KAHULUI, HI - Hale Makua - Kahului received citations from state health inspectors following a January 14, 2025 complaint investigation that uncovered systematic failures in preventing wandering residents from leaving the facility and entering other residents' rooms, including one instance where a cognitively impaired resident successfully left the building unsupervised.
Failure to Update Safety Plans After Elopement Incident
A resident with severe cognitive impairment managed to leave the facility on December 6, 2024, yet inspectors found the nursing home failed to revise the resident's care plan following this serious safety breach. The resident, identified as R1 in the inspection report, had documented wandering behaviors and required supervision or physical assistance for walking even short distances.
Despite the December elopement and multiple documented incidents of R1 entering other residents' rooms at night, the facility's care plan remained unchanged from its original August 23, 2023 start date. According to the inspection report, staff interventions listed in the plan included monitoring the resident's whereabouts, providing redirection, and using a WanderGuard device designed to lock exit doors when the resident approached.
The cognitive assessment revealed R1 scored a 3 on the Brief Interview for Mental Status, indicating severe cognitive impairment. This level of impairment significantly increases risks associated with unsupervised wandering, including falls, confrontations with other residents, and the potential for serious harm if a resident leaves the building and becomes lost or exposed to outdoor hazards.
Inadequate Response to Repeated Room Intrusions
Between November 29, 2024 and January 12, 2025, staff documented multiple instances of R1 wandering into other residents' rooms. On November 29 at 2:41 PM, R1 entered another resident's room at night. Progress notes from December 8 indicated R1 "sometimes walked into other residents' room looking for the toilet," and on December 15 at 8:55 PM, staff found R1 "wandering a lot on the unit" and located in another resident's room.
When questioned by inspectors on January 14, 2025, the Unit Nurse explained the facility's response was to place a "Stop banner" across the door of the room R1 had entered. The nurse acknowledged this solution was not feasible for all resident doorways and could not confirm whether R1's care plan had been revised following these incidents.
Unauthorized room entries create multiple safety and dignity concerns in nursing home settings. Cognitively impaired residents entering other residents' rooms can trigger aggressive responses from startled residents, leading to physical altercations. These intrusions also violate residents' privacy and sense of security in their personal living spaces. The inability to safely use bathroom facilities, as evidenced by R1's pattern of entering other rooms while looking for a toilet, indicates the current interventions were not meeting the resident's basic needs.
Widespread Monitoring and Documentation Failures
The inspection revealed the safety failures extended beyond a single resident. Investigators found the facility failed to properly implement care plans for three of the four residents reviewed during the survey. Problems identified included direct care staff being unaware of specific approaches outlined in residents' care plans, inaccurate monitoring of wandering behaviors that prevented establishing baseline data to measure intervention effectiveness, and failure to develop elopement prevention plans for residents exhibiting wandering behaviors.
Care plan effectiveness requires regular assessment and revision based on observed outcomes. When interventions fail to prevent dangerous behaviors like elopement or repeated room intrusions, regulatory standards require facilities to evaluate why current approaches are ineffective and develop new person-centered strategies. The documented pattern of wandering incidents without corresponding care plan updates indicates a systemic failure in the facility's care planning process.
Additional Issues Identified
Inspectors documented several related deficiencies during the investigation. For another resident identified as R2 who exhibited wandering behaviors, the facility failed to develop an elopement prevention care plan prior to the survey. Staff also did not implement or accurately document required daily checks of the WanderGuard device function for this resident.
A third resident, R3, did not receive required quarterly elopement risk assessments as specified in their care plan. Additionally, the facility failed to recognize and properly assess an elopement incident involving this resident, which should have triggered an immediate care plan review.
The inspection was conducted as a complaint investigation, suggesting these issues came to light following concerns raised about resident safety at the facility. The Centers for Medicare & Medicaid Services classified the violations as creating minimal harm or potential for actual harm to residents.
Electronic monitoring devices like WanderGuard systems serve as important safety tools but function as only one component of comprehensive elopement prevention. Effective wandering management requires individualized assessment of triggers, appropriate environmental modifications, consistent staff implementation of planned interventions, and regular evaluation of whether current approaches successfully address the behavior while maintaining resident dignity and quality of life.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hale Makua - Kahului from 2025-01-14 including all violations, facility responses, and corrective action plans.
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