HONOLULU, HI - Federal inspectors documented serious violations at Hale Nani Rehabilitation and Nursing Center during a July 2024 inspection, including the improper use of physical restraints and systemic failures to report abuse allegations to state authorities.
Physical Restraint Violations
Inspectors observed a resident being physically restrained in a manner that violated federal regulations protecting patient rights. On July 15, 2024, state surveyors found a resident lying in a fully reclined Geri-chair with a wheelchair wedged underneath the extended footrest. This positioning prevented the resident from lowering the chair, even if physically capable of using the side handle.
The arrangement created what federal regulations define as an unlawful physical restraint - a device attached or adjacent to the resident's body that cannot be easily removed and restricts freedom of movement. The wedged wheelchair ensured the resident remained immobilized in the reclined position.
When facility administrators were alerted to the observation, the Nurse Manager acknowledged the practice constituted improper restraint use. The manager confirmed the resident required frequent supervision due to restless behavior and fall history, along with ongoing medication adjustments, but agreed physical restraints were inappropriate for managing these conditions.
Physical restraints in nursing facilities carry significant medical risks. Prolonged immobilization can lead to pressure ulcers, muscle atrophy, decreased bone density, and circulatory problems. Restraints also increase psychological distress, potentially worsening agitation and anxiety. Current medical standards emphasize alternative interventions such as increased supervision, environmental modifications, and appropriate medication management rather than physical restriction.
The facility's own policy, revised in March 2023, explicitly protects residents' rights to be free from physical or chemical restraints not required to treat medical symptoms. The policy defines physical restraints as devices that cannot be removed easily by residents and restrict freedom of movement - precisely matching what inspectors observed.
Failure to Report Abuse Allegations
Inspectors identified multiple instances where the facility failed to report abuse allegations and injuries of unknown origin to state authorities as required by federal law.
The most concerning case involved a resident with advanced dementia who experienced three separate suspicious injuries over several months. In February 2024, the resident sustained bruising to his right hip. Several weeks before the inspection, family members noticed bruising on the bridge of his nose. Most recently, on July 15, 2024, the resident's wife discovered dark purple bruising and swelling on his right hand and thumb. When she held his hand, he screamed in pain.
The resident's wife reported that when she asked him about the hand injury, he indicated "a small man" had hurt him. Given his severe cognitive impairment - assessed as unable to make decisions and not oriented to place, time, or staff - he could not provide reliable information about how injuries occurred.
Despite the resident's wife reporting these concerning injuries, facility administrators failed to notify state survey agencies or Adult Protective Services as required. During interviews, the Assistant Director of Nursing and Director of Infection Control confirmed the hip injury from February had not been reported to Adult Protective Services. The nose bruising from several weeks prior was not reported to either state surveyors or protective services, despite qualifying as an injury of unknown origin.
Regarding the hand injury, administrators initially classified it as an injury of "known origin" and therefore did not report it. However, when questioned by inspectors about how an injury could be considered "known origin" when first identified and reported by family members for investigation, administrators acknowledged the classification was inappropriate.
Federal regulations require nursing facilities to report alleged violations involving abuse, neglect, exploitation, or mistreatment - including injuries of unknown source - immediately, but not later than two hours after the allegation is made. This reporting requirement exists to ensure independent investigation by authorities and protect vulnerable residents who cannot advocate for themselves.
In another case, inspectors found the facility forwarded an abuse allegation report to state surveyors but failed to send it to Adult Protective Services. When interviewed on July 17, 2024, the Assistant Administrator acknowledged the report was not sent to protective services and stated they were unaware of the obligation to report to that agency.
This lack of awareness contradicts the facility's own policy on Freedom from Abuse, Neglect and Exploitation, which explicitly requires reporting alleged violations to "other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities)."
Inadequate Investigation Procedures
In a separate incident, Adult Protective Services contacted the facility in May 2024 regarding allegations of neglect and possible physical or sexual abuse of a female resident. The resident had been transferred to a hospital with a serious electrolyte imbalance after refusing dialysis treatment.
According to facility administrators, Adult Protective Services requested the resident's complete medical record on May 23, 2024, and asked that someone from facility administration contact them. The interim Director of Nursing was assigned to handle the contact but provided no documentation of the conversation with protective services.
The Director of Infection Control and Assistant Administrator confirmed they could not locate any documentation describing what Adult Protective Services was investigating. The interim nursing director simply reported she had "taken care of it" without providing details. As a result, the facility never initiated its own investigation into the allegations and made no report to state surveyors.
