Citations in Hawaii
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Hawaii.
Statistics for Hawaii (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Hawaii
Latest Citations in Hawaii
A resident with severe cognitive impairment and multiple medical conditions was left alone in a facility transport van after returning from dialysis. The resident, who required extensive assistance and used a wheelchair, reported being left unattended by the van driver. Staff interviews and documentation confirmed that only one staff member was present on the van at times, and the driver admitted to leaving the resident alone while attending to personal needs. The resident was found to be emotionally distressed but physically stable upon return to her unit.
Staff did not treat two residents with dignity, as one resident experienced long delays in call light response, lack of privacy after bathing, inconsistent hand hygiene before feeding, and staff speaking in a language the resident did not understand. Another resident was left in a soiled brief for over forty minutes despite a family member's request for help, with staff failing to respond promptly as required by facility policy.
Staff failed to consistently use required PPE, perform hand hygiene, and ensure proper environmental controls when caring for residents on transmission-based and enhanced barrier precautions. Multiple instances were observed where staff entered or exited rooms of residents with communicable diseases, including COVID-19, without appropriate PPE, did not perform hand hygiene after glove removal, and disposed of contaminated PPE outside designated areas. Additional lapses included improper handling of urinary catheters and call lights, and inconsistent availability of PPE and disposal receptacles, all contributing to inadequate infection control.
A resident with limited ROM did not receive consistent restorative nursing aide services, including splint application and exercises, due to insufficient RNA staffing. Staff reported that RNA personnel were often reassigned to CNA duties, leaving gaps in restorative care. The resident confirmed she was not receiving her prescribed exercises and stretches.
Surveyors found that call devices were frequently placed out of reach for several residents with physical limitations, including those with blindness, fractures, and muscle weakness. Observations showed call lights wrapped around bed rails, on the ground, or on shelves, making them inaccessible. Staff interviews confirmed that call devices were not always secured or positioned to prevent them from falling or becoming unreachable, contrary to facility policy.
A medication cart's EHR was left open and unattended in the hallway, displaying a resident's medication list. An RN acknowledged forgetting to lock the EHR, resulting in unprotected personal health information.
A resident receiving oxygen therapy was not accurately assessed upon admission, as their O2 therapy was omitted from the MDS documentation. This led to the absence of O2 therapy in the care plan, lack of review of physician orders, and failure to monitor or label O2 tubing, as confirmed by MDS staff interviews.
A resident admitted with a right leg injury did not receive a copy of the baseline care plan (BCP) within 48 hours of admission. The resident reported not being informed about the plan of care, and review of the electronic health record confirmed the absence of documentation showing the BCP was provided. The DON stated that a care plan discussion took place during a welcome meeting, but there was no evidence that the resident received a copy of the care plan.
The facility did not develop or implement comprehensive, person-centered care plans for three residents with specialized needs, including oxygen therapy, hemodialysis, and catheter care. For these residents, care plans lacked required details such as interventions for O2 therapy, assessment of dialysis access sites, and catheter care, despite existing physician orders and facility policies. Staff confirmed these omissions during interviews and record reviews.
A resident with worsening moisture-associated skin damage (MASD) and a fungal infection on the sacrum and buttocks did not have their care plan updated to include antifungal treatment after the condition was identified. The facility also failed to obtain a physician's order for the necessary intervention.
Resident Left Unsupervised in Transport Van After Dialysis
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including dementia, hypertension, diabetes, and end stage renal disease, was left alone in the facility's transport van for an unknown period of time. The resident, who required extensive assistance for transfers and primarily used a wheelchair, was returning from an offsite dialysis appointment when the incident occurred. Upon arrival at the facility, the resident reported to staff that the van driver left her alone in the vehicle, and she did not know what to do. Documentation and interviews confirmed that the resident was left unsupervised in the van, with the exact duration remaining undetermined. The facility's records showed that, on the day of the incident, the post-dialysis vital signs were taken later than usual, suggesting a delay in the resident's return to her unit. Staff interviews indicated that, at times, only one staff member—the driver—was present on the van, as the transporter might stay with another resident at an appointment, leaving the driver alone to manage the return trip. On the day in question, the driver admitted to leaving the resident in the van while he attended to personal needs, only realizing afterward that the resident was still inside. The resident was found to be alert and verbal upon return to the unit, though she was described as flustered and emotional immediately after the event. Staff confirmed that her physical condition was stable, with no abnormal vital signs or signs of physical harm. The incident was reported through the facility's concern and comment process, and the resident's family was notified. The event highlighted a lapse in supervision and adherence to safe transport protocols, resulting in the resident being left in an unsafe environment.
