125057 | 91-1360 KARAYAN STREET | EWA BEACH | HI | 96706 | 2011-01-20 | 248 | D | 0 | 1 | 66EG11 | Based on observation, record review, and staff interview, the facility did not provide for an on-going program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being for 1 of 9 residents (Resident #3) in the active case sample. Finding includes: Interview with the Activity Director on 1/19/11 revealed that: 1) activities were not always based on the comprehensive needs of residents as assessed by the interdisciplinary team (IDT); 2) goals did not always indicate specific parameters and interventions did not include specific activities to be implemented, nor how/what activities were identified for the resident; and, 3) activities and programs identified by community resources were not considered for integration into the facility's programs. A. During periods of observation on 1/18/11, activities to provide physical, mental and psychosocial well-being for Resident #3 were not observed. For much of the time, the resident was observed with his/her head leaning forward and down toward his/her chest. Interaction between staff and this resident was sporadic and minimal. 1. At about 2:00 P.M., Resident #3 was observed in a standing board. The resident faced an area of floor mats where staff interacted with other residents using touch, toys, and verbal stimulus. Observation revealed there was no active interaction between staff and Resident #3 for 10 minutes. 2. After approximately 10 minutes, the surveyor approached the resident and spoke with the resident. Two nursing staff then approached the resident and spoke with the resident. One staff did range of motion (ROM) to Resident #3's left hand. 3. At about 2:20 P.M., the resident was taken to his/her room, then positioned in a wheelchair. The resident was taken to the other corner of the play mat where he/she had been in the standing board. An overbed table with photos of the resident's family was positioned on the right side of Resident #3. The Activities Coordinator stated dur… | 2015-07-01 |
| 762 | 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 | 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 … | 2020-09-01 |
| 764 | 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… | 2020-09-01 |
| 765 | 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 | 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 previo… | 2020-09-01 |
| 767 | 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 … | 2020-09-01 |
| 768 | 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 H… | 2020-09-01 |
| 769 | 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 | 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 | 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 car… | 2020-09-01 |
| 772 | 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 b… | 2020-09-01 |
| 773 | 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 f… | 2020-09-01 |
| 774 | 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 weaknes… | 2020-09-01 |
| 775 | 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… | 2020-09-01 |
| 776 | 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… | 2020-09-01 |
| 777 | 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 w… | 2020-09-01 |
| 778 | 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… | 2020-09-01 |
| 779 | 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 accuche… | 2020-09-01 |
| 780 | 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 d… | 2020-09-01 |
| 781 | 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 swel… | 2020-09-01 |
| 782 | 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 foo… | 2020-09-01 |
| 783 | 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 | 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 | 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 | 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 | 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 | 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 brow… | 2020-09-01 |
| 789 | 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 sta… | 2020-09-01 |
| 790 | 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… | 2020-09-01 |
| 791 | 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 w… | 2020-09-01 |
| 792 | 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/… | 2020-09-01 |
| 793 | 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 endor… | 2020-09-01 |
