HONOLULU, HI - Federal inspectors cited Maunalani Nursing and Rehabilitation Center after finding that inadequate care protocols led to a resident developing two stage 3 pressure ulcers on both buttocks, despite written orders requiring frequent repositioning.
Facility-Acquired Pressure Ulcers Developed Over Four Months
The August 29, 2024 inspection revealed that a resident identified as R2 developed two stage 3 pressure ulcers after admission to the facility. According to the Director of Nursing, one ulcer began as moisture-associated skin damage in April 2024 and progressed to a stage 3 ulcer. The second ulcer started as a "round open area" in May 2024 and also advanced to stage 3.
Stage 3 pressure ulcers represent full-thickness skin loss extending into subcutaneous tissue, creating deep craters that can expose underlying fat tissue. These wounds indicate prolonged pressure that has caused significant tissue death and require intensive medical intervention.
Repositioning Protocols Ignored Despite Clear Orders
Medical records showed the resident had physician orders requiring repositioning every hour and sitting restrictions of no more than 30 minutes at a time. However, inspection observations revealed these critical care protocols were consistently ignored.
Over multiple days, federal surveyors documented the resident lying in the same position - on her back with the head of bed elevated 45 degrees - for extended periods. On August 26 at 11:15 AM, August 27 at 9:42 AM, and August 28 at 11:31 AM, inspectors found the resident in identical positioning, suggesting inadequate compliance with repositioning orders.
"We get her up for only 30 minutes when she attends Bingo once a week every Tuesday only for 30 minutes," Licensed Practice Nurse 25 told investigators, confirming the resident's extremely limited mobility and activity.
Medical Consequences of Inadequate Pressure Relief
Pressure ulcers develop when sustained pressure reduces blood flow to tissue, causing cell death and tissue breakdown. The human body requires regular position changes to maintain adequate circulation, particularly for immobile residents who cannot reposition themselves.
The facility's own pressure injury policy, revised August 14, 2024, clearly states requirements to "minimize pressure, friction, and shearing" and "limit amount of time resident may be in one position without moving in bed or chair by repositioning resident during a purposeful rounding or more frequently depending upon the resident's condition and specific needs."
For residents at high risk, medical standards typically require repositioning every two hours at minimum, with some cases requiring hourly turns. The progression from minor skin damage to stage 3 ulcers indicates sustained pressure over weeks or months without adequate relief.
Staff Acknowledges Care Plan Violations
During the inspection, nursing staff revealed significant discrepancies between written care orders and actual practice. While physician orders specified hourly repositioning, the Licensed Practice Nurse stated the resident was "being turned every two hours" - a clear violation of the prescribed care plan.
The contrast between required hourly repositioning and actual two-hour intervals represents a 100% increase in pressure duration, significantly elevating the risk of tissue breakdown and ulcer development.
Facility Response and Correction Requirements
The Director of Nursing confirmed during the Quality Assurance Performance Improvement meeting that both pressure ulcers were facility-acquired, developing after the resident's admission. This acknowledgment triggers requirements for the facility to update the resident's Minimum Data Set assessment to reflect two stage 3 facility-acquired pressure ulcers.
The citation carries a "minimal harm or potential for actual harm" classification, affecting "few" residents according to the federal inspection report. However, stage 3 pressure ulcers can lead to serious complications including infection, sepsis, and extended healing times requiring specialized wound care.
Industry Standards for Pressure Ulcer Prevention
Healthcare facilities are required to implement comprehensive pressure ulcer prevention programs including risk assessments, individualized care plans, appropriate support surfaces, nutrition management, and staff training. The development of facility-acquired pressure ulcers often indicates systemic failures in these prevention protocols.
Proper pressure ulcer prevention requires coordinated care including regular skin assessments, adequate nutrition, proper positioning devices, and strict adherence to repositioning schedules. When prevention fails, early intervention becomes critical to prevent progression to deeper tissue damage.
Implications for Resident Safety
The inspection findings highlight the serious consequences when nursing facilities fail to follow established care protocols. Pressure ulcers not only cause significant discomfort but can lead to prolonged hospitalization, surgical intervention, and increased risk of life-threatening complications.
Maunalani Nursing and Rehabilitation Center, located at 5113 Maunalani Circle in Honolulu, must submit a plan of correction addressing the identified deficiencies to continue participating in Medicare and Medicaid programs.
The complete inspection report and facility response are available through the Centers for Medicare & Medicaid Services database, providing detailed information about the specific violations and required corrective actions.
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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