KAHULUI, HI - Federal inspectors documented serious safety failures at Hale Makua - Kahului after a resident with severe dementia escaped the facility and was found outside near a fence, despite wearing a protective monitoring device.
Emergency Exit Security Breach
The December 6, 2024 incident involved a resident with multiple diagnoses including unspecified dementia with anxiety and agitation, cognitive communication deficits, and aphasia. The resident was discovered outside the building behind the activities center after bypassing multiple security measures.
Investigation revealed the door connecting the resident's unit to the activities department was not locked, allowing access to an emergency exit equipped with a 15-second delay mechanism. The resident's WanderGuard bracelet was reportedly functioning, but staff on the resident's unit did not hear the alarm when it activated.
The facility's own investigation found that while the WanderGuard system triggered an alert, it registered on a different unit (North) rather than the resident's assigned unit (Pikake). Another staff member spotted the resident from a window in yet another unit (Ilima) and notified the appropriate staff.
Pattern of Unsafe Wandering Documented
Medical records revealed extensive documentation of the resident wandering into other residents' rooms throughout November and December 2024. Progress notes showed incidents on November 29, December 8, and December 15, with staff documenting the resident "wandering a lot on the unit" and displaying "exit seeking behavior."
One resident reported finding the wandering resident sitting on her toilet, stating she was "surprised to find R1 using her toilet." The resident described how the wandering individual "shook her finger at her to indicate R5 was in the wrong" when discovered.
During the inspection, surveyors witnessed the resident enter another person's room, transfer from a wheelchair to the bed, and lie down. Two staff members entered the room, observed the situation, but left without taking immediate action.
Care Plan and Monitoring Failures
Despite the resident's high elopement risk score of 5 (requiring further assessment), the facility failed to adequately update care plans following the actual elopement incident. The resident's behavioral care plan from November 2022 identified wandering and exit-seeking behaviors, but approaches were not revised after documented incidents.
A certified nursing aide interviewed during the inspection stated she "doesn't know what to do" regarding wandering protocols, indicating staff training gaps. The aide reported monitoring the resident's whereabouts only every one to two hours, despite the documented high-risk status.
WanderGuard System Inconsistencies
Documentation review revealed significant gaps in the WanderGuard monitoring system. The protective bracelet was documented as "not present" during 13 different shifts in December 2024, including the day before the elopement incident.
Flow sheet monitoring for target behaviors showed only five documented instances of unsupervised ambulation out of 63 opportunities, despite progress notes recording 17 separate wandering incidents. This documentation inconsistency raised questions about staff awareness and response protocols.
Medical Intervention Attempts
Following the elopement, the facility's medical team consulted with the resident's physician about potential contributing factors. They identified a possible drug interaction between Remeron (an antidepressant) and Sertraline (another antidepressant) that may have increased wandering behavior.
The resident's Sertraline dosage was decreased to 75 mg for seven days, then reduced to 50 mg, as part of the medication review process.
Facility Response and System Updates
The Administrator reported that staff reenacted the escape to understand system failures. They discovered that while the WanderGuard system triggered appropriately, the emergency exit alarm could not be heard on the resident's unit because doors were closed.
The facility provided a grievance report from another resident complaining about nightly intrusions, stating she was "awakened to find R1 staring at her." In response, staff agreed to place Stop banners across doorways and provide additional education regarding wandering residents.
Regulatory Compliance Issues
Federal regulations require nursing homes to provide comprehensive assessments and develop care plans that address residents' behavioral symptoms and safety risks. The failure to update care plans following actual elopement and continued unsafe wandering represents a significant compliance gap.
Proper dementia care protocols require frequent monitoring, environmental modifications, and individualized interventions based on each resident's specific cognitive and behavioral patterns. Documentation must accurately reflect both incidents and interventions to ensure appropriate care delivery.
The inspection findings highlight the critical importance of coordinated safety systems in dementia care, particularly for residents with documented elopement risks and wandering behaviors.
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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