Failure to Maintain Resident Dignity and Timely Response to Care Needs
Penalty
Summary
Staff failed to treat two residents with respect and dignity, as evidenced by multiple incidents. One resident reported that staff often took up to forty minutes to respond to call lights, with some staff stating they were not assigned to the room and passing by without assisting. The same resident also reported that privacy was not maintained after bathing, as privacy curtains were left open, leaving the resident exposed. Additionally, staff did not consistently wash their hands before feeding the resident, requiring reminders, and would speak in their native language during care, making the resident feel uncomfortable and excluded. Another resident was left in a soiled incontinent brief for over forty minutes despite a family member's request for assistance. The family member notified a nurse at the nurse's station, who instructed her to activate the call light because she was not assigned to that area. The resident was only assisted after forty-five minutes by a CNA. Interviews with staff and review of facility policy confirmed that all staff are required to respond promptly to call lights and assist residents regardless of assignment, and that the nurse should have helped the resident when requested.
Failure to Implement and Maintain Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement and maintain appropriate infection prevention and control practices, as evidenced by multiple observed lapses in the use of personal protective equipment (PPE), hand hygiene, and environmental controls. Staff were observed entering and exiting rooms of residents on transmission-based precautions, including those with confirmed COVID-19, without donning the required PPE such as gowns, gloves, N95 masks, and face shields. In one instance, a certified nurse aide exited a quarantined resident's room wearing only a surgical mask, despite the resident being COVID-positive and facility policy requiring full PPE. Another staff member was observed delivering a meal tray and assisting a resident on Contact Precautions without wearing gloves or a gown, and was unable to articulate the difference between Contact Precautions and Enhanced Barrier Precautions. Hand hygiene practices were not consistently followed. A registered nurse was observed removing soiled gloves, obtaining new gloves, and donning them without performing hand hygiene in between, despite facility policy requiring hand hygiene after glove removal. Additionally, staff did not always change gloves or perform hand hygiene between different care tasks, such as repositioning a resident and then assisting with feeding. Environmental controls were also lacking, as PPE and disposal receptacles were not consistently available inside or outside rooms where required, leading staff to cross hallways in contaminated PPE to dispose of it, or to retrieve clean gloves from outside the room, increasing the risk of cross-contamination. Other infection control lapses included improper handling of indwelling urinary catheters, with catheter bags observed resting on the floor without a barrier, and staff confirming this was not in accordance with infection control standards. Call lights were returned to residents' beds without cleaning after being on the floor, and privacy bags for catheters were allowed to touch the ground. Interviews with staff and the infection preventionist revealed inconsistent understanding and application of PPE protocols, as well as logistical issues with PPE and trash receptacle placement, further contributing to the deficient practices.
Insufficient Staffing for Restorative Nursing Services
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to provide restorative services for a resident with limited range of motion (ROM). On observation, the resident was found eating breakfast in bed with her left arm folded and fisted on her chest, without her prescribed splint. Staff confirmed that the resident should have been wearing her splint daily, but there was no restorative nurse aide (RNA) available that day. The resident also reported that she had not been receiving her exercises and stretches, which she wished to continue. Interviews with facility staff revealed that the RNA program was understaffed, with only one RNA available on most days instead of the required two, and sometimes none due to staff absences or reassignments to CNA duties. Staff trained to provide RNA services reported they were unable to perform these duties when assigned as CNAs due to workload. Review of staffing records confirmed gaps in RNA coverage, and the Director of Nursing acknowledged that RNA staff were reassigned to CNA roles when CNA staffing was insufficient, resulting in no RNA coverage for residents requiring restorative services.
