rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2017-10-20,280,D,0,1,5D9Q11,"Based on observations, staff interviews and electronic medical record (EMR) reviews, the facility failed to ensure that 1 of 16 residents (R #10) was consulted on personal preferences. Findings include: On 10/18/2017 at 2:19 PM R#10 was observed sleeping in bed. Staff #2 explained that staff were alert to resident's coughing as signal that assistance is needed and R#10 didn't want to use the soft call-light because often inadvertently triggered the call light by his/her head movements. Reviewed the resident's Care Plan (CP) which states Potential for Decrease in ADL, that interventions dated 8/24/15 included: I am to use a soft touch call light to call for assistance which is to be placed by my pillow near to my face. I will turn my head/face to touch the call bell. Discussed with Staff #2, that intervention of soft call-light still on ADL CP and there was no intervention that staff should listen for the resident's coughing as signal for assistance. Staff #2 went to ask R#10 if he/she wanted a soft call-light and R#10 responded, yes by nodding his/her head. The resident's sister came to visit at that time and Staff #2 explained to her that R#10 now wanted to use the soft call-light. Staff #2 called for the soft call-light to be re-installed. The facility did not explore care alternatives through a thorough care planning process in which the resident could participate.",2020-09-01
2,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2017-10-20,314,D,0,1,5D9Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and Electronic Medical Record (EMR) reviews, the facility failed to ensure that 1 of 16 residents (R #31) on the Stage 2 Sample Resident List was provided care to promote healing, pain control and prevent infection due to an existing pressure ulcer (PU). Finding include: During an EMR review on 10/17/2017 at 08:31 AM R #31 was admitted with a Stage 4 pressure ulcer to the right buttock and hip. There were no orders for wound vac dressing changes three times per week (Monday, Wednesday and Friday). During an interview on 10/18/2017 at 11:04 AM, Staff #2 stated that staff nurses do the daily wound care which includes the wound vac dressing changes. The wound nurse does weekly assessments once per week. Queried where wound nurse documentation would be located and Staff #2 looked at EMR under Notes but there was no wound nurse documentation for the once a week evaluation. Staff #2 explained that if wound healing, wound nurse wouldn't document because wound healing nicely. Pointed out documentation by Staff #47 written on 10/05/17 at 11:27 in Nurse Note, wound Right butt: no overall improvement noted in R butt wound status. Per Staff #52, (Wound Nurse), obtain surgical consult for R butt wound. Documentation of the EMR revealed inconsistent information regarding the wound characteristics. The wound measurement flowsheet stated the wound had undermining which was at 2 cm; the wound length got larger. Staff #2 stated the inconsistency is probably due to different nurses measuring the wound. Staff #2 further stated that goals were the same, maintain granulation tissue and get closer to surface then outside start to shrink. There was no infection, no redness or warmth around and no slough. Staff #47 documented odiferous on 10/16 and wound nurses both noted wound not odiferous during dressing change. On 10/19/2017 at 9:22 AM observed Wound nurses Staff #52 and #53 do dressing change to R #31's R buttock pressure wound. Staff #53 obtained wound dressing supplies and placed them on the resident's overbed table without sanitizing or covering the overbed table with a clean barrier. Staff #53 had put on clean gloves and started removing the soiled dressing while Staff #52 assisted by placing the opened wound supplies onto the resident's bed, left in the wrapper. With the same gloves Staff #53 was observed to remove the dirty dressing, clean the wound, apply skin prep and the wound vac drape; then she proceeded to measure the wound depth with the same gloves. Discussed observations with both wound nurses and queried about practice of using same gloves between dirty dressing and clean dressing. Staff #52 stated that gloves are usually changed at least 5 times during a dressing change although that was not observed. Also, informed wound nurses that didn't observe them wash hands before putting on clean gloves. Both stated that they used hand sanitizing gel when they entered the resident's room. Informed them that observed them handling the wound vac machine and tubing with the clean gloves on before starting the wound care. Staff #52 stated that they will be sure to wash hands and change gloves between dirty and clean dressing change. During the dressing change R #31 was observed to jerk. Staff #37 stated that last pain med ([MEDICATION NAME] mg) was given at 6 PM. The extended release pain meds are given 12 hrs apart. During the Interview with R #31, the resident stated that he experienced shooting pains during the dressing changes and currently rated pain at 8 on a zero to 10 pain scale. When asked R #31 said that he did not tell the MD about his pain due to not being able to tolerate the [MEDICATION NAME]. Currently the Resident is being weaned off of the [MEDICATION NAME]. The facility did not follow standards of practice for wound care for the resident's Stage 4 pressure ulcer that promotes healing and prevents infection.",2020-09-01
3,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2017-10-20,371,F,0,1,5D9Q11,"Based on observations and staff interviews the facility failed to ensure that residents eating utensils and food preparation dishes were being properly sanitized. Findings include: On 10/16/2017 at 10:19 AM during the initial kitchen tour, the dishwashing machine temperature log for (MONTH) documented temperatures for final rinse cycle were out of range and did not reach 180 degrees Fahrenheit for the final rinse cycle. According to Staff #54, when the staff take temperature and its wrong, it should be checked again. The procedure that the kitchen staff is to follow, is to attach a temperature strip to a coffee mug and run it through the dishwashing machine again. The temperature strip should have been attached to the log with low temperatures to show the correct temperature. During an interview, Staff #54 stated that the dishwasher was broken since (MONTH) and the final rinse temperature was not reaching 180 degrees Fahrenheit. The facility had called the Hobart representative in (MONTH) and was waiting to replace a part. On 10/17/2017 Staff #54 reported that the dishwasher repair was scheduled for 10/19/2017. The facility did not follow proper sanitation of the dishes, eating utensils and cookware to prevent the outbreak of foodborne illness.",2020-09-01
4,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2018-11-16,578,D,0,1,HKBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the resident with the provisions to formulate an advance directives for two residents (R)7 and R20 of 16 residents reviewed. This includes a written description of the facility's policies to implement advance directives and applicable State law. The residents record lacked documentation stating there was follow up to formulate the advanced directive. Findings include: 1. During the initial record review of R 7' s' electronic medical record (EMR) on 11/14/18 at 01:04 PM no advanced healthcare directives were found. 2. During the initial record review of R20's EMR, no advanced healthcare directives were found. During an interview with the Director of Nursing (DON) on 11/15/18 at 03:30 PM requested a copy of the advanced healthcare directives for both R7 and R20 and was provided only a copy of R20's physician's orders [REDACTED]. The policy on advanced directives/ POLST last revised 08/2018 was reviewed and stated .The POLST form is used by East Hawaii . Newly admitted residents may provide the facility with a previously completed copy of an Advanced Health Care Directives form (AD). The AD will be utilized for Legal Authorized Representative designation. H. If resident does not have an Advanced Health Care Directives and/ or POLST completed, staff will offer assistance in completing a POLST . During an interview with the Administrator on 11/16/18 at 9:47 who stated that the advanced healthcare directives used to be in place until a few years ago when we did away with them and started to formulate and require the POLST. While the POLST is a physician's orders [REDACTED].",2020-09-01
5,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2018-11-16,600,G,0,1,HKBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review facility failed to protect resident's right to be free from any type of abuse that results in, or had the likelihood to result in physical harm, verbal abuse, or mental anguish in four Resident's (R) 10, R20, R22, and R30 in the sample of 16. The facility failed to provide care planning interventions and supervision to prevent three incidents involving R30. An incident on 08/09/2018 resulted in R22 striking R30 after verbal confrontation with R30. On 11/04/2018, R30 and R20 had an abusive verbal confrontation that required staff to render a show of force to prevent a physical confrontation. On 11/12/2018, R10 was involved in a verbal confrontation with R30, when he felt R30 was loud and rude to staff. This deficient practice caused harm for R30 resulted in high potential to endanger the other 24 residents residing in the extended care facilitl section. Findings Include: During initial screening of residents on 11/13/2018, R25 expressed she would like to discuss concerns about R30. During a brief interview on 11/14/2018 at 10:50 AM, R25 stated, R30 upset the blind man (R22) to the point he went after him. He is verbally obnoxious. I give the staff credit as they are kind to him. During an interview with resident council members (R10, R22, R25, and R29) on 11/14/2018 at 10:45 AM R22 stated. There's a guy (R30) here who I got into it with. He talks all the time and goes on and on. A couple of months ago I was in the same room and got sick of it and punched him. R10 stated, He is bad to the staff how he talks to them and obnoxious. R29 stated, He was kicked out of bingo and has to know everything about everyone's business. R10 said, He has no respect for women. R25 stated, He (R30) asks one of the CNA's if she'll marry him. She told him she was married, and he tells her to divorce and marry me. When asked if the resident's present felt safe, they replied yes. R10 stated, He's not safe in our environment. When asked to explain, R22 said, Concerned someone will get upset with him because he's so obnoxious, always swearing and in everyone's business. Shared that R30 had been observed to be sitting alone in the dining room this morning. R10 responded. Staff have asked him to stay away, but he gets up and goes to the tables anyway and starts talking. During an interview with Director of Nursing (DON) and Administrator on 11/15/2018, about R30's behavior, AHA described him as Portuguese and very talkative. He is not offensive to everyone. Asked what interventions have been put in place to prevent further altercations involving R30, and AHA stated, We are working with them one to one to help them understand R30's communication style and separate them in the dining area. The residents committed to notify the staff if they feel frustrated with R30's conversation prior to addressing it directly with him. There has not been a second incident with these resident's (R10, R20 and R22). The concern regarding R30's safety discussed at Resident's Council interview was discussed. AHA stated, No one will be able to remain here if threats are made. Clarification made, and it was reiterated that the statements made were not made as a threat but interpreted as [MEDICATION NAME] concern that due to the ongoing verbal persistence of R30, any resident might unexpectedly react and harm R30. The level of frustration verbalized at Resident's Council interview revealed the interventions to date were not adequate and concern expressed for further occurrences. During a brief interview with AHA on 11/16/2018 , additional records were requested for care plans after the three incidents. AHA was asked if there was anything that could have alerted them or factors that could have been foreseen to prevent the incident on 08/09/2018 when R30 was struck. AHA replied, No, there was nothing. EMR reviewed R30 was known and identified on the baseline care plan as having difficult behavior, demanding and verbally abusive communication. On 08/09/2018 RN55 was made aware by R22 that he was upset with R30 and needed to talk. R30 and R22 were left in the room unsupervised resulting in a physical altercation. Interventions put in place after the incident were not effective in reducing behaviors resulting in a second and third incident involving R30. A behavioral contract was not developed with R30 until after the third incident on 11/19/18. On 08/09/2018 at 05:20 PM, an altercation occurred between R30 and R22. The incident report completed by RN55 documentation includes the following: R22 stating earlier that he wanted to talk to R30 about squealing to MSW (Master of Social Work). R22 states MSW talked to him and R10 during the day about complaints of them being mean to R30. Upset R30 went behind his back to talk to MSW instead of saying it to his face, stated he wanted this writer to be there as witness because R30 was lying to MSW. Notified R22 that he can talk to resident but not argue or do anything physical, to call this writer when he was ready to talk. R30 was sleeping when this writer left room at 1700. Notified by Certified Nursing Assistant (CNA)16 at 17:20 that .R22 who was hitting . R30 during dinner. R22 said he brought up the issue of R30 squealing on him then R30 said used profanity. R22 states he lost it got up and started swinging his arms trying to hit R30 who was in bed. R22 is blind and states he just went toward R30's voice. RN55 told R22 he, should have called this writer like he promised. CNA16 states R22 was hitting the left side of R30's body, she pulled R22 away. R30 was moved to another room after the incident. Review of R30's Social Services notes by Social Worker (SW)1 include: On 08/10/2018 at 07:30 AM. R30 again stated he had no physical pain but said he was emotionally hurt. The SW responded the staff would keep him safe. On 08/10/2018 at 02:35 PM. At approximately 12:30 PM the resident said he did not feel safe, and felt restless and not normal. further describing the event as a trauma. The SW said to the degree he could, R30 should try to maintain a normal routine and be involved in activities within the group. R30 said, What if he comes in my room after me? The SW reassured R30 that R22 was not prone to this and, with the two men being in separate spaces, it was not at all likely to happen. On 08/10/2018 at 02:53 PM. R30 stated he felt safe but expressed anger at his former roommate who had hit him. On 08/13/2018 at 02:00 PM. R30 spoke several times with the SW throughout the day. He complained that his former roommates were being mean to him. He described looks and them whispering. The SW said he would attempt to address it with the other men but said the (sic) he needed to give that situation time since there had been overt conflict that previous week. Review of SW1 follow up notes for R22 include: On 08/10/2018 at 07:45 AM. R22 said he was upset the SW had spoken to him about R30's concerns with him (R22). Other residents reported that R22 shouted for R30 to shut up loudly in the dayroom on 8/8/18. R22 said I no care you kick me out of here. The resident (R22) said, I tell him you come to me if you got a problem with me. He said, Don't hide behind other people Brah. The SW also pointed out that three roommates had come and gone with R22 and the third roommate R10. The SW said that such physical attacks could not happen, as all residents needed to feel safe. On 08/24/2018 Subjective findings in R30's progress notes by Advanced Practice Registered Nurse (APRN) reviewed: We discussed the interpersonal challenges he has been having with peers and staff. He has been in 7 care homes. APRN's assessment included Borderline personality disorder-continues to have interpersonal problems, however willing to practice communication strategies with staff and distancing strategies with unfriendly peers. On 11/04/2018 an Office of Healthcare Assurance ([NAME]HA) report revealed a second incident involving R30. The event was described as follows: R20 was heard swearing at R30. Staff heard R20 state in a very loud voice, what! What!; As R20 was swearing, he was approaching R30. (Both men utilize front wheeled walkers for mobility assistance.) R30 was seated with other residents; facing the front of the .building, R30 was reacting to R20 and also began to curse at him. Staff approached both men and asked them to stop their behaviors. R20 appeared to be preparing to strike out at R30, as he was bringing his right hand backwards. However, staff was able to place themselves in a position to gain R20's attention and state, Stop. You need to go back to your room and calm down. R30 continued his taunt. R20 began to become more upset. He was becoming more difficult to redirect. Along with the staff aide, the activity aide, as well as the housekeeper was able to render a show of force, which successfully dc-escalated (sic) the situation. R20 returned to his room. R30 was advised not to approach or antagonize R20. The report documents, There were no issues prior to this event; as these residents had not associated with each other prior to this encounter. Causal factors identified by the facility were documented as: R30, had settled in to the facility; he continues to have a tendency to repeat self; making persistent verbal requests of others. R20, does have instances of verbal outburst that lends to his self-isolation. There were noted precipitating factors that could explain the incident. On 11/06/2018 an email From CNA26 was sent to the Director of Nursing (DON) which said R20 was only inches away from R30's back and ready to swing his hand on his back. R20 were about to turn around when R30 started to talk and teased him to fight. R20 got more upset and unable to redirect.' R20 had no plan to stop attacking R30. On 11/12/2018 a verbal altercation occurred between R30 and R10. The [NAME]HA initial report describes: R10 was trying to stop R30 from speaking loudly and rudely to the Recreational Aide. Survey team was on site 11/13/2018. RN56 nurses notes dated O7/24/2018 stated Resident's daily routine People say I talk too much and identified potential barriers to his discharge/ goals as: Hx difficult behavior, and demanding + verbally abusive. Comprehensive care plan dated 07/25/18 reviewed, no evidence of interventions to address identified difficult behavior and demanding, verbally abusive behavior noted. On 08/10/2018 at 10:34 AM, R30's comprehensive care plan revised after the incident on 08/09/2018, to include the following interventions: Please remind me if my verbal persistence is upsetting others. Let me know what good behaviors look like. Approach me in a gentle sensitive manner. Talk calmly. On 08/14/2018 Additional interventions include: Please ask me if I am upset. Offer me reassurances, but also encourage me to distract myself in places I feel safe, such as my new room or in common areas with staff. Allow me to vent over my feelings of frustration or anxiety, but direct me if I repeat themes after reassuring me this will not re-occur. My feelings get hurt if no one talks to me. On 09/17/2018 Please encourage me to resume my daily routine (out for activities, engaging others in conversation, out for meals etc. Remind me that others may not respond the way I expect them to. On 11/04/2018 After second incident, care plan revised to include: Changed to every 15 minute monitoring due to altercation. On 11/12/2018 after the third incident, care plan revised, I will be monitored so that another resident(s) I had a verbal altercation with will not be in the dayroom at thie(sic)same time as I am until further notice. On 11/16/2018 care plan revision, I will have 1:1 visit with my SW/LTC Administrator to verbalize my feelings and any concerns that I have. On 11/17/2018 care plan revision I am receiving 1:1 supervision due to verbal altercation I had with another resident (R10). 11 dc' d (discontinued) 11/20/2018. On 11/19/2018 NHA (Nursing Home Administrator) informed of behavioral contract developed and R30's agreement and signature provided.",2020-09-01
6,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2018-11-16,726,D,0,1,HKBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to properly date a Peripherally Inserted Central Catheter (PICC) line sterile transparent dressing (dressing) for R135. As a result of this deficient practice, the facility put R135 at risk for infection and/or other PICC line complications. Findings Include: During an observation of a PICC line for R135 on 11/13/18 at 12:30 PM, it was noted that the dressing was not dated. During staff interview with RN57 on 11/13/18 at 12:31 PM, RN57 acknowledged that the PICC line dressing was not dated and should have been. RN57 then stated that the PICC line would be immediately assessed and dressing would be changed and dated. A review of facility policy on Vascular Access Devices; PICCs, Appendix G; PICC, Site Care and Dressing Change stated Central PICC dressing change is a sterile procedure needing dressing kit. BioPatch and [MEDICATION NAME]. A sterile transparent dressing of appropriate size shall be used and changed every 7 days and PRN along with BioPatch and [MEDICATION NAME].",2020-09-01
7,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2018-11-16,761,D,0,1,HKBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to properly discard two medications that were stored in the Lehua Unit Medication Storage Cart. As a result of this deficient practice, two residents (Resident (R) 2, and R6) were at risk of being given an expired medication. Findings Include: 1. During an observation of the Lehua Unit Medication Storage Cart on [DATE] at 09:45 AM, an expired medication bottle of [MEDICATION NAME] was revealed in the storage drawer. This medication belonged to R6, and the label read [MEDICATION NAME] 160 mg/5 ml [MEDICATION NAME], discard after ,[DATE]. 2. During an observation of the Lehua Unit Medication Storage Cart, on [DATE] at 09:46 AM, an expired medication [MEDICATION NAME] was revealed in the storage drawer. This medication belonged to R2, and the label read [MEDICATION NAME] Oral Suspension 40 mg/5 ml, discard after [DATE]. On [DATE] at 09:45 AM, RN57 acknowledged that both medications were expired and should have been removed. According to facility policy on Outdated and Unusable Drugs, it stated All outdated drugs, contaminated drugs shall be returned to the Pharmacy Department for proper disposal.",2020-09-01
8,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2018-11-16,812,E,0,1,HKBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to monitor temperatures to ensure the refrigerators/freezer were in good working condition, and stored food beyond safe use by dates, in two kitchen refrigerators, one resident nourishment refrigerator, and a storage cabinet on the Long-term care unit. The deficiency compromised food safety for the residents. Findings Include: On [DATE] at 10:20 AM, during an interview with the Food Service Manager (FSM), the monthly refrigerator/freezer temperature logs were reviewed that revealed incomplete documentation of temperature monitoring. The FSM stated, They are to check them twice a day and document on the log. There was no evidence the kitchen storeroom refrigerator, or kitchen storeroom freezer temperature was monitored 12 out of 31 days in August, (YEAR). The log revealed the kitchen GC 14 Refer (Juices) refrigerator was not monitored 13 out of 31 days in August, (YEAR). Temperature documented on [DATE], [DATE], [DATE], and [DATE] was 52 degrees Fahrenheit (F), outside the safe range (41 degrees F, or less) for refrigeration with no evidence of corrective action taken after the deviation was noted. On [DATE], staff entered the comment, couldn't find thermometer. On [DATE] at 10:30 AM identified one container of tofu, and one container of sliced apples in a kitchen refrigerator with expired dates on the labels. The FSM confirmed the food, Needed to be thrown out. On [DATE] at 11:38 AM, inspection of the Long-term care nourishment room revealed one opened container of orange juice and a bowl of crystal light jello stored in the refrigerator with use by dates on the labels that had expired. In addition, there were eight unopened lemon water containers and two unopened orange juice containers stored in the cabinet that were beyond the use by dates.",2020-09-01
9,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2018-11-16,842,D,0,1,HKBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to accurately document the dates on a Physician Orders for Life-Sustaining Treatment (POLST) form for Resident (R) 23. As a result of this deficient practice, the POLST form would be invalid, and R23 may not have received the care as indicated on the prepared POLST form. Findings Include: During record review for R23, it was noted that the POLST form did not contain the two dates that was required on the form. These two dates were: 1. Date form prepared, and 2. Date of Physician Signature. The POLST form also stated Any section not completed implies full treatment for [REDACTED]. During staff interview with RN52 on 11/16/18 at 09:39 AM, RN52 acknowledged that the POLST form was not complete and missing the required dates. RN52 then stated that the issue would be followed up and presented to the physician. A review of the facility policy on Medical Record Documentation stated Each documentation entry or documents with multiple sections completed by multiple individuals in the medical record shall be immediately dated, timed and signed by the authorized personnel .",2020-09-01
10,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,640,D,0,1,P3CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to ensure a discharge assessment was transmitted within 14 days of completion. Findings include: On 12/19/19 at 11:46 AM, a record review was done for Resident (R)1. R1 was admitted to the facility on [DATE] from an acute hospital. On 07/18/19, R1 was discharged to the community. On 12/19/19 at 11:42 AM, the transmission receipt for R1's discharge assessment was requested of the Resident Assessment Coordinator (RAC). At 12:47 PM, the RAC reported the resident's assessment was batched with other resident's assessments and upon review of the transmission report confirmed R1's discharge assessment was not successfully transmitted.",2020-09-01
11,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,684,D,0,1,P3CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with resident and staff member, the facility failed to provide a bowel regimen for a resident to address constipation related to the routine and pro re nata (prn) use of opioid medication for pain management for 1 (Resident 18) of 1 residents sampled. Findings include: On 12/17/19 at 02:07 PM, an interview was conducted with Resident (R)18. R18 was asked whether he/she has constipation, R18 responded that he/she takes pain medication which results in constipation. R18 confirmed that sometimes he/she will go without a bowel movement for more than three days. Initially, R18 reported that he/she fixes it on his/her own; however, later reported that medication is provided. On 12/18/19 at 02:58 PM, a record review was done. R18 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the annual Minimum Data Set with assessment reference date of 10/28/19 documents R18 yielded a score of 15 (cognitively intact) upon administration of the Brief Interview for Mental Status. R18 requires extensive assist with one personal physical assist for toilet use. The resident is continent of bowel and bladder. R18 was not coded for constipation. In the medication section, R18 was documented as receiving opioid medications for pain daily in the last seven days. A review of the physician's orders [REDACTED]. every morning; [MEDICATION NAME] powder, 17 gm every 48 hours as needed for constipation with a start date of 10/16/19; [MEDICATION NAME] HCI, 5 mg every four hours for pain, prn; [MEDICATION NAME] HCI, 10 mg every four hours for pain, prn; and routine [MEDICATION NAME] HCI 10 mg. twice a day at 08:00 AM and 05:00 PM. Further review of the facility's intake and output log found the tracking in the electronic health record (EHR) which documents the following: continent of bowel movement (#); incontinent of bowel movement (#); and bowel movements (#). The EHR documents R18 did not have bowel movement from 12/04/19 through 12/06/19. R18 was documented with 0 (zero) for continent of bowel movement and incontinent of bowel movement and no documentation for number of bowel movement. A request was made to review the resident's frequency of bowel movement. The facility provided a vertical report entitled Continent of BM (#). The review found R18 did not have bowel movement from 11/19/19 through 11/20/19; 11/28/19 through 11/29/19; and 12/09/19 through 12/10/19. This report did not indicate R18 did not have a bowel movement from 12/04/19 through 12/06/19, it is documented R18 was continent of bowel movement under the heading of result as 1 (one). The intake and output documented in the EHR did not match the filtered report provided by the facility. On 12/19/19 at 01:15 PM, an interview was conducted with Licensed Nurse (LN)6. Inquired when is the prn of [MEDICATION NAME] for constipation is provided. LN6 responded when the resident does not have a bowel movement on the second day. LN6 further clarified the nurses keep track of residents' bowel movement by shift reports. A review of the physician order [REDACTED]. On 12/19/19 at 02:53 PM, an interview was conducted with the Director of Nursing (DON) and Resident Assessment Coordinator (RAC). A review of the documentation provided by the facility confirmed the aforementioned time periods when the resident did not have a bowel movement. Requested documentation that a prn of [MEDICATION NAME] powder was provided. There was no documentation of administration of [MEDICATION NAME]. The RAC reported, the resident may have refused the prn. Further requested documentation of the refusal. The RAC confirmed there is no documentation of resident's refusal for prn of [MEDICATION NAME] during the aforementioned periods.",2020-09-01
12,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,686,D,0,1,P3CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure prevention of an avoidable facility-acquired pressure ulcer. Although the facility was conducting weekly skin assessments, the assessments did not identify skin issues prior to the emergence of a Stage 2 pressure ulcer to the coccyx. Also, the facility identified an abrasion to the right lateral knee as a result of a mechanical device, the interventions provided did not prevent the abrasion from progressing to a Stage 2 pressure ulcer. Findings include: On 12/18/19, a review of the facility's Resident Census and Conditions of Residents (CMS-672) found documentation of one resident with pressure ulcer (excluding Stage 1). The Facility Matrix provided by the facility on the morning of 12/17/19 did not document Resident (R)2 has pressure ulcer. R2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Observation of the resident during the initial tour of the facility on 12/17/19 found R2 asleep in bed with noted right below knee amputation. On 12/20/19 at 07:57 AM, a record review was done. A review of the physician's orders [REDACTED]. R2 has a care plan to maintain skin integrity, prevent skin breakdown. The following care plan revisions include: 11/07/19 - monitor for presence of [MEDICAL CONDITION]; 11/25/19 - use skin sleeves to bilateral arms for skin protection and do treatment to my right lateral knee; 12/09/19 - turn me very hour when in bed, continue to do skin check routinely, and notify physician/wound nurse of significant findings; and 12/09/19 - continue to encourage to increase fluid intake as tolerated and if not indicated. On 12/20/19, observation at 09:40 AM found R2 asleep in bed (air mattress), the resident was placed on his/her back with legs raised behind the knees. At 10:10 AM, resident was observed in bed, in the same position. The hospice worker was visiting the resident. A request was made for documentation of skin assessments. On 12/20/19 at 09:43 AM, the facility provided documentation of the progress notes related to the R2's pressure ulcers. The note for 10/30/19 documents R2 has a prosthesis for the right leg which he/she applies independently. A Stage 2 pressure ulcer developed as the resident was placing a sock on before applying the rubber cushion for the prosthesis. The skin and weight note dated 10/31/19 documents a pressure ulcer to right lateral knee measuring 1 cm x 1 cm. At this time Glucerna was ordered to increase R2's protein intake. Also, R2 was willing to add [MEDICATION NAME] (protein supplement) to his/her diet. Subsequent note on 11/07/19 documents no change to measurement of the wound. R2 was consuming the Glucerna and [MEDICATION NAME] to promote wound healing. R2 also documented with pneumonia. A nursing note on 11/09/19 notes wound bed is pink with contracted edges and minimal sanguineous draining with no signs and symptoms of infection. The use of duoderm was discontinued and [MEDICATION NAME] with kerrafoam dressing was initiated. The subsequent assessment notes on 11/13/19 a decrease in the wound from 1 cm x 1 cm to 1 cm x 0.8 cm. The note on 11/28/19 found R2 with recent decline in conjunction with changes in mental status (more confused and disoriented). The note on 12/03/19 documents an increase in measurement from 1.0 cm x 0.8 cm to 1.5 cm x 1.0 cm. An alert charting for 12/07/19 notes R2 with an open area to the coccyx measuring 1.2 cm x 0.8 cm. The wound was covered with foam dressing and sensicare was applied. The plan was to reposition every two hours and to get an order for [REDACTED]. On 12/20/19 at 10:13 AM, an interview was done with Licensed Nurse (LN)6. LN6 reported R2 has been experiencing a decline. LN6 also reported R2 was applying the prosthesis independently and upon discovering the application was wrong, the resident was re-educated. LN6 reported the injury to the right lateral knee started as a skin abrasion on 10/16/19 and was treated as an abrasion. Inquired whether weekly skin checks would find any changes to residents' skin to indicate possible skin breakdown. LN6 further explained R2 used to be very active and independent with hygiene care and recently has been more dependent on staff. LN6 responded the weekly skin check would indicate changes and maybe R2's skin breakdowns may have been identified before breaking down to a Stage 2 pressure ulcer. LN6 also reported R2 is being admitted to hospice. On 12/29/19 at 10:43 AM, an interview and concurrent record review was done with the Director of Nursing (DON). A review of the weekly skin assessments was done with the DON. The Stage 2 pressure ulcer to the right lateral knee was first documented on 10/09/19. The Advanced Practice Registered Nurse (APRN) was notified and ordered to apply [MEDICATION NAME] every day for four days. On 10/19/19, R2 went home for an overnight trip. Subsequently on 11/07/19, R2 was sent to the emergency department. The documentation up to 10/21/19 refers to the wound as an abrasion. A referral to the wound as a pressure injury was first documented on 10/31/19 as a Stage 2 pressure ulcer. A review of the weekly skin assessments in (MONTH) prior to the identification of a Stage 2 pressure ulcer to the coccyx (12/07/19) documents no skin issues. The DON reported R2 is declining and has been referred to hospice. The DON recalled prior to the breakdown of the coccyx (12/07/19), R2 went home from 11/01/19 through 11/03/19 for a visit.",2020-09-01
13,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,725,D,0,1,P3CE11,"Based on interviews with residents, the facility failed to ensure the provision of sufficient nursing staff to provide services to assure residents maintain their highest practicable physical and psychosocial well-being. Findings include: 1) On 12/18/19 at 10:00 AM, a confidential interview was done with ten resident council representatives that were invited to participate by the facility staff. The representatives reported staff members will respond to their call light right away; however, they are told they have to wait five to ten minutes as the staff member is providing care for another resident. Three residents reported there has been occasion where they had to wait for 30 minutes. One resident reported this usually occurs during the night shift. And another resident commented that he/she doesn't want to ask for help during the shift change. 2) On 12/17/19 at 01:55 PM, a confidential interview was done with a cognizant resident (the resident yielded a score of 15 on the Brief Interview for Mental Status, which indicates the resident is cognitively intact). The resident reported there are three shifts and identified the 03:00 PM to 11:00 PM as not having enough staff members to provide care. The resident shared that the call light is pressed, the staff member responds, turns off the light, tells you they are busy and will come back. The resident further reported, the call light is being pressed for assistance for repositioning, bathroom and transferring in and out of bed; however, acknowledged that the staff members are run down.",2020-09-01
14,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,726,D,0,1,P3CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to provide nursing professional standard of care for Resident (R)89's peripherally inserted central catheter (PICC). As a result of this deficiency, there is a potential risk for infection. Findings include: Resident (R)89, admitted on [DATE], was receiving intravenous (IV) antibiotic ([MEDICATION NAME] tazobactam) through a peripherally inserted central catheter (PICC). On 12/17/19 at 11:44 AM, licensed nurse (LN)5 prepared to administer intravenous medication for Resident (R)89. Observed the PICC dressing was not labeled, documenting the date, time, and staff that last changed the PICC dressing. LN5 confirmed the PICC dressing should have been labeled with the date, time, and staff initials. Additionally, LN5 confirmed there was no documentation in R89's medical record of the last date the PICC dressing was changed.",2020-09-01
15,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,761,D,0,1,P3CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to discard an expired medication on 1 of 3 medication carts. Findings include: On [DATE] at 12:55 PM, an inspection of the medication cart was done with Licensed Nurse (LN)6. The observation found one bottle of polyethylene [MEDICATION NAME] which was not labeled with an open date. LN6 found the pharmacy label which documented an expiry date of ,[DATE]. The licensed nurse reported this medication will be discarded.",2020-09-01
16,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,812,F,0,1,P3CE11,"Based on observations, staff interview, and review of records, the facility failed to 1. Maintain a safe refrigerated food storage, and 2. Maintain water temperature records for the manual dishwashing station. Findings Include: 1. During an initial tour of the kitchen on 12/17/19 at 09:50 AM, the walk-in refrigerator (GC14) was noted to have employee food stored on one of the shelves. The stored food was not labeled, not dated, and not being monitored. The Food Service Manager (FSM), who accompanied the initial tour, was queried about the stored food and acknowledged that the food was not labeled, not dated, and not being monitored. 2. During a follow up visit to the kitchen on 12/19/19 at 09:59 AM, FSM stated that their dishwashing machine had recently broken down and they were manually washing all the dishes. FSM explained the details of their manual washing process. However, upon review of records the facility had not recorded and/or maintained the water temperature for their washing since they started the manual washing process. On 12/19/19 at 11:00 AM, the FSM acknowledged that the facility had not recorded and/or maintained the water temperature for their manual washing process as previously mentioned. FSM actually created a new updated manual washing log which included the missing washing temperatures.",2020-09-01
