HONOLULU, HI - Federal inspectors found that Kalakaua Gardens nursing home failed to properly update care plans following significant changes in residents' conditions and left a vulnerable resident unsupervised in unsafe situations, resulting in physical harm.
Care Plan Deficiencies Put Residents at Risk
The January 17, 2025 inspection revealed that the facility failed to maintain person-centered care plans that adequately addressed residents' changing medical needs and functional abilities. Inspectors found that comprehensive care plans were not being revised when residents experienced significant changes in their health status, a critical requirement for ensuring appropriate medical care.
One resident, identified as R348 in the report, had functional abilities that were completely omitted from their care plan. The Director of Nursing confirmed during the inspection that the comprehensive care plan was not person-centered and failed to include preventive measures for moisture-associated skin damage (MASD) or pressure ulcers - both serious complications that can lead to infections, prolonged healing times, and increased mortality risk in elderly residents.
This type of care plan failure represents a fundamental breakdown in the nursing home's clinical oversight system. Comprehensive care plans serve as the roadmap for daily care decisions, medication administration, and safety protocols. When these plans lack essential information about a resident's functional capabilities, staff cannot provide appropriate assistance levels, potentially leading to falls, injuries, or medical complications.
Supervision Failures Result in Physical Harm
The inspection documented a particularly concerning incident involving resident R22, who was left unsupervised in the bathroom while seated on the toilet. This lack of supervision directly resulted in the resident being physically harmed on two separate occasions. The facility's failure to update R22's care plan with person-centered interventions after a significant change of condition assessment contributed to these safety failures.
Bathroom supervision is a critical safety measure in nursing homes, as many residents face mobility challenges, cognitive impairments, or medical conditions that make unsupervised bathroom use dangerous. Falls in bathrooms can result in serious injuries including hip fractures, head trauma, and cuts from hard surfaces. For elderly residents, such injuries often lead to hospitalizations, surgical procedures, and declined quality of life.
Medical Standards and Best Practices
Federal regulations require nursing homes to develop comprehensive care plans within seven days of conducting thorough assessments of residents' needs. These plans must be prepared, reviewed, and revised by interdisciplinary teams of health professionals including nurses, physicians, therapists, and social workers.
Care plans should address all aspects of a resident's condition, including physical limitations, cognitive status, medication needs, and safety requirements. When residents experience significant changes - whether improvements or declines - facilities must reassess their needs and update care plans accordingly.
Moisture-associated skin damage prevention is particularly important in nursing home settings, as residents with limited mobility face increased risk of developing painful skin breakdown. Proper prevention protocols include regular repositioning, skin assessments, appropriate hygiene products, and moisture management strategies. Pressure ulcers, which can develop when preventive measures fail, affect approximately 2-28% of nursing home residents and can lead to serious complications including bone infections and sepsis.
Additional Issues Identified
The inspection also revealed that the facility's care planning process lacked the collaborative approach required by federal standards. The interdisciplinary team responsible for developing and updating care plans was not adequately reviewing resident conditions or incorporating necessary interventions when changes occurred.
Documentation showed that staff failed to recognize when significant changes in resident conditions warranted care plan updates, suggesting gaps in clinical assessment skills and oversight procedures. This pattern indicates systemic issues with the facility's clinical management processes rather than isolated incidents.
The facility received citations for failing to develop complete care plans within required timeframes and not ensuring that care plans were prepared, reviewed, and revised by appropriate health professional teams. These violations were classified as causing minimal harm with potential for actual harm, affecting few residents.
Regulatory Response
The inspection findings highlight the importance of robust care planning systems in nursing homes. Federal regulations exist specifically to ensure that residents receive individualized care based on their current medical and functional status. When facilities fail to maintain accurate, updated care plans, residents face increased risks of medical complications, injuries, and inadequate care.
The violations documented at Kalakaua Gardens demonstrate how administrative failures in care planning can translate directly into physical harm for vulnerable residents. Proper care planning requires ongoing clinical assessment, interdisciplinary collaboration, and regular plan updates to reflect changing resident needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kalakaua Gardens from 2025-01-17 including all violations, facility responses, and corrective action plans.
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