KAHULUI, HI - Federal inspectors cited Hale Makua-Kahului nursing home for failing to implement comprehensive safety protocols for residents with dementia who exhibit wandering behaviors, including missed WanderGuard monitoring and incomplete elopement risk assessments.
Missing Safety Device Monitoring
The January 14 inspection revealed significant gaps in monitoring WanderGuard devices, electronic safety systems designed to prevent residents from leaving secure areas undetected. For one resident with Alzheimer's disease and documented wandering behavior, staff failed to check the WanderGuard device on five separate dates between December 29, 2024 and January 8, 2025.
WanderGuard devices function as electronic monitoring systems that alert staff when residents with cognitive impairment approach exit doors. These devices are critical safety tools for individuals with dementia who may become confused about their location and attempt to leave the facility.
The resident in question had a comprehensive care plan specifically addressing wandering risks, which required staff to "check the placement every shift" and monitor the device's functionality daily. Documentation showed the facility's own treatment records contained multiple gaps where required safety checks were not performed or documented.
Incomplete Behavioral Monitoring
Inspectors found additional deficiencies in tracking targeted behaviors for residents with dementia. Staff missed documenting wandering behavior monitoring on seven different date-shifts between November 2024 and January 2025. The facility's tracking system used numerical codes that staff found confusing, with administrators acknowledging the documentation method needed improvement.
During interviews, a unit nurse explained that staff used "1" to document wandering behavior and "2" for medication refusal, with "0" indicating no behaviors occurred. However, the inconsistent documentation made it difficult to track patterns or assess the effectiveness of interventions.
Missing Elopement Risk Assessments
More concerning, inspectors discovered that required elopement risk assessments were either missing entirely or not updated according to facility policy. One resident with documented wandering behavior had no elopement risk assessment completed since admission, despite facility policy requiring quarterly evaluations.
For another resident previously assessed as high risk for elopement, staff failed to complete the required quarterly reassessment in December 2024. This resident had actually triggered an exit alarm in November when found outside an exit door, yet no follow-up risk assessment or care plan revision occurred.
Medical Significance of Wandering
Wandering behavior in dementia patients presents serious safety risks beyond simple exit-seeking. Residents may become lost within the facility, fall while walking unsupervised, or encounter hazardous areas. The behavior typically stems from confusion, anxiety, or attempts to fulfill perceived needs or routines from earlier life.
Proper monitoring protocols serve multiple purposes: preventing dangerous situations, identifying triggers that may increase wandering episodes, and ensuring appropriate interventions are implemented. When monitoring systems fail, residents face increased risks of injury, becoming lost, or experiencing psychological distress from unsuccessful attempts to navigate their environment.
Industry Standards and Protocol Failures
Federal regulations require nursing homes to develop comprehensive care plans that address each resident's specific needs and risks. For residents with dementia and wandering behaviors, this includes regular assessment of elopement risk, consistent monitoring of safety devices, and documentation of behavioral patterns.
The facility's own policy, established in May 2021, clearly outlined requirements for quarterly elopement assessments and interdisciplinary team review of intervention strategies. The policy specifically stated that interventions should be added to care plans after analyzing assessment information, yet inspectors found these requirements were not consistently followed.
Administrative Response
When questioned about the missing assessments, facility administrators expressed surprise that required evaluations had not been completed, stating they believed the charts had been properly audited. The Administrator acknowledged that the current behavior monitoring system was confusing and indicated the facility would consider separating different types of behavioral documentation for clarity.
The inspection classified these violations as causing "minimal harm or potential for actual harm" affecting "some" residents. However, the systematic nature of the documentation gaps and missing assessments indicates broader issues with the facility's safety monitoring protocols for vulnerable residents with cognitive impairment.
Readers can access the complete inspection report through state survey agency records for additional details about the facility's response and corrective action plans.
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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