17,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,880,D,0,1,P3CE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to maintain a sanitary environment and failed to prevent the development and transmission of communicable diseases and infections as evidenced by the following: canister of [MEDICATION NAME] powder had a plastic measured cup (scoop cup) that was stored in the powder for multiple use; and a pad on the shower gurney had multiple tears and cracks, resulting in permeability of the plastic covering and allowing liquids/fluids to seep into the padding and resurface when weight is applied. Findings Include: 1) On 12/20/19 at 09:47 AM, during an observation of the medication cart on the North Wing, a 6-8 ounce canister of [MEDICATION NAME] powder was noted to have the scoop cup stored in the powder. Registered Nurse (RN) 23, who accompanied this observation, was asked about the scoop cup. RN23 stated that multiple hands would grab the scoop cup, but there was no procedure to ensure the cup was either sanitized or any procedure to prevent the spread of infections. RN23 further stated that the facility had most recently been using single use packets and wasn't sure when they switched to using the canister. 2) On 12/18/19 at 11:45 AM, observation of the shower room was done with Certified Nurse Aide (CNA)8. The observation found a shower gurney with a blue padding insert. The blue pad had cracks in the raised area under the head and around the drainage holes. Inquired how is the pad sanitized, CNA8 responded the pad is washed down after use and sprayed with a sanitizing solution. Initially CNA8 stated the residents are placed directly on the plastic padding; however, after discussion that the plastic covering was now permeable, the CNA reported a towel is placed on the padding.",2020-09-01
18,HILO MEDICAL CENTER,125002,1190 WAIANUENUE AVENUE,HILO,HI,96720,2019-12-20,883,E,0,1,P3CE11,"Based on record review, staff interview, and review of policy, the facility failed to provide education regarding benefits and potential side effects for the Influenza Vaccination that was given to two Residents ((R) 15, 28) out of the seven residents reviewed. As a result of this deficient practice, the two residents and/or their representatives was not given the opportunity, or even the discussion, of minimizing the risk for acquiring, transmitting, or experiencing complications from the Influenza vaccination. Findings Include: 1. During a review of the immunization record for R15, it was noted that R15 received the Influenza vaccination on 10/10/19. However, after further record review, there was no documentation noted that the resident and/or resident's representative was provided education regarding the benefits and potential side effects of the influenza vaccination. On 12/20/19 at 12:30 PM, the Director of Nursing (DON) was queried and subsequently provided a consent form for R15 on the Influenza immunization. However, the consent form was for the previous flu season (YEAR)-2019. There was no consent form provided for the current year 2019-2020. 2. During a review of the immunization record for R28, it was noted that R28 received the Influenza vaccination on 10/04/19. However, after further record review, there was no documentation noted that the resident and/or resident's representative was provided education regarding the benefits and potential side effects of the influenza vaccination. On 12/20/19 at 12:30 PM, DON was queried and subsequently provided a consent form for R28 on the Influenza immunization. However, the consent form was for the previous flu season (YEAR)-2019. There was no consent form provided for the current year 2019-2020. A review of the facility policy titled Influenza and Pneumococcal Vaccination Protocol for Acute Care Inpatients and Long Term Care Residents stated the following: Policy, [NAME] Hilo Medical Center Registered Professional Nurses (RPNs) and Licensed Practical Nurses (LPNs) are authorized to give the influenza and/or pneumococcal vaccine to Hilo Medical Center patient and residents, who meet the criteria established by the Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP). B.the nurse screens the patient using the Vaccine Consent/Documentation Tool. Procedure, [NAME] Identify vaccine recipients with the criteria on the Vaccine Consent/Documentation Tool. The form lists the contraindications and timeframes for giving vaccine. As previously mentioned, there was no consent form provided for R15 and R28.",2020-09-01
19,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,157,D,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews, the facility failed to immediately notify the resident's representatives when there was a significant change in the resident's physical condition and health status for 1 of 23 residents (Resident #12) in the Stage 2 sample. Finding includes: During a confidential family interview on 04/11/2017 at 10:31 AM, a family member stated he/she is the person who would be notified of a change in condition involving Resident #12 (R #12). The family member stated there had been a recent change in R #12's health condition. The family member stated he/she had not been promptly notified by staff caring for R #12 of the laboratory tests and an electrocardiogram (EKG) that had been ordered. The family member further said the tests were ordered about a week ago on a Friday, and when he/she came to visit R #12 on Sunday, the resident was going through an exacerbation of her [MEDICAL CONDITIONS]. The family member stated the resident was also found to have swelling (edma) of her face and hands. During a follow-up confidential interview on 04/12/2017 at 9:02 AM, the family member said, I knew (the resident) was quite lethargic but not aware of the labs and EK[NAME] The family member also said there was a decline in the resident's condition and by that Sunday, 4/2/17, the on call physician was called to assess R #12. The family member stated although another family member is the primary contact (he/she) asked for me (this family member) to be contacted first due to a language barrier. The resident's clinical chart documents this family member to be the first person the facility is to call on the resident's contact list. The family member re-verified that no staff informed him/her of the labs and EKG and change in the resident's condition. On 04/13/2017 at 8:06 AM, an interview with Staff #58 was done. Staff #58 said R #12's [MEDICAL CONDITION] gets more complicated, but confirmed that when an EKG and labs are ordered, the family is to be notified. Staff #58 verified based on his chart review, there was no clinical documentation by Staff #100 to show that R #12's family member who is to be contacted first had been notified. Staff #58 said it was important that it be documented, but that it had not been done. The facility failed to immediately notify/contact the family member listed as the first person to contact regarding a change in the resident's condition and the ordered clinical tests.",2020-09-01
20,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,221,D,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with staff members, the facility failed to ensure a resident, Resident #63 was free from a physical restraint. Finding includes: On 4/10/17 at 11:30 [NAME]M. observed Resident #63 in the activity room. The resident was seated in a wheel chair with a gait belt looped through the bars on the sides of the wheelchair and buckled across her lap. Subsequent observation at 11:42 [NAME]M. found the gait belt still buckled across the resident's lap. At 12:21 P.M. Resident #63 was observed eating lunch at a table with the gait belt still affixed to her wheelchair. On the morning of 4/11/17 Resident #63 was observed eating her breakfast in the activity/dining room, the gait belt was affixed to her wheelchair. Subsequent observation at 10:06 [NAME]M. found the resident watching the entertainment. The resident was seated on a bench in the front row. On 4/11/17 at 2:22 P.M. observed Resident #63 asking Staff Member #110 to take her back to the room. Resident #63 was seated in a wheelchair and observed to be wearing a seat belt that was buckled in the front. Resident #63 was observed to self-propel the wheelchair with her feet. The seat belt was removed by the staff member, Resident #63 was observed to stand and walk to the bathroom independently. The resident stood in front of the toilet and started pulling her pants down, at this time, the staff member requested to have the door closed. Second observation at 3:06 P.M. found Resident #63 ambulating on the unit with the assistance of a staff member. Observation from 3:14 P.M. through 3:34 P.M. found Resident #63 propelling herself in the wheelchair around the unit. The seat belt was applied. On 4/12/17 at 8:03 [NAME]M. Resident #63 was observed eating breakfast in the activity/dining room, the seat belt was not applied and there was no gait belt looped across her lap. Subsequent observation at 9:04 [NAME]M. found the resident's seat belt was affixed. A record review done on the morning of 4/12/17 found a physician's orders [REDACTED]. The reason for the use of device is dementia with anxiety and left foot weakness secondary to TIA, gait instability. The form documents that the device is a restraint; however, the team checked that the front buckle belt is not a restraint because the: resident can ask to have it removed; resident can remove it on his/her own; and resident cannot get up on his/her own so is not being restrained. There is no documentation of an assessment for the use of a gait belt to be looped through the sides of the wheelchair as a possible restraint. A review of the Minimum Data Set for significant change with an assessment reference date of 1/9/17 codes daily use of trunk restraint. In Section [NAME] Activities of Daily Living Assistance, Resident #63 was coded as requiring extensive assistance with two person physical assist for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and walk in room and corridor as being totally dependent with one person physical assist. A review of the care plan for restraint was updated on 1/20/17 for the use of front buckle belt. The interventions included: when restraint in use, check q 1 hour and release q 2 hours and inspect skin, circulation and movement; release restraint during activities as appropriate; monitor resident's response to restraint; reposition q 2 hours and as needed; and ambulate with 2 person assistance as tolerated. On 4/12/17 at 1:31 P.M. an interview was conducted with Staff Member #155. The observation of the use of the gait belt looped through the side bars across the resident's lap was shared with the staff member. The staff member reviewed the physician order [REDACTED]. Subsequently an interview was conducted with Staff Member #85. The staff member reported the gait belt is not used to be looped over the resident's lap, the gait belt is kept in the resident's wheel chair for tactile purposes. The staff member further reported the gait belt is not to be used to loop across the resident's lap and the use of the gait belt is to assist the resident to ambulate. On 4/12/17 at 1:44 P.M. concurrent observation of the resident was done with Staff Member #155. The resident was asked to unbuckle the seat belt, the resident grabbed the buckle and stated that it was stuck. Resident #63 was unable to remove the front belt buckle. An interview was done with Staff Member #112 on 4/12/17 at 1:40 P.M. The observation of the use of the gait belt was shared with the staff member. The staff member commented that the gait belt was utilized as a restraint and it should not be used in that manner. An interview was conducted with the staff member providing direct care, Staff Member #28 on 4/11/17. The staff member reported the gait belt is not to be used across the resident's lap, the gait belt is kept in the wheel chair so the resident can play with it. The staff member denied applying the gait belt to the wheelchair and stated it may have been the night staff that applied the gait belt to the wheel chair. The facility failed to ensure Resident #63 was free of a physical restraint as evidenced by the use of a gait belt looped through the bars on the sides of the wheelchair and over the resident's lap without an assessment and plan of care.",2020-09-01
21,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,279,D,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure it developed and implemented a comprehensive, person-centered care plan for 1 of 23 residents (Resident #12), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment in the Stage 2 sample. Finding includes: Cross-reference to findings at F157. Resident #12 (R #12) was admitted to the facility from an acute setting as her cardiac status had stabilized. R #12's admission was for ongoing medical management and rehabilitation services (physical and occupational therapy) due to severe weakness related to her hospitalization . Some of her [DIAGNOSES REDACTED]. Observation of R #12 revealed the resident was arousable but lethargic. A family interview revealed the resident had a recent exacerbation of her [MEDICAL CONDITION] symptoms with noted [MEDICAL CONDITION] (swelling). A review of R #12's clinical chart found a 3/31/17 nursing note which documented upon assessment, the resident was noted to be diaphoretic and lethargic. Arousable but generalized lethargy .Noted increased irregular HR (heart rate) in the 120s and BP 110/79. The record revealed the attending physician was notified and ordered a stat EKG, which was done at 10:10 AM on 3/31/17. Per the attending physician's 3/31/17 note, she assessed the resident as having sinus [MEDICAL CONDITION] wheeze, questionable asthma as symptoms were recurrent, and ordered oxygen as needed. The physician also ordered a new inhalation medication ([MEDICATION NAME]) twice daily for 5 days and noted the resident's history of [MEDICAL CONDITION] and positive fluid retention, and consider checking of BNP . The lab tests drawn on 4/3/17 included a basic metabolic panel and a B-Natriuretic Peptide (BNP) level. The BNP was significantly elevated at 908 pg/mL (normal A 4/2/17 entry by the on-call physician found R #12 was assessed to have [MEDICAL CONDITION], [MEDICAL CONDITIONS] and mild [MEDICAL CONDITION]. Orders were given for a one time [MEDICATION NAME] dose and to increase the resident's routine daily [MEDICATION NAME] dose to 20 mg. Additional orders included increasing the oxygen to 2 Liters/min by nasal prong, to check the resident's oxygen saturation (O2 sat) level every shift and to report to the physician if the O2 sat was 90 or less. Daily weights x 5 days were also ordered and a 4/2/17 nursing entry stated R #12 had a weight gain of at least 2.5# (pounds) and observed with increased facial and bilateral hand [MEDICAL CONDITION]. A concurrent chart review of the resident's care plans was done with Staff #58 on 04/13/2017 at 8:06 AM. During the interview with Staff #58, he stated with regard to the resident's [MEDICAL CONDITION], the attending physician knew of the resident's BNP level and adjusted R #12's medications. He also acknowledged daily weights for five days were ordered. Staff #58 verified there was no care plan developed for the resident's [MEDICAL CONDITION] but that it was important to have one based on the resident's [DIAGNOSES REDACTED]. Staff #58 said, It is every nurse's responsibility to develop a care plan and affirmed a care plan for it was not done. The facility failed to develop a care plan for a resident with a known history of [MEDICAL CONDITION] and during a recent exacerbation of [MEDICAL CONDITION] symptoms.",2020-09-01
22,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,280,D,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's basic care plan for falls was revised for 1 of 23 residents (Resident #77) in the Stage 2 sample. Finding includes: Cross-reference to findings at F323. Resident #77 (R #77) was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R #77's 3/21/17 basic care plan was formulated by an interdisciplinary team (IDT) and included care plans for self care deficit, altered thought process, alteration in comfort and a risk for falls. During an interview with Staff #13 on 4/12/2017 at 2:04 PM, she acknowledged her 3/24/17 assessment of R #77 was not included in the basic care plan with regard to the resident's with left sided weakness, difficulty in communicating, confusion, and functional limitations in her mobility and transfer. Staff #13 said she understood where the handing off of communication may not have been in the basic care plan prior to the injury occurring. She said her entry on 3/24/17 was about therapy and the IDT care plan (on 4/4/17) included additional interventions, but that it was done after the resident's 3/25/17 fall injury occurred. On 04/12/2017 at 2:48 PM, interview with Staff #55 revealed the family stated the resident fell all the time at home. Staff #55 confirmed the resident sustained [REDACTED]. Staff #55 said she would have to look to see if she discussed it with the nurse manager at the time, but the nurse manager should have incorporated it into the resident's care plan. This was in relation to Staff #13's progress note entry of 3/24/17 that based on her assessment of the resident, the recommended plan was to support R #77's left upper extremity at all times, to respond as quickly as possible to her requests to toilet, provide two staff assistance for putting on briefs, and provide program and training for staff to maximize the resident's ADL safety, independence, mobility and quality of life. This was not found in the basic risk for falls care plan. R #77 then sustained a fall with a left shoulder subluxation (dislocation) injury on 3/25/17. Staff #55 acknowledged there should have been something more put in place and that Staff #13's assessment should have been part of it. She acknowledged as Staff #13 is also a licensed professional, her expectation was the staff speak in terms of a communication hand off and some of these things would have been added to the care plan. The facility failed to update/revise the resident's care plan following a therapist's assessment which may have prevented the fall injury from occurring.",2020-09-01
23,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,281,D,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to ensure the services being provided meet professional standards of quality according to accepted standards of clinical practice for 2 of 23 residents (Residents #43 and #76) in the Stage 2 sample. Finding includes: 1) During Resident #43 (R #43's) room observation on 4/10/17 at 2:42 PM, it was noted that she received enteral nutrition via [DEVICE] feedings (GTF). The enteral nutrition (EN) bag that was hanging on the IV pole but not being infused at the time was Fibersource HN. On the bag's label, it had the resident's handwritten name as initials. It was also dated 4/10/17 and 370 cc/hr written on it. There was no start time written on the label when the initial EN infusion began. R #43's physician's orders [REDACTED]. Review of the facility's policy on Enteral Tubes was provided on 4/12/17, but it did not address how the EN formula bags were to be labeled. On 04/13/2017 at 7:25 AM, a room observation was done with Staff #108 for R #43. The resident's EN bag that was hanging on the IV pole had the resident's handwritten name as initials, and 4/12 1300 on it. Staff #108 said, It's missing the feeding order. Staff #108 further said their policy says the EN bag should be labeled with the amount of the flow rate on it. Staff #108 stated, it's not acceptable, and also verified the way staff had labeled the EN bag per surveyor's 4/10/17 observation by omitting the start time was not acceptable. The State Agency references the American Society for [MEDICATION NAME] and Enteral Nutrition (ASPEN), The Journal of [MEDICATION NAME] and Enteral Nutritional Practice Recommendations, Bankhead, R., et al., [DATE], pp. 129-130: D. Labeling of Enteral Nutrition .Practice Recommendations .3. All EN labels in any healthcare environment shall express clearly and accurately what the patient is receiving at any time .4. The EN label should be compared with the EN order for accuracy and hang time or beyond-use date before administration. For R #43, there was a failure by staff to label the EN bag following acceptable standards of clinical practice as the labeling did not include the start times according to the physician's orders [REDACTED]. 2) On 4/20/2017 a record review found the following conflicting documentation for Resident #76: 12/14/2016 admission: Skin Assessment: superficial open area overlying coccyx; no surrounding [DIAGNOSES REDACTED] or discharge, excoriation and [DIAGNOSES REDACTED] in the coccyx 0.5 cm x 0.5 cm dry; 12/18/2016 EZ graph Stage 2, 1 cm x 1 cm to coccyx, open area red/flaky skin. physician notified obtained order for [MEDICATION NAME] boarder till physician can evaluate.; 12/21/2016 glueteal excoriation almost completely closed, physician order [REDACTED]. On 4/11/2017 at 3:15 PM interviewed Staff #14. Staff #14 was asked if Resident #76 was admitted with a pressure ulcer and if the ulcer had become a Stage 2 in 4 days then healed in 3 days. Staff #14 stated the doctor codes the ulcers, nurses are not trained to do the assessment. A concurrent record review was done with Staff # 14, who stated looks like Res #76 came in with an excoriation, a nurse assessed it and called it a Stage 2 then when the doctor came in he correctly called it a healed excoriation. This may have been an error on the staging by the nurse. A review of the facility guideline for staging found that nurses are able to do pressure ulcer assessment using the National Pressure Ulcer Advisor Panel, [DATE]th edition, found in the Clinical Nursing Skills Basic to Advanced Skills by [NAME] Duel, Martin. Incorrect pressure ulcer staging may potentially cause unnecessary treatment delivery to the resident.",2020-09-01
24,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,323,G,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure the resident environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance to prevent accidents for 1 of 23 residents (Resident #77) in the Stage 2 sample. Finding includes: A Stage 2 review was done based on an incident report (IR) involving a fall related injury sustained by Resident #77 (R #77). The facility's self-reported IR stated the resident's 3/25/17 fall appeared to have .more affected her shoulder which was already affected by the cva. She is forgetful at times and does not remember to use the call bell. She does not realize that the left side of her body does not support her anymore. What interventions were implemented after the incident/event to prevent further injury? Immediate measures: 1:1 supervision while in bed and visual supervision when out of bed. Toileting at least every 2 hours with the goal of working on promoting continence, PT/OT have done initial evaluations with resident on 3/23-24 and will be working with resident to increase physical capabilities which will help with all aspects of care and comfort. On site review found R #77 was admitted to the facility on [DATE] from the hospital with several [DIAGNOSES REDACTED]. The resident's chart review found her admission included rehabilitation services (physical and occupational therapy) and that she has confusion. The resident's unwitnessed fall occurred on 3/25/17 in her room, and at the time of the incident, she stated she wanted to go to the bathroom. As a result of the fall, R #77 sustained a left shoulder subluxation (dislocation) injury. The emergency department noted it was a difficult reduction of the shoulder injury and she was given a left arm sling to stay on for at least 7 days. Observation of the resident on 4/12/17 at 10:16 AM in the hallway found she still required the use of a sling. The resident was being assisted by nurses aides with Staff #13 instructing them how to apply a new cross-over type of sling to support her left shoulder/arm. The resident allowed the sling to be applied and spoke very few words to the staff in her native dialect. Chart review of the 3/24/17 therapy evaluation by Staff #13 found her assessment of the resident included, decreased mobility + ADL safety + independence, impaired cognition/safety awareness with impulsiveness and difficulty communicating. She remains aware of the need to toilet, sits for at least several minutes unsupported . Staff #13's plan was to recommend supporting R #77's left upper extremity at all times, to respond as quickly as possible to her requests to toilet, provide two staff assistance for putting on briefs, and provide program and training for staff to maximize the resident's ADL safety, independence, mobility and quality of life. On 04/12/2017 at 2:04 PM, an interview of Staff #13 was done regarding her 3/24/17 evaluation of the resident. She was asked how she communicated her plan to the line staff caring for the resident. Staff #13 replied that if things need to be known immediately, she went directly to a nurse's aide or the nurse. She said if they were not available, she would document it on a sheet for the next shift to get it communicated forward, or speak with the head nurse to communicate it as quickly as possible and do a care plan update. She acknowledged she could update the care plan as well. Staff #13 recalled speaking to a licensed staff about the toileting and transfer for this resident and how important it was for staff to stabilize the other side as she (the resident) really doesn't put any weight on the other side and her ankle on the left side is unstable and can't put weight on it to transfer. Staff #13 thought it may have been added or implemented to the basic care plan and said nursing typically would put it in right away and that the resident came in with a history of falls. Staff #13 acknowledged the resident sustained [REDACTED]. She also said she understood where the handing off of communication may not have been in the basic care plan prior to the injury occurring. Staff #13 was informed that her plan/recommendations were not found in the care plan, which could have potentially prevented an injurious fall from occurring. She said her entry on 3/24/17 was about therapy and the IDT care plan (on 4/4/17) included additional interventions, but acknowledged that it was done after the resident's 3/25/17 fall injury occurred. On 04/12/2017 at 2:48 PM, interview of Staff #55 was done. She affirmed she completed the IR because the DON was on leave. She said the family said R #77 fell all the time at home. She also said the emergency room physician said R #77's shoulder dislocation was a difficult reduction. Staff #55 said she would have to look to see if she discussed it with the nurse manager at the time, but the nurse manager should have incorporated it into the resident's care plan. Staff #55 acknowledged there should have been something more put in place and that Staff #13's assessment should have been part of it. She acknowledged as Staff #13 is also a licensed professional, her expectation was the staff speak in terms of a communication hand off and some of these things would have been added to the care plan. Further review of the post-fall investigation report revealed some of the contributing factors to R #77's fall included the resident's inability to ambulate by herself (stand/pivot), that she was non-English speaking with a lack of safety awareness, she had a condition (tumor excision) resulting in left sided weakness, neurological memory loss causing her to forget she has the left sided weakness, an inability to remember to use her call light, and, that her bed alarm although activated on the bed, had not been activated on the display board. It also noted a lack of staff guidance related to points of communication/exchange (i.e., handoffs/shift reports). In addition, this resident on admission was noted with a history of frequent falls and Staff #55 stated this in her interview. Yet, these assessments were not done until after R #77 suffered the injurious fall to her left shoulder, causing injury to an already weakened left side. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 04/13/2017 at 10:22 AM, the DON acknowledged that harm due to the resident's fall with injury, occurred for this resident. During an interview with the Medical Director on 4/21/17 at 8:30 AM, she stated the communication piece was something they are looking to improve, and mentioned the SBAR method as an example on how to improve communication amongst the staff. The facility failed to fully assess the resident's known pre-disposition to frequent falls concomitant with her clinical condition/status on admission. There was an additional failure in communicating Staff #13's plan/recommendations and failure to immediately implement interventions into the resident's care plan to assure staff would be alerted to the resident's care needs. This failure may have contributed to the resident's subsequent fall and left shoulder injury on 3/25/17.",2020-09-01
25,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,334,F,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with staff members and review of the facility's policy and procedure, the facility failed to ensure 5 (Residents #70, #63, #34, #56 and #57) of 5 residents sampled for immunization had the opportunity to refuse the influenza vaccine. The resident's medical record does not include documentation that the resident or resident's representative was provided with education regarding the benefits and potential side effects of the influenza immunization and the resident received the immunization or refused the vaccination. Findings include: On 4/10/17 the facility provided a copy of the the policy and procedures for Vaccination Pneumococcal and Influenza Inpatient Protocol. The procedure includes if a resident is indicated for the vaccine, the facility will provide the :Vaccine Information Statement (VIS) and will review the appropriate VIS with the resident prior to the administration of the vaccine. The required documentation includes: patient/family education; the date of administration of the pneumococcal vaccine; amount and dosage given; the site of injection; the vaccine manufacturer; the lot number of the vaccine used; the expiration date of the vaccine; and signature of licensed nurse administering the vaccine. The policy did not include provision for the resident or resident's representative to refuse immunization. On 4/13/17 at 9:00 [NAME]M. an interview was conducted with the Director of Nursing (DON) and Staff Member #122. The staff members reported the process for immunizations include sending a letter to the resident or resident's representative to offer the vaccine with the VIS attached. The letters are sent out in (MONTH) and November. Staff Member #122 provided a sample of the immunization packet that is sent to the resident or resident's representative. The letter was reviewed during the interview which notifies the resident or resident's representative that All residents at (facility name) are scheduled to receive: flu vaccine annually; tetanus/[MEDICATION NAME] vaccine - given every [AGE] years, or as medically necessary; tetanus/[MEDICATION NAME]/peruses ([MEDICATION NAME]) - given one time for adults [AGE] years or older; and pneumococcal (a type of pneumonia) - given at age 65 with a second for those people aged 65 and older who got their first does under the age of 65 if five or more years have passed. The letter also documents that the physician has ordered these vaccines and will administer as ordered unless contraindicated. There was no information related to declination of the vaccines. Upon review of this letter, the DON stated the letter informs the recipient of the letter of the right to refuse the vaccines. Staff Member #122 reviewed the letter and confirmed there is no information regarding declining administration of the vaccines. Staff Member #122 reviewed the VIS documents in the packet and found the information statement for the [MEDICATION NAME] vaccine was dated 2/24/2015 which indicates the date when the form was updated, acknowledging the form may have been revised since (YEAR) and the facility may not be providing the most current information (VIS) related to vaccines. The inconsistent process for the five sampled residents was shared during this interview. The inconsistencies included letters that were not dated, letters that were dated and not signed, no documentation education was provided to the resident or resident's representative and no opportunity for the resident to refuse the immunization. Staff Member #122 commented the facility will definitely tighten the process for immunizing the residents. 1) On 4/11/17 an interview and concurrent record review was done for Resident #63 with Staff Member #155. Staff Member #155 confirmed the resident received the flu vaccine on 10/7/16 and the [MEDICATION NAME] on 6/18/16. The staff member reported the resident or representative is provided with information regarding the vaccine on admission then once a year the resident or representative is contacted. The staff member reported staff members are to document in the progress note that education was provided. The staff member referred to the Interdisciplinary Patient/Resident and Family Teaching Record form that documents education was provided to the resident or resident's representative. The staff member could not find documentation on the form that education was provided to the resident and/or representative. The staff member also reviewed the progress note and confirmed there was no documentation in the progress notes related to education and there was no documentation that the resident and/or representative had an opportunity to decline the vaccine. Further review found a letter dated 6/15/16 regarding vaccines informing residents that vaccines (annual influenza vaccine, tetanus/[MEDICATION NAME] and peruses and a pneumococcal vaccine) will be ordered by their physician. Also noted was an enclosed CDC Fact Sheets. This letter was not signed by the Acting DON. This letter was not the same letter that was included in the packet provided by the DON and Staff Member #122. There was documentation of a second letter dated 7/19/16 which was signed by the Acting DON. The letters sent to the resident or resident's representative did not include information to refuse vaccines. 2) On 4/12/17 at 8:52 [NAME]M. an interview and concurrent record review was done for Resident #34 with Staff Member #155. The review found a letter dated 6/15/16 regarding vaccines that will be ordered by the physician which was not signed by the Acting DON. There was another letter dated 7/19/16 which was signed by the Acting DON. The letter in the resident's medical record was not the same letter provided by the staff members during the interview. Subsequently, Staff Member #155 found the Interdisciplinary Patient/Resident and Family Teaching Record which documents on 6/30/16, 8/30/16 and 9/8/16 education was provided regarding vaccinations to the resident. The documentation on this form consisted of the staff member writing the number 8 for vaccinations in the topic/learning objectives column. There was no progress note to document the specifics of the education that was provided. A review of the physician's orders [REDACTED]. There was no documentation that the resident had an opportunity to refuse the vaccine. 3) A review of Resident #70's medical record on the morning of 4/11/17 at 2:55 P.M. revealed she received the Influenza vaccine for the (YEAR) flu season on 10/5/16. The documentation regarding the vaccine was incomplete and did not show how the facility discussed the risks and benefits with Resident #70's Power of Attorney (POA) for receiving the flu vaccine. An interview of the Nurse Manager on the afternoon of 4/11/17 at 2:55 P.M. revealed the facility did not educate the POA for the risks/benefits of the Influenza vaccine. 4) On 4/12/17, a chart review of Resident #56's (R #56) immunization status for influenza and pneumococcal vaccines was done. There was no clinical documentation to show the resident or the resident's representative received the vaccine information statements, including the benefits and risks of both immunizations, and the administration or the refusal of, or medical contraindications to the vaccines. In addition, the vaccine information statements (VIS) forms sent out were for the (YEAR) year, and not the current year for (YEAR). On 04/13/2017 at 7:21 AM, Staff #108 confirmed for R #56, she had received verbal consent from the resident's guardian to administer the vaccines. Staff #108 verified however, there was no documentation in the resident's progress notes about the verbal consent. Staff #108 also said the teaching record the facility used to chart when the VIS was sent out was a process being done on every unit. She acknowledged both the consent and/or declination had to be documented, but that it was not done. 5) In the morning of 4/15/2016 a concurrent record review was done with Staff #58 for Resident #57. Res #57 received an influenza vaccine in (YEAR). Staff #58 was asked to show evidence of the influenza vaccine education provided to resident #57 or POA prior to administration of the vaccine. Staff #58 showed a facility paper in the resident record with a checkmark to topic #8 verbal paperwork sent to family 7/20/16. When asked for evidence for consent for immunization. Staff #58 stated a telephone call was made to the resident's son around that time and the son agreed to the vaccine for the resident. There was no written evidence provided by staff for consent for vaccination or education on side effects and benefits of the vaccine. Failure to provide documented education on the vaccine side effects and benefits; and consent to vaccinate prior to vaccination potentially violates the resident's informed consent rights.",2020-09-01
26,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,353,F,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews, and facility policy reviews, the facility failed to provide sufficient nursing staff based on the staff's inability to provide the necessary care and services based on the resident assessments to ensure each resident is able to reach their highest practicable physical, mental and psychosocial well-being. Findings include: During the interview with the NHA and DON on 04/13/2017 at 10:22 AM, the NHA agreed they have had a staffing problem such that per the DON, the need for coverage was so great, due to the transition and sick calls. The DON also said they were often short 38% of their staff. The NHA said by not having a quality nurse position filled for about 1.5 years, they have seen doubling up of responsibilities with their remaining staff, which has led to a lack of identification of opportunities (for improvement) and they have become more reactive than proactive. The NHA also said it included the communication piece as well. The DON further stated with a 13 week turnover interval for the [MEDICATION NAME] (out of state travel nurses and nurses aides), there was less consistency in the delivery of care to their residents. She stated the real issues thus were not being addressed. The cumulative findings in the areas of Resident Rights, Resident Behavior and Facility Practice, Quality of Care, Quality of Life and Pharmacy Services demonstrates widespread concerns, including harm and substandard quality of care, which are interdisciplinary and includes nursing and administrative services. This deficiency is directly related to the lack of an effective quality assurance and assessment program, to which it is cross-referenced at F520. It is also evidenced and cross-referenced to the survey findings at F157, F221, F279, F280, F281, F323, F334, F371, F425, F431, F441 and F490.",2020-09-01