| 1092 | 1092 | KA PUNAWAI OLA | 125051 | 91-575 FARRINGTON HIGHWAY | KAPOLEI | HI | 96707 | 2017-02-10 | 159 | B | 0 | 1 | XCO611 | Based on interviews, observation, and admission packet review the facility failed to provide access to resident personal funds on weekends. Finding includes: On 2/7/2017 at 10:47 AM Resident #48 was asked if he was able to get his money from his personal funds account, including on weekends. Resident #48 responded he did not know. On 2/8/2017 at 3:27 PM Staff #205 was interviewed. When asked if residents at the facility have access to their accounts on weekends Staff #205 stated that access to accounts are during business office hours, if the resident needs cash for the weekend the business office can have it prepared by Friday. The information sheet given to residents on admission states: Resident Trust Banking Hours: Monday - Friday: 9:00 AM - 4:00 PM. There was no information on the process for cash requests on the weekends. The facility information sheet provided to residents suggest residents personal funds are available during banking hours and not on weekends. | 2020-05-01 |
| 1093 | 1093 | KA PUNAWAI OLA | 125051 | 91-575 FARRINGTON HIGHWAY | KAPOLEI | HI | 96707 | 2017-02-10 | 242 | B | 0 | 1 | XCO611 | Based on resident interviews, facility staff interviews and review of the facility's Admission Packet, the facility failed to provide residents with the ability to choose when they have visitors. Findings include: Resident interviews for Resident's # 311 and 313 on the morning of 2/7/17 revealed there were set visiting hours. Both residents reported the visiting hours were from 8:00 AM to 8:00 PM. An interview with Staff #158 on the afternoon of 2/9/17 revealed that residents were provided the visiting hours of 8:00 AM to 8:00 PM upon admission. Staff #158 reported that the facility staff were not strict with the visiting hours and they don't ask visitors to leave after 8:00 PM. An interview with Staff #7 on the afternoon of 2/9/17 revealed that visiting hours was discussed with residents upon admission. Staff #7 provided a copy of information included in residents' Admissions Packets which noted, Visiting Hours: 8:00 AM - 8:00 PM. Staff #7 reported that the visiting hours were just recommended. Staff #7 further noted they have a No overnight policy. The facility failed to allow residents the choice of visiting hours. | 2020-05-01 |
| 1094 | 1094 | KA PUNAWAI OLA | 125051 | 91-575 FARRINGTON HIGHWAY | KAPOLEI | HI | 96707 | 2017-02-10 | 246 | D | 0 | 1 | XCO611 | Based on observation, interviews, and record review the facility failed to provide residents with reasonable accommodations to have their call lights within reach. (Residents #48, 91, 286) Findings include: 1. On 02/07/17 at 10:37 AM observed Resident #48 in bed with limited mobility, only able to move the fingers on his right hand. There was no call light observed on or near the resident. A random staff was called into the room and asked to locate Resident #48's call light. The random staff located the resident's call light on the night stand. The staff person rested the call light near the resident's right hand. Resident #48 was able to move his fingers to press and activate the call light system. In the afternoon of 02/08/17 Staff #164 was interviewed on the procedures to make sure resident call lights are within reach. Staff #164 stated residents are checked at rounds and with every contact to be sure the call lights are within reach. On 02/08/17 at 5:03 PM Resident #48 was observed in bed with his call light again on the night stand. Shortly after observed Staff #113 going into the resident's room then leaving the room. When asked Staff #113 stated, I just rounded with him, he is OK. Staff #113 was asked if the resident's call light was within reach. Staff #113 reentered the resident's room, took the call light from the night stand and placed it next to the resident's right hand. Resident #48's record review found the resident requires extensive to total assist, is alert and able to make basic needs known. 2. On 02/07/17 at 2:25 PM observed Resident #91 in bed with the residents call light wedged between the mattress and side rail near the resident's head. When asked to located her call light Resident #91 made an unsuccessful attempt to locate the call light cord. Staff #156 was called into the room and asked to locate Resident #91's call light. Staff #156 stated a family member had just left and may have placed the call light there. Staff #156 placed the call light on the resident's chest and asked the resi… | 2020-05-01 |
