HONOLULU, HI - A federal inspection has revealed that Hale Nani Rehabilitation and Nursing Center failed to provide basic foot care for a diabetic resident, ultimately resulting in a toe amputation that could have been prevented with proper nail maintenance.
Preventable Amputation Follows Years of Neglected Care
The most severe violation documented during the July 2024 inspection involved a female resident who lost her left big toe due to infection and gangrene. The resident, identified as R29 in the inspection report, had been living at the facility since 2022 with multiple health conditions including Type 2 diabetes, peripheral vascular disease, and dementia.
According to the inspection findings, the resident's family member reported that facility staff had never cut the resident's toenails during her two-year stay. The family member stated they "did not recall the last time R29 had her toenails cut, and believed she did not get them cut since she was admitted in 2022."
When inspectors observed the resident's remaining foot, they found her toenails were "long, thick, and digging into her nailbed" - a condition that poses serious risks for diabetic patients.
Medical Timeline Reveals Rapid Deterioration
The resident's medical records show a rapid progression from a minor wound to amputation. On June 16, 2024, nursing staff documented discovering "a small amount of pus" from the resident's left big toe during a routine skin assessment. The inspection report noted that "dry skin on the front of the toe came out, showing a pinkish red color" with the bottom of the toe appearing "reddish purplish in color."
Just twelve days later, on June 28, the resident required emergency room treatment for what had developed into a serious infection. Hospital records confirmed the wound was "infected with pseudomonas orzyhabitans and gangrene of the left big toe." The amputation was performed on July 7, 2024.
Diabetic patients face elevated risks for foot complications because high blood glucose levels can damage nerves and reduce blood circulation to the extremities. Poor circulation slows healing, while nerve damage can prevent patients from feeling injuries or infections until they become severe. This makes regular foot inspection and nail care critical preventive measures.
Facility's Own Policies Ignored
The inspection revealed that Hale Nani had established policies specifically addressing diabetic foot care, making the failure to provide proper nail care more concerning. The facility's "Quality of Care Foot Care" policy, dated March 2023, explicitly stated that the facility would "provide care and treatment to maintain mobility and good foot health" and that "residents with complicating disease processes will be referred to qualified professionals for foot care."
Despite these written protocols, inspectors found no evidence that the diabetic resident had ever been referred to a podiatrist during her stay. The Nurse Manager confirmed to inspectors that "nail care for diabetic residents are done by the charge nurse, however, for toenails, it is normally referred to the podiatrist if the nails are thickened and the resident is diabetic."
A Certified Nurse's Aide told inspectors that "the facility had never cut R29's toenails because she was diabetic" - a statement that contradicts both medical standards and the facility's own policies for diabetic care.
Moldy Shower Conditions Threaten Vulnerable Residents
The inspection also documented dangerous sanitary conditions in shower facilities used by residents with serious infections. Inspectors found that a resident with stage 4 pressure ulcers and multiple open wounds was using a shower room contaminated with extensive mold growth.
The inspection report described "dark green and black organic growth, which was fuzzy and raised in appearance, with a strong musty smell" covering the shower floor, walls, and handheld showerhead. The contamination was so severe it had clogged the small holes in the showerhead, meaning contaminated water was spraying directly onto residents during bathing.
This resident was on contact precautions due to a blood infection with gram-positive bacteria - organisms that can cause life-threatening complications including endocarditis, septic arthritis, and bone infections. Exposing such a vulnerable patient to mold contamination creates additional infection risks.
A housekeeping staff member confirmed the shower "appears as if it had not been cleaned in over 2 weeks, at a minimum," despite facility policies requiring daily cleaning of shower rooms.
Range of Motion Care Failures Lead to Lost Mobility
Another significant finding involved the failure to provide adequate range of motion therapy for residents with progressive conditions. A male resident with Amyotrophic Lateral Sclerosis (ALS) reported losing the ability to use his motorized wheelchair due to knee contractures that developed under the facility's care.
The resident told inspectors he was previously able to "stand and pivot with assistance and sit in his $50,000 motorized wheelchair" as recently as Christmas Day 2023. However, inadequate delivery of prescribed restorative nursing services meant he received passive range of motion therapy only 14 times out of 65 scheduled sessions between January and March 2024.
ALS progressively destroys nerve cells that control voluntary muscle movement, making regular range of motion exercises essential for maintaining joint flexibility and mobility. Without consistent therapy, joints can develop contractures - permanent tightening of muscles and tissues that severely limits movement and function.
The facility's own Restorative Nurse Assistant acknowledged that staffing shortages prevented proper care delivery, stating "there is no way one RNA can get through that many residents in one day" when responsible for 31 residents requiring daily services.
Care Planning Failures Exclude Key Medical Team Members
Inspectors found systematic failures in the facility's care planning process, with quarterly meetings conducted without essential medical professionals. Reviews of four residents' care plan meetings showed that attending physicians, registered nurses, and nurse aides - all required participants under federal regulations - were consistently absent from these critical planning sessions.
Instead, only social services and recreation staff attended meetings where important medical decisions about residents' ongoing care should have been made. Comprehensive care planning requires input from all disciplines involved in a resident's treatment to ensure medical, nursing, and therapeutic needs are properly coordinated.
One resident reported he "would like to attend in person but was not given a choice," with facility invitation letters showing the option to attend crossed out with notes stating this "option was not available."
Systemic Staffing Issues Compromise Care Quality
The inspection findings point to chronic understaffing as an underlying factor in multiple care failures. The facility received citations for insufficient nursing staff to meet residents' needs safely and promote their well-being.
Residents and staff consistently reported staffing shortages affecting care delivery. The ALS patient stated he was "so tired of being told we are short-staffed by management" and that care quality had "decreased since he got here a year ago."
Adequate staffing levels in nursing homes are essential for preventing complications and maintaining residents' functional abilities. When facilities lack sufficient personnel, routine but critical care like nail trimming, range of motion exercises, and environmental cleaning may be deferred or omitted entirely.
Regulatory Response and Implications
The violations identified during the July 19, 2024 inspection resulted in multiple citations under federal nursing home regulations. These included failures to provide activities of daily living assistance, appropriate treatment and care, range of motion services, proper care planning, and adequate staffing.
Federal regulations require nursing homes to provide care that helps residents maintain their highest practicable physical, mental, and psychosocial well-being. The documented failures at Hale Nani represent significant departures from these standards, with residents experiencing preventable complications that reduced their quality of life and functional independence.
The inspection findings demonstrate how seemingly minor care omissions - like neglecting nail trimming - can cascade into serious medical emergencies requiring surgical intervention. For vulnerable populations like nursing home residents, consistent attention to basic care needs serves as a crucial safeguard against preventable complications.
Families considering nursing home placement should inquire specifically about facilities' protocols for diabetic foot care, range of motion therapy, environmental sanitation, and staffing levels to ensure their loved ones receive appropriate protective care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hale Nani Rehabilitation and Nursing Center from 2024-07-19 including all violations, facility responses, and corrective action plans.
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