27,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,371,E,0,1,1M3411,"Based on observations, staff interviews and facility policy review, the facility failed to maintain a walk in refrigerator and walk in freezer to ensure proper food storage. Findings include: An initial tour of the kitchen on the morning of 4/10/17 at approximately 9:30 [NAME]M. found a walk-in refrigerator and the walk in freezer both of which didn't latch when the door was left to shut on it's own. When shutting the door, the door did not completely shut until a staff member pressed it against the door frame. The top edge of the refrigerator door appeared uneven, sloping downward from left to right. At the top of the door, the space between the left side of the walk in refrigerator door and the refrigerator door frame had a gap of approximately 2 inches and narrowed toward the bottom to approximately 0.75 inches. The temperatures for the walk in refrigerator were maintained at or below 41 degrees. However, the possibility for the temperature to rise above 41 degrees was high based on the necessity for the the staff to push the door shut. In addition to the walk in refrigerator, the walk in freezer also did not latch when the the door was left to shut on it's own. A sign was taped to the freezer door to remind staff to push the door shut. When shutting the freezer door, the door did not completely shut until a staff member pressed it against the door frame. The edge of the freezer door appeared uneven, sloping downward from left to right. At the top of the door, the space between the left side of the walk in freezer door and the freezer door frame had a gap of approximately 2 inches and narrowed toward the bottom to approximately 1 inch. A gray strip around the freezer door was loose at the corner. The Maintenance staff re-glued the gray strip until it was permanently fixed. Additionally, the floor was wet under the door to the walk in freezer. Staff #12 reported that she thought the wetness was from condensation. The temperatures for the walk in freezer were maintained at or below 0 degrees. However, the possibility for the temperature to rise above 0 degrees was high based on the necessity for the staff to push the door shut. A review of the walk in refrigerator and walk in freezer temperature logs on the morning of 4/13/17 revealed the temperature levels for (MONTH) and (MONTH) (YEAR) were maintained within acceptable ranges. The foods in the freezer were frozen solid without any thaw. An interview of Staff #12 on the morning of 4/12/17 revealed the facility was aware that the walk in refrigerator and walk in freezer doors were not working properly. Staff #12 further noted the kitchen staff taped a sign to the walk in freezer door indicating the door was malfunctioning for an unspecified amount of time. As of survey date, 4/13/17, the facility had not contracted a vendor to assess the doors of the walk in refrigerator and walk in freezer. A review of the facility's policy titled, Food Storage and Preparation with revision date of 10/2015 revealed, (11) Preventive refrigerator, freezer, and ice machine maintenance to be provided routinely and as needed by contacting food service supervisor. The facility failed to maintain the doors for one of the walk in refrigerators and the walk in freezer.",2020-09-01
28,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,425,F,0,1,1M3411,"Based on observations, interviews, and policy reviews the facility failed to utilize the pharmacy for consultation services on all aspects of the provision of pharmacy services in the facility. Findings includes: Cross to F 431 1) On 4/12/2017 at 10:40 AM interviewed Staff #116 regarding the procedure for discarding discontinued narcotics. Staff #116 stated that liquid narcotics are disposed into the drain and the controlled pills are discarded into the sharps container. The policy for disposal of discontinued narcotics was provided by Staff #116 and reviewed. The policy dated 12/12 stated: 1. The director of nursing and the consultant pharmacist will monitor for compliance with federal and state laws and regulations regarding the disposal of medications. The nursing care center should maintain approved containers to separate and securely store different types of pharmaceutical waste until it is scheduled for pick up. b. Authorized personnel who have access to medications should deposit pharmaceutical waste in the appropriately labeled container. Each container used to collect, separate and store each type of pharmaceutical waste will be labeled with the type of waste to be stored in the container. 2. Controlled Substances listed in Schedules II, III, IV and V remaining in the nursing care center after the order has been discontinued are retained in the nursing care center - until destroyed as outlined by state regulation. a. Transfer to a container for release to a pharmaceutical waste contractor, was checked off on the policy. At 1:36 PM the same day interviewed the DON regarding nursing practice for disposal of discontinued resident narcotics. The DON shared the policy for disposal of controlled drugs used on the nursing floors dated 12/12 is old, a new policy dated 5/16 is on line but has not been changed in the PharMerica policy binders used by the nursing staff. At 1:41 PM the same day interviewed Staff #108 regarding disposal of narcotics procedure. Staff #108 stated the narcotics are popped out of the blister pack and thrown into the sharps container, sometimes the pills are crushed. The liquid narcotics are poured onto a paper towel and discarded. Later that afternoon contacted the pharmacist consult (Staff #181) for the facility. When asked the recommendation and policy for disposal of controlled medications at the facility Staff #181 shared, the pharmacist does not have a role in narcotics disposal, once the medication leaves the pharmacy it belongs to the resident, nothing is returned to the pharmacy. Upon request from the facility pharmacy can advise the facility on discarding controlled medication. When informed about the practice of throwing away discontinued narcotics in the sharps containers or down the drain Staff #181 stated, we don't look at that; we are more concerned with out of date drugs. A review of the pharmacy contract titled 'Hawaii Health Systems Corporation Agreement for Goods or Services Based Upon Competitive Sealed Proposals states 2.12 Provide experienced, trained Geriatric Consultant Pharmacist to perform the following services: As per CMS requirements provide assistance with tracking, destroying; and reconciling unused controlled substances. Failure to provide pharmacy consultative services for discontinued controlled substances may potentially provide opportunity for misuse of controlled discontinued substances. 2) On 4/12/2017 at 10:40 AM reviewed the temperature log on the 3rd floor of the facility. The log titled MEDS Refrigerator/Freezer Temperature Log was printed REFRIGERATOR STANDARD: 33 degrees - 40 degrees FAHRENHEIT. The recorded refrigerator temperatures for (MONTH) (YEAR) was found to be documented at 34 degrees on (MONTH) 7 and (MONTH) 8, and at 35 degrees on (MONTH) 12, (YEAR). The refrigerator contained some of the following medications and amounts: Calcitonin Salmon Nasal Solution 1 box; Cathflor Activase a 2 mg vial; Biscodyl Suppository 13 packets; Acetaminophen Suppository 10 packets; Octreotide 50 mcg one box; Ativan vials, 4 bags with 5, 3, 5, and 5 vials per bag. The printed manufacturers label recommended temperature storage at 36 - 46 degrees for the Octreotide, Calcitonin Salmon Nasal Solution and Ativan. The temperature log was concurrently reviewed with Staff #116. Staff #116 provided a printed copy of the facility policy titled, Refrigerator/Freezer Temperature control and Maintenance. The policy stated: Refrigerator standard range if 33 degrees to 40 degrees Fahrenheit. On the same day at approximately 11:06 AM the temperature logs for the 4th and 2nd floors were reviewed. Observed that all the units were using the same standard log with the incorrect temperature range of 33 to 40 degrees Fahrenheit. The refrigerator on the second floor was observed to have the following medications and amounts: pneumococcal vaccine premeasured syringes one box; Calcitonin Salmon Nasal Spray 1 box; Influenza premeasured syringes 1 box; Tetanus 2 vials, and Ativan 3 vials. On 4/12/2017 at 1:49 PM pharmacy consultant (Staff #181) was interviewed by phone and asked about the effect of the drug temperature being at 35 degrees when the manufacturers recommendation is at 36 degrees. Staff #181 stated, one degree is not going to matter, even if the package says 36 degrees, it is OK. When asked if the manufacturer could be consulted for the medications found on the 2nd and 3rd floors stored below the manufacturers recommendation, Staff #181 stated a call would be made to the manufacturer but a response would not be available for a few days due to the time zones. Later that afternoon interviewed the DON regarding the discrepancy on the facility medication temperature log, the facility policy for refrigerated medications for storage range of 33 - 40 degrees versus the manufactures recommendation for refrigerated medications to be stored at 36 - 46 degrees. Also the concern for the efficacy of the medications stored out of temperature range. The DON shared the policy and logs were revised on 12/2016. Requested copies of the temperature logs for the past 4 months from (MONTH) (YEAR) to (MONTH) (YEAR) from all the nursing units for review. On 4/13/2017 at 3:49 AM contacted the drug manufacturers Merck, for the pneumococcal vaccine; Phizer for the Ativan vials; and Sagent Pharmaceuticals for the Octreotide vial. Each manufacturer interviewed was asked about the efficacy of the drug when stored below the recommended 36 - 46 degrees. Ativan stored below 36 degrees had no information or recommendations of use. The Octreotide drug stability studies indicated the drug was stable up to 3 months under the accelerated conditions. Accelerated conditions are described as below 36 degrees. The pneumococcal vaccine efficacy was determined by the total number of hours kept below the manufacturers recommended temperature. On 4/13/2017 at 7:30 AM obtained from the DON the collection of medication refrigerator temperature logs from (MONTH) (YEAR) to (MONTH) (YEAR) for the entire facility, which had been requested from the DON on 4/12/2017. The following temp logs provided were missing: 4 North - missing (MONTH) (YEAR) and (MONTH) (YEAR); 3rd floor - missing (MONTH) (YEAR). Review of the 2nd floor refrigerator log found that the pneumococcal vaccine had been stored below 36 degrees for 216 hours from Jan - (MONTH) (YEAR). At 7:48 AM spoke to the Merck manufacturer consultant by phone regarding the 216 hours the pneumococcal vaccine was stored below 36 degrees. Per the manufacturers recommendation, given the number of hours kept below 36 degrees the recommendation was not to administer the vaccine to any patients and remove the vaccine from inventory. The manufactures advise was shared with Staff #108 and the DON. Review of the facility policy for potency of medications titled Refrigerator/Freezer Temperature control and Maintenance date effective 12/2016 found that the policy was not signed as approved and reviewed by a PharMerica consultant. Review of the contract agreement between HHSC and the Pharmacy Corporation of America states: 2.0 Contractor Requirements. The contractor shall provide Long Term Care Pharmacy services pursuant to the provisions specified below: 2.1 Provide the facility with a comprehensive range of professional pharmaceutical services related to the use, storage, distribution and administration of medicines. Inconsistency of nursing staff practice in the proper disposal of controlled drugs; failure to update the PharMerica binder used on the floors by nursing staff on the disposal of controlled drugs; and failure to provide consultative pharmaceutical service for policy development and review in the area of medications stored in refrigerator/freezer has the potential for pharmaceutical errors.",2020-09-01
29,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,431,F,0,1,1M3411,"Based on observation, interviews, and policy review the facility failed to provide pharmaceutical services to meet the needs of each resident. Findings include: Cross reference to F 425 1) On 4/10/2017 at 11:50 AM observed an IV bag hanging for Resident #44. The IV bag was not labeled with a resident's name or dated. At 12:00 PM interviewed Staff #116 regarding the unlabeled IV bag. Staff #116 agreed the bag hanging should be labeled. Staff #116 shared Resident #44 receives TPN nourishment through her PICC line and after the TPN is infused an IV bag is hung until the line is flushed. Staff #116 brought out an unopened IV bag to show that the pharmacy label is attached to the outside plastic wrap of the IV bag, when the bags are opened the pharmacy label is discarded. Unlabeled medications has the potential for medication errors. 2) On 4/12/2017 at 8:13 AM observed an unlocked treatment cart with one drawer pulled out resting in the hall outside of the dining hall. The opened drawer contained ointments. There was no staff seen near or around the opened cart. Shortly after observed Staff # 116 came out of the dining room. Staff #116 was asked about the unattended, unlocked treatment cart with the treatment drawer opened. Staff #116 stated she went to check a resident and had left the cart unlocked. Staff #116 agreed the cart should have been locked. Unlocked treatment carts has the potential for medication loss and misuse. 3) On 4/12/2017 at 10:40 AM interviewed Staff #116 regarding the procedure for discarding discontinued narcotics. Staff #116 stated that liquid narcotics are disposed into the drain and the controlled pills are discarded into the sharps container. The policy for disposal of discontinued narcotics was provided by Staff #116 and reviewed. The policy dated 12/12 stated: 1. The director of nursing and the consultant pharmacist will monitor for compliance with federal and state laws and regulations regarding the disposal of medications. The nursing care center should maintain approved containers to separate and securely store different types of pharmaceutical waste until it is scheduled for pick up. b. Authorized personnel who have access to medications should deposit pharmaceutical waste in the appropriately labeled container. Each container used to collect, separate and store each type of pharmaceutical waste will be labeled with the type of waste to be stored in the container. 2. Controlled Substances listed in Schedules II, III, IV and V remaining in the nursing care center after the order has been discontinued are retained in the nursing care center - until destroyed as outlined by state regulation. a. Transfer to a container for release to a pharmaceutical waste contractor, was checked off on the policy. At 1:36 PM the same day interviewed the DON regarding nursing practice for disposal of discontinued resident narcotics. The DON shared the policy for disposal of controlled drugs used on the nursing floors dated 12/12 is old, a new policy dated 5/16 is on line but has not been changed in the PharMerica policy binders used by the nursing staff. At 1:41 PM the same day interviewed Staff #108 regarding disposal of narcotics procedure. Staff #108 stated the narcotics are popped out of the blister pack and thrown into the sharps container, sometimes the pills are crushed. The liquid narcotics are poured onto a paper towel and discarded. Later that afternoon contacted the pharmacist consult (Staff #181) for the facility. When asked the recommendation and policy for disposal of controlled medications at the facility Staff #181 shared, the pharmacist does not have a role in narcotics disposal, once the medication leaves the pharmacy it belongs to the resident, nothing is returned to the pharmacy. Upon request from the facility pharmacy can advise the facility on discarding controlled medication. When informed about the practice of throwing away discontinued narcotics in the sharps containers or down the drain Staff #181 stated, we don't look at that; we are more concerned with out of date drugs. A review of the pharmacy contract titled 'Hawaii Health Systems Corporation Agreement for Goods or Services Based Upon Competitive Sealed Proposals states 2.12 Provide experienced, trained Geriatric Consultant Pharmacist to perform the following services: As per CMS requirements provide assistance with tracking, destroying; and reconciling unused controlled substances. Failure to provide pharmacy consultative services for discontinued controlled substances may potentially provide opportunity for misuse of controlled discontinued substances. 4) On 4/12/2017 at 10:40 AM reviewed the temperature log on the 3rd floor of the facility. The log titled MEDS Refrigerator/Freezer Temperature Log was printed REFRIGERATOR STANDARD: 33 degrees - 40 degrees FAHRENHEIT. The recorded refrigerator temperatures for (MONTH) (YEAR) was found to be documented at 34 degrees on (MONTH) 7 and (MONTH) 8, and at 35 degrees on (MONTH) 12, (YEAR). The refrigerator contained some of the following medications and amounts: Calcitonin Salmon Nasal Solution 1 box; Cathflor Activase a 2 mg vial; Biscodyl Suppository 13 packets; Acetaminophen Suppository 10 packets; Octreotide 50 mcg one box; Ativan vials, 4 bags with 5, 3, 5, and 5 vials per bag. The printed manufacturers label recommended temperature storage at 36 - 46 degrees for the Octreotide, Calcitonin Salmon Nasal Solution and Ativan. The temperature log was concurrently reviewed with Staff #116. Staff #116 provided a printed copy of the facility policy titled, Refrigerator/Freezer Temperature control and Maintenance. Purpose: To maintain proper temperatures for food safety and potency of medications. The policy stated: Refrigerator standard range if 33 degrees to 40 degrees Fahrenheit. On the same day at approximately 11:06 AM the temperature logs for the 4th and 2nd floors were reviewed. Observed that all the units were using the same standard log with the incorrect temperature range of 33 to 40 degrees Fahrenheit. The refrigerator on the second floor was observed to have the following medications and amounts: Pneumococcal vaccine premeasured syringes one box; Calcitonin Salmon Nasal Spray 1 box; Influenza premeasured syringes 1 box; Tetanus 2 vials, and Ativan 3 vials. On 4/12/2017 at 1:49 PM pharmacy consultant (Staff #181) was interviewed by phone and asked about the effect of the drug temperature being at 35 degrees when the manufacturers recommendation is at 36 degrees. Staff #181 stated, one degree is not going to matter, even if the package says 36 degrees, it is OK. When asked if the manufacturer could be consulted for the medications found on the 2nd and 3rd floors stored below the manufacturers recommendation, Staff #181 stated a call would be made to the manufacturer but a response would not be available for a few days due to the time zones. Later that afternoon interviewed the DON regarding the discrepancy on the facility medication temperature log, the facility policy for refrigerated medications for storage range of 33 - 40 degrees versus the manufactures recommendation for refrigerated medications to be stored at 36 - 46 degrees. Also the concern for the efficacy of the medications stored out of temperature range. The DON shared the policy and logs were revised on 12/2016. Requested copies of the temperature logs for the past 4 months from (MONTH) (YEAR) to (MONTH) (YEAR) from all the nursing units for review. On 4/13/2017 at 3:49 AM contacted the drug manufactuers Merck, for the Pneumococcal vaccine; Phizer for the Ativan vials; and Sagent Pharmaceuticals for the Octreotide vial. Each manufacturer interviewed was asked about the efficacy of the drug when stored below the recommended 36 - 46 degrees. Ativan stored below 36 degrees had no information or recommendations of use. The Octreotide drug stability studies indicated the drug was stable up to 3 months under the accelerated conditions. Accelerated conditions are described as below 36 degrees. The Pneumococcal vaccine efficacy was determined by the total number of hours kept below the manufacturers recommended temperature. On 4/13/2017 at 7:30 AM obtained from the DON the collection of medication refrigerator temperature logs from (MONTH) (YEAR) to (MONTH) (YEAR) for the entire facility, which had been requested from the DON on 4/12/2017. The following temp logs provided were missing: 4 North - missing (MONTH) (YEAR) and (MONTH) (YEAR); 3rd floor - missing (MONTH) (YEAR). Review of the 2nd floor refrigerator log found that the Pneumococcal vaccine had been stored below 36 degrees for 216 hours from Jan - (MONTH) (YEAR). At 7:48 AM spoke to the Merck manufacturer consultant by phone regarding the 216 hours the Pneumococal vaccine was stored below 36 degrees. Per the manufacturers recommendation, given the number of hours kept below 36 degrees the recommendation was not to administer the vaccine to any patients and remove the vaccine from inventory. The manufactures advise was shared with Staff #108 and the DON. Review of the facility policy for potency of medications titled Refrigerator/Freezer Temperature control and Maintenance date effective 12/2016 found that the policy was not signed as approved and reviewed by a PharMerica consultant. Review of the contract agreement between HHSC and the Pharmacy Corporation of America states: 2.0 Contractor Requirements. The contractor shall provide Long Term Care Pharmacy services pursuant to the provisions specified below: 2.1 Provide the facility with a comprehensive range of professional pharmaceutical services related to the use, storage, distribution and administration of medicines. Failure to properly label medication; failure to secure and lock treatment cart inventory; inconsistency of nursing staff practice in the proper disposal of controlled drugs; failure to update the pharmMerica binder used on the floors by nursing staff on the disposal of controlled drugs; and failure to provide consultative pharmaceutical service for policy development and review in the area of medications stored in refrigerator/freezer has the potential for pharmaceutical errors.",2020-09-01
30,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,441,F,0,1,1M3411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with staff member, the facility failed to establish and maintain an effective infection prevention and control program including the tracking and analyzing of outbreaks of infection. Findings include: 1) On 4/13/17 at 9:00 [NAME]M. an interview was conducted with the Director of Nursing (DON) and Staff Member #122. The staff members were asked how they collect, trend and analyze their data related to infection control. Staff Member #122 reported the nurses will submit infection surveillance forms to report any concerns regarding infections as well as discuss infection issues in daily rounds. This information is collected for data and reviewed for trends. The staff member also reported the infection program also tracks the immunization process. The DON and Staff Member #122 confirmed the facility had an outbreak of Norovirus in (MONTH) (YEAR). The Norovirus reportedly was isolated to the 4th floor; however, a resident on the 3rd floor also had Norovirus. Further queried whether the facility determined the source of the Norovirus outbreak. Staff Member #122 responded it's impossible to figure it out; however, the facility makes note if a cruise ship was in the port and possibly the Norovirus may have come from the children visiting from the school or a staff member being infected from their child. The data and trends collected by the facility were not specific enough to identify the origin of the Norovirus. A request was made to review their infection log/data. The facility provided data from (MONTH) (YEAR) through (MONTH) 6, (YEAR). The data included the resident's name, medical record number, room number, type of infection, culture, antibiotic and comment. The staff members were queried whether the infection control program determines whether infections were hospital or community acquired. The response was they did not think this is part of the policy to track whether infections are hospital or community acquired. Further discussion confirmed the facility does not perform root cause analysis of infections. The facility did not develop an infection prevention and control program which includes analysis of outbreaks of infection (root cause analysis) to formulate corrective action and plan for continued prevention. 2) On 4/12/2016 at 8:40 AM observed Staff #180 prepare 2 prefilled syringes of normal saline and 2 prefilled syringes of [MEDICATION NAME] to do a PICC line flush for Resident #44. Staff #116 was present orientating Staff #180. Staff #180 opened the individual packaging of each syringe and placed all of the syringes on top of the resident's bed with no protective barrier between the bedding and the syringes. Staff #116 picked up all of the syringes on the bed and failing to wipe the table or use a protective barrier, placed the syringes on the resident's over bed table. Observed Staff #180 use each syringe to do the PICC line flush. After the procedure an interview was held with Staff #116 and Staff #180, regarding use of a protective barrier for the clean syringes. Staff #116 agreed a protective barrier should have been used for infection control practice. Failure to maintain a clean working environment when administering medications has the potential for development and transmission of infection. 3) On 4/12/2016 at 9:04 AM observed Staff #180 do a PICC line flush for Resident #44. Staff #116 was present orientating Staff #180. The PICC line had two ports. Staff #180 opened one line, did an alcohol wipe to the needleless hub, inserted the normal saline syringe tip into the hub, and pushed the normal saline flush through the PICC line. Staff #180 then disconnected the normal saline syringe and without doing an alcohol wipe to the hub connected a [MEDICATION NAME] syringe tip and pushed the [MEDICATION NAME] solution through the PICC line. Staff #180 then opened the second PICC line, wiped the PICC port with alcohol, connected the normal saline syringe and pushed the normal saline into the line. Staff #180 then disconnected the syringe and without doing an alcohol wipe connected a [MEDICATION NAME] syringe into the hub and pushed the [MEDICATION NAME] solution into the line. After the observation interviewed Staff #116 on the observation. Staff #116 was asked if an alcohol wipe should have been done prior to the [MEDICATION NAME] flush for each line. Staff #180 stated, no need to do the wipe because the port is still clean. A concurrent review of the facility policy was done with Staff #180. The policy for IV Site Care and Maintenance. Procedure 4. states, Scrub needleless injection cap prior to each entry with alcohol. Failure to do the recommended alcohol cleanse prior to each entry into the needleless IV port has the potential for development and transmission of infection. 4) On 04/10/2017 at 12:46 PM, during observation of the second floor nursing unit's lunch service, Staff #140 was observed sitting next to Resident #4 (R #4). Staff #140 was feeding the resident while she sat in bed. This resident had a contact isolation sign posted at the entrance to her room. The sign stated, Stop Check with nurse before entering room .Wear Gloves for all contacts, Wear Yellow Gown within 3 feet, If splashing possible wear face shield . The Nursing Home Administrator (NHA) was standing in the hallway with the surveyor and confirmed surveyor's observation that Staff #140 was not wearing any personal protective equipment (PPE), such as a disposable gown and gloves while assisting the resident to eat. The NHA asked the staff to stop feeding the resident and to wash her hands and come out of the room to wear the appropriate PPEs. Surveyor queried Staff #140 and asked why she was not wearing any PPEs. Staff #140 replied, I think when you're feeding, not supposed to. All I hear is we use iso gowns, gloves, mask when we doing patient care. The NHA told Staff #140 that it includes feeding this resident, and asked the staff to wear the appropriate PPEs before returning to the resident's bedside. On 04/10/2017 at 12:51 PM, the Staff #108 stated there was a new order from R #4's attending physician that said staff was to gown only for peri-care, but acknowledged the signage did not reflect that. Staff #108 also said the attending physician wanted to ensure the family who visits daily during dinner would be able visit without wearing the PPEs as a quality of life matter for this [AGE] year old resident. The NHA pointed out this was inconsistent for the staff as to what they are supposed to be following for contact isolation, and if there was any breach because of not wearing the PPEs, then there was a potential risk for transmission to others, such as other residents, staff and her visitors. On 04/11/2017 at 9:46 AM, chart review found the (MONTH) (YEAR) Physician's Order Statement said the resident is on contact isolation from 8/15/16 for a [DIAGNOSES REDACTED]. On 04/12/2017 at 9:42 AM, the DON provided their policy and procedure, Isolation Precautions, No. 125-400-040. It stated, V. [NAME] Contact Precautions: These precautions are to be used to reduce the risk of transmission of resistant microorganisms by direct or indirect contact with a patient and/or patient's environment .CDC recommends continuing Contact Precautions routinely for ALL patients colonized or infected with MDROs. Gowns and gloves should be worn at a minimum. Masks are worn if splashes or projectile secretions are possible .HCWs (Health Care Workers) should always explain the necessity of PPEs and expanded precautions to the patient, patient's family and visitors. The facility failed to ensure staff followed the contact isolation precautions increasing the risk and potential for transmission of disease.",2020-09-01
31,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,490,F,0,1,1M3411,"Based on record review, interviews and review of the facility's policies and procedures, the facility failed to ensure it is administered in a manner that enables it to use its resources effectively and efficiently in order for the residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Finding includes: There is non-compliance with this regulation based on the deficient findings/outcomes in the areas of Resident Assessment, Quality of Care with substandard quality of care and harm for R #77, Quality of Life, Nursing Services and Pharmacy services. This is evidenced and cross-referenced at F157, F221, F279, F280, F281, F323, F334, F353, F371, F425, F431, F441 and F520. Inclusive are the survey observations, interviews, record reviews, and reviews of the facility's policies and procedures. Per interview with the NHA on the morning of 4/21/17, he acknowledged the preliminary survey findings and stated that aside from the transition period the long term care unit is going through, he attributes the lack of an effective QAPI (quality assurance and performance improvement) program to have been a factor that may have prevented the facility to have identified these care related issues found by the State Agency. The NHA also stated they have taken steps to remedy how quality improvement measures and policy making will be addressed by their governing body in the future.",2020-09-01
32,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2017-04-21,520,F,0,1,1M3411,"Based on observations, record review, interviews and review of facility policies, the facility failed to maintain an effective quality assessment and assurance (QA&A) committee which included analyses of identified performance improvement activities, including specific standards for quality of care and related outcomes for their residents. Finding includes: On 04/13/2017 at 10:22 AM, an interview with the NHA, DON and Staff #122 was done. They were asked about their quality assurance/performance improvement (QAPI) plan and what quality care areas were being reviewed. The DON stated each department attends their QAPI meetings to discuss department specific PI projects. The DON said they also review the Casper Report and what their triggers were. The NHA stated they also reviewed their audits on documentation, such as the prior survey's bathing citation as an example. The NHA said the nurse managers were actively involved in the audits as well. The DON and NHA concurred however, that most of their PI work has been focused on the transition process with their facility to transfer management to a new entity effective 7/1/17. Despite knowing the needs of the long term care unit and the need to maintain the quality of care, they both acknowledged their focus has been directed on the lack of staffing related to the transition. The NHA said their QAPI meetings entailed more of a review of the Casper Report in aggregate and were general discussions about their dashboard. They acknowledged the State Agency's preliminary quality concerns found during the survey, but yet were unable to demonstrate they had identified similar concerns, or any new concerns using their own PI methodology to demonstrate an effective PI program. Thus, based on the State Agency's clinical outcomes and quality concerns, the facility failed to demonstrate areas of quality performance improvement measures, including the identification of, or monitoring the effect of any implemented changes and with improvements to their action plans. The facility's primary focus has been on the transition process, however, the outcomes found in the areas such as Resident Assessment and Quality of Care was not identified in their on-going quality improvement process. Cross-reference to findings at F157, F221, F279, F280, F281, F323, F334, F353, F371, F425, F431, F441 and F490.",2020-09-01
33,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2019-05-31,657,D,0,1,IFL211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review (RR) and observation, the facility failed to revise/update changes in the care plan for three of 18 residents (R16, R6, and R279) in a timely manner. Care planning drives the type of care a resident receives. Because of this deficient practice, interventions and monitoring to promote effective continuity of care to safeguard against adverse events may not have occurred. This has the potential to affect all other residents in the facility. Findings include: 1)Interview on 05/29/19 at 09:09 AM with resident (R)6 who states sometimes my bowel movement is like a golf ball and sometimes I drop one or two and sometimes I go six or seven times a day and it is like golf balls . They are not giving me anything for the bowel movement. Record Review (RR) on 05/30/19 at 09:19 AM reveals doctors orders for 1) [MEDICATION NAME] evacuation 10 mg suppository. 2) Milk of Magnesia (Mom) in evening if not adequate bowel movement for to days. 3) Enema use one rectally whenever necessary if no/inadequate bowel movement for two days. RR and concurrent interview with Nurse manager, staff(S)2 on 05/31/19 at 10:02 AM shows no care plan was developed for constipation. This was confirmed with S2. 2) RR of R16 revealed she was taking an anticoagulant/blood thinner (Xarelta) for a [DIAGNOSES REDACTED]. She was transferred to an acute care hospital on [DATE] for possible [MEDICAL CONDITION]. The blood thinner was discontinued at that time. R16 was readmitted to the facility on [DATE]. She was restarted on the blood thinner after her condition stabilized on 02/28/19. Review of R16's care plan failed to reveal any goal, interventions, or monitoring for complications related to the blood thinner. On 05/30/19 at 09:23 AM, during an interview with Unit Manager (UM1), queried if R16's care plan included monitoring for complications of a blood thinner. UM1 said, the care plan wasn't updated. UM1 agreed monitoring R16 for complications related to the blood thinner should be in the care plan. On 05/30/19 at 01:51 PM UM1 provided a copy of an updated care plan for R16 that included Risk for Hemodynamic Instability R/T . use of Xarelto. 3) RR revealed R279 had a stroke with left [MEDICAL CONDITION] (loss of some motor function) and needed assistance with activities of daily living. R279's progress notes revealed the following: 05/16/19 at 02:30 PM entry by PT aide, patient found asleep in w/c (wheel chair) with left arm caught in w/c . 05/23/19 at 06:55 AM entry by PT aide, Lap/arm tray put on left arm rest to increase patient safety due to arm (left) getting caught in wheel. Nursing educated on importance of using tray and to only remove for meals RR revealed no progress notes of skin assessment after the two incidents that R16 caught his arm in the wheelchair, and R279's care plan did not include the intervention of the lap/arm tray implemented by PT aide. 05/29/19 an entry was made to R279's care plan, Left arm tray remove at meals. 05/30/19 09:04 AM during an interview with UM1, reviewed R279's progress notes and care plan. UM1stated, theres not an incident report because there was no injury. UM1 also stated, I was not aware of the first incident. On 05/30/19 at 09:45 AM, observed R279 while receiving physical therapy. It was observed that R279 had limited use of his left arm. An interview was conducted at that time with the PT aide (PT) that witnessed R279's arm caught in the w/c. She stated, He (R279) often leans to the left and left arm drops to the side. The lap tray was put on to help prevent this from occurring. When asked what the liklihood was that R279 could dislodge his arm without help, she replied, He probably couldn't. On 05/30/19 at 10:06 AM during an interview with the Occupational Therapy Manager (OT), she stated, I didn't know about it (the incidents R279 caught his arm in w/c) until yesterday. PT is a [MEDICATION NAME] and just started. Nursing is being trained to keep the lap tray on the w/c except at meal time. When asked what should have occurred, OT stated, It should have been reported to me the same day, and we would have monitored him. If not a one-time incident, it should be put in the care plan, and staff educated.",2020-09-01
34,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2019-05-31,686,G,0,1,IFL211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to intervene in a timely manner when the resident refused to remove compression gloves to left hand for five days. As a result of this deficient practice, R54 out of two sampled residents (R54 and R23) developed a Stage 4 pressure ulcer to the left fifth digit. Findings include: Observation on 05/30/19 at 12:03 PM of R54's dressing change with Staff(S)1. S1 stated, R54 acquired the wound in the hospital and his finger was amputated. R 54 wears compression gloves for [MEDICAL CONDITION] arthritis associated with joint pain in his hands. R54 had compression gloves on and would refuse to take them off or let the nurses monitor his hand and it was too late. Record Review on 05/30/19 at 01:01 PM shows in the past, R54 requested that his 4th finger on left hand be removed due to contracture, pain and a buttonneire deformity. Treatment record of doctors orders written on 01/14/18 to monitor both hands for impaired skin integrity twice a day. (Gloves off 04/13/19). Treatment record comments shows on 4/08/19 the resident declining to remove gloves up until 04/13/19. On 04/13/19, documentation stating wound skin impaired noted to left 5th digit. Doctor notified. From that point on, gloves were off. Progress notes dated 04/13/19 states R54 was complaining of pain to touch to left 5th digit of left hand. Resident did not want to remove gloves at first. Resident removed it later and left 5th digit by flexor/crease with wound open 1.3 centimeter length. Whitish, pink with scant bleeding. Cleansed with normal saline and covered. Called doctor at 10 AM and informed of open wound to left 5th digit. Keep clean and open to air. Further RR reveals doctor visit on 04/13/19 at 1400. Doctors exam confirmed R54's left fifth finger with open wound at proximal interphalngeal (PIP) joint, tendon visible, wound moist, swelling and [DIAGNOSES REDACTED]. Appears to have infection and swelling and [DIAGNOSES REDACTED]. Interview on 05/30/19 at 04:03 PM with S2 who stated There was no documentation from 04/06/19 to 04/13/19 until the wound was discovered at Stage 4. No report or attempt to call the MD about the refusals. I think it should have been reported. He is a man who decide what he wants and does not want. The nurses should have reported. Interview on 05/30/19 at 04:14 PM with S3 who stated The gloves was an ongoing problem and when you would try to remove them, he would get upset. I did not let the doctor know that he was refusing to take the gloves off. He would become agitated with us. I feel that we could have discovered the wound earlier but the amputation was unavoidable. Interview on 05/30/19 at 04:30 PM with medical doctor who stated he has never been very cooperative. He wanted the 5th finger off and he wouldn't cooperate with treatment. It's possible that the pressure ulcer developed within the five days that he refused to take the gloves off. The facility failed to intervene in a timely manner by reporting refusal of treatment for [REDACTED].",2020-09-01
