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)
Latest Citations in Hawaii
The facility did not have a comprehensive Water Management Program (WMP) to prevent Legionella and other waterborne pathogens, lacking a risk assessment, detailed water system description, and specific testing protocols. A resident with multiple health conditions tested positive for Legionella antigen after being admitted for rehabilitation, and the facility was unable to provide documentation of a completed risk assessment or a coordinated WMP at the time of the survey. Existing measures, such as water heater temperature logs and ice machine maintenance, were insufficiently documented and did not meet CDC and ASHRAE standards.
The facility did not notify the physician when two residents experienced a change in condition that required oxygen administration. In both cases, nursing staff provided oxygen for shortness of breath and documented the intervention, but failed to inform the provider as required by facility policy and physician orders. The DON confirmed that these incidents met the criteria for a significant change in condition and that provider notification should have occurred.
Three residents experienced deficiencies in medical record documentation, including misfiled nursing notes, inconsistent and incomplete records of oxygen administration, and an inaccurate discharge notice that did not reflect a resident's true condition. Facility leadership confirmed missing assessments and documentation errors, and the facility's own policy for thorough and accurate records was not followed.
A resident's belongings were collected and bagged by CNAs after hospital transfer, and a family member later discovered a visibly soiled bed pad/brief with urine and feces among the items. Staff interviews and video review confirmed the soiled item was included in the belongings given to the family.
A resident admitted for post-stroke rehabilitation had a PIV catheter in place for several days without a physician's order, and staff used a hospital weight as the admission baseline instead of obtaining a new weight on the facility scale. Significant discrepancies in weights were not verified or reported, and required neurological assessments were not documented after the resident was found unresponsive. These failures resulted in a lack of appropriate treatment and care according to orders and resident needs.
A resident was administered Lisinopril despite a documented systolic blood pressure below the ordered threshold, in violation of the physician's order. The facility did not identify or report this medication error to the DON or Administrator as required by policy.
A resident experienced two unplanned tracheostomy decannulations during care, both of which were managed without distress or complications. Although the incidents were reported in facility incident reports, there was no corresponding documentation in the EHR by nursing or respiratory staff, contrary to facility policy requiring such documentation for changes in condition.
A resident with a recent stroke was admitted for rehabilitation, but staff failed to update the care plan to address stroke-related risks or implement aspiration prevention measures. The resident developed a moist cough and respiratory distress, with staff not recognizing early signs of aspiration, failing to communicate key symptoms to the physician, and not administering ordered treatments. The family ultimately requested hospital transfer after observing the resident's decline, and the resident was admitted in respiratory distress and later placed on hospice.
A resident's medical record contained late entries by nursing staff, resulting in incomplete documentation and failure to communicate important care instructions, such as keeping the head of bed elevated. Additionally, a nurse documented physician notification about the resident's improved respiratory status, but the physician confirmed this communication did not occur.
A resident dependent on staff for transfers was injured when two staff members, including one not fully trained, operated a mechanical lift and failed to ensure proper sling strap placement, resulting in a fall and serious injuries. In a separate incident, another resident with dysphagia and a physician order for suctioning was found with a suction machine at the bedside that was not fully set up, leaving her at risk in the event of a respiratory emergency.
Failure to Implement Comprehensive Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to provide evidence of a comprehensive Water Management Program (WMP) necessary to prevent the spread of Legionella and other waterborne pathogens in the building water systems. During interviews and document reviews, it was found that the facility did not conduct a risk assessment to identify areas where Legionella and other pathogens could grow and spread. The WMP lacked a detailed description of the building water system, did not specify testing protocols, and omitted acceptable ranges for control measures. The documentation provided was a basic outline and did not include required elements such as a specific risk assessment, a detailed water system diagram, or a building description. A resident with multiple comorbidities, including chronic anemia, urinary retention, chronic kidney disease, and asthma, was admitted to the facility for rehabilitation after a hospital stay for septic shock. The resident later tested positive for Legionella antigen during a subsequent hospitalization for septic shock secondary to acute cystitis and pneumonia. The facility received notification of the positive Legionella case but was unable to provide documentation of a completed risk assessment or a comprehensive WMP at the time of the survey. The infection preventionist confirmed that the risk assessment was started only after the notification of the positive case and had not been completed. Further interviews revealed that the facility manager was unaware of when the current water system diagram was developed and confirmed that no risk assessment had been conducted as part of the WMP. Measures in place, such as water heater temperature logs and ice machine maintenance, lacked documentation of acceptable parameters and specific procedures. The facility relied on annual municipal water quality reports, which were not included in the current plan. The documentation and policies provided did not reflect a coordinated WMP consistent with CDC and ASHRAE standards, and there was a lack of documentation of program activities.
