HONOLULU, HI - Federal inspectors documented numerous safety and care deficiencies at The Care Center of Honolulu during an August 2024 inspection, including improper medication handling, inadequate staffing transparency, and serious lapses in infection control protocols.
Medication Safety Breaches Put Residents at Risk
The inspection revealed significant medication management failures that created potential safety hazards for residents. On August 14, 2024, inspectors observed a registered nurse improperly disposing of an 81-milligram aspirin tablet in an unlocked trash bin attached to a medication cart. The medication remained visible and accessible in the open waste container as residents passed by unsupervised.
The nurse later admitted she was "unsure of how to properly dispose of the medication," according to the inspection report. This incident occurred while a resident independently wheeled past the medication cart, highlighting the accessibility risk of the improperly discarded medication.
Proper medication disposal protocols require unused medications to be secured in locked containers or sharps disposal systems to prevent unauthorized access. The facility's Unit Manager confirmed that non-controlled medications should be disposed of in closed systems, not open trash bins accessible to residents and visitors.
Controlled Substance Accountability Failures
The inspection also uncovered lapses in controlled substance tracking procedures. On the second floor nursing unit, inspectors found that the required Controlled Item Checklist was missing signatures from both the outgoing night shift nurse and incoming day shift nurse for August 14, 2024. This documentation gap occurred despite the medication cart being unlocked and in active use for preparing resident medications.
The night shift nurse explained that she had completed the narcotic count with the day shift nurse but failed to sign the documentation sheet before handing over the medication cart. "She didn't want RN24 to wait on her to start her morning medication administration, so she handed off the medication cart prior to signing the narcotic count sheet," the nurse told inspectors.
Federal regulations require strict accountability for controlled substances, including proper documentation of counts during shift changes. These safeguards help prevent medication diversion and ensure residents receive prescribed medications as ordered.
Staffing Information Hidden from Families
The facility failed to meet federal requirements for posting daily staffing information in clearly visible locations for residents and families. Inspectors found that staffing information was buried among employee notices on bulletin boards with small, hard-to-read print that required standing within two feet to decipher.
Family members interviewed during the inspection confirmed they were unaware of where to find staffing information. "Nope, I don't know where it is, and staff never told me where it was at," one family member told inspectors when asked about the location of daily staffing posts.
On individual nursing units, staff names were written on dry erase boards positioned more than 10 feet from unit entrances, making them difficult for families to locate and read. The inspection found that Unit 3 had no visible staffing information posted at all on August 12, 2024.
Federal regulations require nursing homes to post staffing information prominently to help families understand the level of care available. This transparency allows family members to make informed decisions and advocate effectively for their loved ones.
Medical Documentation Compromises Patient Safety
The inspection revealed serious medical record inaccuracies that could compromise resident safety. For a resident with a tracheostomy and feeding tube who was ordered to receive nothing by mouth, nurses repeatedly documented over multiple days that the resident was "taking nutrition and hydration orally."
This documentation appeared to be copied and pasted across multiple nursing assessments, creating a pattern of inaccurate medical records. The facility's Unit Manager acknowledged the documentation was incorrect and stated that "copying and pasting of assessments or portions of assessments should not happen."
Accurate medical documentation is essential for ensuring appropriate care. When records contain false information about a resident's eating status, it can lead to serious medical complications, including aspiration pneumonia if staff attempt to provide oral nutrition to someone who should receive nothing by mouth.
Privacy Violations Expose Resident Information
Inspectors documented a significant privacy breach when they found a medication cart computer displaying a resident's electronic health record in a public hallway. The screen faced the dining room where five residents were present, and a visitor was observed looking at the exposed medical information while waiting for staff assistance.
The nurse responsible for the computer had left it unattended without logging off, violating both facility policy and federal privacy regulations. The incident demonstrates how simple procedural failures can result in serious violations of resident privacy rights.
Infection Control Lapses Create Health Risks
The inspection identified multiple infection control violations that could expose residents to preventable infections. During a wound dressing change for a resident with a stage four pressure ulcer, a licensed practical nurse failed to sanitize her hands after removing contaminated gloves before putting on clean ones.
When questioned by inspectors, the nurse acknowledged she should sanitize her hands and immediately corrected the procedure. However, this lapse occurred during care for a resident with an active wound infection and septicemia, conditions that make proper infection control procedures particularly critical.
Another infection control failure involved a resident's oxygen humidifier bottle that had fallen to the floor due to broken securing mechanisms. The facility's Infection Preventionist confirmed that floor placement was unacceptable because "the floor is not sanitary with possible germs, bile, and infectious diseases on the floor."
Pharmaceutical Oversight Deficiencies
The facility failed to properly manage physician responses to pharmacist recommendations during monthly medication reviews. For two residents, pharmacists identified potential medication issues but received inadequate physician responses without proper documentation or rationale.
In one case, a pharmacist recommended adding pain medication options for a resident, but the physician's response was limited to an unsigned handwritten note stating "No new order." The facility could not provide documentation showing the physician was properly notified or had provided clinical reasoning for rejecting the recommendation.
For another resident with a feeding tube, medications continued to be ordered for oral administration nearly a year after a pharmacist recommended clarifying administration routes. This failure to implement pharmaceutical recommendations can compromise medication effectiveness and resident safety.
Additional Issues Identified
The inspection also documented problems with meal service consistency, inadequate food safety protocols, improper binding arbitration agreement procedures, and failures to maintain required dishwasher sanitization logs. These additional violations contributed to an overall pattern of compliance failures across multiple operational areas.
The Care Center of Honolulu must address these deficiencies to ensure resident safety and regulatory compliance. Federal regulations exist to protect some of society's most vulnerable individuals, and nursing homes must maintain consistent adherence to these standards to provide safe, quality care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Care Center of Honolulu from 2024-08-15 including all violations, facility responses, and corrective action plans.
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