Failure to Ensure Call Devices Were Accessible to Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call devices were consistently placed within reach and accessible for six sampled residents, all of whom had intact cognitive function but varying physical limitations. Observations revealed that call devices were often wrapped around bed rails, placed on the ground, or positioned on shelves, making them inaccessible to residents who were in bed. In several instances, residents were unable to locate or reach their call devices when asked to demonstrate their use, and staff confirmed that the devices were not always within reach. Specific examples included a resident with legal blindness and Parkinson's disease who repeatedly had her call device placed out of reach, either wrapped around the bed rail or positioned on the bed's edge. Another resident with a spinal fracture and muscle weakness was unable to locate his call device, which was placed at the top of a pillow and out of reach. Additional residents were observed with call devices on the ground, behind their backs, or on shelves, and staff interviews confirmed that the devices were not always secured or positioned to prevent them from falling or becoming inaccessible. The facility's own policy required that the call system be accessible to residents while in bed, but multiple observations and staff interviews demonstrated that this standard was not consistently met. The failure to ensure call devices were within reach prevented residents from independently calling for assistance and did not accommodate their needs and preferences as required.
EHR Left Open, Exposing Resident Medication Information
Penalty
Summary
A deficiency occurred when the electronic health record (EHR) on a medication cart was left open and unattended in the hallway, displaying a resident's list of medications. This was observed during a morning survey, and the information was visible and not protected. When interviewed, the registered nurse responsible acknowledged forgetting to close the EHR and stated that it should be locked every time staff walk away.
Failure to Accurately Assess and Document Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a comprehensive assessment accurately reflected a resident's status, specifically omitting oxygen (O2) therapy from the admission Minimum Data Set (MDS) for one resident. The resident was receiving O2 therapy at the time of admission, but this was not documented in Section O of the MDS. As a result, the resident's O2 therapy was not included in the care plan, physician orders for O2 were not reviewed, and the O2 tubing was not properly monitored or labeled. Interviews with MDS staff confirmed that O2 therapy should have been documented in the MDS and acknowledged the omission.
Failure to Provide Baseline Care Plan Copy to Resident
Penalty
Summary
The facility failed to provide a copy of the baseline care plan (BCP) to a resident within 48 hours of admission, as required. The resident, who had been admitted with a right leg injury and was receiving physical and occupational therapy, reported that the facility did not discuss his plan of care with him and that he did not receive a copy of his care plan. Review of the electronic health record confirmed that there was no documentation showing the BCP was given to the resident. Although the Director of Nursing indicated that a care plan discussion occurred during a welcome meeting with the Interdisciplinary Team, there was no evidence in the chart that the resident was provided with a copy of the care plan.
Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans for three residents with specific clinical needs. One resident receiving oxygen therapy did not have a care plan addressing O2 therapy, including the type of delivery system, parameters, delivery method, or monitoring requirements, despite facility policy requiring these elements. The resident's O2 tubing was also not labeled with the date it was last replaced, and physician orders lacked necessary details. Both the MDS Director and DON confirmed the absence of a care plan for this resident's oxygen therapy. Another resident undergoing hemodialysis had a care plan that omitted interventions for assessing the dialysis access site for thrill and bruit, even though these checks were being performed and documented per physician orders. The DON confirmed that the care plan should have included these interventions. A third resident with an indwelling catheter for urinary retention did not have a care plan addressing catheter care, goals, or interventions, despite documentation of urinary retention and physician orders for catheterization. The DON verified that catheter care should have been included in the resident's care plan.
Failure to Update Care Plan for MASD and Fungal Infection
Penalty
Summary
The facility failed to update the care plan for Resident 136 to include a new intervention for treating moisture-associated skin damage (MASD) with an antifungal after the condition was identified. Despite recognizing that the resident had developed a fungal infection and MASD on the sacrum and buttocks, which had worsened since admission, the facility did not obtain a physician's order for an antifungal treatment or revise the resident's care plan accordingly. This deficiency was identified through interviews and record reviews, and it involved one of four residents sampled for non-pressure skin conditions.
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