Administrators acknowledged they should have documented the protective services discussion and investigated the allegations. The lack of investigation meant potential abuse or neglect was never examined by the facility, leaving other residents potentially at risk if staff misconduct occurred.
Environmental and Dignity Concerns
Inspectors documented additional violations affecting resident dignity and quality of life. One resident reported being placed in a room with extensively peeling paint covering the walls after returning to the facility from a hospital stay. The resident expressed confusion about the room assignment and questioned why staff would place her in a room with obvious wall damage.
The Director of Maintenance confirmed the maintenance department conducts weekly facility walkthroughs to identify peeling paint. When found, repairs occur only when rooms are unoccupied due to odors from the repair process, which takes approximately 24 hours for mudding, sanding, and painting. The director acknowledged no work order was submitted to repair the peeling paint before the resident was assigned to the room.
The facility patched the damaged room only after the resident moved back to her previous room on July 17, 2024. This practice violated the resident's right to be treated with dignity and provided an environment that promotes quality of life.
In another case affecting four residents sharing a bathroom, a toilet malfunctioned for weeks without proper repair. One resident reported during a July 18, 2024 Resident Council meeting that the toilet had not been flushing properly for an extended period, creating unsanitary conditions. She stated maintenance would repair it temporarily, but it would break again.
Inspectors tested the toilet on July 19, 2024, and found it failed to flush on the first three attempts, finally flushing on the fourth try. In a second test, the toilet flushed only on the seventh attempt. A certified nursing assistant confirmed the toilet sometimes failed to flush depending on how the lever was pushed.
The Director of Maintenance reviewed work orders showing the facility had addressed toilet issues three times in June 2024, replacing internal components. However, during the inspection observation, the director identified that the toilet handle was bent and the seal was offset - problems that would continue preventing proper flushing unless the bent handle was replaced.
Assessment and Care Planning Deficiencies
Inspectors found the facility failed to complete comprehensive assessments for residents, resulting in missing care plans for important health and safety issues. One resident who smoked cigarettes since age young adulthood was never identified as a smoker during the admission assessment process.
On July 15, 2024, inspectors observed the resident leaving the facility unsupervised to smoke in the parking lot, carrying cigarettes and a lighter in his shirt pocket. A Registered Nurse confirmed the resident regularly went to the parking lot to smoke and also smoked during trips outside the facility for dialysis treatments. Staff did not secure the cigarettes or lighter because the resident was cognitively intact.
Review of the resident's electronic health record revealed no documentation identifying him as a smoker and no smoking safety assessment. The Director of Nursing confirmed residents who smoke should have care plans addressing associated risks. However, because the comprehensive assessment failed to identify the smoking habit, no smoking assessment was conducted and no care plan was developed.
The facility's own policy on Physical Environment for Independent and Supervised Smokers requires nursing staff to assess residents who smoke for smoking safety on admission, quarterly, and as needed. The complete absence of any smoking-related documentation represented a failure to follow established protocols.
Smoking presents multiple health and safety concerns in nursing facilities. Beyond the obvious health risks of tobacco use, unsupervised smoking by residents creates fire hazards. Residents with cognitive impairment, mobility limitations, or oxygen use face elevated risks of burns and fire-related injuries. Proper assessment allows facilities to implement appropriate supervision levels and safety measures.
Regulatory Context
The violations documented at Hale Nani Rehabilitation and Nursing Center represent breaches of fundamental resident rights protections established under federal nursing home regulations. The restraint-free environment requirement, abuse reporting mandates, and comprehensive assessment standards exist to protect vulnerable individuals who depend on nursing facilities for care.
Physical restraint regulations specifically prohibit any restriction of movement that is not medically necessary to treat symptoms. The emphasis has shifted from restraint use to person-centered approaches that address underlying causes of behavior through increased supervision, environmental adaptation, and medical management.
Abuse reporting requirements mandate immediate notification to both state survey agencies and Adult Protective Services to ensure independent investigation of allegations. These dual reporting pathways recognize that facility self-investigation may be inadequate when staff members are implicated.
The Centers for Medicare & Medicaid Services can impose enforcement remedies for regulatory violations, including civil monetary penalties, denial of payment for new admissions, temporary management, and termination from Medicare and Medicaid programs for the most serious or uncorrected deficiencies.
Facility Response
Hale Nani Rehabilitation and Nursing Center is required to submit a plan of correction addressing each deficiency cited during the inspection. The plan must detail specific actions taken to remedy violations, measures to prevent recurrence, and monitoring systems to ensure compliance.
For complete details about the violations and the facility's correction plan, the full inspection report is available through the Centers for Medicare & Medicaid Services Nursing Home Compare website.
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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