Hale Malamalama: CNA Told Resident to Urinate in Diaper - HI
The CNA also shouted at the resident and made other inappropriate comments during the incident, according to a January 31 federal inspection report. When interviewed by inspectors, the nursing assistant admitted telling the resident to wet herself rather than providing needed toileting assistance.
The facility failed to investigate potential neglect even after staff raised concerns about delayed care for residents.
A second case involved a hospice patient whose care became the center of a loud argument between two nursing assistants in her room. The confrontation was so disruptive that the charge nurse had to physically separate the CNAs, who were "shouting at each other" near the resident's bedside.
The hospice patient, identified in the report as a woman with chronic kidney disease, diabetes, stroke-related paralysis, and complete bowel and bladder incontinence, had been found soiled by staff. Adult Protective Services opened a case on her behalf, though she died before the investigation concluded.
When inspectors interviewed the Director of Nursing about the incident, she acknowledged receiving an unsigned statement about CNAs arguing "loudly inside" the resident's room. The DON said the conflict arose over resident assignments during shift change.
"I went to intervene and saw them close to each other still arguing," the charge nurse wrote in the unsigned statement. "Prior to the incident, I learned that they were arguing about resident assignment."
The DON told inspectors she viewed the confrontation as an interpersonal conflict between staff that had been resolved through reassignment. One CNA had questioned why she had been assigned to care for the soiled resident, and an agency CNA agreed to take over the patient's care instead.
But the facility never investigated whether the resident had received adequate care that day.
When inspectors asked the DON if she had reviewed the patient's medical records to identify potential care issues, specifically whether CNAs had documented timely brief changes, she said no. Only when pressed during the interview did the DON review the documentation.
She agreed there was "lack of evidence" the hospice patient had been checked every two hours for incontinence that day, as required.
The resident was completely dependent on staff for all physical, emotional and social needs due to her medical conditions, which included hemiplegia and hemiparesis affecting her dominant right side following a stroke. She also had difficulty swallowing.
Despite a CNA expressing concern that staff were not changing residents in a timely manner, and despite the disruptive argument in a vulnerable patient's room, facility administrators conducted no investigation into potential neglect.
The DON told inspectors she had only recently learned that Adult Protective Services had opened a case on the hospice patient. APS had requested documentation from the facility related to the resident's care.
The first resident who was told to urinate in her diaper suffered what inspectors classified as "minimal harm or potential for actual harm" from the verbal abuse and neglect. The inspection report indicates the nursing assistant's refusal to provide toileting assistance was witnessed by others.
Federal regulations require nursing homes to protect residents from abuse and neglect, and to ensure residents receive necessary services to maintain their highest level of physical and mental well-being. CNAs who refuse to provide basic care like toileting assistance violate both regulatory requirements and basic human dignity.
The facility's failure to investigate staff concerns about delayed incontinence care represents a systemic breakdown in oversight. When employees raise red flags about potential neglect, administrators are required to conduct thorough investigations to protect vulnerable residents.
Instead, Hale Malamalama treated serious care concerns as workplace personality conflicts.
The hospice patient's case illustrates how inadequate staffing and poor assignment practices can escalate into harmful situations for residents. Rather than ensuring the woman received appropriate care from qualified staff, the facility allowed CNAs to argue over who would be responsible for her care while she remained in soiled conditions.
The timing of the incidents suggests ongoing problems with staff training and supervision. Both cases involved CNAs either refusing to provide care or arguing about care responsibilities rather than focusing on residents' immediate needs.
For the resident who was told to wet herself, the psychological impact of such treatment extends beyond the immediate humiliation. Elderly nursing home residents often struggle with dignity and independence issues related to incontinence. Having staff mock or dismiss these concerns can cause lasting emotional trauma.
The facility's response to both incidents demonstrates a concerning pattern of minimizing serious care failures. Rather than treating the CNA's refusal to provide toileting assistance as potential abuse, administrators appear to have handled it as a minor personnel matter.
Similarly, the loud argument in a dying patient's room was dismissed as a shift change disagreement rather than examined for underlying care quality issues.
The inspection found that few residents were affected by the documented problems, but the cases reveal systemic issues with staff accountability and administrative oversight that could impact care quality facility-wide.
Adult Protective Services' involvement in the hospice patient's case suggests the problems may have been more serious than facility administrators recognized. APS typically opens investigations when there are credible concerns about abuse, neglect, or exploitation of vulnerable adults.
The resident who died had multiple complex medical conditions requiring skilled nursing care. Her complete incontinence meant she depended entirely on staff for basic hygiene and comfort. Delayed brief changes can lead to skin breakdown, infections, and unnecessary suffering.
When CNAs argue over assignments rather than ensuring timely care, residents like this woman pay the price through prolonged exposure to waste and potential medical complications.
The facility's Director of Nursing acknowledged during the inspection that documentation showed gaps in required incontinence checks, but only after inspectors specifically asked her to review the records. This suggests administrators were not proactively monitoring care quality or following up on staff concerns.
Both cases occurred despite the facility's obligation to maintain policies and procedures protecting residents from abuse and ensuring adequate care. The nursing assistant who told a resident to urinate in her diaper violated basic professional standards, while the facility's failure to investigate neglect concerns violated federal oversight requirements.
The inspection report does not indicate what disciplinary action, if any, the facility took against the CNA who refused toileting assistance or made inappropriate comments to residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hale Malamalama from 2025-01-31 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HALE MALAMALAMA in HONOLULU, HI was cited for violations during a health inspection on January 31, 2025.
The CNA also shouted at the resident and made other inappropriate comments during the incident, according to a January 31 federal inspection report.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.