HONOLULU, HI - Federal inspectors discovered that Liliha Healthcare Center had operated without a Director of Nursing for several months while also failing to follow basic infection control protocols during wound care procedures.
Facility Operated Months Without Required Leadership
During a January 31, 2025 inspection, the facility's administrator confirmed that no Director of Nursing was present and stated the facility was actively searching for one. The previous DON had departed several months earlier, leaving other staff members to assume portions of the critical leadership role's responsibilities.
Quality Assurance Performance Improvement meeting minutes for the two months prior to the inspection showed no DON participation, confirming the extended absence of this federally required position. The Centers for Medicare & Medicaid Services mandates that skilled nursing facilities maintain a Director of Nursing to ensure proper clinical oversight and resident care coordination.
The facility's own assessment documents acknowledged the importance of having a DON, stating that nursing services include 24-hour nursing care provided by a team that specifically lists a Director of Nursing as a core component of their staffing structure.
Infection Control Failure During Wound Care
Inspectors observed a concerning breach of infection prevention protocols on January 29, 2025, during wound care for a resident with sacral wounds. The observation revealed staff performing wound assessment before addressing contamination, creating potential infection risks.
During the 10:13 AM observation, Resident 35 was found to have bowel movement on her buttocks that extended to the bottom edge of her sacral wound dressing. A Physician Assistant proceeded to remove the dressing and assess the wound area before the bowel movement was cleaned and before placing a clean brief under the resident.
This sequence violated basic infection control principles that require cleaning contamination before wound assessment. A Certified Nurse Aide cleaned the bowel movement only after the wound assessment was completed, reversing the proper order of care procedures.
Medical Implications of Protocol Violations
The absence of a Director of Nursing creates significant gaps in clinical oversight and quality assurance. Directors of Nursing serve as the primary clinical leader responsible for ensuring nursing staff follow evidence-based protocols, maintain professional standards, and provide safe resident care.
Without DON oversight, facilities face increased risks of protocol violations, medication errors, and gaps in care coordination. The position requires specialized knowledge of federal regulations, clinical best practices, and staff supervision techniques that cannot be easily distributed among other team members.
The infection control violation observed during wound care represents a fundamental breach of sterile technique principles. Assessing wounds in contaminated environments significantly increases infection risk, particularly for residents with compromised immune systems or existing wounds that provide entry points for bacteria.
Proper wound care protocol requires establishing a clean field before wound assessment. When fecal matter remains present during wound evaluation, bacteria can transfer from the contaminated area to the wound site, potentially leading to serious infections including cellulitis, sepsis, or delayed wound healing.
Staff Knowledge Contradicts Practice
Multiple staff members interviewed during the inspection demonstrated awareness of proper infection control protocols, making the observed violation particularly concerning. The facility's Infection Preventionist confirmed on January 29 that cleaning resident incontinence should occur before wound examination.
A Unit Manager reinforced this protocol on January 30, stating that incontinence cleaning must precede wound care to prevent infection. The involved Certified Nurse Aide also acknowledged on January 31 that residents require cleaning before wound dressing procedures to prevent infection.
This gap between staff knowledge and actual practice suggests implementation failures rather than training deficiencies, highlighting the importance of consistent clinical supervision and quality oversight.
Industry Standards and Requirements
Federal regulations require skilled nursing facilities to maintain infection prevention and control programs designed to provide a safe environment and prevent the development and transmission of communicable diseases. These programs must include policies addressing wound care in potentially contaminated situations.
Professional nursing standards universally require establishing clean working environments before wound assessment or treatment. The Centers for Disease Control and Prevention emphasizes that healthcare-associated infections remain a significant patient safety concern, with proper infection control measures serving as the primary prevention strategy.
Facilities must ensure all staff members consistently follow established protocols, regardless of their professional credentials or experience level. This incident involved a Physician Assistant, demonstrating that protocol adherence requirements extend to all healthcare providers within the facility.
Regulatory Response and Implications
The inspection classified the infection control violation as having minimal harm or potential for actual harm affecting few residents initially, but noted the potential impact on all residents requiring dressing changes. This classification reflects the inspector's assessment that while no immediate serious harm occurred, the practice created unnecessary infection risks.
The absence of a Director of Nursing represents a more systemic concern affecting the facility's ability to provide required oversight and ensure compliance with federal care standards. This violation impacts the facility's fundamental organizational structure and clinical leadership capacity.
Federal regulations provide facilities with opportunities to correct identified deficiencies through formal plans of correction, but sustained compliance requires addressing underlying system issues rather than isolated incidents.
The inspection findings highlight the interconnected nature of regulatory violations, where leadership gaps can contribute to frontline care failures, ultimately affecting resident safety and care quality outcomes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Liliha Healthcare Center from 2025-01-31 including all violations, facility responses, and corrective action plans.
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