Failure to Notify Physician of Change in Condition Requiring Oxygen Administration
Penalty
Summary
The facility failed to notify the physician of a change in condition for two residents who required administration of oxygen. In the first case, a male resident with a history of stroke, dysphagia, and mild cognitive impairment experienced shortness of breath with oxygen saturation dropping to 87-89%. Nursing staff administered oxygen as ordered, but there was no documentation that the provider was notified of this change in condition, nor was there documentation of how long the resident required oxygen. The Director of Nursing confirmed that this met the criteria for a condition change and that the provider should have been notified. In the second case, another resident complained of shortness of breath and was administered oxygen, resulting in improved oxygen saturation. The event was recorded in the facility's communication book, but not in the resident's electronic medical record, and there was no documentation of notification to the on-call physician, despite a physician's order requiring notification if oxygen was applied or increased. The facility's policy requires notification of the attending physician for significant changes in a resident's condition or when medical treatment is altered. These failures were confirmed through interviews and record reviews.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, resulting in deficiencies related to documentation of oxygen administration, misfiled nursing notes, and inaccurate discharge information. For one resident, the electronic medical record contained a nursing progress note that was intended for a different resident, and this error was not identified prior to the survey. Additionally, the documentation of oxygen administration for two residents was inconsistent and incomplete across multiple record-keeping systems, including nursing notes, vitals reports, and respiratory administration records. There were missing assessments, discrepancies in the timing and documentation of oxygen use, and a lack of clarity regarding when oxygen was administered or discontinued. Interviews with facility leadership confirmed that the records did not provide sufficient information to determine the accurate use of PRN oxygen and that required assessments were missing. For another resident, a complaint of shortness of breath and subsequent oxygen administration was documented in a unit communication book but was not entered into the resident's official nursing progress notes. The nursing notes for that day did not reflect the resident's complaint or the intervention provided, and the DON confirmed that this documentation should have been included in the progress notes. This omission resulted in an incomplete medical record for the resident. A third resident received a Notice of Discharge that inaccurately stated her health had improved sufficiently to no longer require facility services, despite therapy and assessment records indicating a decline in her condition and ongoing need for skilled nursing care. Interviews with the social worker and administrator revealed that the discharge notice did not accurately reflect the resident's true condition, and the administrator acknowledged marking the form incorrectly. The facility's own documentation policy requires that records be timely, accurate, objective, thorough, and complete, but these standards were not met in the cases reviewed.
Soiled Bed Pad/Brief Included in Resident's Discharge Belongings
Penalty
Summary
The facility failed to ensure the safe handling and disposal of a soiled bed pad/brief for one resident. After the resident was transferred to the hospital, staff collected and bagged the resident's belongings, which were then placed at the nursing station for pickup by a family member. Upon receiving the belongings, the family member discovered a soiled bed pad/brief, visibly contaminated with urine and feces, inside a clear bag labeled with the resident's name and room number. Photographic evidence confirmed the presence of the soiled item among the resident's personal effects. Interviews with the certified nurse aides involved in packing the belongings revealed that while they recognized the bags as the resident's, neither could recall specifically packing the clear bag containing the soiled item. One aide confirmed packing the blue bags but not the clear ones, while the other could not recall which bags they packed but denied knowingly including soiled items. Video surveillance confirmed that the clear bag with the soiled bed pad/brief was handed off to the family member as part of the resident's belongings. The administrator and surveyors reviewed the evidence and confirmed the deficiency.
Failure to Provide Appropriate Care and Documentation for Post-Stroke Resident
Penalty
Summary
Nursing staff failed to provide the standard of quality care to a male resident admitted for rehabilitation following a stroke. The resident, who had dysphagia, expressive aphasia, mild cognitive impairment, and was dependent on staff for all activities of daily living, had a peripheral intravenous (PIV) catheter in place for three days without a physician's order. Documentation showed that the PIV was eventually pulled out by the resident, resulting in bleeding, but there was no evidence of an order for the PIV at any time during his stay. Additionally, staff used the resident's hospital weight as his baseline admission weight instead of obtaining a weight on the facility's scale, as required by facility policy. Subsequent weights showed significant discrepancies, with no repeat weights performed to confirm accuracy and no documentation that nursing staff or the provider were notified of the large weight loss. Furthermore, licensed staff did not document a neurological assessment or monitoring as required after the resident was found unresponsive to verbal stimuli and unable to be awakened. There was no evidence of reassessment or documentation of the resident's neurological status during the shift, despite the facility's stroke program and staff education on the importance of neurological monitoring. These actions and omissions resulted in a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Identify and Report Medication Error
Penalty
Summary
The facility failed to identify and report a medication error as required by its policy. A resident with an order for Lisinopril 2.5 mg, to be administered orally in the evening and held if the systolic blood pressure (SBP) was less than 120 mm Hg, received the medication despite having an SBP of 113 mm Hg documented on the Medication Administration Record. The medication order was not followed, and the error was not detected or reported to the Administrator or Director of Nursing (DON) for review and appropriate action. During an interview and concurrent review of the resident's records with the DON, it was confirmed that the medication should have been held and that the facility had not previously identified or reported the error.
