HONOLULU, HI - A March 2025 state inspection of Oahu Care Facility revealed significant care deficiencies, including a resident elopement that resulted in actual harm and systematic failures in pressure ulcer prevention and documentation across multiple residents.
Resident Elopement Results in Injuries
The most serious violation documented during the inspection involved a resident with dementia who left the facility undetected on February 9, 2025, and was later found blocks away on a high-traffic avenue with multiple injuries.
The resident, identified as R3, had been admitted to the facility in January 2025 following hospitalization for a fall that caused acute traumatic injury to her cervical spine. Her medical history included Stage 5 Chronic Kidney Disease and dementia. Staff had previously documented "nondirectable exit seeking behavior" and fitted her with a WanderGuard bracelet—an electronic monitoring device designed to alert staff when at-risk residents approach exits.
According to the inspection report, on the afternoon of February 9, nursing staff observed the resident's WanderGuard bracelet triggering an alarm near the elevator, and staff escorted her away from the area. A nurse administered medications at 3:26 PM, and a certified nurse assistant then escorted her to the dining room for activities. However, activity staff "did not observe R3 walking out of the dining room."
When a nurse went to administer scheduled medication at 4:00 PM, the resident could not be located. Staff initiated missing resident procedures approximately 10 minutes later and contacted emergency services.
A good Samaritan found the resident on a nearby avenue and transported her to the emergency room. Hospital records documented the resident had sustained multiple large skin tears to her right elbow and bilateral knees. Medical staff noted the patient was "disoriented to place and time" and did not recall what happened. After wound irrigation and dressing, she was discharged back to the facility.
Upon the resident's return, facility administrators tested the WanderGuard bracelet and discovered it was faulty—the device did not trigger the elevator door alarm until the administrator was standing directly in front of the elevator and had already called for it. A technician dispatched to the facility on February 12 confirmed the equipment malfunction.
Elopement incidents pose significant risks to residents with cognitive impairment. Disorientation can lead to falls, exposure to traffic, inability to seek help, and delayed medical treatment. For a resident already recovering from spinal injury, the additional trauma from this incident represented a serious setback.
Systematic Pressure Ulcer Care Failures
The inspection also identified a pattern of inadequate pressure ulcer prevention across multiple residents, with documentation gaps suggesting that required repositioning was not being performed.
Pressure ulcers, also known as bedsores, develop when sustained pressure reduces blood flow to soft tissue, causing cell death. Repositioning every two hours is a fundamental nursing intervention that redistributes pressure and allows blood flow to return to compressed tissue. Without regular repositioning, existing wounds can worsen and new wounds can develop.
Three residents were cited in this deficiency:
Resident R1 was admitted with an unstageable wound ulcer on his coccyx—meaning the wound was covered with dead tissue that prevented accurate depth assessment. Wound care notes from May 2024 described the wound as "necrotic and malodorous with large, purulent drainage," indicating active infection. Despite the severity of this wound, there was no documentation that the required two-hour repositioning was being completed.
Resident R2 had multiple pressure ulcers on admission, including Stage 2 and Stage 3 wounds on the buttocks, coccyx, and left ankle. The care plan specified repositioning at least every two hours, but again, documentation showed this was not being tracked.
Resident R4, admitted in March 2025 for rehabilitation after falls, had a sacral Stage 2 pressure ulcer on admission that was not identified on her baseline care plan. Records showed no documentation of turning or repositioning until the treatment administration record was initiated on March 25—six days after admission.
When interviewed, staff demonstrated knowledge of proper repositioning protocols. One certified nurse assistant stated: "We change their position every two hours and document that in the I-pad, under Activities of Daily Living, repositioning and sign our name." However, when asked to show documentation for specific dates, the staff member confirmed that no repositioning was recorded for R2 on March 24 or March 11.
The Director of Nursing acknowledged the failures, confirming "there were no tasks triggered for the repositioning for both R1 and R2 upon admission" and stated the facility would improve processes going forward.
Facility Policies Not Followed
The facility's own repositioning policy, revised in May 2013, clearly states that "repositioning is critical for a resident who is immobile or dependent upon staff for repositioning" and that "positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised."
The policy also requires documentation of the position used, the name of the caregiver providing the intervention, and proper signatures. Inspectors determined these policy requirements were not being followed.
For residents with existing wounds, failure to reposition can lead to wound deterioration, deeper tissue damage, increased infection risk, prolonged healing times, and significant pain. Advanced pressure ulcers can require surgical intervention and substantially extend hospital stays.
Corrective Actions Taken
Following the elopement incident, the facility implemented several corrective measures. Staff began conducting 15-minute checks on all residents with WanderGuard bracelets until the monitoring system was confirmed functional. Education sessions on wandering and elopement policies were completed on February 10, 2025.
At the time of the March survey, inspectors tested the WanderGuard system and found all equipment and resident bracelets functioning properly. Documentation of bracelet monitoring—including placement, device quality, and skin integrity checks—showed compliance for all current residents.
The inspection classified the elopement as past non-compliance with actual harm, indicating the facility has since corrected the issue. The pressure ulcer documentation deficiency was cited at the level of minimal harm with potential for actual harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oahu Care Facility from 2025-03-25 including all violations, facility responses, and corrective action plans.
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