Nuuanu Hale: Stage 4 Pressure Injury Neglect - HI
The patient, identified as R54, told inspectors during a February 3 interview that she was frustrated because she tries to turn and position herself by gripping the bed rails and lifting up to relieve pressure, but cannot hold the position long because it becomes too painful. She said staff only repositioned her when she specifically asked, and if she didn't ask, they provided no help.
Inspectors watched R54 attempt to reposition herself by using her arm strength and holding onto the bed rail, lifting herself up for less than thirty seconds before collapsing back to a flat position on her back. No pillows or wedges were available to help her reposition.
R54 was admitted to the facility with multiple serious conditions including the stage 4 pressure ulcer on her tailbone, diabetes complications, and infection of amputation stumps on both lower legs. She had her right leg amputated above the knee. A December assessment showed she was cognitively intact but needed substantial help with basic movements like rolling left and right in bed.
During a second observation the next day, R54 was again lying flat on her back and said her arm was sore from trying to turn herself. When inspectors asked if the facility offered a wedge to help her reposition without having to grip the bed rails, she said she had been given a hard foam wedge but it was too uncomfortable, so she removed it.
R54 told inspectors she had requested pillows instead to help with repositioning. Staff told her they would look for pillows but never returned with any.
The wound team had recently informed R54 that her pressure injury was getting bigger, adding to her frustration with the inadequate positioning assistance.
When inspectors interviewed the unit manager and infection preventionist on February 6, they confirmed that residents with pressure injuries who cannot turn themselves should be repositioned every two hours and may use wedges or other devices to assist. The infection preventionist acknowledged that R54 used her arm to turn herself and had been offered a wedge and pressure mattress, but refused the wedge because it was too hard.
Staff had suggested covering the wedge with a blanket to make it more comfortable, but this solution was not implemented effectively.
The unit manager stated that when residents refuse treatment, nursing staff should educate them and try different approaches, offering alternative interventions while explaining the risks and benefits. All refusals should be documented in progress notes.
However, the unit manager confirmed that R54's refusals were never documented. More significantly, inspectors found that R54's care plan had not been updated to reflect her pressure injury status and did not include person-centered interventions to help with turning and positioning every two hours or specify the use of pillows, wedges, or other positioning devices.
The facility's own policy on pressure injury prevention, reviewed in June 2023, requires that "the goals and preferences of the resident will be included in the plan of care" and that "interventions will be documented in the care plan and communicated to all relevant staff." The policy also states that interventions should be modified when needed, including considerations for "resident non-compliance."
The comprehensive care plan policy requires describing services needed to maintain residents' highest physical, mental, and psychosocial well-being, including any services not provided due to residents exercising their right to refuse treatment. It mandates that care plans be reviewed and revised after each assessment and that alternative interventions be documented when needed.
The policy specifically requires staff to inform residents of "risks and benefits of proposed care, of treatment, and treatment alternatives" and to "attempt alternate methods for refusal of treatment and services" while documenting such attempts in the clinical record.
None of these required steps were followed for R54. Despite her clear need for positioning assistance and her specific request for pillows instead of the uncomfortable foam wedge, staff failed to update her care plan, document her preferences, or implement alternative positioning solutions.
The inspection found that this failure to provide necessary treatment consistent with professional standards put R54 at risk of her stage 4 pressure injury worsening. Stage 4 pressure injuries are the most severe type, extending through skin and tissue to underlying muscle and bone.
R54's case represents a breakdown in multiple systems meant to protect vulnerable residents. She was cognitively intact and able to communicate her needs clearly, yet staff failed to respond appropriately to her requests for positioning assistance or provide suitable alternatives to equipment she found uncomfortable.
Federal inspectors cited the facility for failing to provide necessary treatment to promote healing of the stage 4 pressure injury and for not ensuring residents maintain their ability to perform activities of daily living. The inspection also found communication failures affecting other residents whose primary language was not English.
The violations occurred during a February 6, 2025 health inspection that found deficiencies affecting some residents. R54 continues to struggle with positioning herself using bed rails while her pressure injury reportedly grows larger.
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.
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
NUUANU HALE in HONOLULU, HI was cited for neglect violations during a health inspection on February 6, 2025.
She said staff only repositioned her when she specifically asked, and if she didn't ask, they provided no help.
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.