HONOLULU, HI - Federal inspectors cited Maunalani Nursing and Rehabilitation Center after staff failed to prevent two stage three pressure ulcers on an immobile resident who required complete assistance with repositioning.
The August 29, 2024 inspection revealed the facility's breakdown in basic pressure ulcer prevention protocols led to facility-acquired wounds representing full thickness skin loss on a resident who depended entirely on staff for movement and self-care.
Facility-Acquired Wounds Documented
The resident, identified as R2, is a female patient with neurological conditions and coronary artery disease who was readmitted to the facility in late December 2023 following a hospital stay. Medical assessments confirmed R2 was cognitively intact but experienced significant physical impairment affecting both upper and lower extremities, making her completely dependent on staff for mobility and self-care activities.
Initial assessments documented no pressure ulcers when R2 returned to the facility. The annual Minimum Data Set assessment completed February 27, 2024 showed no unhealed pressure ulcers at that time.
However, by April 11, 2024, a change of status assessment documented R2 had developed a stage three pressure ulcer. The facility incorrectly coded this wound as "present on admission" in their documentation system, despite the earlier assessment showing no such injuries.
Understanding Stage Three Pressure Ulcers
Stage three pressure ulcers represent full thickness skin loss where subcutaneous fat may be visible. These wounds penetrate through the entire dermis layer and can expose underlying tissue. At this severity level, the damage extends beyond superficial skin layers and requires significant medical intervention to heal.
These injuries develop when sustained pressure on bony prominences restricts blood flow to tissue. Without adequate circulation, cells begin to die, creating progressively deeper wounds. The timeline for pressure ulcer development varies, but damage can begin forming within hours when pressure remains unrelieved.
For immobile residents, prevention requires consistent repositioning every one to two hours around the clock. This frequency ensures no single area bears sustained pressure long enough to compromise tissue integrity.
Documentation Errors Compound Care Failures
During the inspection, surveyors interviewed the Director of Nursing on August 29, 2024 regarding the discrepancy in medical records. The DON confirmed R2's pressure ulcers were facility-acquired and acknowledged the coding in the Minimum Data Set was incorrect and required updating.
This admission confirmed the wounds developed under the facility's care, not before admission as the documentation suggested. The quarterly review completed July 12, 2024 continued to incorrectly code the stage three pressure ulcer as present on admission, perpetuating the documentation error for months.
When surveyors observed R2 on August 26, 2024, she was lying on her back with the head of her bed elevated at a 45-degree angle. The resident stated she preferred staying in her room and only attended Bingo on Tuesdays. This sedentary lifestyle, combined with complete dependence on staff for repositioning, created heightened vulnerability to pressure injuries.
Required Prevention Protocols
Evidence-based pressure ulcer prevention requires comprehensive care planning for at-risk residents. Standard protocols include:
Scheduled turning and repositioning every one to two hours for immobile residents, with documentation of each position change. The specific schedule depends on individual risk factors, but no resident should remain in one position for extended periods.
Pressure-redistributing surfaces such as specialized mattresses or cushions that reduce pressure on vulnerable areas. These devices complement but do not replace repositioning requirements.
Skin assessments during each repositioning to identify early signs of pressure damage. Detecting stage one pressure injuries (non-blanchable redness) allows intervention before progression to deeper wounds.
Nutrition and hydration management to support skin integrity and healing capacity. Protein deficiency and dehydration increase pressure ulcer risk and impair wound healing.
The inspection findings indicate these fundamental prevention measures broke down in R2's care. The facility failed to implement adequate repositioning protocols, allowing sustained pressure that resulted in two stage three wounds.
Risks and Complications
Stage three pressure ulcers create serious health risks beyond the immediate tissue damage. These wounds provide entry points for bacterial infections that can progress to life-threatening conditions including sepsis. The exposed subcutaneous tissue is particularly vulnerable to colonization by harmful microorganisms.
Healing stage three pressure ulcers typically requires weeks to months of intensive wound care, including specialized dressings, debridement of dead tissue, and potentially surgical intervention. The healing process diverts bodily resources and can impact overall health status, particularly for residents with existing medical conditions.
Pain management becomes a significant challenge, as these deep wounds cause considerable discomfort that can limit mobility further and reduce quality of life. The presence of pressure ulcers often necessitates increased medication use and more intensive nursing care.
Systemic Vulnerability
Federal surveyors noted the deficient practice placed R2 at increased risk of infection and poor health outcomes. More broadly, inspectors concluded all residents requiring staff assistance for mobility face similar risks when repositioning protocols fail.
This finding suggests the breakdown extended beyond one resident's care, indicating potential systemic issues with the facility's pressure ulcer prevention program. Any facility caring for immobile or partially mobile residents must maintain robust systems ensuring consistent implementation of prevention protocols.
The facility received a citation for failing to provide appropriate pressure ulcer care and prevent new ulcers from developing, with the harm level classified as minimal harm or potential for actual harm affecting few residents.
Maunalani Nursing and Rehabilitation Center is located at 5113 Maunalani Circle in Honolulu, Hawaii. The complete inspection report contains additional details about the facility's corrective action plan.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maunalani Nursing and Rehabilitation Center from 2024-08-29 including all violations, facility responses, and corrective action plans.
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