35,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2019-05-31,842,D,0,1,IFL211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have accurate information in the medical record of one of 18 sampled residents. The medical record for R61 had conflicting information on the Advanced Healthcare Directive (AD) and the Provider Orders for Life-Sustaining Treatment (POLST). An AD is a legal document used to provide guidance about what types of treatments you may want in case of a future unknown emergency. A POLST form is a medical order for the specific treatments you want during a medical emergency. A POLST form does not replace an advance directive, but they work together. Findings Include: A review of R61's Advanced Care Planning documents revealed the POLST and AD had conflicting information. The POLST (Section C, artificially administered nutrition) signed by Surrogate dated 01/31/13 includes an order for [REDACTED]. During an interview with Social Worker (SW1) on 05/29/19 at 01:44 PM, inquired what the process was to obtain advance directives on admission. She stated, most of our residents come from acute care and they do them there and send with the resident. If they do come from the community, the SW will ask on admission if they have one, and give them information in the admission packet. When asked who was responsible for viewing the content of the advanced care planning documents to ensure they matched, and she said, I'm not sure.",2020-09-01
36,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2018-06-22,584,D,0,1,GCA011,"Based on observation and interview, the facility failed to ensure the bedroom landing mats placed at the bedside was sanitary, safe and in good condition for 1 of 24 residents (R33). In addition, the facility failed to ensure the bathroom floor's black skid strips were in good condition for 1 of 24 residents (R56) and a dining room table was maintained in good, safe condition. Findings Include: 1) During the observation of Resident 33's (R33) bedside landing mat on 06/20/18 at 08:43 AM, it was found that both of the resident's beige colored landing mats had long cracks and tears throughout. As a result, some of the woven mesh underneath the beige cover could be seen. 2) During a bathroom observation 06/20/18 at 08:31 AM, it was found that R75's bathroom floor had large black skid strips that were peeled off and missing on four of the strips. 3) On 06/21/18 at 09:34 AM, during a concurrent room observation with Staff 5 (S5), she confirmed the beige floor mats for R33 were in disrepair, worn and torn. S5 said the mats needed to be replaced. S5 also concurred it did not present to be a safe and clean home environment, as there was a potential risk for falls due to the tears on the surface of the mats, and that the mats were potentially unsanitary due to the exposure of the woven material visible through the tears. 4) On 06/20/18 at 09:07 AM, R56 was observed holding onto the edge of a round table in the activity/dining room on 4 North. Portions of the table's white laminate type of siding were missing/torn off, leaving an uneven surface that could potentially affect (poke or scratch) one's skin. R56 gripped onto the side where the missing laminate was and used her hands to push and pull her wheelchair back and forth. No staff was present to observe her. On 06/21/18 at 09:52 AM, a concurrent observation of the activity/dining room on 4 North was done with S5. S5 verified there were portions of white siding missing on the table's edge. S5 said she did not want anything to cause injury to the residents and maintenance would be notified.",2020-09-01
37,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2018-06-22,689,D,1,1,GCA011,"> Based on observation, record review and interview, the facility failed to ensure the residents' environment remains as free of accident hazards as is possible, and each resident receives adequate supervision to prevent accidents for 2 of 38 residents (R56 and R31) reviewed. Findings Include: 1) On 06/19/18 at 11:18 AM, R56 was observed sitting at a table with oversized red Lego-type and wooden building blocks on it. The building blocks were being used by another resident, R71, who is blind. R56 had already grabbed one of the large red blocks and was trying to insert it into her mouth but it was too big. After licking it, she put it down on the table. She then grabbed a blue rectangular wooden block and tried to insert that large block into her mouth as well. S15 was in the hallway and was asked to observe R56. S15 intervened and said R56 was not supposed to be handling these building blocks. The blocks were pushed toward R71 without being sanitized and R71 resumed using them. S15 said it was not okay that R56 was found putting the big wooden block into her mouth or the other red blocks. S15 said they were only staffed with one aide and although their activity room got very crowded, it was how they're running us more now. S94 then moved R56 to her usual table in the adjoining room. S94 said the aide who had been sitting next to R56 left, and she was tending to residents on the other side. Observation found there are walls which separated the three adjoining rooms. As a result, staff attending to residents in the first TV room where most of the residents congregated, could not fully view the residents in the middle room by the round table against the wall. And, if staff were in the first room, they would not be able to see the residents in the third low stimulation room, unless the resident sat on the couch in the low stim room. Otherwise, their view was blocked by the side walls. Thus, when R56 was found with the building blocks in her mouth, although S94 was in the first room, she could not see R56 and had been busy attending to the residents in the first room. There was no staff supervising or watching R56. S94 stated, We only have one staff in here usually and it's really hard with just one staff. 2) R31's random observations and record review was done, including a review of a facility reported incident (FRI). It was revealed from interviews of S5, S1 and S2 on 6/21/18 that on the morning of 3/15/18, a night charge nurse (S23) who was assigned to R31's care on the 4th floor had taken a late dinner break. S5 stated there was a unit protocol already in placed for the night shift staff whereby breaks after 0500 (5:00 AM) were not allowed. S5 verified S23 did not follow the unit protocol and as the charge nurse that night, was to have followed it. Interviews with S1 and S2 revealed S23 was a newer nurse, had fallen behind on her paperwork and thus took a late dinner break on the morning of the incident. As a result, there was one less staff available on the unit. The two certified nurse aides had been attending to other residents when R31 fell at 5:20 AM, with the resident calling out for help after her fall. R31 was a fall risk and S5 said R31 calls out for help because she cannot use her call light. S5 said also at the time, it was when most of the residents were going to be getting up. The breaks cannot occur during the turns, so at 0430 and 0500 everyone starts going and at 0500, the residents start to get a little more restless. So should be no breaks at 0500. The staff should be on the unit. Thus a potential contributing factor was that S23 failed to follow the unit's protocol, leaving the unit short staffed when she should not have done so.",2020-09-01
38,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2018-06-22,725,D,0,1,GCA011,"Based on observation, record review and interview, the facility failed to ensure it has sufficient nursing staff to provide nursing and related services to assure resident safety and for each resident to attain or maintain the highest practicable physical, mental and psychosocial well-being for 11 of 24 residents (R56, R71, R31, R46, R75, R6, R39, R16, R30, R40 and R44) on one of the 4th floor nursing units. Findings Include: Cross-reference to findings at F689. On 06/19/18 at 10:55 AM, R56 was found in the hallway yelling out loud that she wanted to go to the activity room. Even after two minutes of yelling, no staff attended to her. At 10:57 AM, surveyor approached S15 who was standing by a medication cart at the end of the hallway. S15 stated S90 had just brought R56 into the hallway after toileting her. However, the resident remained yelling while trying to push her wheelchair forward, but could not move. S90 then attended to the resident and wheeled her into the activity room. The nursing unit's census included 24 residents. On 06/19/18 at 11:28 AM, there were ten residents in the activity room. There was one certified nurse aide (S94) who was attending to R75 at the time. One resident, R6, was loudly mumbling words over and over and tried to reach out and grab other people while sitting at her table. R71 was observed touching the wall, touching the building blocks in front of her and/or sat trying to move her wheelchair around. S94 was not able to either calm or attend to these residents one to one, as they were spread out in two of the adjoining rooms. Then after the incident with R56 whereby she was found trying to insert the large building blocks into her mouth, S94 stated, We only have one staff in here usually and it's really hard with just one staff. On 06/19/18 at 12:30 PM, during the lunch observation, it was found that R31 was able to feed herself. By 12:39 PM however, the spinach and beans were pushed toward the edge of her plate and ready to come off. The same observation was made earlier for R46 at 12:23 PM. R46 was using her left pointer finger to push her food onto her spoon so the food would not come off the edge of her plate. S15 observed this and concurred that these residents could benefit from a lipped or divided plate. No staff had observed R31 and R46's food coming off the edge of the plate as they were focused on delivering the meal trays to the residents and trying to feed those residents who needed closer monitoring and assistance. On 06/20/18 at 08:55 AM, observed R56 rocking back and forth in her wheelchair as if she wanted to move, but could not. R56 yelled out occasionally, and then quieted down. S97 said R56 rocks for comfort and liked to be by the window in the low stim room. However, during random observations of R56, she was often left alone with no meaningful activity. The low stim room however, was found to be a room where certain residents were left unsupervised because staff said it was to provide for a low stimulation environment. Yet, the observed outcome was that these residents (R56 and R39) were often left unattended with their needs not being assessed. At 09:07 AM, S97 stated in their activity room they had a lot of residents with dementia.with behavioral. S97 expressed that it was really hard to monitor them. S97 said they separated the residents out, such that the TV room had six residents, the middle room had two residents and the other adjoining low stim room had two residents, including R56. S97 said due to her own health status, she would have to call for back-up help, which would then leave the floor staff short of one more aide. On 06/21/18 at 09:38 AM, S5 said they have one person to monitor the three adjoining activity rooms. S5 acknowledged their activity room floor plan did not allow for visibility from one side to the other because of the walls. S5 said some of their residents who were known to be socially disruptive, made it difficult for only one staff to attend to all of these residents congregated in those rooms. S5 said because their unit had these socially disruptive residents, they were not brought up to attend the 5th floor group activities which residents of the other floors enjoyed. On 06/21/18 at 03:18 PM, an interview with S94 was done. S94 said often only about three of their residents attended the 5th floor large group activities. S94 said as soon as they (the three 4th floor residents) make noise they were brought down to the 4th floor right away due to their behaviors. S94 said as a result, one staff on their unit is always locked down to monitoring. S94 said although they may have four aides scheduled, only three aides could provide direct care since one person was assigned to the activity room to do unit activities with the residents. S94 said the unit activities were pretty much the same thing every day such as watching a DVD movie for those who can, and going to the low stim room for others. Random observations found it was the same routine for the residents as S94 described, but without enough staff to oversee the care for the majority of the residents placed in the rooms. On 06/21/18 at 03:42 PM, R39 was observed in the low stim activity room sitting alone in a wheelchair. R39 kept saying, Ah, ah, ah, ah, ah, both moaning and mumbling some illegible words. S51 was in the first large TV room assisting R16, and was unable to see R39. At 03:44 PM, S51 came into the low stim room from the hallway with R16 at her side. She saw R39 and said, what's wrong papa? but walked past R39, through the rooms and out into the hallway. R39's needs were not assessed as S51 did not attend to him with R16 at her side, nor did S51 ask for help. S51 walked into the low stim room again with R16, walked past R39 and had R16 sit at a table in the first room. At 03:48 PM, S51 was observed attending to R31 and to R71. R16 then tried to stand up and surveyor had to let S51 know what R16 was attempting to do. S51 quickly turned around as she was talking to R71, and said, Oh, wait! and then asked R16 if she wanted to walk again. At 03:51 PM, another aide came into the room; then a licensed staff at 03:52 PM. The staff however, were all situated in the first room where R31, R6 and R16 were. The licensed staff then walked into the low stim room where R39 was, but turned around and walked back to the first room. At 03:54 PM, S51 came to R39's side to ask if he was okay. Yet, S51 and other staff failed to attend to R39's needs when he had been moaning and saying things. During an interview with S5 thereafter, S5 was queried whether there was sufficient staff to care for each resident in meeting their highest practicable well being on this unit. S5 said no, because of the type of engagement their residents required which was for more one to one interaction. S5 said their unit had residents with more behaviors, were more dependent and the cognitively lower functioning residents. On 06/22/18 at 07:29 AM, S94 said it was to a point where they were burning out. S94 said their residents were often bypassed and not brought to attend the 5th floor activities. S94 acknowledged that safety too was a concern with just one staff monitoring 10 or more dependent residents with mood and behavioral issues. S94 said their staffing was decreased from five aides to four. S94 stated, We're trying to provide activities, so actually our day shift has three aides for 24 residents since the assigned activity monitor (one of the four aides) cannot toilet the residents. S105 who was feeding R30 at this time, was observed trying to engage R30 during the meal, but had to also watch R16 because she would stand unassisted and unexpectedly. R40 was then seen pouring her orange juice (OJ) into her oatmeal. R71 sat in the middle room eating hurriedly out of her bowls, but S105 could not see her from where she was sitting with R30 because of the side wall. S105 said, it's difficult when you have (R16), (R40), (R44), (and another newly admitted resident) trying to stand all at once--it makes it hard. Observation of the breakfast found S105 trying to keep an eye out for the other residents around her while she was trying to assist and feed R30. But, S105 was not able to prevent R40 from pouring her OJ into the oatmeal, nor could S105 see R56 and R39. These two residents were sitting in their wheelchairs in the low stim activity room unattended and out of S105's view. On 06/22/18 at 07:45 AM, S5 stated their residents were those with advanced dementia with behaviors. S5 said approximately 15 of the 24 residents could be socially disruptive and/or physically/verbally aggressive during care. S5 said this made it hard for their unit staff and for new hires or floaters to work on this unit. S5 acknowledged because their residents were more dependent with ADLs (activities of daily living) and because of their behaviors, they were not included in the large group activities upstairs. S5 said given the needs of these residents, staffing for this unit is not available. S5 concurred the way S105 had to feed R30 while on edge trying to keep an eye out for R16 and the rest of the residents was what their staff endured. S5 also acknowledged that although their fall rates have decreased, she concurred with the surveyor's observations that many of their residents were left unattended, without adequate supervision/engagement due to lack of staff coverage. S5 said it has been difficult to ensure their 14 residents who required assistance with meals and approximately 17 residents who required extensive to total assistance in their ADLs received their highest quality of life as a result.",2020-09-01
39,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2018-06-22,812,D,0,1,GCA011,"Based on observation, interview and policy review, the facility failed to distribute food to residents in a sanitary manner. The deficient practice placed residents at risk for illness, infection and the potential for foodborne illness. Findings Include: During the lunch observation on 06/19/18 at 12:41 PM, Staff 36 (S36) was passing trays to the residents. S36 was observed to wipe his brow and touch his cheek on two occasions, and did not sanitize his hands before passing a tray to the next resident. S36 was observed to empty a tray into the refuse can and then passed another tray to a resident without sanitizing his hands. During an interview with S36 on 06/19/18 at 02:45 PM, he stated he didn't sanitize his hands after throwing food into the garbage or when he proceeded to get another resident's tray. S36 said, I guess I had the white coat syndrome. Review of the Hand Hygiene policy 125-500-020 stated, To reduce to as low as possible, the number of viable microorganisms on the hands in order to prevent transmission of healthcare associated pathogens from one patient to another, and to reduce the incidence of healthcare associated infections. 4. Before eating, after eating, . S36 did not follow sanitary hand hygiene practices.",2020-09-01
40,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2018-06-22,849,D,0,1,GCA011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility and the hospice did not collaborate in the development of a coordinated plan of care for 1 of 3 residents (R179) receiving hospice services. Findings Include: On 06/20/18 at 08:17 AM, R179 was heard yelling from her room. Staff 6 (S6) stated R179 was a hospice resident. S6 said when staff attends to her yelling, she tells them that she didn't know she was yelling. Surveyor went to R179's bedside and asked her if she was in pain. R179 replied, Yes, all over. A staff came into R179's room to get towels from the closet and stated she would attend to R179 after finishing up with another resident. S6 came to assess R179's pain and informed S22. After adjusting R179's position and pillows, S22 asked resident what type of pain meds she preferred, either [MEDICATION NAME] or Tylenol. R179 stated, Do I have a choice? When queried later, S22 stated that R179 used to be able to say what type of pain she had (e.g., pain level of 9-10), but from yesterday, she was unable to. S22 said, [MEDICATION NAME] is prn every 4 hrs and last dosage given last night at 20:15 (8:15 PM). S22 stated she just gave R179 [MEDICATION NAME] because, Resident was crying so probably severe pain. After receiving the pain meds, R179 was provided breakfast and observed that resident ate without pain and a CNA assisted her. On 06/20/18 at 08:38 AM, interviewed S6. He stated that R179 will be discharged from hospice because the resident was admitted as hospice but as full code and that it did not make sense to him. S6 talked to the hospice provider and was told the hospice provider got into trouble for not accepting residents who were full code and R179 was placed into hospice care at the hospital she was transferred from. The [DIAGNOSES REDACTED]. The hospice benefit period was 06/08/2018 - 09/05/2018. The hospice physician's signature on 06/08/18 also included information of the resident's code status (attempt resuscitation); diet as tolerated; activity as tolerated; and oxygen 2-5L via NC/Mask for dyspnea/comfort PRN. On 06/20/18 at 09:26 AM, interviewed S20. She stated the hospice nurse came twice a week and the hospice CNA three times a week. There was no set schedule for the hospice nurse but she came in to address R179's change in mental status. R179 became delusional, confused with increased yelling, so S20 suggested it was over medication with benzodiazepine which the hospice nurse agreed with on 06/17/18. The benzodiazepine was discontinued on that date and the telephone order read back (TORB) was done with the hospice physician. On 06/21/18 at 10:33 AM, review of the facility's baseline care plans (CP) for R179 was done. The activities assessment, under Emotional Mood/Behavioral Status, per (friend/therapist), noted R179 had history of delusions while hospitalized . There was no family on the island and R179's former therapist assisted the resident with her current situation. The baseline CP included intervention/approaches for, Staff to administer medications (meds) as ordered and observe for effectiveness and side effects. The medications ordered for R179 included meds for depression, diabetes, [MEDICAL CONDITION], and low [MEDICAL CONDITION] function. The meds ordered as needed (PRN), included [MEDICATION NAME] for pain, Tylenol suppository for pain/fever, [MEDICATION NAME] for pain/fever, and [MEDICATION NAME] for pain/shortness of breath. The hospice CP with start date 06/08/18 and last updated on 06/18/2018 for problem of physical comfort alteration secondary to [DIAGNOSES REDACTED]. /stress level. Notify MD if necessary. On 06/22/18 at 08:28 AM, surveyor interviewed the hospice nurse. She stated the hospice director developed the CPs for R179 and the hospice nurse will add to it if something came up. The meds were the previously established hospice meds which the hospice MD would adjust as needed. The CPs were faxed over at admission and the hospice nurse does a 24 hour follow-up to ensure CPs are appropriate. There were no changes to R179's CP at the 24 hr follow-up. Queried the hospice nurse about the pain meds and when facility staff should use [MEDICATION NAME] sulfate (MS) versus [MEDICATION NAME]. She stated that PRN MS was a standard pain med for hospice and should be specified in the order. Review of the admission physician orders [REDACTED]. On 06/22/18 at 09:23 AM, S22 said she was on vacation when R179 was admitted . Queried S22 what pain meds she would give R179 for pain, and S22 stated she would ask resident her preference. When S22 returned from vacation, she didn't have time to look at R179's CP and just asked resident her preference and she wanted [MEDICATION NAME]. On 06/22/18 at 09:26 AM, interviewed S20 and she stated that after R179 was admitted on [DATE], the hospice physician came once on 06/11/18. S20 stated the hospice admission process was confusing because the facility never admitted a hospice resident before. S20 said usually the resident was already in the facility and switched to hospice status. S20 wasn't sure if she should call the family/representative for changes in R179's condition or call the hospice nurse, stating she didn't want to duplicate calls to the family/representative. On 06/22/18 at 09:41 AM, interviewed the hospice CN[NAME] She said she gave R179 a bath on Mondays, Wednesdays, and Fridays at 10:00 AM. Queried the CNA if there was a CP developed by hospice for her to follow. There was no CP found for this. The long term care staff was unaware of the hospice staff's schedules, whether R179 was an appropriate hospice admission, whether the type of pain meds given to R179 achieved pain relief as her different pain meds had similar parameters to follow, and, the facility staff was not familiar with the roles of the hospice staff nor followed a coordinated CP delineating each care and service the hospice was to provide for R179.",2020-09-01
41,KULA HOSPITAL,125003,100 KEOKEA PLACE,KULA,HI,96790,2018-06-22,880,D,0,1,GCA011,"Based on observation and interview, the facility failed to ensure it maintained a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 24 residents (R56, R71) in the sample. Findings Include: On 06/19/18 at 11:18 AM, R56 was observed sitting at a table with oversized red Lego-type and wooden building blocks on it. The building blocks were being used by another resident, R71, who is blind. R56 had already grabbed one of the large red blocks and was trying to insert it into her mouth but it was too big. After licking it, she put it down on the table. She then grabbed a blue rectangular wooden block and tried to insert that large block into her mouth as well. S15 was in the hallway and was asked to observe R56. S15 intervened and said R56 was not supposed to be handling these building blocks. The blocks were pushed toward R71 without being sanitized and R71 resumed using them. On 06/21/18 at 09:38 AM, S5 said they have one person to monitor the three adjoining activity rooms. S5 was informed of the observation whereby the blocks were not sanitized before it was given to R71, but had no comment. S94 said a lot had been going on that day when R56 tried to insert the blocks into her mouth. S94 said they usually wiped each block with the purple top disinfecting wipes and dried them for a couple minutes before putting them away. However, on 06/19/18 the blocks were not sanitized before they were returned to R71.",2020-09-01
42,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2019-07-12,550,D,0,1,QXJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff members, the facility failed to ensure a resident is provided care with respect and dignity to promote and enhance her quality of life during skin assessments resulting in the resident feeling embarrassed. Findings include: Resident (R)78 was admitted to the facility on [DATE] from an acute facility. R78 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. On 07/09/19 at 10:50 AM an interview was conducted with R78. R78 reported that she is uncomfortable with the skin assessment, it made her feel like a criminal. The resident clarified, she asked to undress and lay in bed for the skin assessment. R78 further reported another staff member was also present. Queried whether the staff member draped her body during the assessment, R78 replied, no. R78 also shared that she doesn't understand why another staff member has to be present and was not asked whether it was okay to have another staff member present during the assessment. R78 also stated that she doesn't understand why the skin assessment has to be done weekly. On 07/12/19 at 08:15 AM an interview was conducted with Licensed Nurse (LN)2. Inquired how are skin assessments performed. LN2 reported residents usually come from the acute hospital and are dressed in a hospital gown. LN2 reported residents are not asked to undress and are informed the nurse will check their bottom and for women, look under their breast. LN2 further explained the resident's hospital gown is removed only to expose areas that are being assessed. The LN confirmed there are two nurses present during the skin check to assist with turning and one person to write and one person to measure. A record review was done on 07/10/19 at 01:19 PM. A review of the admission Minimum Data Set (MDS) with assessment reference date of 06/21/19 found R78 yielded a score of 15 (cognitively intact) when the Brief Interview for Mental Status was administered. R78 was also noted to require limited assistance with one person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture).",2020-09-01
43,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2019-07-12,689,D,0,1,QXJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and record review, the facility failed to utilize a bedside blue mat, as indicated on the care plan for Resident (R) 2. With this deficient practice, the facility put R2 at risk for increased accident hazards. Findings Include: Resident 2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the latest minimum data set ((MDS) dated [DATE] revealed that R2 had a brief interview of mental status (BIMS) score of 3 indicating the resident had severe cognitive impairment. The resident was assessed to require extensive assistance, dependent with all activities of daily living (ADL's). A review of the MDS Coordinator's note showed that R2 was at risk for falls, due to depression and taking [MEDICAL CONDITION] medication. On 07/09/19 at 01:36 PM, R2 was observed in his room, sleeping on his bed. At the same time, a blue bedside mat observed not in use and leaning up against two chairs. On 07/10/19 at 07:20 AM, R2 was observed in his room, sleeping on his bed. At the same time, the blue bedside mat was again not in use and leaning up against two chairs. On 07/10/19 at 10:30 AM, R2 was observed in his room, lying in his bed. This time; however, the blue bedside mat was now in use, placed on the floor next to R2's bed. On 07/10/19 at 01:25 PM, Licensed Nurse (LN) 3, was interviewed about the bedside mat usage. LN3 stated that whenever R2 is lying or sleeping in bed, the blue bedside mat should be used and placed on the floor next to the bed and the care plan should say that as well. On 07/10/19 at 01:25 PM A review of R2's care plan stated the following: Problem: resident is at risk for falls due to confusion and resident is very forgetful, requires assist with ADL's. Interventions: bedside blue mat initiated on 04/23/18.",2020-09-01
44,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2019-07-12,842,E,0,1,QXJ511,"Based on record review, staff interview, and review of a list of approved abbreviations provided by the facility, the facility failed to use approved abbreviations and/or acronyms when charting in the progress notes, for four of the nine residents reviewed. With this deficient practice, there was a risk of misinterpreting the un-approved abbreviations and thus causing adverse outcomes for any, or all the residents. Findings Include: 1. During review of the clinical notes for Resident (R) 11, the following abbreviations/ acronyms were used, in various places, in the clinical notes: OOP, SO. According to the Accepted Abbreviations - Medical Terminology list (provided by the facility), these abbreviations/acronyms were not approved to be used for charting. 2. During review of the clinical notes for Resident (R) 27, the following abbreviations/ acronyms were used, in various places, in the clinical notes: OOP, ATB. According to the Accepted Abbreviations - Medical Terminology list (provided by the facility), these abbreviations/acronyms were not approved to be used for charting. 3. During review of the clinical notes for Resident (R) 61, the following abbreviations/ acronyms were used, in various places, in the clinical notes: OTA, ABT, CDI. According to the Accepted Abbreviations - Medical Terminology list (provided by the facility), these abbreviations/acronyms were not approved to be used for charting. 4. During review of the clinical notes for Resident (R) 12, the following abbreviations/ acronyms were used, in various places, in the clinical notes: P[NAME], ASE, ABT. According to the Accepted Abbreviations - Medical Terminology list (provided by the facility), these abbreviations/acronyms were not approved to be used for charting. On 07/11/19 at 02:24 PM, an inquiry regarding facility approved abbreviations with the Chief Nursing Officer (CNO) was made. CNO provided the list of facility approved abbreviations titled Garden Isle Healthcare, Accepted Abbreviations - Medical Terminology which is currently in use and being followed by the facility.",2020-09-01
45,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2019-07-12,880,D,0,1,QXJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy and protocol (P&P) review, the facility failed to ensure that staff used infection prevention and control program (IPCP) standard precautions in wound dressing change for 1 of 2 residents observed for dressing change. The deficient practice put resident (R)25 at risk for an infection. Findings Include: On 07/11/19 at 10:00 AM observed licensed nurse (LN) 1 prepare for dressing change to R25's [DEVICE]. LN1 gathered the dressing change supplies from the treatment cart and dropped the normal saline (NS) ampoule onto the floor, which was picked up and placed into the plastic basket with the other clean dressing supplies. In R25's room observed LN1, who placed the plastic basket of supplies onto R25's overbed table with paper towels underneath, and then helped to reposition R25 with clean gloves on. LN1 changed gloves without sanitizing hands, and then removed the soiled dressing from the PEG site. LN1 was also observed to use the NS ampoule that was dropped on the floor in the dressing change. After leaving R25's room informed LN1 of observations as written above. LN1 stated that she should have discarded the dropped NS [MEDICATION NAME], and changed her gloves after removing the soiled dressing but forgot. On 07/12/19 at 08:07 AM interviewed the DON on the facility's IPCP and she stated that staff are inserviced right there and then, when seen with improper hand hygiene and/or glove changes. The last hand hygiene inservice was held on 04/23/19. The facility's policy and protocol for dry, clean dressing was revied and it was noted that it was last updated on 09/14/17, and states, Steps in the Procedure; . 4. Have biohazard or plastic bag readily available . 6. Wash and dry your hands thoroughly; 7. Put on clean gloves and remove and discard dressing; 8. Wash and dry your hands thoroughly; 9. Open dry, clean dressing(s). 12. Wash and dry your hand thoroughly; 13. Put on clean gloves.",2020-09-01
46,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2018-07-13,578,E,0,1,2CGJ11,"Based on electronic medical record (EMR) reviews, interviews and policy review, the facility failed to ensure that for a resident who does not have an advance directive (AD), the resident (R) was informed of his or her right to develop one, provided assistance in doing so or was periodically reassessed in his/her decision making capacity to do such, for 5 of 33 residents (R6, R79, R54, R60 and R73) in the survey sample. Findings Include: 1) An EMR review conducted for R79 on 07/11/18 at 8:21 AM revealed this resident did not have an AD, but only a POLST. On 07/12/18 at 3:47 PM, during an interview with the Social Services staff, they confirmed R79 did not have an AD, but only a POLST. 2) An EMR review conducted for R6 on 07/11/18 at 9:46 AM revealed he did not have an advance directive (AD), nor were there clinical notes showing the resident was informed of his right to develop one or provided assistance in doing so. 3) On 07/11/18 01:03 PM the EMR review for R54 found that the resident had a Designation of Code status acute care form signed by his spouse on 8/20/12; the form designated do not resuscitate, (DNR). On 07/12/18 at 02:00 PM interviewed the resident care manager (RCM) on the Kona unit and she validated that R54 did not have an advanced directive on file. The RCM stated that 54's spouse was coming to the facility and the SW would be discussing AD with her. 4) The EMR review for R73 noted on the physicians orders (PO), DNR. On 07/12/18 at 01:58 PM interviewed the Kona unit RCM who provided a designation of code form that was signed in 12/2012. The RCM stated that the form was a POLST, and not an advanced directive form. 5) The EMR review for R60 found that a POLST was signed on 11/03/15. On 07/12/18 at 2:02 PM validated with the Kona unit resident case manager (RCM) that R60 did not have an advanced directive on file. A review of the facility's policy and procedure (P&P), Advanced Directive (effective date 9/1/2017) stated, . 5. Social Services will check with resident/guest or resident/guest representative to confirm treatment choices at the time of the initial care conference, during quarterly and annual care conferences, or at the time of significant change of condition. The resident/guest has the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive. 6. Changes or revocations of a directive, which can be written or oral, must be noted in the resident/guest's medical record. All of the above residents (R79, R6, R54, R60, and R73) did not have documentation in their clinical record about the treatment choices in the formulation of, or refusal of an AD during quarterly and annual care conferences, or at the time of significant change of condition.",2020-09-01
47,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2018-07-13,584,D,0,1,2CGJ11,"Based on resident and staff interview the facility failed to ensure that the personal property for 1 of 33 residents (R60) on the survey sample was not lost or stolen. Findings include: On 07/10/18 at 12:32 PM during interview of R60, she reported that she had a pink and white sleeveless dress that was sent for wash to the facility laundry and never returned. The resident stated that the dress has been missing for couple weeks now. On 07/12/18 at 02:06 PM interviewed LN19 about the facility procedure when a resident reports about a missing personal item. LN19 stated that if laundry was not returned, then staff would ask the laundry department and help the resident to locate the item. If staff were unable to find the missing item, a facility form was used to report to the social worker that the resident is missing personal item(s). The social services department would help the resident resolve the missing item. The resident reported to LN1 about the missing dress, and LN1 stated that a missing item form was not completed because the dress was returned the day after the resident reported it missing. According to LN1, R60 also told her that it was found. Both LN19 and LN1 stated that they would clarify with R60 about the missing dress. On 07/13/18 at 11:30 AM queried R60 if her missing dress was found and she reiterated that the pink and white dress did not return from the laundry and told staff again that it wasn't in her closet. Interviewed LN19, and she validated that staff went through clothes with R60 and the pink and white sleeveless dress was not found. The staff completed a missing item form which was sent to social services for follow-up.",2020-09-01
