Resident 56 arrived at Nuuanu Hale with paralysis on his right side from a stroke, muscle weakness, and existing contractures in his right arm and leg. His care plan specifically called for monitoring during range of motion exercises and stated that occupational and physical therapy would evaluate and treat as needed.
But federal inspectors found no evidence anyone followed through.
During five separate observations between February 3rd and 5th, inspectors consistently found the same troubling scene. The resident's arms were bent to his chest with closed fists holding rolled hand towels in both hands. His right leg was bent with the knee drawn toward his stomach while his left leg lay straight.
The facility's electronic health records contained no documentation that range of motion exercises were ever performed. There was no monitoring for pain, intolerance, or muscle spasms during such exercises, despite the care plan requiring exactly that surveillance.
When inspectors asked about the hand towels clenched in the resident's fists, they discovered another gap. No documentation existed showing therapy had recommended the towels, that a physician had ordered them, or that they were included in the care plan.
The Director of Nursing admitted the facility lacks a rehabilitation nursing aide program. Certified nurse aides are encouraged to perform passive range of motion exercises for residents, she said, but there's no system for documenting when it happens.
"There is no place for the CNAs to document and do not have a way to keep track of residents receiving PROM services," the nursing director told inspectors.
She couldn't explain the hand towels either, stating she hadn't seen that treatment documented anywhere in the resident's records.
The failures extended beyond this single case. Inspectors found the facility failed to properly maintain care plans for four of 18 residents they reviewed.
Another resident's family noticed their loved one had lost the ability to feed himself, requiring assistance with meals after a December hospitalization. The facility's assessment coordinator documented this "significant change" in the resident's condition, noting he had declined from needing only setup help to being completely dependent for feeding.
But when inspectors reviewed his care plan with the unit manager, they found no interventions addressing this decline or need for meal assistance. The unit manager confirmed the care plan should have been updated to reflect the significant change.
A third resident with quadriplegia and contractures in both legs presented another missed opportunity. Physical therapy had finished treating him and provided specific recommendations: facility staff should perform passive range of motion exercises in bed two to three times per week.
The physical therapy assistant confirmed these directions were shared with nursing staff. But the resident's care plan never incorporated the therapy department's recommendations.
"This should have been included on resident's care plan," the Director of Nursing acknowledged when confronted with the omission.
A fourth case involved a resident requiring continuous oxygen. She had physician orders for oxygen at two liters per minute via face mask to keep her blood oxygen saturation above 90 percent. But during eight separate observations over four days, inspectors found her oxygen mask positioned on the side of her face rather than covering her mouth and nose.
The resident told inspectors she puts the mask on herself when needed and takes it off when she doesn't need it. During one observation, the oxygen concentrator was running but the tubing connecting her face mask wasn't even connected to the machine.
Staff described the situation as the resident's preference - she wanted the oxygen running continuously for comfort rather than medical necessity. But her care plan failed to reflect this arrangement or document that she had been assessed and educated to independently manage her oxygen mask.
The facility's own oxygen administration policy requires that "the resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders."
These systematic failures in care planning left vulnerable residents without proper documentation of their needs and interventions. The stroke patient with contractures represents the most concerning case - his condition specifically required range of motion exercises to prevent further deterioration, yet staff couldn't demonstrate they were providing this basic care.
Without proper documentation, there's no way to verify residents received the treatments their conditions demanded or to track whether their care was preventing further decline.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nuuanu Hale from 2025-02-06 including all violations, facility responses, and corrective action plans.