| 1095 | 1095 | KA PUNAWAI OLA | 125051 | 91-575 FARRINGTON HIGHWAY | KAPOLEI | HI | 96707 | 2017-02-10 | 281 | D | 0 | 1 | XCO611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and review of the facility's policies and procedures, the facility failed to ensure the services for enteral nutrition met the professional standards of quality for 2 of 24 residents (Res #72 and #1) in the Stage 2 sample. Finding includes: 1. On 2/07/2017 at 8:45 AM, during the initial tour of the Wailani unit, the nourishment refrigerator had two 1 Liter Glucerna 1.2 cal enteral nutrition (EN) containers dated 2/1 and 2/4/17 250 ml for a resident whom Staff #164 said had been discharged . Staff #164 said the reason the containers were kept half used was because if the resident (Res #72) eats under 50 percent of her meal, she gets this. These are hers. Staff #164 was asked when these were opened and how long used EN containers were kept for use as this resident was discharged . Staff #164 replied, Yeah it's dated 2/1/17, this one is 2/4/17. They both should have been discarded after the initial connection, and the product label says it should be 48 (hours). But those 2 should have been discarded. 2. On 2/07/2017 at 2:18 PM, observation of Res #1 found she received EN via her gastrostomy tube ([DEVICE]) as per the physician's orders [REDACTED]. The green bag was labeled with the resident's name with 2/7/17 written on it. However, the EN container did not have anything written on the label, but had been used. On 2/07/2017 at 2:27 PM, Staff #190 confirmed that he/she hung the [MEDICATION NAME] 1.2 cal EN container for Res #1 at noon. Staff #190 acknowledged it was a new one today and began writing Res #1's name, date and start time of 1200 on the container's label. Staff #190 reiterated he/she knew the start time because, I know it, I did it. On 02/10/2017 at 9:30 AM, Staff #158 produced a facility policy, Tube Feeding Administration, which stated, Procedural steps .10. Change feeding bag, tubing and syringe used for placement check .Label with date and resident's name. Another policy provided by the NHA o… | 2020-05-01 |
| 1096 | 1096 | KA PUNAWAI OLA | 125051 | 91-575 FARRINGTON HIGHWAY | KAPOLEI | HI | 96707 | 2017-02-10 | 329 | D | 0 | 1 | XCO611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to monitor the drug regimen to ensure that there was adequate indications of use for 1 resident of 6 in the Stage 2 investigation for unnecessary drugs. (Resident #60) Finding includes: On 02/07/17 at 2:34 PM observed Resident #60 sitting up in her bed with many personal items stacked around the bed and nearby wall. Resident #60 refused to be interviewed when asked. On 02/08/17 at 9:29 AM approached Resident #60 who was again sitting up in bed, when asked to be interviewed, Resident #60 again refused. At 10:29 AM on the same day a medication review found Resident #60 was on [MEDICATION NAME] ([MEDICATION NAME])10 mg every day for depression. A record review on 02/09/17 at 1:38 PM found Resident #60's care plans on [MEDICAL CONDITION] medication use and depression with approaches that included to monitor behavior and report any negative observations to MD. Staff #164 was asked to show documentation of the monitoring done by the facility for adverse reactions to [MEDICATION NAME] and the resident's behaviors of depression. Staff #164 showed a Behavior Monitoring Form for Res #60 written on the form was: [MEDICATION NAME] 10 mg daily and Depressed Mood, Withdrawn. There was no documentation on the form to show staff had been monitoring for signs and symptoms of the medication or behavior symptoms of depression. Staff #164 shared a form titled Skilled Medicare Documentation and an entry for Resident #60 that stated, Document behavior PRN with episode: Depression. Staff #164 stated documentation for depression is only as needed if the behavior occurs. On 02/09/17 at 2:08 PM a concurrent record review and policy review was held with Staff #204. The review found the following entries: 12/29/2016 refused [MEDICATION NAME] and [MEDICATION NAME], many attempts to persuade resident but kept refusing; 2/7/17 refused to be changed, didn't want to be bothered; and 2/8/2017 refused to … | 2020-05-01 |