48,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2018-07-13,641,D,0,1,2CGJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical record (EMR) review and staff interview the facility failed to accurately assess and code in the minimum data set (MDS) for 1 of 33 residents (R4) on the survey sample. Findings Include: On 07/10/18 at 01:44 PM during EMR review for R4 it was noted that the resident required one person support for bed mobility on the MDS dated [DATE], and the MDS dated [DATE] noted R4 required two plus persons physical assist for bed mobility. On 07/12/18 at 11:05 AM interviewed the MDS coordinator and inquired about the change that R4 had, inquired if this was a decline in bed mobility or if this was a coding error. MDS coordinator stated that she would follow up with floor staff and let me know. 07/12/18 03:21 PM MDS coordinator stated that this was a coding error on her part and that she would submit a modification for the 04/30/18 MDS.",2020-09-01
49,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,241,D,0,1,U50511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of their individuality. Dignity also means interactions with residents such that facility staff carry out activities that assist the resident to maintain and enhance their self-esteem and self-worth. This facility failed to ensure staff responded in a timely manner to a resident's request for assistance for 2 of 31 residents (Resident #183 and Resident #171) in the Stage 2 sample. Findings include: 1. Resident #183 was admitted to the facility as a short stay resident and was receiving skilled rehabilitation services. During an interview with Resident #183 on 10/26/16 at 8:07 AM, they stated, To be perfectly honest, I think they are short staffed. I get up to use the bathroom, but I'm not allowed to get up by myself because of my fracture and they don't want me to fall. And I don't want to have accidents either, but sometimes, I wait, and I wait, and I wait, and I've had a couple of accidents--yes, shi-shi (urine) or bowels, either one. They said because they couldn't wait for staff to attend, they get out of bed, when I'm really desperate. Resident #183 said because of the long wait times, they have had four accidents. When asked how staff responded when they had these accidents, they said, Not especially anything and I tell them, oops sorry. A lot of times, it's right at the toilet and I can't get there fast enough and I know it's coming. When you gotta go, you gotta go, and they're not here for me. They're busy elsewhere, which is understandable, a lot of other people are here. They're very nice here, don't get me wrong. But, whether it's the early morning, late at night, sometimes there's not enough of them and that's the only reason why I think they're short handed. During an interview with the MDS-C on 10/27/2016 at 1:28 PM, they said Resident #183 scored a 15 on their BIMS, and is alert and oriented x 3 based on the MDS ARD of 10/11/16. They stated this resident is totally continent. On 10/28/2016 at 7:52 AM, a re-interview with Resident #183 was done. They reiterated there is a problem with the shortage of staff and, the primary reason is because they're having to attend to others. They said it was their honest observation being admitted at this facility and it was undignified for them having these accidents of soiling themselves. 2. Resident #171's family member was interviewed on 10/25/16 at 1:21 PM. Resident #171 was admitted on [DATE] for skilled rehabilitation services after an acute hospital stay. During the interview, the family member stated the resident was not treated with respect and dignity and stated it was because of how a nurse's aide did not want to assist the resident to be toileted. The family member said it recently happened when the resident had to wait until after the lunch was over. The family member stated as a result, the family member had to assist the resident to be toileted and they had soiled themselves. On 10/28/16 at 8:58 AM, during another interview with Resident #171's family member, the family member reiterated the nurse's aide who did not want to toilet the resident also walked down the hall the opposite way, just like ignoring us. The family member said, I was going to put them on, but the therapist came and took the Resident #171 and had to help me, because (the aide) said the residents are eating. But already Resident #171 wanted to make, so it came out, all on the bed because their diaper was leaking and the wheelchair was all with the shi-shi (urine), and the therapist took Resident #171 to the bathroom to clean them up and put on the diaper. (The aide) was in the next room, and said can you take them because they want to get out of bed to go to the bathroom, but we're still having lunch, so have to wait. Resident #171 came all wet because they couldn't wait. The family member said afterward, another nurse's aide came to help change the soiled bedding. The family member said it was upsetting, they felt ignored, and because Resident #171 all wet, the bed and the chair all soaked like that, Resident #171 got angry, so I got angry. On 10/28/2016 at 9:24 AM, interview with the speech therapist (ST #1) was done. ST #1 verified the family's member's account when Resident #171 had recently transferred themselves to the chair and was soiled. ST #1's said the reasoning was because the aide for Resident #171 had been attending to another resident who fell , which coincided with Resident #171's request to be toileted. ST #1 said they reported it to the day charge nurse, LN #3, and verified the aide was attending to the other resident while they stepped in to help Resident #171. On 10/28/2016 at 9:38 AM, LN #3 confirmed that ST #1 had told them that Resident #171 was all wet and (the aide) was also going to do Resident #171, change them also, but therapy was the one who had to change them because they went there to do the therapy early. LN #3 said they did not go to speak with Resident #171 nor to the family member after the incident happened. LN #3 was asked whether they thought about providing an explanation to the resident and/or family member, but LN #3 stated, No, I was only talking to the therapy. On 10/28/2016 at 9:52 AM, RCM #2 said if the charge nurse was aware of what happened, the charge nurse, is supposed to investigate with the family, ask the family, and the charge nurse is supposed to inform me or the DON. RCM #2 acknowledged LN #3 should have done that, and understood why the family member felt there was no respect or dignity afforded to Resident #171, after having soiled themselves when the family member asked for staff assistance.",2020-09-01
50,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,272,D,0,1,U50511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical review (EMR) and staff interviews, the facility failed to ensure that 1 of 31 residents (Resident #90) on the Stage 2 resident sample list, received a comprehensive assessment as part of an ongoing process to identify mood and behavioral symptoms and psychosocial well-being, Also, documentation of assessment information in support of clinical decision making was not found. Findings include: On 10/26/2016 at 07:59 AM, reviewed Resident #90's physician orders [REDACTED]. The resident was prescribed antidepressants and anti-anxiety medications and was sampled for unnecessary medications for Stage 2 of the survey. On 10/26/2016 at 4:00 PM, further EMR review on Resident #90 noted on the facility's PharMerica Resident Change in Condition MRR Request Form, a request to change Resident #90's antidepressant medication due to the resident exhibiting inappropriate sexual behaviors. The form documented: Status change: Increased sexual behaviors, touching self inappropriately in public. Resident kissed another resident. Diagnosis: [REDACTED].>Current medications: [REDACTED] Possible contributing medications: [REDACTED] Name medication regimen is not thought to directly contribute to inappropriate sexual behaviors. however, __ may benefit from a change in therapy (see below). Pharmacy recommendation: Changing Name [MEDICATION NAME] ER 50 mg once daily to [MEDICATION NAME] may provide continued therapeutic benefit for treatment of [REDACTED]. Please consider decreasing [MEDICATION NAME] ER to 50 mg by mouth once every other day x 3 doses. Then start [MEDICATION NAME] 10 mg by mouth once daily x 7 days then increase to [MEDICATION NAME] 20 mg by mouth once daily thereafter. Pharmacist Signature: Name Date: (MONTH) 13, (YEAR). On 10/27/2016 at 8:20 AM, interviewed LN#3 and asked them to access the EMR to find any documentation regarding Resident #90's inappropriate sexual behavior, as the surveyor could not find any. The LN #3 accessed the resident's Behavior Monitoring Log on the EMR which documented, Behavior #1 masturbating in Makai lobby, and on 10/02/2016 the behavior log was marked with 1, and N/A in the Interventions column. The LN #3 went to the EMR Notes tab and could not find any corresponding progress notes on 10/01/2016. Under the Care Plans tab there was a care plan (CP) ___will not show any inappropriate behavior around other residents within the next quarterly review. The interventions included: __ reports he is not aware of his behavior during staff approach. He reports he is fixing his Foley catheter; assist in covering self; assist to private area like his room; direct care staff to remove female residents when __is in the TV unit area; discuss with __in a straightforward matter of fact manner that his behavior is inappropriate. On 10/27/2016 at 8:50 AM interviewed RCM #3 to access the EMR. Asked RCM #3 to verify behavior log documentation on 10/02/16, and RCM #3 was not able to find any progress notes in the EMR to corroborate with the behavior monitoring log. The RCM #3 stated that the nurse on that date during evening shift would know what happened. Queried RCM #3 if the staff that observed Resident #90 kissing another resident made an incident report, and RCM #3 stated that there were no progress notes on the incident on 10/02/2016 but that social worker (SW) services may have the documentation. On 10/27/2016 at 9:56 AM interviewed social workers (SW), and both SWs stated that they investigated the incident of Resident #90 kissing a female resident after being informed by LN #4. According to both SWs, Resident #90 was interviewed and counseled about inappropriate behavior of kissing female resident in the TV lobby. Resident #90 claimed to have given a female resident a chaste kiss of Aloha on the cheek after receiving condolences on the recent passing of his wife. Resident #90 apologized to the SWs for kissing the female resident and stated that he is Hawaiian style and wanted to thank her with a kiss on the cheek. The SWs both stated that Resident #90 understood after being told by them that kissing of other resident is inappropriate in the facility. The SW's stated that they also spoke with the female resident and she didn't think that Resident #90 had any sexual overtures and didn't feel offended or unsafe in the facility. When asked for documentation of SW interviewing and counseling of residents on the incident and inappropriate sexual behaviors, both SW's had none to provide. Both SW's stated that they developed a care plan (CP), to address Resident #90's inappropriate behaviors. On 10/27/2016 at 10:22 AM interviewed LN #4 who had witnessed the incident of Resident #90 kissing a female resident in the TV lobby. According to LN #4, she saw Resident #90 bend down and kiss the female resident more towards her lips than the cheek area and repeatedly. LN #4 was at the nursing station within view of the TV lobby on the third floor where the female resident was sitting. Resident #90 was ambulating around the unit with the FWW and stopped to talk to the female resident. It was then that LN #4 observed Resident #90 bend down to kiss the female resident more than once. The LN #4 called out to Resident #90 to stop and another LN #5 ran over to separate them. From LN #4's observations the female resident was holding on to Resident #90 hand and didn't want to separate. Also, LN #4 had observed Resident #90 masturbating in the TV lobby, and resident would be looking around to see if anyone around. LN #4 stated that when they observed Resident #90 masturbating, they was sitting at the nursing station and stood up to ask Resident #90 if everything was ok and resident replied, I'm Ok and stopped what he was doing. LN #4 stated that they wern't the only one that observed Resident #90 masturbating in the TV lobby because other nursing staff have also reported same observations. LN #4 stated that they reported observations to RCM #3 who reported the incident to the SWs. On 10/27/2016 at 10:36 AM, interviewed the DON regarding Resident #90's inappropriate sexual behaviors with no documentation of dates, incidents, interviews, and/or IDT meetings to address the behaviors. According to the DON, Resident #90 walked into their office and DON had a spontaneous conversation with Resident #90 but cannot remember the date. Resident #90 was concerned because the DON observed the resident the evening before that conversation, sitting in the TV area with hands on his groin area. The DON stated that they had discussed with Resident #90 that others could perceive this differently and think it was inappropriate. The resident stated that they tend to sit like that and agreed it could be observed doing something inappropriate. The DON stated that they did not talk to Resident #90 about masturbating in the TV lobby. The DON verified that there was no documentation on Resident #90's inappropriate sexual behaviors as discussed by the SWs, nursing staff and themselves. On 10/27/2016 at 10:50 AM, interviewed RCM #3 and he stated that their role is that of a nursing supervisor. The RCM #3 stated that after nurses reported inappropriate sexual behaviors displayed by Resident #90, the incidents were reported to the team (DON & SWs). The issues were discussed but RCM #3 stated that they would have to go through Resident #90's EMR to find any documentation. On 10/28/16 reviewed the EMR for Resident #90 and noted that RCM #3 and SW made late entries on 10/27/2016 in progress notes to document the above incidents: Social service wrote: On 9-8-16 writer spoke with Resident #90 in SS office, RCM informed SS that Resident #90 was observed touching his private area out in Mauka 3 lobby area. Writer followed up with Resident #90 and he confirmed he is not touching self and is fixing his Foley tube. Resident #90 verbalize to writer that he keeps his hands close to his private area all his life as he is most comfortable, Writer informed Resident#90 .He is not a risk to others. He doesn't go into other resident's rooms, no displays of aggressive behaviors or sexual behaviors towards others. Nursing Late Entry: Writer asked Resident #90 about any issues with the catheter, if has any itch on the area or any discomfort; because per nurses he is seen putting his hand near his genitals; resident verbalized that he does not have any discomfort in area; writer discussed this incident with the IDT; as for further intervention for past sexual behaviors, writer made a medication review consult thru pharmacist; added a behavior log for further monitoring of past sexual behaviors; Resident #90 is not a threat to any resident in the facility and has not displayed any sexually aggression to anyone; or noted to be sexually inappropriate to anyone, The EMR review also included these CPs: CP: ___had been noted with hands close to his genitals. ___confirmed he is not touching self inappropriately and is fixing his Foley tube. ___verbalize to SS that he keeps his hands close to his private area all his life as he is most comfortable. Goals: ____will not be observed having close hand contact to genitals with in the next quarter Int: ___reports he is not aware of his behaviors during staff approach. He reports he is fixing his Foley catheter, assist __in covering self, assist to private area like his room Direct care staff to remove female residents when ___is in the TV unit area Discuss with ___in a straightforward matter of fact manner that his behavior is unacceptable ___Reports he has a habit of placing his hands in his upper thigh area close to his private part ___has regular visits with neurology doctor. MD response made d/t behaviors and MD stated d/t SE of his [MEDICAL CONDITION] medication Remind ___of need to respect other resident's rights OBSERVE ___at times-keep other female resident distance from him CP: __is on [MEDICATION NAME] for REM disorder/[MEDICAL CONDITION] __has [MEDICATION NAME] DX: Situational depression. [MEDICATION NAME] d/c'd on 09/16/16 and started on [MEDICATION NAME] on 9/25/16 for situational depression.",2020-09-01
51,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,278,D,0,1,U50511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on EMR review and staff interview the facility failed to ensure that the assessment for urinary continence was accurately reflected for 1 of 31 residents (Resident #99) sampled on the Stage 2 Sample Resident List. Findings include: On 10/27/2016 at 3:08 PM the EMR review for Resident #99 found that the resident's minimum data set (MDS) 3.0 on admission date of [DATE], coded urinary continence as frequently incontinent (code 2). By the 90 day quarterly review assessment on 09/06/2016, Resident #99 was coded for always incontinent (code 3) for urinary continence. On 10/28/2016 at 8:23 AM conducted an EMR review on Resident #99 for decline in urinary continence. The progress notes dated 06/03/16 documented that Resident #99 was alert, pleasantly confused, able to follow simple instructions, denied pain and discomfort, incontinent of bladder. The evening shift on 06/03/2016 also documented that Resident #99 was incontinent of bladder. On 10/28/2016 at 9:19 AM interviewed the MDS-Co-ordinator and they accessed the EMR documentation on 06/03/2016 where the RN wrote that the resident is incontinent. The MDS-Co-ordinator looked at the CNA flowsheet and found that Resident #99 was continent only first couple of shifts but incontinent thereafter. Discussed discrepancy of nurses progress notes and CNA flowsheet documentation. The MDS-Co-ordinator stated that the CNA's will be receiving training in coding and probably coding error for urinary continence, as coded frequently (2), and should have been always incontinent (3) from admission.",2020-09-01
52,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,323,D,0,1,U50511,"Based on a review of a self-reported incident report (IR) submitted to the State Agency (SA) and investigated through record review, staff interviews and policy and procedure review during the recertification survey, the facility failed to ensure that the resident's environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. Finding include: On 3/7/16, an IR was filed with the SA regarding Resident # 68 who sustained an unwitnessed fall in the shower room on 3/4/16. The IR documented that Resident #68 was found laying on floor with their head up against (BR) bathroom wall. Resident #68 complained of left ribcage pain and bilateral hip pain. On 3/5/16, radiology department notified facility of left rib fracture. On 10/27/16 at 7:26 AM, Resident #68's Electronic Health Record review (EHR) and concurrent review with the Minimum Data Set Coordinator (MDS-C) dated 4/6/16 was done. In Section C. Cognitive level noted the resident scored a 4 on the Brief Interview for Mental Status (BIMS). According to the Centers for Medicare Services' Resident Assessment instruction (RAI) Version 3.0 manual, the BIMS is a brief screener that aids in detecting cognitive impairment 13-15: cognitively intact: 8-12: moderately impaired; 0-7 severe impairment. 10/27/16 at 7:31 AM, EHR review reveals a careplan with fall prevention interventions stating: 1) Provide one assist with stand pivot transfers from bed to wheelchair. 2) Check on Resident #68 frequently while resting in bed or while up in wheelchair. 3) Ensure laser alarm in place, on and functioning at all times when Resident #68 is in bed and care is not being given. 4) Ensure bedside mattress in place. 5) Assess for dizziness and allow to rest approximately 2-3 minutes prior to transfers from sitting to standing position. 6) Assess for side-effects of Mirtazapine use (twitching, abnormal thinking, restlessness, nausea, dizziness) and notify MD PRN. 7) Keep floor clean, dry and free of clutter. 8) Keep floor clean, dry and free of clutter. 9) Provide low bed. 10) Ensure clip alarm is attached to Resident #68's clothing and that it is located on the inside of their bed towards the wall when they are in the bed. 11) Ensure pad alarms are in place, on, and functioning at all times when care is not being given. Interview on 10/27/16 at 9:32 AM, MDS-C confirms that intervention #11 (Ensure pad alarms are in place, on, and functioning at all times when care is not being given) was added on 3/7/16 to the careplan after Resident # 68 fell on on 3/4/16. LN #1 acknowledged that intervention #11 was added to the careplan after the fall (Ensure pad alarms are in place, on, and functioning at all times when care is not being given). Interview on 10/27/16 at 10:00 AM with Resident #68. Resident #68 is able to recall their spouse and verbalize their needs. Resident # 68 stated that they would like to visit her spouse. Observation on 10/27/16 at 12:10 PM at bedside. Resident #68 was assisted out of bed and transferred to wheelchair to visit spouse. After transport to the Kona unit, this surveyor and CNA #1 went to check on assistive device - pad alarm. CNA #1 acknowledged that the pad alarm was in place; however, the alarm button was not turned on. CNA #1 turned on the alarm button which beeped and a green light was noted. On 10/27/16 at 3:11 PM, interview with Resident Care Manager #2 (RCM). RCM #2 stated that Resident #68 fell in the bathroom. RCM #2 could not remember if there was a certified nurses aide with Resident #68. 10/27/16 at 3:20 PM, Interview with LN#1 stated that We found Resident #68 on the floor with their head against the wall by themselves. Resident #68 is able to roll by themselves. We are not sure how Resident #68 got there. Immediately after the fall, Resident #68 complained of left rib pain and we called the MD. Resident #68 was x-rayed the next day. Resident #68 underwent restorative treatment as ordered also. Resident #68 would refuse pain meds. Resident #68 is now back to their baseline level. When asked how did Resident #68 get to the bathroom on their own? LN #1 stated that Resident #68 is able to propel themselves and staff will push Resident #68 as well. When asked if this as avoidable, LN #1 stated that yes, we could have been checking on Resident #68 more frequently and make sure they call for assistance. The facility could not provide a monitor sheet that showed how they frequently monitor and check the residents. LN #1 stated that Resident #68 has only had one fall in the last six months.",2020-09-01
53,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,371,D,0,1,U50511,"Based on observation and staff interview, the facility did not store, prepare, distribute and serve food under sanitary conditions. Finding include: On 10/25/16 at 8:00 AM, an initial tour with the kitchen manager (KM) revealed an expired quart of yogurt in the entrance refrigerator. The date opened was labeled 10/18/16. KM stated that once food item opened, it is labeled with the date opened and will have an expired date within three days. The yogurt had been expired for four days. On 10/28/16 at 10:00 AM, inspection of the Kona 2 snack and nourishment room revealed an expired 1/2 gallon orange juice container. Staff acknowledged the expiration date and threw away the carton immediately. In summary, the facility failed to store food under sanitary conditions.",2020-09-01
54,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,441,D,0,1,U50511,"Based on observation and staff interview, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Findings include: Observation of a medication pass for Resident #130 was done on 10/27/2016 at 6:45 AM with licensed nurse #4 (LN #4). LN #4 said they were going to test the resident's blood sugar and took out a glucometer from their clothing pocket, saying we share it and placed the glucometer directly onto the resident's blanket. After the testing was done, LN #4 sanitized their hands, grabbed the glucometer and returned it to the cart. The glucometer had not been sanitized yet, but was placed atop the clean medication cart. LN #4 sanitized their hands again, then pulled a Sani cloth wipe and proceeded to wipe the glucometer and placed it back onto the same spot atop the medication cart. Per interview with LN #4, they acknowledged there was a breach in infection control as they had kept the glucometer in their pocket, laid it on the resident's bed and returned it to the clean medication cart without having sanitized it before placing it down. LN #4 said they were kinda new to all this but understood the cross-contamination observed. On 10/27/2016 at 10:32 AM, during an interview with the Resident Care Manager (RCM #1), they verified it was not their practice for licensed staff to leave the glucometer in their clothing pocket. RCM #1 validated it is an infection control issue as to how LN #4 performed it, and they should have used a separate small plastic container to hold the glucometer/supplies for blood sugar checks. RCM #1 also acknowledged the potential for transmission of disease with the way the glucometer was placed on the resident's bed to the clean cart without being wiped down first.",2020-09-01
55,GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER,125004,"3-3420 KUHIO HIGHWAY, SUITE 300",LIHUE,HI,96766,2016-10-28,514,D,0,1,U50511,"Based on staff interviews and EMR reviews the facility failed to ensure that the clinical record for 1 of 31 residents (Resident #90) on the survey Stage 2 sample resident list, had enough record documentation for staff to conduct care programs and to manage the resident's progress in maintaining or improving behavioral and psychosocial status. Findings include: On 10/27/2016 at 8:20 AM, interviewed LN #3 and asked then to access the EMR to find any documentation regarding Resident #90's inappropriate sexual behavior, as the surveyor could not find any. The LN #3 accessed the resident's Behavior Monitoring Log on the EMR which documented, Behavior #1 masturbating in Makai lobby, and on 10/02/2016 the behavior log was marked with 1, and N/A in the Interventions column. The LN #3 went to the EMR Notes tab and could not find any corresponding progress notes on 10/01/2016. On 10/27/2016 at 8:50 AM interviewed RCM#3 to access the EMR. Asked RCM#3 to verify behavior log documentation on 10/02/16, and RCM #3 was not able to find any progress notes in the EMR to corroborate with the behavior monitoring log. The RCM #3 stated that the nurse on that date during evening shift would know what happened. Queried RCM #3 if the staff that observed Resident #90 kissing another resident made an incident report, and RCM #3 stated that there were no progress notes on the incident on 10/02/2016 but that social worker (SW) services may have the documentation. On 10/27/2016 at 9:56 AM interviewed social workers (SW), and both SWs stated that they investigated the incident of Resident #90 kissing a female resident after being informed by LN #4. According to both SWs, Resident #90 was interviewed and counseled about inappropriate behavior of kissing female resident in the TV lobby. When asked for documentation of SW interviewing and counseling of residents on the incident and inappropriate sexual behaviors, both SWs had none to provide. Both SWs stated that they developed a care plan (CP), to address Resident #90's inappropriate behaviors. On 10/27/2016 at 10:22 AM interviewed LN #4 who had witnessed the incident of Resident #90 kissing a female Res in the TV lobby. According to LN #4, they saw Resident #90 bend down and kiss the female resident more towards her lips than the cheek area and repeatedly. Also, LN #4 had observed Resident #90 masturbating in the TV lobby, and resident would be looking around to see if anyone around. LN #4 stated that she wasn't the only one that observed Resident #90 masturbating in the TV lobby because other nursing staff have also reported same observations. LN #4 stated that she reported observations to RCM #3 who reported the incident to the SWs. On 10/27/2016 at 10:36 AM, interviewed the DON regarding Resident #90's inappropriate sexual behaviors with no documentation of dates, incidents, interviews, and/or IDT meetings to address the behaviors. The DON verified that there were no documentation on Resident #90's inappropriate sexual behaviors as discussed by the SWs, nursing staff and themselves. On 10/27/2016 at 10:50 AM, interviewed RCM #3 and he stated that his role is that of a nursing supervisor. The RCM #3 stated that after nurses reported inappropriate sexual behaviors displayed by Resident #90, the incidents were reported to the team (DON & SWs). The issues were discussed but RCM #3 stated that he would have to go through Resident #90's EMR to find any documentation. On 10/28/16 reviewed the EMR for Resident #90 and noted that RCM #3 and social services made separate late entries on 10/27/2016 in progress notes to document above incidents of the residents inappropriate sexual behaviors.",2020-09-01
56,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,156,E,0,1,8L5Q11,"Based on observation and interviews with resident and staff member, the facility failed to ensure names, addresses and telephone numbers of all pertinent State and advocacy group is posted in a form and manner accessible to residents and resident representatives. Findings include: The resident council interview was done on the afternoon of 10/25/17. The resident representative identified a staff member as the Ombudsman and was not aware the State Agency could be contacted for complaints. Inquired where the posting is located, the representative pointed to the side of nursing station, stating there is a bulletin board located there with the information. Observation found there is no bulletin board for the residents outside of the nurses' station. Further observation found two bulletin boards, one located on the wall outside of the Weinberg Family room and a second bulletin board on a wall outside of the social services office. The information for the telephone number and address of the State Agency was printed on an 8-1/2 by 11 inch paper and tacked on the second row of the information posting. The print and placement were noted to make it difficult for a resident seated in a wheelchair to review. On 10/25/17 at 4:00 P.M. concurrent observation and interview was conducted with Staff Member #324. Staff Member #324 confirmed there are two bulletin boards in the entire facility. The staff member confirmed the information posted on both boards would be too high for residents in wheelchairs to view the information. The staff member also acknowledged the print was small which would be difficult for residents with visual impairment and/or seated in the wheelchair to read.",2020-09-01
57,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,241,D,0,1,8L5Q11,"Based on interviews the faility failed to ensure residents were treated in a respectful and dignified manner for one out of 26 Stage 2 residents. Findings: During an interview with Resident # 98's husband on (MONTH) 23, (YEAR) he stated that staff #-- quite often would speak to his wife and himself in a disrespectful manner. He went onto say this has occured on many occassions and that he and his wife find the manner in which they are spoken to by staff #-- offensive. He also stated he would ask staff #-- to do things for his wife in a particular manner and that staff #-- would not do so. He used an example of asking staff #-- to fold the blanket down on his wife's bed in a particluar way so that it was easy for her to pull it up when she needed it. Staff # --proceeded to fold the blanket into a small square and place at the end of her bed that would make it difficult for her to reach when she needed it. During another interview with Resident #98's husband on (MONTH) 25, (YEAR), he continued to express his concerns about staff #-- manner in which he speaks to both himself and his wife and the blanket incident.",2020-09-01
58,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,242,D,0,1,8L5Q11,"Based on interviews with residents and staff members, the facility failed to ensure a resident has a right to make choices about aspects of his or her life that are significant to the resident for 3 (Residents #53, #248 and #180) of 15 residents interviewed. Findings include: 1) On 10/23/17 at 1:15 P.M. an interview was conducted with Resident #248. The resident was asked whether she is able to choose how many times a week a bath or shower is provided. The resident responded she receives showers twice a week, Mondays and Thursdays. Resident #248 clarified her preference would be for three times a week. A record review was completed on 10/26/17 at 8:15 [NAME]M. A review of the admission Minimum Data Set (MDS) with assessment reference date (ARD) of 2/16/17 notes in Section F0400. Interview for Daily Preferences, Resident #248 reported it is very important to choose between a tub bath, shower, bed bath or sponge bath. The resident's care plan for Activities of Daily Living Assistance notes the resident prefers a shower. A subsequent quarterly MDS with an ARD of 8/17/17 documents, Resident #248 yielded a score of 13 (cognitively intact) when the Brief Interview for Mental Status was administered. On 10/25/17 at 10:00 [NAME]M. an interview was done with Staff Member #114. Inquired how the facility determines the frequency of showers a resident receives. The staff member reported during the first family meeting the facility offers showers twice a week and bathing frequency is discussed. The families are asked how often the resident received showers at home or the resident will be asked if they want more showers. The staff member also reported families and residents are periodically asked about the frequency of showers, usually during the quarterly assessments. On 10/26/17 at 8:20 [NAME]M. Staff Member #113 was asked to provide documentation of the discussion related to frequency of showers during the admission and subsequent quarterly review. Subsequently an interview was done with the Assistant Director of Nursing (ADON) at 8:34 [NAME]M. The ADON reported residents or their representatives are asked their preferences (evening or afternoon) and frequency for bath/shower. The residents or their representatives are asked at the time of admission and periodically during their quarterly reviews. A request was made to the ADON to provide documentation of the facility's discussion with the resident or the representative related to baths/showers. On 10/26/17 at 9:35 [NAME]M., Staff Member #113 reported a review of Resident #248's electronic record found there is no documentation at admission or subsequently related to asking the resident's preference for the frequency of baths/showers. 2) An interview with Resident #53's spouse on the afternoon of 10/23/17 at 1:30 P.M. revealed she and/or her husband were not given the choice of how many showers he received weekly. Resident #53's spouse stated, I would like him to bathe every day. She reported she did not have a choice but rather was informed of the facility's shower schedule. On the morning 10/26/17 at 9:30 [NAME]M., a review of Resident #53's weekly shower schedule found he received showers on 10/19/17, 10/21/17, 10/23/17, 10/25/17, and 10/26/17. Resident #53 did not refuse any showers offered. An interview of Staff #55 on the morning of 10/26/17 at 9:30 [NAME]M. revealed residents/families are able to discuss their shower preferences during the initial family meeting which occurred shortly after a resident's admission. After the initial family meeting, Staff #55 stated shower preferences were discussed at Resident Care Conferences on a quarterly basis. An interview of the Assistant Director of Nursing (ADON) on the morning of 10/26/17 at 8:35 [NAME]M. revealed residents' shower frequency was based on their preferences. A review of Resident #53's latest Resident Care Conferences dated 10/3/17 and the one prior on 7/19/17 did not discuss his shower preferences. The facility failed to give Resident #53 and/or his family members the opportunity to choose his shower frequency. 3) During an interview on 10/23/17 at 12:56 PM, Resident #180 stated that she would like to take a bath three times a week, instead of two times per week as scheduled. On 10/25/17 the activities of daily living (ADL) verification worksheet was reviewed. In the past month the resident had showers on 9/28/17; 10/02/17; 10/05/17;10/09/17; 10/12/17; 10/16/17; 10/19/17; 10/23/17 and 10/26/17, concurring with the staff interview and review of the care plan which states Her shower at this time are Mondays and Thursdays in the morning. The resident's Care conference notes for the same period were reviewed and revealed that the resident's preferred shower schedule is not documented. During an interview on 10/25/17 at 1:40 PM staff #85 stated that the frequency for showers/ bath's is not written in the bath policy. The resident and/or representative is interviewed upon admission, the bath preference is discussed and care planned. The resident and/or representative are informed the resident can choose how many times per week they prefer a shower and/or bath. If a resident wants a bath more often during the week they need to ask the CNA or Licensed Nurse. The request will be given to the Senior CNA who will find out what the resident's preferences are and put it on the shower schedule. At the most recent Interdisciplinary Team Meeting the resident did not request a change in shower frequency from two to three times per week. Review of the bath (shower) policy on 10/26/17 concurred with staff #85 that type and frequency of shower and amount of assistance required should be listed under the resident's plan of care for self-care deficits. The facility failed to give Resident #180 the oportunity to choose the frequency of weekly showers.",2020-09-01
