KANEOHE, HI - Federal inspectors cited Ann Pearl Nursing Facility for nine significant violations during a February inspection, including failures in medication administration, infection control, and trauma-informed care that put residents at risk of harm.
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Medication Errors Create Risk for Multiple Residents
The most serious violation involved a 16% medication error rate, more than three times the federal maximum of 5%. Inspectors observed five medication errors during 31 administration opportunities, affecting at least three residents.
During observations on February 27, nursing staff failed to administer blood pressure medication to one resident for six consecutive days, documenting it as "unavailable" when the medication was actually accessible in the facility's electronic storage system. The same nurse was observed opening a delayed-release capsule and mixing it with applesauce, despite facility policies prohibiting this practice with extended-release medications.
Medical Context: Medication errors in nursing homes can have severe consequences. Blood pressure medications must be given consistently to prevent cardiovascular events. Opening delayed-release capsules destroys their time-release mechanism, potentially causing dangerous drug level fluctuations. The observed error rate indicates systemic medication management failures that could affect all 125 residents at the facility.
In another incident, a nurse left partially consumed medication at a resident's bedside despite policies requiring direct observation of complete ingestion. Federal regulations mandate that nursing homes maintain medication error rates below 5% to ensure resident safety and therapeutic effectiveness.
Infection Control Failures During Wound Care
Inspectors documented serious infection control violations during wound care for a resident with methicillin-resistant Staphylococcus aureus (MRSA), a dangerous antibiotic-resistant bacteria. During a wound dressing change on February 25, staff failed to perform hand hygiene between removing contaminated gloves and putting on new ones.
The resident, who was on contact precautions due to MRSA infection in leg wounds, required specialized wound care protocols. However, staff removed gloves, requested additional supplies, and put on new gloves without sanitizing hands - a critical breach of infection control standards.
Medical Analysis: MRSA is a serious healthcare-associated infection that can spread through improper hand hygiene and contact with contaminated surfaces. The bacteria can cause life-threatening infections including pneumonia, bloodstream infections, and surgical site infections. Proper hand hygiene between glove changes is essential to prevent transmission to other residents, particularly those with compromised immune systems or open wounds.
The facility's breach occurred during a high-risk procedure involving wound care, creating potential for MRSA transmission throughout the facility. Contact precautions require strict adherence to hand hygiene protocols specifically because of the serious nature of resistant infections.
Trauma-Informed Care Deficiencies
The facility failed to provide adequate trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). Despite admission documentation noting PTSD with avoidant behavior, staff never developed a trauma-informed care plan to address the resident's specific triggers and needs.
The resident reported inability to sleep due to disruptive noises from other residents and staff talking loudly in hallways. According to facility policy, residents should be screened for trauma upon admission and quarterly thereafter, with care plans developed to address identified triggers.
Clinical Importance: PTSD in nursing home residents requires specialized care approaches that minimize re-traumatization. Untreated trauma responses can worsen mental health conditions, increase agitation, and interfere with medical treatment compliance. Environmental triggers like loud noises and disruptions can cause significant distress for trauma survivors.
Industry standards require facilities to implement trauma-informed care that recognizes trauma's impact on residents' behavior and health. Without proper assessment and intervention, residents with PTSD may experience increased anxiety, depression, and behavioral symptoms that complicate their overall care.
Safety Hazards Throughout Facility
Multiple safety violations created accident risks for residents. Inspectors found wet floors in hallways and resident rooms that remained unaddressed for over 20 minutes, with no warning signs posted. Multiple staff members walked through the wet areas without taking corrective action.
A blind resident with cognitive impairment was repeatedly observed with cigarettes and a lighter in his possession, despite facility policies requiring these items to be secured by nursing staff. The resident was seen smoking unsupervised and keeping smoking materials in common areas, creating fire hazards in a facility where other residents use oxygen therapy.
Respiratory Care and Safety Equipment Issues
The facility failed to follow physician-ordered oxygen therapy protocols when staff changed a resident's oxygen delivery method without medical authorization. Staff replaced an ordered face mask with a nasal cannula during meal assistance, potentially reducing oxygen delivery effectiveness.
Additional safety violations included inadequate seizure precautions for a resident with epilepsy. Despite facility policies requiring padding on all bed rails for seizure protection, only one side rail had protective padding installed when the resident experienced a seizure.
Additional Issues Identified
Other violations included failure to update care plans after a resident with dementia walked out of the facility, and inadequate follow-up on pharmacist recommendations for psychotropic medication management. The facility also failed to provide ordered range-of-motion therapy and splint applications for a stroke survivor, with documentation showing treatment provided only two out of seven days during assessment periods.
Physical therapy equipment including elbow and wrist splints were found unused at the resident's bedside despite daily orders for application. Staff inconsistently documented provision of passive range-of-motion exercises, which are critical for preventing further functional decline in stroke survivors.
The inspection revealed systemic issues across multiple care areas that could affect resident health, safety, and quality of life. These violations demonstrate the need for comprehensive staff retraining and improved oversight of clinical care practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ann Pearl Nursing Facility from 2025-02-28 including all violations, facility responses, and corrective action plans.
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