| 1097 | 1097 | KA PUNAWAI OLA | 125051 | 91-575 FARRINGTON HIGHWAY | KAPOLEI | HI | 96707 | 2017-02-10 | 371 | E | 0 | 1 | XCO611 | Based on observation and staff interviews, the facility failed to ensure the food was prepared and distributed in a sanitary environment, and failed to ensure food was served in a sanitary manner to residents during dining. Findings include: 1. On 2/09/17 at 10:16 AM, a kitchen tour with Staff #100 was done. Staff #100 looked at the ceiling vent above the food steam table and identified an AC vent. Staff #100 said, it's discolored and blackened--shouldn't be like that. Should be white. After looking at the other similar ceiling vents in kitchen, Staff #100 confirmed all the vents in the kitchen needed to be cleaned. For the one beige vent, Staff #100 thought it retracts hot air, and further said, looks like dust. yeah, needs to be cleaned too. On 2/10/17 at 8:49 AM, during a interview with Staff #121, he/she stated that Staff #100 mentioned the kitchen vents and that they scrubbed and cleaned them. Staff #121 acknowledged it was never put on a preventive maintenance (PM) log, but stated, It will be my new PM for ac vents. On 2/10/17 at 10:21 AM, during an interview with Staff #93, he/she said maintenance used to have their own cleaning schedule for the kitchen vents, but now there's new staff and could not recall when it was last done. Staff #93 stated going forward, if the vents were not maintained on a quarterly schedule, he/she will initiate a reminder request to maintenance to do the cleaning. 2. On 02/07/17 at 12:45 PM a dining observation was done in the main dining room. Observed Staff #10 take a tray off the serving shelf and walk to a random resident seated a table with other residents. While walking towards the table a quarter sheet paper fell off from the tray onto the floor. Staff #10 picked the paper off the floor and proceeded to place the tray in front the random resident. Without hand sanitizing Staff #10 placed the quarter sheet of paper on the center of the table then removed the wrap and lids covering the random residents food. Another resident seated at the same table grabbed the quarter sheet… | 2020-05-01 |
| 1098 | 1098 | KA PUNAWAI OLA | 125051 | 91-575 FARRINGTON HIGHWAY | KAPOLEI | HI | 96707 | 2017-02-10 | 441 | F | 0 | 1 | XCO611 | Based on observations, staff interviews and facility policy review, the facility failed to maintain a safe, sanitary environment for residents. Findings include: 1. On the afternoon of 2/9/17, observations of the shower rooms on Unit 1 found several shower chairs and gurneys. One shower chair on Unit 1 had brown and yellow substances on the inner rim of the shower seat. An interview with Staff #156 on the afternoon of 2/9/17 at approximately 1:30 PM revealed that she disinfected shower chairs between residents using a Cavi Wipe. She was unable to show the surveyor which Cavi Wipe was used. Another staff member walked by and Staff #156 asked Staff #23 about disinfecting the shower chairs. Staff #23 stated they used the Heavy Duty Alkaline Bathroom Cleaner or the pink spray (due it's pink color). Staff #23 stated they used the pink spray to spray the shower chair and wait about 1 minute then rinse it off and dry the chair. Interview of Staff #15 on the afternoon of 2/9/17 at approximately 1:45 PM revealed she, too, used the same pink spray between residents. She allowed the solution to remain on the surface of the chair for a few seconds then run hot water to rinse and towel dry. On the afternoon of 2/9/17 at approximately 2:00 PM, observation of the shower chairs on Unit 2 found the chairs/gurneys were also stored in the shower rooms. An interview of Staff #41 on Unit 2 at approximately 2:30 PM revealed she used the pink spray on the shower chairs and leaves it on for an unspecified amount of time. While waiting for the pink spray to sit on the shower chair, Staff #41 will go to the resident's room and change the linens/make the bed. She then returns to the shower chair, runs hot water over it then towel dries the chair before beginning with the next resident. An interview with Staff #163 on the morning of 2/10/17 at approximately 9:30 AM, revealed she wasn't sure which solution was used to clean shower chairs/gurneys. Staff #163 provided the oversight for the facility's infection control program. Staff #163 state… | 2020-05-01 |
| 1423 | 1423 | KA PUNAWAI OLA | 125051 | 91-575 FARRINGTON HIGHWAY | KAPOLEI | HI | 96707 | 2016-01-07 | 253 | B | 0 | 1 | VUPG11 | Based on observation and staff interviews, the facility failed to provide necessary services to maintain a sanitary and comfortable environment. Findings include: 1) An initial tour was conducted on 1/4/16 at 07:38 A.M. During the tour, it was observed on the 100 hallway's shower room an old, dirty, and dusty Gojo dispenser attached to the wall. According to the Maintenance Supervisor and his Assistant the dispenser is no longer in use. The shower curtain inside this shower room is very dirty at the bottom area, there was blackish/brownish color seen at the bottom of the curtain. The shower room on the 200 hallway, it was observed that the shower area is dirty and both Maintenance Supervisor and his Assistant acknowledged that it needs cleaning and scrubbing. Inside this shower room, there