Failure to Document Unplanned Tracheostomy Decannulations in EHR
Penalty
Summary
The facility failed to ensure proper documentation in the electronic health record (EHR) for two unplanned decannulations of a resident's tracheostomy tube. On two separate occasions, the resident experienced unplanned decannulations while being cared for by certified nurse aides, with both incidents being witnessed and reported in facility incident reports. In both cases, the tracheostomy tube was reinserted without difficulty, and the resident did not show signs of distress or decreased oxygen saturation. However, a review of the resident's EHR revealed that there were no progress notes written by a nurse or respiratory therapist regarding these unplanned decannulations, despite the facility's policy requiring nursing staff to document care provided and changes in the resident's condition in the medical record. Interviews with staff, including the respiratory therapist and the director of nursing (DON), confirmed that the expectation was for the nurse who responded to the incident to document the event in the EHR. The respiratory therapist involved in the incident stated he did not believe it was expected of him to chart the change in the EHR. The DON confirmed that the nurse should have documented the incident. The facility's documentation policy, provided by the DON, specifies that nursing staff are required to document care and changes in the resident's condition in the medical record, including through progress notes.
Failure to Identify and Intervene in Acute Change of Condition Following Stroke
Penalty
Summary
Facility staff failed to identify and appropriately intervene in an acute change in condition for a resident who had recently suffered multiple strokes and was admitted for rehabilitation. The resident's care plan did not address the recent stroke or include standard interventions for stroke patients, such as elevating the head of the bed to prevent aspiration. Staff did not recognize the resident's occasional moist cough during meals as a potential early sign of aspiration, nor did they communicate this symptom to the physician. Documentation was inconsistent, with conflicting information about the resident's distress when positioned on his back, and the care plan lacked necessary interventions for aspiration prevention. On the evening of admission, the resident developed an increased moist cough and audible congestion, with oxygen saturation dropping to 78%. Staff performed suctioning and notified the physician, who ordered Duoneb and Robitussin for cough and respiratory symptoms. However, staff did not administer these medications as ordered. Progress notes included late entries after the resident was discharged, and there was a lack of timely and accurate communication among staff and with the physician regarding the resident's symptoms and response to interventions. The family was not kept adequately informed of the resident's deteriorating condition and ultimately had to request hospital transfer after observing significant respiratory distress the following morning. Interviews with nursing staff revealed gaps in hand-off communication and a lack of prompt action in response to the resident's low oxygen saturation and persistent symptoms. The physician was not informed that the resident's cough occurred during oral intake, which may have influenced the care plan. The Director of Nursing confirmed that the care plan should have addressed the resident's stroke diagnosis to prevent aspiration. As a result of these deficiencies, the resident was admitted to the hospital in respiratory distress due to aspiration and subsequently placed on hospice care.
Failure to Maintain Accurate and Timely Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and timely documentation in the medical record for one resident, resulting in incomplete records and lack of communication regarding care instructions. Specifically, a registered nurse entered a late progress note into the electronic health record after the resident had already been discharged to the hospital, documenting that the head of bed should remain elevated, but this information was not communicated to staff in a timely manner. Additionally, another nurse wrote a late progress note indicating that a physician had been notified about the resident's decreased coughing and wheezing, but the physician confirmed that this notification did not occur. These late entries led to incomplete and inaccurate documentation of the resident's condition and care provided.
Failure to Prevent Accidents During Mechanical Lift Transfer and Inadequate Emergency Equipment Setup
Penalty
Summary
A deficiency occurred when a resident who was dependent for transfers was being moved using a mechanical lift by two staff members, one of whom was not fully trained or authorized to operate the lift. During the transfer, the sling straps on the left side slipped off the hanger bar as the resident was being lifted, resulting in the resident falling and sustaining left-sided rib fractures and a pneumothorax, which required hospitalization and chest tube placement. The staff involved included a CNA who was orienting and not permitted to provide care, and another CNA who was responsible for the transfer. The facility's policy required two trained staff for mechanical lift transfers, but documentation confirmed that the orienting aide had not completed the required training checklist. Interviews and vendor inspection determined that the lift was functioning properly and that the incident was due to user error, specifically improper attention to strap placement and monitoring during the lift. Another deficiency was identified when a resident with a history of stroke, gastrostomy, and dysphagia was observed in bed with a suction machine at the bedside that was not fully set up. The machine was missing essential components, including the suction canister, tubing, and yankauer, despite a physician order for suctioning as needed for oral secretions. The nurse on duty confirmed that the suction equipment was not ready for use and acknowledged its importance in preventing accidents, especially given the resident's risk for respiratory emergencies due to her medical condition and NPO (nothing by mouth) status. Both deficiencies were substantiated through interviews, record reviews, and direct observation. The first involved a failure to ensure that only trained staff operated mechanical lifts, leading to a serious resident injury. The second involved a failure to provide care consistent with physician orders, leaving a resident at risk in the event of a respiratory emergency due to incomplete setup of emergency equipment.
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