59,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,329,D,0,1,8L5Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview and facility policy review, the facility failed to ensure that the medication regimen for one of five residents, Residents #234, was closely monitored for mood and behaviors. Findings include: Resident #234 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #234 had a physician's orders [REDACTED]. The facility did not provide routine mood and behavior monitoring for Resident #234, making it unclear why he was receiving an antipsychotic medication. A review of Resident #234's medical record on the afternoon of 10/25/17 revealed no documentation of behaviors in the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/8/17 (Admission). A review of the nurse's notes did not find notes titled Behavior or any documentation that indicated he was experiencing mood/behavior issues. Additionally, the facility was not routinely monitoring Resident #234's behaviors. On the afternoon of 10/25/17, a review of a form titled, Behavior Monitoring, dated 10/19/17 revealed Resident #234: Did not display moods during the monitoring period; No behavior symptoms displayed during the monitoring period; Resident was currently taking [MEDICAL CONDITION] medications to address mood/behavior symptoms; Current medications are effective in alleviating mood and/or behavior symptoms; No [MEDICAL CONDITION] side effects observed during the monitoring period; There's a current plan of care with intervention to address the resident's mood and/or behavior symptoms; The interventions in place are effective for the resident's mood and/or behavior symptoms. The form further noted the monitoring frequency was to continue weekly monitoring. The rationale for monitoring frequency was left blank. An interview of Staff #46 on the afternoon of 10/25/17 at 3:53 P.M. found Resident #234 had been transferred to his current unit from another unit in the facility on 10/17/17. Staff #46 reported the resident was doing okay during the evening shifts until 10/24/17. She reported Resident #234 experienced hallucinations on the evening of 10/24/17 when he was distressed and reported seeing his foot detached from his body. Staff #46 further noted the resident was attempting to lift the table to pick up his detached leg from under the table. She informed Resident #234 she didn't see anything and turned his wheelchair around. The resident then attempted to hit the Certified Nurses Aide (CNA) who was standing behind his wheelchair. The resident then attempted to stand and climb over his foot rest. Staff #46 stated that it became unsafe as Resident #234 almost tripped over his foot rest. Staff #46 reported Resident #234's behaviors to the physician and an order was placed for [MEDICATION NAME] 0.25mg every 8 hours as needed for restlessness, hallucinations, and difficulty to redirect. Staff #46 was asked where she documented Resident #234's behaviors. She replied she did not document the behaviors on the evening of 10/24/17 and stated, but I can do a late entry. When asked what the facility's policy was for monitoring residents' behaviors, Staff #46 stated, I don't know the policy. A review of Resident #234's care plan found one for the use of antipsychotic medication related to [MEDICAL CONDITION]. Interventions included, Evaluate indications for usage of antipsychotic medications including specific behaviors and effect of behaviors on resident and/or others. Identify target behaviors and document in clinical record. An interview of Staff #113 on the afternoon of 10/25/17 at 3:55 P.M. found her understanding of behavior monitoring was initial monitoring occurred when a resident was new to the facility, had newly identified mood/behaviors, or changes in [MEDICAL CONDITION] medications. This initial monitoring was done every shift for one week. After the first week, the nurses monitored residents weekly for a total of 8 weeks. After the eighth week, the staff would discontinue behavior monitoring. When asked about Resident #234's behaviors on the evening of 10/24/17, Staff #113 reported they hadn't followed the facility's policy of monitoring behavior every shift after a change in Resident #234's [MEDICAL CONDITION] medications. Additionally, Staff #113 reported that Staff #46 should have entered a nurse's note for Resident #234's behavior on the evening of 10/24/17. An interview of the Assistant Director of Nursing (ADON) on the morning of 10/26/17 at 8:20 [NAME]M. revealed the facility started (10/19/17) routine behavior monitoring for any resident on [MEDICAL CONDITION] medications. The ADON reported the facility was changing their policy to include mood and behavior monitoring every shift for as long as the resident was receiving [MEDICAL CONDITION] medications. The ADON further noted that since this is a recent change in their policy, not all nurses are aware. The ADON reported that Resident #234 should be monitored for behaviors every shift for as long as he is on [MEDICAL CONDITION] medications. A review of the facility's policy titled, Mood and Behavior Management Policy and Assessment Procedure with revision date of 2/16 noted, B. Routine Behavior Monitoring: 1. Initiation of new [MEDICAL CONDITION] medications or changes (whether increasing or decreasing) in current dosage of [MEDICAL CONDITION] medications is made. The facility failed to closely monitor and document Resident #234's behaviors, making it unclear for the rationale of using an antipsychotic medication.",2020-09-01
60,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,371,E,0,1,8L5Q11,"Based on observations and staff interviews the facility failed to ensure proper food handling practices to prevent the outbreak of foodborne illness. Findings include: On 10/23/2017 at 10:15 AM during the initial kitchen tour with Staff#163, observed that the bread storage rack had brown plastic trays to place the bread loaves on and the brown racks were discolored with blackish residue. According to Staff#163 the bread company provided the bread rack and can probably provide a new rack. The walk-in refrigerator #4 contained 4 packages of sliced Swiss cheese with expiration date of 10/07/17 and cole slaw and creamy Italian dressing with no expiration dates. Staff#163 removed the items at that time. The facility did not follow food handling practices to prevent the outbreak of foodborne illness.",2020-09-01
61,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,431,D,0,1,8L5Q11,"Based on observations, staff interview and facility policy review, the facility failed to properly label and store medications. Findings include: During a review of medication storage on two of the six units in the facility on the morning of 10/25/17 at 10:43 [NAME]M. found multiple bottles of medications which were incorrectly labeled and/or stored: 1) Artificial Tears Solution which noted it was opened on 8/10/17. Staff #80 reported the facility's policy was to discard eye drops 60 days after it was opened (10/10/17). Additionally, the medication was discontinued on 9/1/17 but the bottle was still being stored in the medication cart. 2) Artificial Tears Solution which was opened on 10/6/17. The pharmacy label covered the bottle's expiration date and the label did not contain an expiration date. 3) Artificial Tears Solution with a label which noted the prescription was filled on 7/24/17. Staff #80 reported the bottle had been opened but the opened date was not written on the bottle. Staff #80 was unsure of when the bottle should be discarded. 4) Artificial Tears Solution which was opened on 9/12/17. The pharmacy label was blank as though the words were rubbed off - no name, medication name or prescription fill date could be visualized on the label. The manufacturer label noted the expiration date of 2/2020. 5) Artificial Tears Solution which was opened on 10/25/17 but the expiration date of the medication was covered by the pharmacy label. 6) Dorsolamine HCl Ophthalmic Solution with a pharmacy label which was blank as though the words were rubbed off. Additionally, the eye drops were opened on 8/16/17 indicating an expiration of 10/16/17, 60 days since opened. 7) Artificial Tears Solution which was opened on 9/17/17. The pharmacy label covered the bottle's expiration date. 8) Haloperidol 1mg tab which was individually wrapped and did not contain a label. The expiration date was 5/2017. 9) Tuberculin PPD Solution which was opened on 9/18/17 was found in the medication refrigerator. Staff #80 noted that PPD Solution should be discarded 30 days after opening (10/18/17). 10) Alcohol Wipes - 5 boxes containing 200 wipes in each did not have expiration dates on the boxes or the individual packets. Staff #80 stated the expiration may have been on the larger box they were shipped in. However that larger box had already been discarded. Staff #80 stated she wasn't sure if the alcohol wipes were effective since there wasn't an expiration date. On the morning of 10/26/17 at 8:20 [NAME]M., a review of the facility's policy titled, Medications and Medication Labels with revision date of 5/16 noted: 1. Each prescription medication will be labeled to include: h. Expiration or end-of-use date, if not dispensed in original manufacturer packaging; 4. The provider pharmacy permanently affixes label to the outside of prescription containers. Medication labels are not inserted into vials, bags or other containers. For medications designed for multiple administration (for example, inhalers or eye drops), a label is affixed to product to assure proper resident identification; and 5. Non-prescription medications not labeled by the pharmacy are kept in the manufacturer's original container. Nursing care center personnel may write the resident's name on the container or label as long as the required information is not covered, if applicable by state regulations. The facility failed to properly label and store medications.",2020-09-01
62,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2017-10-26,469,E,0,1,8L5Q11,"Based on observation, interview with resident and staff members and review of the facility's invoices and e-mails, the facility failed to ensure the maintenance of an effective pest control program. Findings include: On 10/23/17 at 1:27 P.M. while standing in the hallway outside of Room 148, a staff member was observed to stomp his foot on the ground, kick something on the ground toward the bathroom and began talking to the Resident #287. The staff member then walked over and picked something off the floor with a paper towel. The staff member was heard informing the resident that he killed a cockroach. Subsequently an interview was done with Resident #287. The resident replied negatively regarding cockroaches; however, reported there are a lot of lizards on the ceiling above her and has concerns that they may fall on her while she is lying in bed. Throughout the survey (10/23/17 through 10/26/17) ants were observed to be crawling on the conference room table. On 10/26/17 at 11:55 [NAME]M. an interview and walk through the facility was done with Staff Member #365. The staff member reported the facility has a contract for pest control. The contractor will come in quarterly for maintenance; however, Staff Member #365 does not keep track/log of when the contractor provides quarterly maintenance. Staff Member #365 also reported the facility will call their contractor if there are concerns. The staff member stated he was not aware of lizards in the facility. The staff member was agreeable to review and provide invoices and e-mails that document that quarterly maintenance (pest control) services were provided by the contractor. On 10/26/17 at approximately 12:30 P.M. Staff Member #365 provided invoices documenting the following: quarterly pest control and rodent control on 9/12/17; rodent control trapping on West Wing Nursing Station on 1/4/17; rodent control trapping, day health on 1/4/17; and quarterly pest control and quarterly rodent control on 12/8/16. A review of the e-mails provided found services were provided on the following dates: 9/26/17 (Pikake Unit, Room 103 ants in room on the floors and walls); and 10/6/17 (Ilima Unit, large black ants on clerk and nurse desk area as well as on wall and floor). An e-mail dated 9/7/17 from the contractor notes the need to schedule the following pest control services: quarterly pest control in/out on 9/12/17 and kitchen monthly pest control on 9/12/17. There is no documentation of quarterly pest control services by the contractor from 12/8/16 through 9/12/17. The facility failed to ensure an effective pest control program was maintained as evidenced by no documentation of quarterly and annual pest control services from the facility's contractor.",2020-09-01
63,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,561,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with resident, the facility did not promote a resident's right to make choices regarding personal hygiene (shaving) for 1 (Resident 162) of 2 residents sampled. Findings include: On 11/20/19 at 11:30 AM an interview was conducted with Resident (R)162. During the interview, R162 was observed to be unshaven. The resident had short hair stubbles on cheeks, chin and over the lip. R162 was asked if facial hair is his preference. The resident responded, no, clarifying staff members shave him twice a week when he receives a shower. R162 further explained that he would prefer to shave himself as there are times when staff members cut him by the lip, chin and under his chin while shaving him. R162 also reported he receives a shower twice a week (Tuesday and Friday) but wouldn't mind showering more often. A record review found a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/28/19 documenting R162 is independent for cognitive skills for daily decision making regarding tasks of daily life. R162 is also noted to require extensive assist with one person physical assist for personal hygiene (how resident maintains personal hygiene, including shaving). R162 also requires one person physical assist for part of bathing. A review of the annual/comprehensive MDS with an ARD of 05/13/19 notes for the resident's preferences for customary routines and activities, R162 rated choosing between a tub bath, shower and sponge bath as very important. The care plan for activities of daily living notes R162 will participate with combing his hair, shaving and cleaning dentures daily. The intervention includes providing sufficient time for the resident to complete bathing, dressing and performing personal hygiene, as well as, providing adequate rest periods between activities (especially after receiving [MEDICAL TREATMENT] treatment).",2020-09-01
64,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,568,E,0,1,6SOG11,"Based on interviews with resident and staff members, the facility failed to establish a process/system to ensure residents with personal funds are actually provided with their financial statements. At the time of survey, there was 102 residents with a personal fund account. Findings include: On 11/20/19 at 11:30 AM an interview was conducted with Resident (R)162. R162 affirmed he has a personal funds account with the facility. Further queried whether he receives a quarterly statement from the facility. R162 responded he does not receive statements from the facility notifying him of how much money he has in his account. The resident speculated he may have about a hundred dollar in his account but not sure. On 11/26/19 at 09:20 AM an interview was conducted with the Financial Controller (FC) and Business Office Clerk (B[NAME]). The B[NAME] confirmed R162 has a personal funds account. Inquired how often does the facility provide statements to the residents? The B[NAME] replied the residents are provided with monthly statements. Further queried what is the process for providing the statements to the residents. The B[NAME] responded, the business office will print the statements, the statements are provided to social services to disperse, then social services will deliver the statements to the units and the unit clerks will provide the statements to the residents. And for those residents that have a representative, the statements are mailed to the representative. The business office does not have documentation/log that the resident actually received their statements. The business office provided a listing of all residents with personal funds. There are 102 residents with accounts. A review of R162's statement for 09/01/19 through 09/30/19 documents he has more than a hundred dollars in his account. The statement lists the facility address for this resident and does not indicate the statements are mailed to a representative. On 11/26/19 at 09:33 AM an interview was conducted with Social Services (SS) staff member. Inquired what is the role of social services for providing financial statements to residents. The SS initially replied we don't do anything. Upon further query, SS replied the business office prints out the statements then the ward clerks on the unit delivers the statements. And for those that have a representative, the statements are mailed.",2020-09-01
65,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,640,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff member, the facility failed to successfully transmit data within 14 days of discharge for Resident (R)1. Findings include: On [DATE] at 02:18 PM a record review was done for R1. R1 was admitted to the facility on [DATE] from an acute hospital. R1 expired on [DATE] and there was no Minimum Data Set (MDS) assessment submitted over 120 days. There is documentation in the electronic health record a MDS was done on [DATE]; however, there was no evidence the discharge assessment was transmitted. On [DATE] at 02:32 PM, an interview and concurrent record review was done with the Resident Assessment Assistant (RAA). The RAA confirmed the assessment was done; however, was not successfully transmitted.",2020-09-01
66,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,641,D,0,1,6SOG11,"Based on record review and interview with staff members, the facility failed to accurately reflect a resident's status for skin conditions. Findings include: Cross Reference to F684. A review of the facility matrix provided by the facility found Resident (R)93 was identified with a facility acquired pressure ulcer. A review of the comprehensive Minimum Data Set (MDS) with an assessment reference date of 11/07/19 found in Section M. Skin Conditions, R93 was coded with a stage 3 pressure ulcer. The documentation from the facility's private supply vendor assessed R93 was a stage 3 pressure ulcer. Further record review and interview with staff members found R93 has a wound to the left inner buttock, which is not a stage 3 pressure ulcer.",2020-09-01
67,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,658,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with facility staff, the facility failed to meet professional standards of quality. Observation of two medication carts found each cart with one pill splitter with residual pill powder from unknown medications. As a result of this deficiency, residents were placed at risk of experiencing a potential adverse outcome, due to resident's allergies [REDACTED]. Findings include: On 11/22/18 at 09:20 AM, observed medication pass on one of four units. Each medication cart contained a medication pill splitter. Observed medication powder residue on the inside compartment (the area pill is secured, blade for splitting the medication, and the internal compartments) for both medication pill splitters stored on the medication carts. Licensed Practical Nurse (LPN)13 and Registered Nurse (RN)17 both confirmed the pill splitter was used to split various medications for multiple residents. RN17 and LPN13 confirmed the residual pill powder on the pill splitter poses a potential risk to residents and should have been cleaned. LPN13 and RN17 could not confirm the standard professional method used to properly clean the pill splitter to avoid a potentially harmful situation for a resident. An interview on 11/23/19 with the Director of Nursing (DON) confirmed the pill splitter should be cleaned with soap and water after each use.",2020-09-01
68,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,684,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with staff members, the facility failed to ensure a resident, Resident (R)93 with a wound was accurately assessed and based on the assessment, determine appropriate treatment and interventions for healing and prevention of further skin breakdown to maintain his highest practicable physical well being. The wound reportedly was erroneously assessed as a stage 3 pressure ulcer. The facility also failed to coordinate and provide continuity of care for R93 as evidenced by observation of not applying the heel lift boot at all times; using a half sheet to pull resident up to reposition (creating shear and friction); not following recommendation of the Advanced Practice Registered Nurse to place resident on right side while in bed, not having an OTC ([MEDICATION NAME]) available for treatment, and lack of interventions to decrease moisture while in the facility and during [MEDICAL TREATMENT] treatment. Findings include: Cross Reference to F641. Resident (R)93 was admitted to the facility on [DATE]. R93's [DIAGNOSES REDACTED]. R93 has history of skin breakdown to his right buttock, excoriation to the scrotum and also to his right outer ankle. R93 was identified on the facility matrix with a facility acquired pressure injury. A review of R93's comprehensive Minimum Data Set with an assessment reference date of 11/07/19 found in Section M. Skin Conditions, R93 was coded with a Stage 3 pressure ulcer, this pressure ulcer was not present upon admission/entry or reentry. On 11/25/19 at 01:33 PM the facility provided a copy of the Care Area Assessment (CAA) which was signed by Resident Assessment Coordinator (RAC)1 on 11/17/19. A review of the CAA notes R93 with a stage 3 pressure ulcer to the left buttock that initially started as shearing, but worsened. R93 noted to be incontinent of bowel and bladder, utilizing briefs to manage incontinence. R93 also requires extensive assistance with one to two person staff assist for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). R93 received [MEDICAL TREATMENT] three times a week, requiring him to sit for a prolonged period during treatment. R93 was also noted to have open wounds to the scrotum and right buttocks, which have healed. A review of the R93's care plan found interventions related to risk for skin breakdown and moisture associated skin damage due to bowel and bladder incontinence. The interventions included: use of pressure reducing cushion to wheelchair and alternating pressure mattress; reduce potential for shearing, friction, rub injury, or bruising during transfers, elevation and repositioning by using a turn sheet; activity staff will assist with repositioning and encourage good fluid intake; keep right lower extremity rotated outward with direct pressure off of right lateral malleolus while in bed, use the heel lift boot at all times; and offer assistance with toileting before a big event or outing. The clinical note dated 11/08/19 notes an interdisciplinary team meeting was done to address weight loss due to decreased oral intake. There is documentation of open wound to left buttock, scrotum and right shin. R93's [MEDICATION NAME] level was noted to be within normal limits. The team decided to provide Boost pudding at med pass once a day to promote wound healing. On 11/20/19 at 11:30 AM and 02:15 PM, R93 was observed lying in bed asleep. R93 was positioned on his back with a pillow placed under his right knee. On 11/22/19 at 11:37 AM, R93 was observed asleep, placed on his back with a blue bolster pillow under his upper right extremity. On 11/26/19 at 09:12 AM, R93 was observed lying in bed with his right leg bent at knee (v-shape) with a pillow placed under the knee and ankle. R93 had an elastic bandage on his right foot which extended above the ankle. Interview with Certified Nurse Aide (CNA)5 found the resident has a foam boot which is placed on for two hours and removed every two hours. CNA5 also reported R93 is repositioned every two hours. On 11/20/19 at 09:25 AM an interview was done with the Neighborhood Supervisor (NS)1. NS1 reported R93 has a stage 2 pressure ulcer to the left buttock and a stage 1 pressure ulcer to the right buttock, further reporting it started as excoriation. NS1 also reported R93 had a scrotal wound which has healed. NS1 explained the resident goes to [MEDICAL TREATMENT] and despite attempts to coordinate with them to offload, it has been difficult. A review of the wound assessment worksheets found an assessment dated , 06/17/19 of a stage 2 wound to the left inner buttocks measuring 0.8 cm (length) x 1 cm (width) x There was no documentation of wound assessments from 06/17/19 until 07/14/19. The assessment of 07/14/19 notes the wound deteriorating. There was no documentation of wound assessment from 07/14/19 until 09/17/19. The size of the wound increased to 3 cm (length) x 1.5 cm (width) x 0.1 depth. The resident's wound was noted to be a previous wound that is now open despite barrier cream administration. The wound was noted with scant serosanguinous exudate. On 10/01/19 the wound was documented to have improved, the treatment included cleansing with normal saline and apply [MEDICATION NAME] to affected areas. The wound deteriorated on 10/22/19, slough was noted. On 10/22/19 the wound noted to deteriorate, increased in size measuring 3.7 cm (length) x 5.2 cm (width) x Further review found a report dated 11/12/19, entitled (Facility Name) - Wound Care *Skin Integrity* Evaluation which documents the presence of a stage 3 pressure ulcer to the left buttock. The size was 16.00 cm (length) x 2.60 (width) x The last assessment dated [DATE] notes the wound measured 1.5 cm (length) x .75 cm (width) x A review of the APRN note of 09/23/19 notes the wound to the medial left buttocks worsening and R93 complaining of pain while sitting during [MEDICAL TREATMENT] treatment. Also noted the [MEDICATION NAME] was not available and house stock zinc oxide was being used. The APRN notes open wound is not over bony prominence, there is partial thickness to the wound, probably due to shearing. The plan was to use baza cream three times a day and as needed after peri-care until [MEDICATION NAME] is available. Further recommendations include: keep pressure off site by positioning on right side when in bed, may use bordered foam dressing for comfort during [MEDICAL TREATMENT] and continue to monitor. On 11/25/19 at 12:43 PM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON reported the facility does not have a wound nurse. The ADON explained the assessment of 11/12/19 which documents a stage 3 pressure ulcer was done by the private supply vendor. The ADON reported the vendor is a certified wound nurse and makes recommendations for treatment. Inquired whether it is within the vendor's scope to assess wounds and did the vendor actually assess R93's wound. The ADON was agreeable to follow up. On 11/25/19 at 12:54 PM the ADON provided a copy of the service agreement by the vendor. At this time the ADON shared that she did not notice the resident was assessed with [REDACTED]. On 11/25/19 at 11:36 AM an interview was conducted with the APRN. The APRN reported R93 went out on pass with his family and returned with excoriation to the left inner buttock which is not a pressure ulcer as it is not on a bony prominence. The APRN explained the wound is on the inside of the buttock, the fatty part where the butt cheeks touch. Further queried whether a root cause analysis was done to determine the type of wound the resident has and what were contributory causes for the breakdown. The APRN responded it could be moisture associated skin damage. A subsequent interview was done with the ADON regarding the lapse of documentation of the wound. The ADON reported the lapse may have been attributed to the healing of the wound. And when the assessments started again, the wound may have presented itself again. On 11/25/19 at 03:30 PM, the NS1 now reports R93's wound started with moisture and the house barrier cream was used. The NS recalled the wound was noticed after the resident returned from a family visit. The NS confirmed the resident's family will provide peri-care during his visit. The NS stated she has been trying to work with the [MEDICAL TREATMENT] facility to assist in repositioning and providing incontinence care. The NS reported although R93 receives [MEDICAL TREATMENT], he continues to urinate. At this time, the NS1 was asked to clarify how are staff repositioning the resident to reduce shearing and friction. The NS explained a half sheet in the middle of the bed is being used and the sheet is pulled up to reposition. The NS further clarified the half sheet is different from using the bed sheet, decreasing friction and sheer.",2020-09-01
69,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,689,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to identify potential accident hazards for the following: on two units the housekeeping and supply closets were not secured and supplies on delivery cart were not secured. As a result of this deficient practice, the facility put the safety and well-being of the residents at risk for accident hazards. Findings include: 1) During an observation of the Gardenia Neighborhood Nursing Unit on 11/21/19 at 08:42 AM, a housekeeping closet door was not secured. The closet contained various cleaning solutions including OxyFect H Peroxide disinfectant cleaner and Clorox germicidal bleach. Resident (R)182 was seen propelling self with his/her wheelchair near the unsecured closet and there was no staff in the immediate vicinity. R182 was admitted to the facility on [DATE]. A review of R182's Minimum Data Set (MDS), comprehensive assessment, with an assessment reference date (ARD) of 11/03/19 showed the Brief Interview for Mental Status (BIMS) score was 9 (nine) which indicates that R182 has moderately impaired cognition. During staff interview with the Housekeeper (HSKPR)1 on 11/21/2019 at 10:40 AM, HSKPR1 stated that the housekeeping closet door should be secured at all times. HSKPR1 also revealed that the door has to be pushed a little harder in order for it to close completely. 2) During an observation of the North Neighborhood Nursing Unit on 11/21/19 at 11:00 AM, a central supply closet was not secured. The closet contained various supplies including Sani-cloth germicidal disposable wipes, [MEDICATION NAME] shampoo gel, Purell hand sanitizer foam, and Attend briefs. Resident (R)32 was seen propelling self with his/her wheelchair near the unsecured closet and there was no staff in the immediate vicinity. R32 was admitted to the facility on [DATE], a review of the MDS, quarterly assessment, with an ARD of 03/09/17 showed the BIMS score was 3 (three) which indicates that R32 has severely impaired cognition. During staff interview with Certified Nurse Assistant (CNA)1 on 11/21/19 at 11:10 AM, CNA1 acknowledged that the central supply closet door should have been secured. 3) On 11/25/19 at 12:20 PM, observed a flatbed cart, filled with boxes of supplies, unattended in the hallway of 1 of 4 units. Observed Resident (R)171, self-propel his/her wheelchair up to the unattended cart and used his/her wheelchair to stand. Once standing, R171 reached into an uncovered plastic bin, which contained various items including a box of (100 count) lancets. R171 proceeded to feel around in the uncovered plastic bin and attempted remove items. Staff observed R171 reaching into the uncovered bin, however, did not attempt to relocate or secure the supplies on the cart. R171 was left unattended at the supply cart. R171 was observed to leave the area and return to his/her room. A review of R171's medical record, care plan, and progress notes documents a history of hoarding items and aggression towards other residents in the facility. A review of the Minimum Data Set, comprehensive assessment, with the Assessment Reference Date of 10/03/19, R171 scored an 11 (eleven) on the Brief Interview for Mental Status, indicating R171 has moderately impaired cognition.",2020-09-01
70,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,690,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews with facility staff, and record review, the facility failed to provide appropriate catheter care and monitoring of the catheter tubing for sediment build up/clotting for Resident (R)159. As a result of this deficiency, R159 is placed at an increased risk for further complications and infection related to the use of a foley catheter. Findings include: R159 was admitted on [DATE] with the [DIAGNOSES REDACTED]. On 11/19/19 at 11:20 AM, initially observed small clots and sediment in the resident's catheter tubing. Observed the catheter tubing on six (6) subsequent days (11/19/19 at 01:03 PM; 11/20/19 at 10:10 AM; 11/20/19 at 12:51 PM; 11/21/19 at 09:28 AM; 11/21/19 at 12:45 PM; and 11/22/19 at 09:45 AM). Each day there was an increase in number of visible small clots and in the size of the build-up of sediment in the tubing. On 11/22/19 at 10:10 AM, observed the catheter tubing with registered nurse (RN)17. RN17 confirmed the catheter tubing and bag should be changed due to the number of small clots, sediment visible in the catheter tubing, and the possible obstruction of urine flow. On 10/23/19, R159 was diagnosed with [REDACTED]. Subsequently, on 10/24/19 R159 was diagnosed with [REDACTED]. R159 returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of R159's Minimum Data Set (MDS), Assessment Reference Date (ARD) of 10/27/19, documents R159 is totally dependent on staff for all care including bed mobility, transferring (bed/wheelchair), personal hygiene, dressing, eating, and toilet use. On 11/22/19 at 09:11 AM, observed certified nurse aides (CNA)21 and CNA3 provide catheter care to R159 due to fecal incontinence. CNA21 wiped R159's perineal area (soiled with feces) with a disposable wipe then used the same disposable wipe to clean the right labia majoria. The disposable wipe was visibly soiled with feces. The facility's policy and procedure, Catheter Care, instructs staff to not contaminate area with feces and to clean the area from front to back. CNA21 used another single disposable wipe and cleaned the catheter tubing, starting approximately 3 inches away from the meatus (insertion site), with a back and forth motion which would reintroduce contaminants. R159's care plan documents to clean around the catheter with soap and water, not a disposable wipe. The facility's policy and procedure for catheter care, documents staff is to cleanse the area at the catheter insertion site, starting at the meatus and working away from the body.",2020-09-01
71,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,692,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with resident and staff members, the facility failed to ensure 1 of 3 residents was monitored for weight loss. The system for reporting significant weight loss for a resident receiving daily weights was not established; therefore, the resident was not assessed by a Registered Dietitian (RD). Also, the facility failed to develop a care plan to address weight loss related to the resident's [MEDICAL CONDITION] and use of diuretics. Findings include: Resident (R)209 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 11/19/19 at 2:30 PM an interview was done with R209. R209 reported loosing weight, approximately 4 to 5 pounds. Further inquired whether she was on a special diet, she replied no. Observation also found R209's lower extremities were mottled with red spots and appeared to be swollen. R209 reported she fell at home and the red spots were the result of [MEDICAL CONDITION] crawling on the carpet. On 11/20/19 at 09:15 AM R209 was observed sitting outside of her room and had eaten all her breakfast. R209 stated breakfast is the best meal. Record review found the following weights for R209: 166 (11/01/19); 163 lbs. (11/06/19); 159 lbs. (11/13/19); 153 (11/14/19); 148 (11/19/19); 145 (11/21/19) and 143 (11/25/19). On 11/01/2019, the resident weighed 166 lbs. and on 11/25/2019, the resident weighed 143 pounds which is a 14% weight loss in less than a month. A review of the physician's orders [REDACTED]. twice daily for generalized [MEDICAL CONDITION]. The admission Minimum Data Set with an assessment reference date of 11/06/19 notes R209 did not have a weight loss and indicates R209 received diuretics during the assessment period. A review of the Comprehensive Nutritional Assessment, signed 11/11/19 notes the following diet recommendations: 3 gram sodium; regular texture; and fluid restriction. R209 also noted to have fair to good intake at meals with 2+ [MEDICAL CONDITION]. The assessor also notes R209 had slight weight loss since admission suspected due to fluid. A subsequent Mini Nutritional assessment dated [DATE] notes R209's food preferences and a plan to weigh the resident daily prior to breakfast. R209's care plan was reviewed on 11/22/19 at 11:11 AM. The goals include: maintaining stable weights (+/- 5% admission weight, ideal body weight 112.5 lbs.) and labs; being free of signs and symptoms of constipation and dehydration; and maintaining the best quality of life by being well nourished. On 11/26/19 at 08:39 AM a copy of the care plan was provided by the facility. A review of the document found the goal of maintaining stable weights was discontinued (no date documented of when this goal was discontinued). In addition the goal of loosing weight due to [MEDICAL CONDITION] and [MEDICATION NAME] treatment was added to the care plan. There is no documentation of the date this goal was added to the resident's care plan. On 11/25/19 at 10:05 AM an interview was done with the Neighborhood Supervisor (NS)1. Inquired whether the Registered Dietitian (RD) was notified of R209's weight loss. NS1 reported weights are sent to the RD weekly (Saturdays) and based on the calculated percentage of loss or gain, this would trigger the need to do a comprehensive review and consult the RD. NS1 reported R209 receives [MEDICATION NAME]; therefore, weight loss was expected. On 11/26/19 at 07:20 AM an interview and concurrent record review was done with the Dietitian Coordinator (DC). The DC reported R209's record regarding the weight loss was reviewed. Inquired when was she informed of the resident's weight loss, DC replied yesterday (11/25/19). The DC reported R209 had a planned weight loss, inquired whether this was included in the resident's care plan, the DC reported she would check on this. Concurrent record review found no care plan related to a planned weight loss. The DC further explained R209 was [MEDICAL CONDITION] and on [MEDICATION NAME] so the weight loss was expected. Further queried how to determine whether the loss is attributed to fluid loss or a true weight loss. The DC reported even if a weight loss is expected the nursing staff needs to report the loss to the dietitian. The DC clarified R209 is on daily weights and there may have been a glitch in the new system as this resident was not included in the weight reports. The system supports reports for residents on weekly and monthly weights but not daily weights. Therefore, R209's weight loss was not triggered. The DC explained the process entails nursing to upload weights in the electronic medical record (EMR) and the report is received by the dietitians on Saturday. Staff members are required to report a 2% weight loss in a week to the dietitian, physician and as applicable the resident's representative. Also, a reportable is a 5% weight loss in a month. The DC provided an update for R209 which was dated 11/25/19. The note documents R209's weight as 143.4# on 11/25/19, 147.6# on 11/18/19, and 161.8# on 11/11/19 which reveals a 2.8% decrease in one week (between 11/18/19 to 11/25/19) and 9% decrease (11/11/19 and 11/18/19). A review of the meal intake found the resident's food intake at meals ranges from 50-100% and R209 meets the daily fluid intake. Also noted R209 received [MEDICATION NAME] intravenously, continues on oral diuretic ([MEDICATION NAME]) and has +1 [MEDICAL CONDITION] to bilateral lower extremities. The DC notes it is suspected the weight loss is mainly due to fluid as the resident has had fair to good intake since admission. There is an expectation of continued weight loss. The plan is for nursing to notify the dietitian of weekly significant weight changes. On 11/26/19 at 08:39 AM the facility provided a copy of R209's care plan. The facility copy now included the goal for wanting to lose weight due to [MEDICAL CONDITION] and [MEDICATION NAME] treatment and weight loss is expected and beneficial. The interventions include the following: monitor resident for greater than 2% weight changes weekly; send weekly reports to dietitian for further evaluation of weight changes greater than 2%; and report the significant changes to the physician, dietitian and resident representative.",2020-09-01
72,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,755,D,0,1,6SOG11,"Based on staff interview and a review of facility records, the facility failed to document the narcotic count log on 1 of 4 units. As a result of this deficiency, there is a risk of potential diversion of controlled medications. Findings include: On 11/22/19 at 09:30 AM, a review of the narcotic log on one of four units found the narcotic log was not completed. On 11/19/19, the off-going (night shift) and the oncoming (day shift) failed to complete the narcotic log. The staff did not document the number of actual narcotic medication counted between the shifts; however, as evidenced by their initials, they attested to the count (which was blank). A review of the individual narcotic count sheets for every resident notes a total of 5 of 11 medications were administered. Licensed Practical Nurse (LPN)25 confirmed, the facility utilizes the narcotic log as part of a three-check system to count and account for narcotic medications. The count on the narcotic log is used at the change of each shift. One licensed nurse from the off-going and the licensed nurse coming on duty reconcile the narcotic log against the actual narcotic medication (tablets, solutions, patches) stored in the narcotic drawer and the resident's individual narcotic sheet. LPN25 confirmed the narcotic log should not be left blank.",2020-09-01