was another Gojo dispenser attached to the wall that was old, dirty, and dusty and was no longer in use. An environmental tour was done with the Maintenance Supervisor and the Housekeeping Supervisor on 1/6/16 at 09:40 A.M. In room 202, the caulking around the sink is visible with brownish/blackish color. The Maintenance Supervisor took a clean paper tower and wiped it. It showed brownish color on the paper towel. Both maintenance and housekeeping staff acknowledged that the sink is dirty and needs to be scrubbed. In room 202, the wall on the left hand-side, it was noted that the wall has scraped off paint. The Wailani hallway where most of the residents wait to be taken to the dining room/activities the wall panel was observed to have scraped paint. In room 208, the bottom of the door panel is coming apart; in rooms 204, 206, 206, and room 212, there were wooden chipped noted on the doors. The door jam in 216 has scraped off paint on the left side. An interview was conducted with the Maintenance Supervisor, Assistant Maintenance Supervisor, and the Housekeeping Supervisor on 1/4/16 and 1/6/16. The staff all acknowledged that the identified areas need cleaning, fixing, and painting. 2) On the morning of 1/4/16 observed the wall… | 2019-03-01 |
| 1424 | 1424 | KA PUNAWAI OLA | 125051 | 91-575 FARRINGTON HIGHWAY | KAPOLEI | HI | 96707 | 2016-01-07 | 258 | D | 0 | 1 | VUPG11 | Based on observation and confidential resident interviews and interviews with staff members, the facility failed to provide maintenance of comfortable sound levels. Findings include: A confidential resident interview was conducted on 1/4/16 at 8:00 A.M. The resident reported there is a resident in his unit that screams in the middle of the night which wakes him up. The resident's roommate interjected and confirmed his roommate's report. He also stated that the screaming wakes him at night. A confidential interview conducted on 1/4/16 at 10:15 A.M. a resident on another unit reported that there is a resident that yells all day and it is constant, even at 5:00 A.M. The resident further expressed becoming nervous in response to the yelling. A follow up was done with the roommates on 1/6/16 at 8:09 A.M. The roommates reported that they are not clear who is screaming at night; however, the screaming wakes them from their sleep. One resident stated a comment was made to facility staff; however, did not file a complaint. On 1/6/16 at 8:25 A.M., a follow up interview was done with the resident on the other unit. This resident identified three residents that are screaming and yelling. Inquired when does this occur, the resident responded anytime of the day or night. This resident did not complain to staff, as it was thought that staff would not believe this is occurring and the resident does not want to change rooms. The resident commented that the yelling upset him/her and this resident also yells in the dining room. Interview with Licensed Nurse on 1/6/16 at 9:00 A.M. confirmed there was a resident that was screaming on one unit; however, this resident has been discharged . Observation on the morning of 1/6/16 found the resident identified as a yeller being wheeled by staff in the hallway and the resident was yelling out. Subsequently, the same resident was observed wheeling himself alone and yelling out. | 2019-03-01 |
| 1425 | 1425 | KA PUNAWAI OLA | 125051 | 91-575 FARRINGTON HIGHWAY | KAPOLEI | HI | 96707 | 2016-01-07 | 281 | D | 0 | 1 | VUPG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, interviews, and policy review, the facility did not ensure services provided or arranged by the facility met professional standards of quality as care plans for certain classifications of medications were not developed upon admission for 2 Residents (Residents #316 and #317). Findings include: 1) On 1/5/16 at 2:03 PM, observed Resident #316 sitting in a wheelchair in his room. The resident reported that he was recently admitted to the facility on [DATE] due to many falls at home. This time he fractured his left shoulder which was observed in a sling. Bilateral lower legs and arms noted to be dark blue/gray in color and left lower leg was wrapped in a gauze bandage. Record review on the afternoon of 1/5/16 noted the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record noted physician orders on 12/31/15 included [MEDICATION NAME] 20 mg po TID and [MEDICATION NAME] 100 mg po BID. No care plan could be found for the diuretic, [MEDICATION NAME] and antibiotic, [MEDICATION NAME]. Concurrent record review and interview with the Unit Manager done on the afternoon of 1/5/16 confirmed that care plans were not done for the diuretic and antibiotic. Review of the facility policy on Resident Care Plan noted an interim care plan is to be completed upon admission. Interview with the MDS (Minimum Data Set) Coordinator on 1/6/16 at 9:50 A.M. revealed interim care plans should have been developed for the use of the diuretic and antibiotic upon admission to the facility. 