73,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,756,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure the attending physician responded to the pharmacist's recommendation regarding the use of an antipsychotic medication ([MEDICATION NAME]) for Resident (R)137. As a result of this deficiency, R137 could potentially experience adverse outcomes and may not be receiving the lowest possible dose with the most benefit. Findings include: A record review found a progress note, 04/27/19 at 09:39 AM by Pharm1 documenting a Drug Regimen Review (DRR) was completed. Pharm1 documented, R137 has been receiving an antipsychotic [MEDICATION NAME] 0.25 mg QAM (every morning) and 0.5 mg QPM (every night) since 10/21/18. Pharm1 requested the attending physician complete an evaluation of the current dose and to consider a gradual taper of the dose to ensure (R137) is receiving the lowest possible effective/optimal dose. There was no documentation of the pharmacist's report to the physician regarding use of [MEDICATION NAME] or a response from the physician. A subsequent review by the pharmacist on 05/30/19 at 09:31 PM, notes the attending physician failed to respond to a previous request for an evaluation/gradual taper of dose for [MEDICATION NAME]. At this time, Pharm1 planned to resend last months note (dated 04/27/19). On 11/22/19 at 08:51 AM, the Assistant Director of Nurses (ADON) was unable to find the 04/27/19 documentation of the correspondence from the pharmacist to the attending physician. The ADON provided documentation which was dated 05/31/19 in which the attending physician responded to the pharmacist. The date of the response is illegible (possibly (MONTH) 2019).",2020-09-01
74,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,758,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with staff members, the facility failed to address the gradual dose reduction and use of an antipsychotic to treat a specific condition for 1 of 5 (Resident 189) residents reviewed for unnecessary medication. The facility inconsistently monitored the resident's targeted behaviors for use of [MEDICATION NAME], the targeted behaviors to address the use of [MEDICATION NAME] was changed over a period of time which does not provide accurate monitoring of the targeted behaviors related to the drug usage. Also, the start date of the medication was inconsistent, therefore, there was no documentation by the pharmacist of a recommendation for gradual dose reduction and the pharmacist did not address the increase of the [MEDICATION NAME]. Findings include: Resident (R)189 was admitted to the facility following an acute hospitalization on [DATE]. R189's [DIAGNOSES REDACTED]. R189 also has an indwelling foley catheter. On 11/19/19 during the initial tour, R189 was observed laying in bed asleep. Subsequent observation at 02:14 PM found the resident lying in bed with a pillow between his legs. On 11/20/19 at 09:10 AM, R189 was observed to be asleep in bed with the television on. At 11:30 AM, R189 appeared awake and attempted to screen the resident for appropriateness of interview. R189 attempted to sit up, setting off his clip alarm, a staff member entered the room and he asked whether lunch was coming. Inquired if he was hungry, he replied no. The screening was discontinued. Later stopped in to visit the resident at 02:15 PM, he was lying in bed asleep. A record review done on 11/22/19 at 07:35 AM noted physician orders [REDACTED]. (start date of 07/22/19) at hour of sleep for [MEDICAL CONDITION] with behavioral disturbance; and [MEDICATION NAME] 50 mg. (start date of 06/30/19) twice a day for [MEDICAL CONDITION] with behavioral disturbance. A review of the [MEDICAL CONDITION] medication review found the recorded date a medication was initiated is inconsistent. The review for 08/23/18 has an initiation date of 07/31/18 for [MEDICATION NAME] (50 mg. twice a day). A subsequent review, dated 06/24/19 for [MEDICATION NAME], the same dosage documents an initiation date of 05/25/18. There is also documentation of [MEDICATION NAME] 100 mg at bedtime in the review for 08/23/18 and 01/29/19. On 06/29/19 the [MEDICATION NAME] dosage was changed to 50 mg at bedtime. Subsequently, the dosage was increased to 150 mg at night on 06/30/19 as documented in the 10/28/19 assessment. There is no documentation of a gradual dose reduction. Also, the pharmacist is not documented as a participant in all the [MEDICAL CONDITION] medication review meetings. Further review of the [MEDICAL CONDITION] medication review found the monitoring of targeted behaviors related to the use of the medications varied. The targeted behaviors identified for the use of [MEDICATION NAME], 50 mg twice a day include: restlessness, anxiety, and calling for wife (08/23/18); yelling, aggressive talking, wandering and disorientation (01/29/19); exit seeking, yelling and verbalizing accusations (06/24/19); and agitation, yelling, exit seeking and throwing personal belongings (10/28/19). The use of [MEDICATION NAME] at bedtime identified the following targeted behaviors: 50 mg - falling asleep and staying asleep (06/24/19); 100 mg - yelling aggressive talking, wandering and disorientation (08/13/18); and 150 mg. agitation, yelling, exit seeking, and throwing personal belongings (10/28/19). The review also documents the number of occurrences of the targeted behavior which determines whether an increase of medication or a gradual dose reduction is indicated. On 11/25/19 at 09:20 AM an interview was conducted with Neighborhood Supervisor (NS)1. Inquired how does the facility monitor residents' targeted behavior. It was explained the nursing staff documents a progress note when a resident exhibits a behavior. NS1 further reported the ADON will count the target behaviors for the [MEDICAL CONDITION] medication review meetings to document the number of occurrences since the last review. NS1 clarified the ADON has to go through the resident's record to calculate the occurrences. A review of R189's care plan found interventions under Mood and Behavior for the interdisciplinary team to recommend gradual dose reduction based on the following: target behaviors are no longer present; target behaviors no longer affect the health and safety of the resident and/or others; target behaviors are successfully redirected with use of non-pharmacological interventions; and whether the side effects/risks outweigh the benefits of treatment. A review of the pharmacist drug regimen review found notification on 04/20/19 regarding consideration of dose reduction for [MEDICATION NAME] (15 mg qd since 06/25/18). The subsequent note of 05/19/19 documents [MEDICATION NAME] at 22.5 mg. The review does not address the increase of [MEDICATION NAME] from 100 mg to 150 mg at bedtime. The review on 07/16/19 notes possibly re-evaluate co-administration of [MEDICATION NAME] and [MEDICATION NAME] due to recent suicidal tendency. Also noted on the 08/07/19 review, consideration of tapering of [MEDICATION NAME] to discontinue started due to geri-psych evaluation (polypharmacy). Further noted resident found on floor on 07/18/19 at 07:00 AM. The review does not address the increase of [MEDICATION NAME] from 100 mg to 150 mg on 07/22/19 at bedtime. The pharmacist does not address consideration of dose reduction for use of [MEDICATION NAME] 50 mg. twice a day with a start date of 05/25/18 or 07/31/18. On 10/22/19, the APRN documents a GDR for [MEDICATION NAME] is contraindicated. The review of the psychiatric consultant report dated 07/10/19 notes the following findings: no depressed, no recent suicidal ideation, sleeping well, no side effects with [MEDICATION NAME] to [MEDICATION NAME] change and still with possible constipation and low back pain. The recommendation was to consider stopping [MEDICATION NAME] and monitoring for [MEDICAL CONDITION]. Subsequent visit, dated 08/14/19 notes R189 denied suicidal thoughts and stated he puts the cord around his neck to know which remote is which and to easily reach it. The recommendation was to continue to monitor for [MEDICAL CONDITION] and continue to work on polypharmacy.",2020-09-01
75,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2019-11-26,761,D,0,1,6SOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to: label the blister back for a blood pressure medication with the correct dose for one Resident (R)47 which would place the resident at high risk for injury due to receiving the wrong medication and/or the wrong dose of medication; appropriately discard an antibiotic ointment medication from the treatment cart (the label was non-readable); and failed to label medications with discharge date s. Findings include: 1) During a medication administration observation with LN52 noted a blister pack for R47, the medication was [MEDICATION NAME] (a medication to decrease blood pressure) give 25 milligram (mg) tab 37.5 mg (1.5 tabs) by mouth (PO) twice per day (BID) Diagnosis: [REDACTED]. A hand written note in black ink was noted on the top left corner of the blister pack that stated direction changed, refer to chart. When asked what the correct dosage for R47 was LN52 stated, the new dose was just changed and the new order states to give 25 mg (1 pill) BID. We were giving 25 mg, 1-1/2 tabs, daily which totals 37 mg. LN52 verified that the dosage was changed and now R47 receives only one 25 mg tab, and the label on the blister pack does not reflect the new dose. Medical record reviewed. The Medical Doctor (MD) order dated 11/02/19 states [MEDICATION NAME] 25 mg tabs. Give 1 tab PO BID. During an interview with LN52 on 11/22/19 at 11:00 AM, discussed the labeled blister pack. LN52 stated that in a situation where the order is changed and the medication is the same but the dosage is changed, normally the new dose is written on the top left corner of the blister pack and highlighted in yellow. The nurses normally don't cross out the old dosage information and will continue to use the medication in the blister pack until it runs out. LN52 further explained, since each blister has 1-1/2 tabs, and the order is now 1 tab, they will use the whole tab, then the half tabs (2) until they are all gone or there is only one half tab left. During an interview with the Charge Nurse (CN) on 11/22/19 at 11:21 AM who stated that when we have an order for [REDACTED]. The CN concurred that the blister pack for the [MEDICATION NAME] should be immediately discarded and a new blister pack is obtained from the pharmacy with the correct dose. 2) During a random inspection of the medication/ treatment cart on 11/22/19 at 11:02 AM in the Pikake neighborhood a small tube of Mupirocin (an antibiotic) ointment was found in a drawer. The label appeared old with the print completely worn off making it non-readable. When Licensed Nurse (LN)52 was asked if he knew which resident it belonged to or when the expiration date for the ointment was, LN52 responded that its very hard to tell which resident, I can't see the name . I think we should throw it away. 3) On 11/22/19 at 08:58 AM an inspection of the medication cart on the Ilima Unit was done with the assistance of Licensed Nurse (LN)2. The observation found a vial of [MEDICATION NAME] labeled with an opened date of 10/26/19 with no discard date. Inquired when is insulin discarded, LN2 responded after 28 days and confirmed the discard date should have been written on the label. Observation of other opened vials of insulin found it was labeled with a discard date. Further queried what is the discard date for this vial. LN2 asked another nurse how long before insulin is discarded, the nurse responded 28 days but for [MEDICATION NAME] it is 42 days. LN2 calculated the dates and stated this vial is to be discarded tomorrow (11/23/19). Further inspection found an opened bottle of lantoprost (eye drops for [MEDICAL CONDITION]) labeled with an open date of 11/17/19. LN2 was asked when is this medication discarded. LN2 replied, she thinks it is 30 days and confirmed there was no discard date documented on the label. During the exit conference on 11/27/19, the facility staff reported labeling medications with the discharge date is not required. At this time, a request was made for the pharmacy policy regarding labeling of medications. The facility was agreeable to provide the pharmacy policy and procedure via facsimile. On 12/03/19, the facility sent a policy and procedure entitled Medication Storage, Storage of Medication. The procedure notes the following: 12. Insulin vials should be stored in the refrigerator until opened. Date insulin vials when first opened, may store opened vial in refrigerator or at room temperature. Do not freeze insulin. If insulin frozen, do not use (Refer to Section 9.12, Expiration Dating). Correspondence through e-mails with the Administrator from 12/03/19 to 12/04/19 found the facility was unable to provide Section 9.12, Expiration Dating or a policy and procedure related to labeling medications with expiration date.",2020-09-01
76,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,584,E,0,1,6SFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to have an adequate process in place to ensure mosquito nets installed in several of the resident's rooms in the East and West neighborhoods were adequately maintained, and equipment removed when not in use. As a result of this deficiency, there were several rooms on the east and west neighborhoods that did not have a clean, homelike environment. Findings Include: 1. On 11/27/2018 at 10:47 AM observed several resident rooms in the West Neighborhood had mosquito nets installed. The nets were tied in a knot to keep them from hanging on the floor and pulled to the side of the room. Several other rooms (Rm), Rm 5, Rm 7A, Rm 8B, Rm10A, Rm 10B, Rm 11A, and Rm 14A had a rope/string hanging above the center of the resident's bed. The hanging ropes made the rooms look unappealing and not homelike. Several of the mosquito nets were in poor condition and needed to be replaced or cleaned. Rm 12A was discolored and gray, Rm 13B had multiple holes and Rm 8B had dead insects in the net. During an interview with Registered Nurse (RN)126 on 11/29/2018 at 3:30PM, looked at the mosquito net in Rm 12A and stated that it needed to be taken down or washed. We used the nets when residents were getting bit a lot, but we are not currently using many. That was quite a while ago. If a family requests one, we will put one up. We fill out a work order and maintenance put it up. RN126 stated, I'm not sure who cleans them, housekeeping or maintenance. During an interview on 11/30/2018 at 10:00 AM with the Maintenance and Equipment Coordinator who explained Maintenance does PM (preventive maintenance) on the mosquito nets every six months and we change them out. We don't wash them, we throw them away and put a new one up. It's nursing's responsibility to do a work order to replace it. 2. During a resident interview on 11/28/18 at 08:33 AM observed a small rope hanging over the middle of R183's bed (four to six feet). R183 stated its creepy isn't it? but I think it is for a mosquito net. The doors are left open wide all of the time and sometimes we have mosquitos here. During an observation of a few of the rooms on the East neighborhood on 11/28/18 at 09:09 AM observed mosquito nets attached to the middle of the ceiling and hanging to the side of the bed tied in a knot in several of the rooms on the East neighborhood. During an interview with the Nursing Supervisor on the East neighborhood on 11/19/18 at 03:00 PM, who stated the mosquito nets are put up for residents when they or their families request. Maintenance puts the nets up and takes them down. She wasn't aware of the ropes/ strings that hang down over the bed and asked to be shown where they are. Accompanied her to room [ROOM NUMBER] B where the string was found hanging down from the ceiling over the residents bed. She responded by saying that must be kept in place in case the resident requests a mosquito net. Every month maintenance staff put put up, take down or clean the nets. Infection control mosquito nets policy section 4 reviewed To ensure that resident remain protected from mosquitos and any infections caused from mosquito bites. 1. Residents can request mosquito nets to be placed over the bed at any time . Maintenance conducts bi-annual checks under their preventative main. If mosquito nets are found inept, they are discarded . Replaced bi-annually and as needed via work order. During an interview with the Assistant Administrator on 11/29/18 at 03:40 PM who stated the nets are taken down and thrown away when they become dirty or worn.",2020-09-01
77,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,656,D,0,1,6SFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement respiratory care into Resident (R)54 comprehensive person-centered care plan. The deficient practice resulted in the lack of measurable objectives and timeframe's to appropriately evaluate treatment plan for R45's oxygen (O2) therapy. Findings include: During an observation on 11/28/18 at 01:57 PM R54 was in bed on her right side with oxygen (O2) via nasal cannula. The O2 concentrator was set at two liters (L). R54 Respirations were noted to be steady and slightly labored. The minimum data set (MDS) assessment summary dated 11/02/18 was reviewed. R54 was ordered 02 for comfort, and denied any shortness of breath (SOB). R54 is anticipated to decline due to her non modifiable conditions and power of attorney (POA) has agreed to no hospitalization s at this time. Comprehensive care plan reviewed, no respiratory goals or interventions were noted on R54 care plan. During an interview with Registered Nurse (RN)173 on 11/29/18 at 05:01 PM who stated that R54 is declining, we discussed with the family about hospice and they declined. The MD was the Locum and made a note about offering hospice care. The family decided not to have R54 hospitalized . The family is supportive and comes here often. Physician (MD) orders reviewed with Nursing supervisor revealing no orders for O2. Per RN173 on 10/17/18 R54 was declining and thought to be actively dying. The oxygen was placed at that time for comfort. We did not pursue an order for [REDACTED].>",2020-09-01
78,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,657,D,0,1,6SFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review (RR), the facility failed to meet professional standards of care that would dictate the care plan be revised/updated to reflect changes in condition and approaches for meeting the needs of two Resident's (R), R44, and R127. Care planning drives the type of care a resident receives. Because of this deficient practice, interventions to promote continuity of care and communication amongst nursing staff to safeguard against adverse events were not identified and documented in a timely manner. Findings Include: RR of R127's medical records revealed that R127 had a reoccurring [MEDICAL CONDITION] of the left thigh. R127's care plan identified the problem at risk for skin breakdown i.e. ulcers, rashes, skin tears, with the goal of extrinsic risk factors for skin breakdown will be reduced or eliminated. 11/15/2018 Physician (MD)1 addendum note for R127, includes: recurrent left upper thigh [MEDICAL CONDITION]/rash of left medial and lateral thigh. The warmth of the room and keeping pt. covered contributes to this .ask if pt (sic) can be kept a little cooler. RR of R127 revealed no evidence of documentation that the care plan had been revised to identify interventions to address the contributing factors to the [MEDICAL CONDITION] (warmth of the room, and keeping the resident covered) identified by MD1. During an interview with RN126 on 11/28/2018 at 02:25 PM who stated, I hadn't seen that entry. Inquired if MD1 had communicated the concern to anyone, and RN126 replied, No, but it should have been in the care plan. RR of R44 revealed a new [DIAGNOSES REDACTED]. There was no evidence of documentation that the care plan for R44 was updated to include appropriate interventions and monitoring to minimize complications related to the Pneumonitis (i.e. shortness of breath, fever, drop in oxygen level). During an interview and RR on 11/29/18 with RN126 who agreed the care plan had not been updated to include the new [DIAGNOSES REDACTED]. It was an oversight. If care planning is not complete or is inadequate, the consequences may negatively impact the resident's quality of life, as well as the quality of care and services received.",2020-09-01
79,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,689,D,0,1,6SFF11,"Based on observations and interview the facility failed to identify a resident's risk for an accident, including the need for supervision and assistive devices for one of 68 residents ((R)117) in the survey sample. The deficient practice did not provide adequate supervision and professional standards of practice placing R117 at an increased risk for injury. Findings Include: On 11/27/18 at 12:11 AM observed a certified nursing assistant (CNA) 194, pushing R117 in her wheelchair backwards down the hallway. The resident was talking in her native language and appeared agitated at the CN[NAME] Queried CNA194 why R117 was being pushed backwards in the wheelchair. The CNA 194 stated that R117's wheelchair footrests were broken and going forward may cause her feet to be run over. On 11/30/18 at 10:00 AM interviewed the unit's charge nurse (CN) 279 and inquired about R117's broken foot rests. The CN279 stated that residents in wheelchairs should not be pushed backwards, and only if going through a door. The CN279 stated that she will re-educate staff.",2020-09-01
80,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,761,E,0,1,6SFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure six medication labels were properly labeled with discard dates, and one medication remained in inventory beyond the expiration date. The deficient practice had the potential to affect the efficacy of the expired drug, and the timely identification and removal of medications when they are expired. Findings Include: 1. An inspection of the medication room on the West Neighborhood was completed on [DATE] at 09:34 AM. Pharmerica, is contracted to supply all pharmaceuticals except for over the counter medications, which are purchased by the facility. The procedure for both Pharmerica and the facility is to hand write the discard date on the label of the medication container or package. Registered Nurse (RN) 126 was present during the inspection and asked to review the labels for expiration and discard dates. The following did not have discard dates written on the label: One bottle Antacid, one bottle of Polyethylene [MEDICATION NAME] Powder, one package of Nicotine gum, one bottle of [MEDICATION NAME] and one bottle Sentry Multivitamin. 2. The WEST Neighborhood Medication cart number two was inspected on [DATE] at 10:00 AM which revealed the labels of one bottle of [MEDICATION NAME] and one bottle of [MEDICATION NAME] 1 milligram (mg) did not have discard dates. 3. During an observation of the North Neighborhood Medication Cart on [DATE] at 08:56 AM, an expired packet of [MEDICATION NAME] was found in the storage drawer. The label read discard after ,[DATE]. During an interview with Licensed Nurse (LN) 2 on [DATE] at 08:57 AM who acknowledged that the [MEDICATION NAME] packet was expired and should have been removed. The facility policy on disposal of medications was reviewed stating It is the policy and practice of Hale Makua Health Services that all medications that have been discontinued, expired, or require wasting will be identified and removed from the medication supply in a timely manner and disposed of in accordance with federal and state laws. 4. During a random inspection of the medication refrigerator on East Nursing station medication room on [DATE] at 09:27 AM with the Nursing Supervisor, an open multi-dose vial of positive protein derivative, (PPD) solution was found with no label dating when it was opened. 5. During a tour of the East unit on [DATE] at 01:35 PM, room [ROOM NUMBER]A a small intravenous (IV) bag was found hanging next to R321's bed did not have a date/time hand written on the IV bag or tubing to indicate when it was placed or needed to be discarded. During an interview with the Nursing Supervisor on [DATE] at 02:00 PM who stated we usually hang up the IV antibiotic and throw it away the next day. Medical record reviewed revealing R321 has a [DIAGNOSES REDACTED].",2020-09-01
81,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,812,E,0,1,6SFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure safe food handling processes. The kitchen staff did not ensure proper storage by tracking when to discard perishable food. The deficient practice placed residents at risk for illness. Findings Include: During the initial kitchen tour on [DATE] at 10:27 AM with the director of nutrition services (DNS), found in the kitchen small pantry, an opened case of parmesan cheese packets with expiration date of ,[DATE]. In the produce refrigerator observed a bunch of brown colored celery, and in refrigerator #6 there was a bottle of blackberry puree with an expired date.",2020-09-01
82,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,842,D,0,1,6SFF11,"Based on interview, record and policy review, the facility failed to document the signature date on an Advance Health-Care Directive (AHCD) form for Resident (R) 162. As a result of this deficient practice, the AHCD form would be invalid, and R162 may not have received the care as indicated on the prepared AHCD form. Findings Include: During record review for R162, it was noted that the AHCD form did not contain a date that was required on the form. The AHCD form read Signatures; Sign and date the form here. The section where the date was required contained a signature instead. During an interview on 11/29/18 at 03:04 PM with the Director of Health Information Management (HIM Director), HIM Director acknowledged that the AHCD form was missing the required date. During review of the Facility policy on Advance Directives which stated The Director of Admissions will review any advance directive to be sure it is valid under current law.",2020-09-01
83,HALE MAKUA - KAHULUI,125007,472 KAULANA STREET,KAHULUI,HI,96732,2018-11-30,880,E,0,1,6SFF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record and policy review, the facility failed to post a warning sign of contact precautions at the entrance of two resident rooms, Resident (R) 192 and R8's room. The deficient practice put the staff and visitors at risk of contracting R192's known illness of [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) and R8's active infestation of lice. The facility also failed to ensure direct contact staff demonstrated proper use of gloves with hand hygiene and proper technique for wound care/dressing change. The deficient practice increased R204's risk of illness/ complications of infection. Findings Include: During a record review for R192, revealed the resident had a [DIAGNOSES REDACTED].>During an observation of R192's room, on 11/27/18 at 12:24 PM, several carts were noted to be parked outside the room. One of the carts was yellow, and the other cart was blue and gray. The carts were not marked with a warning sign that would indicate that R192 was on contact precautions. Anyone could have entered the room not knowing that contact precautions were needed. During an interview with Charge Nurse (CN) 41 on 11/27/18 at 12:28 PM, CN41 acknowledged that a warning Sign should have been posted at the entrance of R192's room. Facility policy titled Hale Makua Infection Control Manual for LTC, Contact Precautions was reviewed, it stated At the time a resident is place on Contact Precautions, the Unit Clerk will notify all pertinent departments. Before entering the room of a resident on Contact Precautions, staff and visitors should consult with a licensed nurse for instructions on specific precautions to be taken and Personal Protective Equipment to be used. 2. During an observation on 11/27/2018 at 12:30 PM observed a conspicuous sign outside R8's room that said isolation. The sign did not have any other information (i.e. type of isolation or instructions to report to the nursing station prior to entry) on it. Two residents, R8 and R44 were observed in the room sitting in wheel chairs approximately 5 feet apart. Neither R8 or R44 had any personal protective equipment (PPE) on to prevent transmission of a condition requiring isolation by direct or indirect contact. During an interview on 11/27/2018 at 01:15 PM Licensed Practical Nurse (LPN)130 stated, R8 has head lice, and is on contact precautions. On 11/28/2018 at 10:00 AM, observed the isolation sign on R8's room was gone. During an interview with LPN130 at 10:15 AM who stated that we took it down because someone thought it was a dignity issue. During further interview with LPN130, she pointed out a very small magnet sign located on the door frame. It was difficult to see. On 11/30/2018 Maintenance worker (MW) 115 went to R8's room to check the temperature and was advised R8 was in isolation. Prior to entering the room, MW115 approached surveyor and stated, I didn't see an isolation sign. After the small signage was pointed out to MW115 he put on the appropriate PPE and entered the room. During an interview with RN126 on 11/28/2018 at 2:00PM about the presence of R44 observed in the isolation room [ROOM NUMBER] on 11/27/2018. RN126 stated, That is her regular room. She has been sleeping in another room while R8 is on isolation. R44 didn't want to go to another room and is able to wheel herself around in her wheelchair. She keeps going back into her old room. The facility did not have a process in place to ensure R44 did not enter the isolation room putting her at risk. 3. On 11/29/2018 at 11:16 AM, observed LPN107 preparing for and providing wound care/dressing change on R204's left heel. LPN197 did not clear and clean a space for supplies and did not prepare the supplies in advance. LPN107 did not perform proper hand hygiene and wash hands prior to beginning removing the old dressing. After LPN107 put non-sterile gloves on, she removed the old dressing and disposed of it. With the same gloves LPN107 opened two different drawers on the dressing cart and removed clean supplies from each of the drawers. Some of these supplies were placed on R204's bed. The remainder of the dressing change was completed after washing hands and putting on new gloves. Professional standards of care state when changing a dressing, standard of care is to use aseptic technique to avoid introducing infections into the wound. Position the resident, wash your hands, clear and clean available space for dressing supplies (usually a bedside table), prepare the supplies for the dressing, and wash hands. To remove dressing, after washing hands, put on non-sterile gloves, and remove the old dressing. A wound assessment and visual check should be done. The gloves should be removed, hands washed, and new gloves put on to clean the wound, and again to put on the new dressing.",2020-09-01
84,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2017-06-02,280,D,0,1,HXLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and medical record review (MRR) the facility failed to utilize interdisciplinary expertise to improve range of motion (ROM) for 1 of 24 residents (R#129) on the Stage 2 survey sample resident list. Findings include: On 06/01/2017 at 12:13 PM observed R#129 with splint on the right (R) hand. On 06/01/2017 at 12:37 PM, the MRR on R#129 found that a ROM assessment was last done on 4/28/17. The interdisciplinary conference notes included the rehab report for U/E Range of Motion: No changes noted with _R#129's U/E ROM this screen .Resident received U/E ROM 2 x/week on unit since her return from acute hospital. Use of R handroll for contracture management and utensil with build-up handle for facilitating in feeding. The care plan (CP)#2, I am at risk for further decline in ROM d/t impaired mobility secondary to medical problems; with Goals: I will have no further decline in ROM; and interventions included: 6. encourage me to use utensil with build-up handle for feeding; 7. Use right handroll 2-3 hrs every am and pm shift for contracture management. Check for redness or skin breakdown. Discontinued use of handroll immediately if redness or skin breakdown, & notify CN or OT department; 8. maintenance OT/PT programs 2 x/week UE/LE exercises. Behind the CP#2 were instruction sheets for R handroll use with instructions to place handroll on right hand for 2-3 hours every a.m. and p.m. shift. On 06/01/2017 at 2:32 PM observed R#129 sleeping in bed and the handroll was not placed in R#129's hand, but around the wrist. The resident's family member was at the bedside visiting and stated that R#129 cannot stretch fingers & whenever they try to stretch the fingers R#129 complains, sore. The family member also tried to use a pressure ball in the hand but R#129 refused. Queried Staff#59 if the resident's handroll was properly placed and Staff#59 stated that R#129 moved the handroll and sometimes will throw it. On 06/02/2017 at 11:42 AM observed R#129's food tray with Staff#24 and Staff#88 in the dining/activity rm. There was a regular spoon on the resident's tray and not a built-up spoon as was ordered by the rehab therapist. According to Staff#24, the resident used the built-up spoon only when dining in-room because they didn't want to misplace the built-up spoon. Staff#88 further stated that R#129 didn't like to use the built-up spoon and would sometimes throw it. Staff#88 went to get the built-up spoon from R#129's rm and stated that she would try to make the resident use it. Discussed with Staff#24 that the use of the built-up spoon should be re-evaluated as resident observed to be using small disposable plastic cups to drink pureed food. The facility did not explore care alternatives through a thorough care planning process in which the resident was able to select from alternative treatments after staff observed that R#129 would throw the built-up spoon and the handroll. 2) On 06/01/2017 at 1:59 PM reviewed Resident (Res) #50 medical record. Care plan was reviewed and noted that there is a plan in place for risk for Diabetes Mellitus and [MEDICAL TREATMENT] (HD)-related complications. It was noted that the last review date was 04/17/2017 and next review to be done in July. The care plan stated that the resident will continue to maintain post HD weights within target weight goal of 105.6 lbs +/- 5 lbs. Reviewed note from the [MEDICAL TREATMENT] facility from 05/15/2017 which had the new DW (Dry Weight) 47 kg (103.4 lbs) per staff from Liberty [MEDICAL TREATMENT] Hawaii, LLC and this information was not on Res #50 care plan. On 06/01/2017 at 2:46 PM interviewed staff #24 and staff #124 to find out why the new dry weight 47 kg was not placed on Res #50 care plan and staff #24 stated that it would be updated in (MONTH) at the next care plan revision. It was explained to staff #24 and #124 the importance of this information that needs to be shared with all the staff who are taking care of this resident to avoid any injury that could result in harm to the resident. The facility failed to update 2 of 27 residents Care Plans from the Stage Two survey sample which may result in injury to the resident.",2020-09-01
85,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2017-06-02,313,D,0,1,HXLB11,"Based on record review, resident and staff interview the facility failed to ensure that 1 resident of the 27 Sample Stage 2 residents received proper treatment and assistive devices to maintain their vision. Findings include: On 06/01/2017 at 12:09 PM Resident (Res) #123 was observed eating his lunch without use of glasses. At 12:27 PM interviewed Res #123 and resident stated that they do not use glasses and feels their eyesight is good. On 06/02/2017 at 10:56 AM review of resident's record showed there were no eyeglasses on the property sheet, no care plan for the use of eyeglasses and no mention of the need for eyeglasses in the physical completed by the physician. Interview of staff #4 at that time stated that resident can read without glasses and that resident did not come in with glasses. On 06/02/2017 at 11:30 AM record review of last quarterly MDS, which was completed on 04/21/2017 has the following checked off under vision: Impaired-sees large print, but not regular print in Newspaper/books. Interview of staff #28 shared that the resident's family makes their appointments at the VA and that maybe the daughter could bring in glasses for the resident. At that time Res #123 did not have an eye appointment scheduled. On 06/02/2017 at 11:40 AM interview with staff #65 stated that resident was tested for his vision before it was documented in the MDS and the resident was only able to read the large print on the newspaper and not the small print, the coding was done correctly for Res #123. The facility failed to ensure that the resident receive proper treatment and assistive devices to maintain their vision.",2020-09-01
86,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2017-06-02,325,D,0,1,HXLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and medical record reviews (MRR), the facility failed to ensure that the physician participated in the nutritional assessment, and that a more in-depth nutritional assessment was done to identify nutrition related risks for 1 of 24 residents (R#129) on the survey Stage 2 sample resident list. Findings include: On 06/01/2017 at 12:03 PM observed R#129 eating lunch in the activity/dining room (rm) on the facility's second floor unit. The resident was able to self-feed the pureed meal served on a divided plate. The resident drank all of the fluids served in 6 ounce plastic cups and also the 1/2 cup of applesauce. After finishing all of the liquids of milk, apple juice, water and pureed applesauce, R#129 started to eat spoonfuls of pureed beef mac casserole and chicken rice soup. The resident was sampled for nutrition due to having a body mass index (BMI) of 18.2 and with no physician ordered supplement. On 06/01/2017 at 1:01 PM the MRR on R#129, found that the 2/7/17 speech/swallowing therapy evaluation for swallowing recommendations were for pureed solids and honey consistency liquids with feeding by nursing to observe for actual swallow. The residents weight (wt) on 5/24/17 was 87 lbs; 5/10/17 was 89 lbs in the units weight book. On 06/01/2017 at 1:05 PM interviewed Staff#24 as noted that the last nutritional assessment was done on 2/1/17 after an acute hospitalization for [DIAGNOSES REDACTED] ulcer perforation when R#129 was on GT feeding. Staff#24 stated that R#129 pulled out his/her gastrostomy tube (GT) on 2/14/17, and was put on intravenous (IV) fluids and pureed diet. The R#129 also pulled out the IV. On 2/15/17 the MD recommended not to replace GT/JT because the resident would continue to pull out tubes and would replace if he/she had poor intake. Since 2/15/17 R#129 received a pureed diet and doing well. Staff#24 stated that registered dietitian (RD) was included on interdisciplinary (IDT) meetings and provided documentation for the 2/14/17 IDT meeting on R#129, which the RD noted significant wt loss and resident on TF. Queried Staff#24 if RD did nutritional evaluation after R#129 switched to pureed diet and CN provided that 5/2/17 IDT meeting notes documented, see RD notes 5/2/17, but Staff#24 unable to locate RD notes. Staff#24 called RD and RD had documentation in her office. Continued to do MRR and R#129's care plan (CP) #12 dated 5/9/17, I am underweight related to significant weight loss AEB BMI Queried Staff#24 if supplement should be in treatment record. Staff#24 looked at R#129's treatment record and there was no supplement included. Staff#24 went to the unit's refrigerator and Boost Plus 120 ml was on the nourishment tray for R#129. According to Staff#24, the IDT develops each resident's CP and the resident's supplement should have been on the treatment record. On 06/01/2017 at 2:10 PM interviewed Staff#24 who was find out why the RD didn't reassess R#129 for supplement recommendation after the GT was discontinued on 2/15/17 but she could not provide an explanation. Queried Staff#24, on why supplement was started on 5/17 but sig wt loss was noted at the 2/17 IDT meeting, and she could not provide an answer. The resident's nursing assessment on 3/20/17, documented a wt of 85.2 lbs; and on 3/29/17, wt 85.4 lbs. On 06/01/2017 at 2:16 PM interviewed the RD and she related that on 2/17/17 the resident's niece and family were convincing R#129 to eat because the resident was refusing to eat and on that date started the supplement on a trial basis to see if the resident would drink the supplement. The IDT progress notes dated 2/17/17 Nutrition Follow-up, documented, Boost Plus 240 ml PO TID between meals. On the 5/2/17 IDT conference notes documentation; decreased Boost Plus 120 ml TID btw meals d/t improved intakes. Staff#24 and the RD looked through R#129's medical record and could not find an MD order for the supplement. On 06/02/2017 at 11:01 AM, the MRR on R#129, found a physicians telephone order dated 06/01/17 written with, (late entry for 5/2/17); 1) D/C Boost Plus 240 ml P.O. TID between meals 2) Decrease to Boost Plus 120 ml P.O. TID between meals. T.O. Dr. R. Gries, signed by Staff#24. On 06/02/2017 at 11:42 AM observed R#129's food tray with Staff#24 and Staff#88 in the dining/activity rm. There was a regular spoon on the resident's tray and not a built-up spoon as was ordered by the occupational therapist. According to Staff#24, the resident used the built-up spoon only when dining in-room because they didn't want to misplace the built-up spoon. Staff#88 further stated that R#129 didn't like to use the built-up spoon and would sometimes throw it. Staff#88 went to get the built-up spoon from R#129's rm and stated that she would try to make the resident use it. Discussed with Staff#24 that the use of the built-up spoon should be re-evaluated as resident observed to be using small disposable plastic cups to drink pureed food. The facility failed to provide nutritional care and services consistent with a comprehensive assessesment as the MD did not write the order for nutritional supplements, the built-up spoon was not re-evaluated for use when staff knew that the resident did not want to use it.",2020-09-01
87,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2017-06-02,333,D,0,1,HXLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that 1 resident of the 27 Stage Two sample of residents was free from significant medication error. Finding includes: On 05/31/2017 at 3:00 PM while reviewing Resident (Res) #95 chart and Medication Administration Record (MAR) a medication error was discovered. Res #95 has a doctor's order written on 04/11/2017 for the following medication [MEDICATION NAME] 70-30 vial, inject 18 U SQ q AM and 6 U SQ q PM, If resident eats 25% or less give [MEDICATION NAME] 70-30 9 U SQ Q AM and 3 U SQ q PM. Hold if BS On 06/02/2017 at 10:42 AM met with staff #28 to discuss medication error that occurred on 05/26/2017. Staff #28 reported that staff #20 discussed medication error with them on 05/31/2017 and they filled out the event report and notified the resident's physician and the physician in turn clarified the order. The facility failed to ensure this resident was free from a significant medication error which could have resulted in an injury to the resident.",2020-09-01
88,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2017-06-02,428,D,0,1,HXLB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interviews the facility failed to review medications in collaboration with the MD for 1 of 24 residents (R#84) on the Stage 2 survey sample residents list. Findings include: On 06/01/2017 at 8:38 AM the MRR on R#84 found on the (MONTH) (YEAR) physician order [REDACTED]. for the [DIAGNOSES REDACTED]. The facility's pharmacist review dated 5/15/17 noted, 5/3 decrease (drawn arrow pointing down); 5/3 INR 3.1 re-titrate; MD Warfarin update. The lab results for PT/INR done on 5/03/17, had results of , PT 31.8 secs/ INR 3.1. The physician telephone order on 5/3/17 noted, Coumadin 1 mg PO on MWFSS and 2 mg PO on TTH. Check Protime in 1 month. The MD progress notes on 5/18/17 for the recertification visit noted on the, Plan: On coumadin cont medication. Adjust dose as indicated. Q 2 week INR checks .; Medications ordered: Warfarin 2 mg oral tab; Sig - route: Take 1 tablet by mouth once daily on T, TH, Sa, Su and take 1/2 tab on the other days for thinning the blood . Interviewed Staff#24 to clarify discrepancy of Jun 17 PO and MD visit on 5/18/17 with different orders for Warfarin. Staff#24 had to check with the MD as could not find documentation that new order was clarified with MD. MD report was faxed to facility on 5/22/17 12:36:54 AM. The IDT progress notes on 5/28/17 noted that the MD was notified & staff received telephone order for [NAME]itussin DM Q 6 hr for cough as R#84 was coughing/wheezy earlier that day. The residents CP#13, I am at risk for possible SE r/t use of Warfarin, included interventions: 1. Provide medication as ordered. (Warfarin Na). Observe for side effects like bleeding, behavioral changes, skin rashes, etc, document and notify MD as indicated. Lab works as indicated. Notify MD for changes. 3. Check my skin every shift and monitor for early signs of skin breakdown like redness blisters, rashes, bruises or an signs of bleeding, document and notify MD as indicated 5. refer to Pharmacy/MD for drug review and follow recommendations. The facility failed to ensure that R#84 was administered the correct dosage of Coumadin as prescribed.",2020-09-01
89,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,578,D,0,1,55H911,"Based on record review and interview the facility failed to complete an advanced health care directive (AHCD) for one of four residents investigated (resident (R)29 ). Findings include: Electronic Medical Record (EMR) for R29 reviewed. No AHCD or documentation that the resident or family representative refused to have an AHCD was found in record. The Maluhia resident's rights and responsibilities and advance directive and decision-making support documentation reviewed for R29. The Family member (FM)1 Advance Directives form checked that R29 does not have an advanced directive and that FM1 would like to have more information about advanced directives. Plan for follow up stated check with social worker. Signed and dated by the Power of attorney and dated 7/01/14. No follow up from the Social Worker (SW) was documented in the EMR. During an interview with the SW23 on 07/11/19 at 12:30 PM stated during the admission process, we will discuss the AHCD with the resident and/ or representative. If they have an AHCD done, we will review it and file it, but if they don't have one they will be given the forms to complete. We will have our notary do it. At the annual Inter-disciplinary team meeting (IDT) we can review it and /or follow up. When R29 was admitted to Maluhia, we completed the intake forms and did not follow up to ensure family was given information on the AHCD. Now moving forward we are addressing the AHCD at the time of admission and annually at the IDT meeting to ensure it was done.",2020-09-01
90,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,584,D,0,1,55H911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide clean bed rails in good condition for one of two residents (R)256 investigated. The deficient practice compromised the infection prevention control for R256 and lacks a homelike environment . Findings include: During an observation of the bed rails for R256 on 07/09/19 at 12:55 PM noted they appeared to have soiled tape wrapped around the rails that contained yellow/ brown residue on the tape. During an interview with the Licensed practical nurse (LPN)21 on 07/12/19 at 09:20 AM , upon review of the taped rails and asked what the tape was for LPN21 responded I am not sure but I will follow up and get back to you. During an observation on 07/12/19 at 09:42 AM the Director of Nursing (DON) and Head Nurse (HN)22 went into room [ROOM NUMBER] with LPN 21. The HN22 responded that the rails are taped because the foam on the rails was peeling off, I will ask maintenance to change it.",2020-09-01
91,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,695,D,0,1,55H911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that a resident who needs respiratory care, including [MEDICAL CONDITION] care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one of one residents (Resident (R) 20) selected for review. This deficient practice had the potential to affect the other residents identified by the facility to require [MEDICAL CONDITION] care. Findings Include: On 07/09/19 at 03:33 PM, a random observation of Resident (R) 20 was done. R20 has a [MEDICAL CONDITION] and a care plan for being at risk for respiratory difficulty related to his [MEDICAL CONDITION] (trach) site. R20's care plan states he also requires frequent suctioning 4-6x (times) per day, including suctioning to [MEDICAL CONDITION] as needed for excessive oral secretions, and to assess his respiratory status (i.e., increased respiratory rate). During this observation, R20 exhibited an increased respiratory rate, intermittent gurgling like sounds and had whitish secretions coming out from [MEDICAL CONDITION] onto a napkin placed around [MEDICAL CONDITION]. At that time, the certified nurse aide (CNA) 1 who had taken R20's vital signs was in the hallway along with registered nurse (RN) 3. CNA1 stated she reported R20's status to the on-coming evening shift nurse, RN1, about five minutes prior. CNA1 said she told RN1 that R20 needed to be suctioned and had an increased respiratory rate around like 30 (breaths per minute). RN3 then stated the nursing endorsement can wait at the change of shift and went to find RN1. On 07/09/19 at 03:37 PM, RN1 came to attend to R20 at bedside. She prepped using sterile technique, but had some difficulty donning the gloves since she opened the sterile glove set on the resident's bed, along with [MEDICAL CONDITION]. There was an overbed table to use, but she did not use it. At 03:42 PM, she began the tracheal suctioning of the resident and suctioned R20 three times. Afterward, RN1 removed a napkin that had been placed around [MEDICAL CONDITION]. Upon removal, the front part of R20's clothing was wet from the secretions. RN1 said she was going to ask the CNA to change him. She also said, I'm gonna change this one too, (the [MEDICAL CONDITION] under the ties) and stepped out to get some saline. Upon her return, she cut a small hole in the middle of a new napkin and placed it over [MEDICAL CONDITION]. It was observed RN1 did this to replace the soiled one. On 07/09/19 at 03:49 PM, RN1 said that CNA1 told her that R20 needed to be suctioned but did not mention any urgency. RN1 stated she had been, counting and getting report from the day shift nurse. She affirmed however, she heard from the endorsement report that R20 needed to be suctioned more frequently than usual. At 04:03 PM, RN1 said she was going to suction R20 again. In the same manner as the first set up, she placed her sterile glove [MEDICAL CONDITION] again on R20's bed. At 04:06 PM, RN1 began the second round of tracheal suctioning, which she did twice. After this, she confirmed it was not until RN3 informed her about R20 that she dropped everything to do this. RN1 said, If she (CNA1) would tell me he really needed then I would have come. It wasn't mentioned that he was gurgly. On 07/09/19 at 04:14 PM, per a re-interview of CNA1, she re-verified she mentioned to RN1 that R20 needed to be suctioned and his breathing rate was higher when RN1 was getting report. On 07/09/19 at 04:37 PM, during an interview with the unit's head nurse, RN2, she said RN1 was a per diem nurse. Then during a concurrent observation at R20's bedside with RN2, she saw [MEDICAL CONDITION] and said, should always be visible and open and removed the napkin which RN1 had placed over it through the cut out opening to replace the soiled one. On 07/09/19, at approximately 5:10 PM, during an interview with RN3, she said, We have some young nurses, but the nurse has to go to the resident and assess and you can ask someone else to cover what you're doing. I'll be talking to them. On 07/11/19 at 09:09 AM during an concurent record review and interview with RN2, it was found that RN1 had no documentation related to her care provided to R20 on the evening shift of 07/09/19. There was no nursing assessment, no interventions/care provided, nor a follow-up note on R20's respiratory status. R20 had been suctioned five times, had increased secretions and an increased respiratory rate. Further, RN2 verified the only entry was a 07/09/19 15:30 (3:30 PM) entry showing R20's respiratory rate was documented at 30 breaths/minute with a warning High of 28.0 exceeded. When RN2 was asked about the expectations/standard of care for documentation by licensed staff, RN2 said she spoke to her staff about communication and the need to respond. She also said that nursing staff were no longer to place napkins over [MEDICAL CONDITION]. RN2 said R20 recently finished a course of antibiotics for seven days for pneumonia, and acknowledged there was a lack of documentation by RN1 regarding R20's condition and status. On 07/11/19 01:10 PM, during a concurrent review with RN2 regarding the job description (JD) for RN1 as a per diem nurse, it stated under major duties and responsibilities, [NAME] Nursing Care: . 3. Assesses resident's condition (physical and psychological); prioritizes needs; . 5. Reports and records pertinent observations and reactions to care rendered. B. Patient care activities, 2. b. Assess and reflects condition of resident accurately. d. Documents assessments. On 07/12/19 at 10:24 AM, RN2 said if there was anything out of baseline, the licensed staff, need to do a progress note. Even if they did do the suctioning, (only that documentation) looks like just a routine event versus something else going on at that time. She said for RN1 as a per diem nurse, she worked on the unit about once or twice a month, but affirmed there should have been some documentation by RN1 about her assessments and provision of care provided to R20 on 07/09/19. This failure to document was an indication of the lack of competency using standard nursing practices, for a resident who requires and is dependent on staff to provide airway management and on-going care.",2020-09-01
92,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,726,F,0,1,55H911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the licensed nurses contained documentation that the core competencies were filed in each employees education record. The deficient practice compromised competent nursing care is being provided to all of the residents residing in the facility. Findings include: 1) During an investigation into the competency of one licensed nurse (LN) on 07/11/19 at 03:41 PM it was discovered that the employee competencies for the entire nursing staff were missing from their employee training records. During an interview with the Director of Nursing (DON) on 07/11/19 03:43 PM stated that the employee skills and competency checklists for one licensed nurse were not found. Upon further investigation by the Employee Education coordinator it was discovered that none of the nursing staff had the skills and competency checklists filed in their employee records. The DON added that any training completed by the employee is documented and filed in their personal records. We keep everyone's records in the files until the employee leaves work at the facility. Our legal person drafted an affidavit for the employee in question and was notarized and signed stating that she completed the competency checklist. I told the level asked the level six Registered Nurses have all Licensed Nurses complete the core competency training as soon as possible. Each licensed nurse who could not provide a copy of the core competency check list will complete a notarized affidavit stating the requirements were completed at the time of hire. In the interim, we have already started to re-certify our licensed staff in the competency's and it will take a while. 2) Cross-reference to findings at F695. On 07/12/19 at 10:24 AM, RN2 said if there was anything out of baseline, the licensed staff, need to do a progress note. Even if they did do the suctioning, (only that documentation) looks like just a routine event versus something else going on at that time. She said for RN1 as a per diem nurse, she worked on the unit about once or twice a month, but affirmed there should have been some documentation by RN1 about her assessments and provision of care provided to R20 on 07/09/19. RN2 also failed to document her observation and action of removing the napkin that had been placed over [MEDICAL CONDITION] site during a concurrent observation on 07/09/19 at 04:37 PM. This failure to document nursing assessments and actions was an indication of the lack of competency to follow standard nursing practices, and especially for a resident who requires and is dependent on staff to provide airway management and on-going care.",2020-09-01
93,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,804,E,0,1,55H911,"Based on observation, interview and record review the facility failed to monitor safe temperatures on the steam table during meal preparation. The deficient practice placed residents at risk for food borne illness. Findings include: During an observation of the tray line on 07/11/19 between 11:30 AM to 11:50 AM during the lunch preparation it was noted that dietary staff were serving up the menu items onto trays for individual resident meals for the long term care (LTC) facility, the Adult Day Health Center (ADHC) and Meals on Wheels. The trays were then loaded into carts. Dietary staff did not check the internal temperatures of the beef tomato, peas or rice being served for the lunch time meal. The temperature logs for the steam table were not found. During an interview with the Dietary manager (DM) at 11:50 AM regarding the location of the temperature logs replied the log is kept on the bulletin board and pointed to a large bulletin board on a wall near the walk in freezer. Review of the temperature logs for the steam table revealed a blank temperature log. When asked when do the dietary staff check the temperatures the DM replied the temperatures are checked before and after the tray line and written down later. Observed the DM walk over to the tray area and retrieve a digital thermometer out of the drawer, clean with an alcohol wipe and proceed to the tray line while stating we keep the food really hot then checked the temperature of the beef tomato 190 degrees Fahrenheit (F), and the peas 200 degrees F. Facility Food Temperature Safety guide reviewed. Ground Meats are to be kept at 155 degrees F. The (YEAR) food and drug administration (FDA) food code reviewed. A summary chart for minimum cooking food temperatures and holding times required. Chapter 3 Meats (145 degrees) and 3 minutes holding time required for safe temperatures.",2020-09-01
94,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,842,D,0,1,55H911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review (RR) the facility failed to maintain accurate medical records for one resident (R)85 of 47 sampled residents. Medical records were not updated to reflect the most current diagnoses. There was a discrepancy of active [DIAGNOSES REDACTED]. This deficient practice has the potential to affect all residents. Findings include: 1. R85 was admitted to facility 12/24/09 after acute care hospitalization . Transfer [DIAGNOSES REDACTED]. urinary tract infection, and status [REDACTED]. Hospital course included, [MEDICAL CONDITION]. This patient was treated on her outpatient medication, [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION]). 2. A Pre-admission Screening /Resident Review Psychiatric Evaluation Part II Serious Mental Illness (SMI) Criteria (PASRR11) was completed on 06/23/16. The PASARR II revealed the facility marked Yes, to The patient is [AGE] years or older and has a possible [DIAGNOSES REDACTED]., but the PASARR II did not list [MEDICAL CONDITION] as a diagnosis.The [DIAGNOSES REDACTED]. 3. Minimum data set assessment ((MDS) dated [DATE] active [DIAGNOSES REDACTED]. 4. RR revealed one of the current active [DIAGNOSES REDACTED]. 5. During an interview 07/11/19 at 10:00 AM with the MDS Coordinator (RN 12), she confirmed that [MEDICAL CONDITION] was currently listed as an active [DIAGNOSES REDACTED]. 6. RR of psychiatric consults dated 05/23/19, 01/12/17, 06/23/16, and 09/18/14 revealed no documentation of [MEDICAL CONDITION], hallucinations or paranoia. 7. On 07/11/19 08:28 AM during an interview with the Director of Nursing (DON), the discrepancy of the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. She stated when R85 first came to the facility, R85's records indicated [MEDICAL CONDITION] and she was on medication. All residents were rescreened in (YEAR) to identify those who needed the additional PASARR 11 pre-admission screening. R85 was identified as needing the screening, which was completed on 06/23/16. DON did not think R85 had [MEDICAL CONDITION]. On 07/12/19 DON reported that the psychiatrist had examined R85 that morning and made the recommendation to discontinue the [DIAGNOSES REDACTED]. 8. Psychiatry consult for R85 dated 07/11/19 included the following: Psychiatric [DIAGNOSES REDACTED]. There is no evidence of [MEDICAL CONDITION]- no delusions, hallucinations . No evidence of [MEDICAL CONDITION] - suggest removal from any problem list to avoid confusion. After receiving the psychiatrist's recommendation, the attending physician was contacted, and gave a verbal order that read, DC (discontinue) Dx (diagnosis) of [MEDICAL CONDITION] per psychiatrists recommendation. [MEDICAL CONDITION] was removed as an active [DIAGNOSES REDACTED].",2020-09-01
95,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2019-07-12,880,E,0,1,55H911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review (RR) and interviews, the facility failed to clearly identify and communicate the appropriate personal protective equipment (PPE) and precautions to be taken while performing their daily routine (i.e. housekeeping) or while providing care for residents that were on droplet precautions (actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions). One resident (R)33 of the five sampled did not receive enough education to understand why he was placed on droplet precautions or why he continued to be on them. Two other residents (R11 and R66) were also affected by the lack of knowledge/training related to the use of PPEs. The facility did not have a clearly defined policy or process in place to direct staff how to determine when the precautions were no longer needed, nor how to consistently implement transmission based precautions. Findings include: 1. The facility had residents on droplet precautions located on two different units (second and third floors). 2. On 07/09/19 at 09:00 AM, observed a laminated orange sign posted next to the doors of Room (Rm) 215, 216, 217 and 218. The sign read: Droplet Precautions . Respiratory protection: Mask required when working within 3 feet of patient (or when entering room). Check your hospital policy. At that time observed Rm 215, 217, and 218 were shared rooms with other residents. Rm 216 had separate entrances between them. There were droplet precaution signs posted over the bed of 215-3, 216-1, 217-3 and 218-2. 3. On 07/09/19 at 11:30 AM, during an interview with R33, he stated, I don't know why I have that sign (droplet precaution) up there. Asked if staff had informed him why he needed it (the precaution sign above his bed), and he replied, they just say because I have a cough. I've had a cough since I came in here. I'm afraid my family won't bring my grandkids in. 4. On 07/09/19 at 12:00 PM, during brief interview with RN13 about the droplet precaution signs, heard R33 calling from his room. RN13 responded and entered the room without putting on any PPE. RN13 was within three feet of R33 and had a conversation about the precaution sign. RN13 was not able to answer R33's questions to his satisfaction and requested RN11 to speak with him. RN11 informed R33 it's because of your cough. Remember, we discussed this. R33 was still frustrated. At that time, RN11 did not provide any additional information to R33 why he had droplet precautions or when the sign could come down. 5. Review of policy number ORIC0017 titled Outbreak control: Respiratory & [MEDICATION NAME] infectious conditions dated 01/23/19, directs staff for droplet precautions, to put on the PPE upon entering the patient's room. The policy did not include any direction for staff to determine duration of precautions. 6. 07/10/19 10:11 AM during an interview with the Infection Preventionist (IP), asked what the facility policy was for droplet precautions, and what staff are expected to do when resident is in a shared room. IP replied, I know, it isn't clear. I've done research on this, and the literature supports that three feet (distance from resident) is enough, and would apply in shared rooms. I've looked for different signs that would simplify this for the staff but can't find any. We have an annual competency and demonstration of donning and doffing (putting the PPE on and off), but we may need to add something about transmission to link to the type of isolation. We do need to make it clear how multiple occupancy rooms are addressed, and the signs need to be changed. 7. 07/10/19 12:02 PM Collaboratively reviewed R33's medical records with IP. IP discussed R33's course of treatment with RN11. R33's antibiotics were discontinued on 06/07/19. R33's temperature was 99 degrees on 07/04/19 and 96.9 degrees on 07/10/19. RN11 confirmed R33 had been afebrile (no fever) for some time but still had some cough. IP interviewed R33 and listened to his lungs. R33 expressed concern to the IP over the posted sign and why he was on precautions. IP explained he had a fever earlier and increased cough so needed to be put on droplet precautions. R33 understood the explanation. IP determined R33 no longer needed the precautions and removed the sign. 8. On 07/11/19 at 09:00 AM, observed staff putting PPE (gloves and mask) on prior to entering rooms with droplet precaution signs. Asked CNA15 if she had been informed the practice had been changed, and she replied, we were told to put it on before we enter now. 9. On 07/11/19 at 04:00 PM, during interview with RN11, asked when the communication had gone out to staff regarding the change in required PPE (put on entry versus three foot distance) . She said at shift endorsement on the evening shift. Asked if she had received that communication from IP, and she replied No. Stated there had been a discussion and questions the previous day, so to be cautious, she had instructed the staff to put the PPE on prior to entering the room rather than using the three-foot guideline. 10. On 07/12/19 at 07:52 AM interviewed RN16 about staff orientation and training for transmission-based precautions and what staff was taught to do for droplet precautions. Also asked if there were any special instructions for shared rooms. RN16 stated they are taught to use mask and gloves for droplet precautions. We use isolation signs on the front of the door. Asked how staff know which resident in a shared room has the precautions, and RN16 said, I'm not sure with the beds. Visitors check in with nursing. 11. On 07/12/19 at 03:00 PM, observed RN14 in the process of putting on a gown to enter Rm 217 (shared room with one resident on droplet precautions). The IP asked RN14 why she was putting on the gown and explained to her she did not need it with droplet precautions. 12. On 07/09/19, during the initial tour of the 3rd floor makai nursing unit, it was observed that Resident (R) 11 was on droplet precautions due to fever, cough and a finding of pneumonia per the registered nurse (RN) 4 caring for R11. The signage at the door of R11's room stated Droplet Precautions. This was a semi-private room (two resident beds) and R11 was in the bed by the window. At 09:11 AM, a housekeeper (H) 1 entered R11's room pushing a large dry mop. H1 entered the front part of the room without wearing any personal protective equipment (PPEs). RN4 was observed entering after H1 and asked him to come out and gave him a yellow mask to wear. Interview of H1 thereafter revealed he was supposed to wear gloves and a mask, but said he forgot to do so. 13. On 07/10/19 at 06:58 AM, an interview with RN 2 was done. She stated for droplet precautions, Because we have multiple residents with similar symptoms, so droplet precautions, we have to wear mask, gloves and gown. If we're just going in there to talk to them, or they're not coughing and we're about 3 feet away, no need to gown. 14. On 07/10/19 at 07:39 AM, on the 2nd floor mauka nursing unit, observed RN5 enter R66's room to turn off his bed alarm. There was signage for Droplet Precautions posted at R66's door. RN5 did not wear any PPEs when she entered the room. When RN5 exited the room and was asked whether she was to wear any PPEs, she said, Oh I just went in to turn off the alarm, but yeah, yeah, that is for the entire room and said she should have worn PPEs prior to entering the room. In addition to the orange Droplet Precaution sign, there was also a green placard for visitors. The fifth bullet on the green sign stated, Use of gloves, and mask when visiting. 15. On 07/10/19 at 09:35 AM, during a brief interview with RN 3, she said, Yes, before they (staff) enters room they should be wearing PPEs. Even if the resident in bed 2, because the air circulates and the other resident (in bed 1 by the door) may need help that staff should be wearing PPEs before they entered the residents' rooms identified with droplet precautions. 16. On 07/11/19 at 08:16 AM, H2 was briefly interviewed. H2 said he wears all PPEs before entering the room with droplet precautions in place, and proceeded to do so. 17. On 07/11/19 at 09:22 AM, during a medication administration observation for R66, RN6 donned full PPEs. She said, We have to (wear) full PPEs outside before entering the room. This was a change from yesterday, which was just a mask and gloves for some staff and none for others based on random observations. 18. On 07/12/19 at 12:45 PM, during an observation of the 3 makai unit, RN7 said for droplet precautions, just the mask to put on. CNA2 was seen with only a mask on in room [ROOM NUMBER], which had signage for droplet precautions posted when she brought out the first meal tray with no gloves on. A visiting chaplain also went into the room to visit the resident in bed 1, and he only wore gloves. CNA2 said, it's only the mask for the PPEs because R11 was the one identified for droplet precautions and not her roommate. There was a failure to systematically ensure transmission based precautions were properly implemented by staff and monitored by the infection control preventionist and designated head nursing staff of the affected units.",2020-09-01
96,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2018-08-28,686,D,0,1,QVE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and review of facility policy, the facility failed to place a pillow between resident's feet to prevent pressure on her feet. This practice would put Resident (R) 73 at risk for developing a pressure ulcer (PU) on her feet. This deficient practice had the potential to affect the 4 residents identified by the facility to have pressure ulcers. Findings Include: On 08/22/18 at 10:06 AM during record review (RR) of R73's electronic medical record (EMR) noted R73 had documentation of recurrent open area on her right big toe dated 06/18/18. Reviewed R73's skin assessment dated [DATE] at 1304 found there was a PU that was unstageable that was acquired in facility. On 08/27/18 at 11:14 AM at R73's bedside, with licensed practical nurse (LPN)1, requested to see R73's right foot. LPN1 pulled back R73's blanket and sheet noted R73's right big toe was healed. LPN1 stated I will put a pillow when it was discovered that R73's feet were resting near each other, side by side, touching each other. Further RR found PU documentation on 08/14/18 stated PU was new but at bottom of documentation it stated under notes Wound RN assessed and seen-resolved. Record review (RR) found R73 coded for a stage 2 PU on her last annual Minimum Data Set ((MDS) dated [DATE]. It was noted on R73's care plan (CP) that she is at risk for skin breakdown due to vegetative state, incontinence and diabetes. R73's CP was in place for PU wound and foot care but no intervention listed to place a pillow between feet to prevent the development of a PU. On 08/27/18 at 11:55 AM interviewed Head Nurse (HN) 2 who stated staff should be placing a pillow between residents feet to prevent putting pressure on the foot/feet. Review of facility Skin Care and Pressure Injury Prevention policy stated D. Protection from Friction, Shear and Pressure 6. Use positioning wedges or pillows. 7. Suspend heels while in bed. Neither of these were done for R73 upon observation 08/27/18 at 11:14 AM, putting this resident at risk to develop another PU on her feet.",2020-09-01
97,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2018-08-28,689,D,0,1,QVE911,"Based on observations and staff interview, the facility failed to secure a storage room located on the third floor. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards. Findings Include: 1. During an observation of the storage room (located on the third floor) on 08/21/18 at 10:13 AM, it was noted that the door (which contained a key pad lock mechanism) to enter the room was not locked and anyone could have entered freely. There was also no staff in the immediate vicinity to prevent anyone from entering the room. The room had three large trash containers, one floor buffing machine, a fan blower, two orange road cones, a wooden cabinet to store biohazards, and other miscellaneous items such as trash bags, and a floor sweeper. Access to this room may have put the safety of the residents and the public at risk for accident hazards. On 08/21/18 at 10:20 AM, after the above observation, the Administrator was questioned about the door. The Administrator stated that the door to that storage room should have been locked and secured. Then, upon further investigation of the door lock, it appeared that someone stuffed a napkin so that the door latch would not lock. The Administrator acknowledged the risk for accident hazards if the residents or the public had access to that room.",2020-09-01
98,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2018-08-28,700,D,0,1,QVE911,"Based on observation, record review, staff interview and facility policy review the facility failed to assess two residents (Resident (R) 34, R53) selected from the 40 resident sample for risk of entrapment from bed rails prior to installation and failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails. This deficient practice has the potential to affect all residents at the facility who have bed rails and newly admitted residents. Findings Include: 1) On 08/21/18 at 08:30 AM observed R34's bed had bilateral upper quarter bed rails on the bed. On 08/27/18 at 03:20 PM record review (RR) of R34 hard copy medical chart and electronic medical record (EMR) did not find an assessment for risk of entrapment from bed rails and no informed consent to use bed rails. Inquired with head nurse (HN)2 on 2 Makai unit who confirmed that R34 did not have a risk assessment for bed rail use and no informed signed consent form to use bed rails. HN2 explained the facility had started a new process in (MONTH) (YEAR) that includes doing an assessment and also the bed rail consent form with each resident's next MDS assessment. 2) On 08/21/18 at 02:42 PM observed R53 had bilateral upper bilateral quarter side rails on her bed. On 08/27/18 at 04:14 PM RR found R53 is total dependence on staff for activities of daily living (ADLs) such as feeding, brushing teeth and bathing. R53 had upper bilateral quarter side rails (these were removed during survey) and is immobile in bed even though her care plan (CP) states that bed rails are used for bed mobility. Inquired with evening shift RN1 who confirmed that R53 could not use bed rails on her own. RN1 stated R53 can hold rolled wash cloths in her hands and can hold onto the bed rail if her hand is placed there by staff. RR of resident's hard medical chart found that R53 had a side rail evaluation dated 04/24/18 and it stated no side rail in use. RR noted R53 did not have a signed informed consent for bed rail use. Inquired with HN2 who confirmed that R53 and R34 do not have signed informed consents to use bed rails. Review of facility's Bed Safety policy, provided by HN2, stated Policy Interpretation and Implementation 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails.",2020-09-01
99,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2018-08-28,880,D,0,1,QVE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to maintain infection control precautions for two residents out of 40 residents selected for review. Resident (R)8's open suction tubing with opposite end attached to suction canister was left on the bed side table. R73 had an open 0.9% Sodium Chloride (Normal Saline) container with an open date of 07/19 left at bedside with suction equipment was found on 08/28/18. The deficient practice had the potential to affect all residents who require suctioning at the facility. Findings Include: 1) On 08/21/18 at 08:30 AM observed R8's suction tube, leading from the suction canister, left on R8's bedside table and open end laying on top of the bedside table. On 08/21/18 at 09:45 AM inquired of HN2 if suction tube should be left open and on R8's bedside table and she concurred that suction tubing should not be left open on the bedside table. Later in the day, after lunch, HN2 stated that she changed out all of the suction attachments for all the residents on 2 Makai. 2) On 08/21/18 at 09:00 AM observed R73's bedside table with suction machine, tubing and normal saline. Noted that normal saline was open and dated 07/19. On 08/21/18 at 09:45 AM inquired of HN2 how long facility keeps open normal saline and she stated 24 hours. On 08/28/18 at 10:10 AM interviewed licensed practical nurse (LPN)2 who confirmed that she opened the 0.9% Sodium Chloride (Normal Saline) on 07/19 and stated that she used it one time for R73's [DEVICE] dressing change to cleanse the site, dated the bottle 07/19 and accidentally left it at bedside. LPN2 stated that it was her fault that she forgot to throw it out. LPN2 confirmed that they only use and keep the normal saline for 24 hours once it is opened.",2020-09-01
100,MALUHIA,125009,1027 HALA DRIVE,HONOLULU,HI,96817,2018-08-28,908,E,0,1,QVE911,"Based on observation, staff interview, and review of facility policy, the facility failed to perform routine maintenance, based on manufacturer's recommendation, and failed to keep preventative maintenance records for two out of fourteen oxygen concentrators reviewed. This deficient practice put the residents at risk for the development and transmission of communicable diseases and infections. Findings Include: 1. During an observation and interview, on 08/21/18 at 2:30 PM, with staff RN3. RN3 stated the cleaning of all Oxygen Concentrator Filters were done on a weekly basis by the Certified Nursing Aides (CNA). However, during an interview with CNA1 on 08/21/18 at 2:31 PM, CNA1 was unable to cite when and how the cleaning of the Oxygen Concentrator Filter was performed. During an interview with the Central Supply Manager (CSM) on 08/21/18 at 3:03 PM, CSM stated that the floor CNAs were the ones to do the cleaning of the Oxygen Concentrator Filters. However, CSM acknowledged that the facility did not keep a record of the cleaning and there was no way to verify that the Oxygen Concentrator Filters were being cleaned as recommended by the manufacturer. During a review of facility policy pertaining to the cleaning and disinfection of equipment, it stated that the cleaning and filter changing of the Oxygen Concentrator's will be done based on manufacturer's recommendations. The facility failed to perform that. During an interview with Director of Nursing on 08/28/18 at 09:00 AM, it was acknowledged that the manufacturer's recommendations for their oxygen concentrators were not being followed.",2020-09-01