2) Resident #317 was admitted to the facility on [DATE] following an acute admission related to right [MEDICAL CONDITION] after a fall. Record review done on 1/6/16 at 8:38 A.M. notes the resident has a physician's order for [MEDICATION NAME], 20 mg. tablet every morning for [DIAGNOSES REDACTED]. A review of the Interim Care Plan dated 12/31/15 found no care plan to address the use of a diuretic ([MEDICATION… | 2019-03-01 |
| 1426 | 1426 | KA PUNAWAI OLA | 125051 | 91-575 FARRINGTON HIGHWAY | KAPOLEI | HI | 96707 | 2016-01-07 | 309 | D | 0 | 1 | VUPG11 | **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 a resident (Resident #301) who receives [MEDICAL TREATMENT] from an outside entity receives the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and care plan. Findings include: On 1/5/16 at 12:45 P.M. observed Resident #301 in his room with his lunch on the bedside tray. The lunch tray consisted of a cup of nepro (liquid protein supplement), soup, pureed vegetables and bread with finely chopped pasta. Also observed two bottles of water (330 ml each), one of the bottles was full and the other partially empty. At 1:07 P.M. observation was made with the Certified Nurse Aide (CNA) of the resident's lunch tray. The CNA reported the resident drank 120 ml of water and 120 ml of the nepro. The CNA reported that the fluid amount is included in the total amount of consumption (food and liquids); therefore, the resident's intake will be recorded at 70%. The CNA reported that the aides will report to the nurse how much the resident drank at the end of shift. Second observation on 1/6/16 at 8:00 A.M. found the resident had a cup of water and a cup of milk on his breakfast tray. Record review done on the afternoon of 1/5/16 notes Resident #301 was admitted to the facility on [DATE] following an acute hospitalization . The admission [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the resident's care plan dated 12/2/15 for potential for complication related to [MEDICAL TREATMENT] for [DIAGNOSES REDACTED]. Interview with the Licensed Nurse (LN #1) was done on 1/5/16 at 2:25 P.M. Inquired whether the resident is on fluid restriction and how does nursing document the amount of fluids the resident drank. The LN responded that she did not believe the resident is on fluid restriction and nursing will monitor the I/O for new admission for thr… | 2019-03-01 |
| 1427 | 1427 | KA PUNAWAI OLA | 125051 | 91-575 FARRINGTON HIGHWAY | KAPOLEI | HI | 96707 | 2016-01-07 | 371 | D | 0 | 1 | VUPG11 | Based on observation and interview with staff members, the facility failed to store food under sanitary conditions. Findings include: On 1/6/2016 at 2:00 PM observed in the resident nourishment refrigerator on the Wailani wing the following: (4) Yoplait Light individual serving size with expiration dates of 12/28/15; a bag of crackers in a quart size ziploc bag with no label or use by date; and 1/2 loaf of bread in a brown paper bag with no label or use by date. In the lower food storage bin of the same refrigerator were 4 bags of food, each bag held plastic containers with food and plastic bags of food all without labels and use by dates. The Infection Control Nurse present at the time of the observation stated that all foods stored in the refrigerator should be labeled and dated. Posted on the refrigerator door was a notice, Refrigerator rules: All food should be labeled and dated, with a use by date of 3 days from date of storage. Use by date: may be up to 3 days from date the item was placed in the refrigerator or date item was opened. Label all items with the following information: Resident Name; Room Number; and Use by Date. The following items will be discarded: improperly labeled items, items past the use by or expiration dates, and items left by discharged residents. The facility policy on Food Brought into Facility guidelines state: 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 within four hours should be discarded. The facility policy for Nourishment Storage Areas state: Food is covered, labeled and dated appropriately. Food is rotated and/or discarded according to facility guidelines. | 2019-03-01 |
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CREATE TABLE [cms_HI] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );