HONOLULU, HI - Federal inspectors documented significant care planning failures at Avalon Care Center after the facility delayed treatment for a resident's worsening fungal infection for five days, allowing the wound to expand dramatically.
Treatment Gaps Left Resident Without Proper Care
The inspection revealed that despite identifying a worsening moisture-associated skin damage (MASD) with fungal infection on a resident's sacrum and bilateral buttocks, facility staff failed to update the care plan or obtain physician orders for antifungal treatment from March 29 through April 3, 2025.
During this five-day period, the resident's condition deteriorated significantly. Wound measurements showed the affected area increased by 473 percent, expanding from 21.3 square centimeters to 122.22 square centimeters. The length of the wound grew by 158 percent, while the width increased by 394 percent.
The resident told inspectors during a bedside interview that she had skin breakdown and rash on her back, which she attributed to a reaction from adult briefs. She explained that facility staff had switched her to pull-up style briefs and "her rash was getting better."
Documentation Reveals Progressive Deterioration
Medical records showed a clear timeline of the resident's declining skin condition. The initial wound evaluation on March 14 documented dimensions of 21.3 square centimeters in area, with length of 9.57 centimeters and width of 4.69 centimeters.
A second evaluation on March 26 showed the condition had worsened, though specific measurements were not recorded. The wound care registered nurse documented that the resident reported itchiness from the briefs and noted relief after switching to pull-up style briefs on March 25. The nurse also documented notifying the practitioner and the resident's responsible party.
The third evaluation on April 1 revealed the dramatic expansion in wound size, with positive percentage increases indicating significant deterioration. Despite this clear evidence of worsening condition, no new treatment orders were implemented.
Missing Physician Orders Created Treatment Gap
The facility had an active order for treating the resident's MASD with Triad Paste, normal saline solution cleansing, and application every shift for 14 days beginning March 14. However, this treatment was discontinued on March 28, leaving no physician orders in place to address the ongoing condition from March 29 through April 3.
Moisture-associated skin damage occurs when prolonged exposure to moisture from incontinence causes skin breakdown. Without proper treatment, MASD can progress to secondary fungal infections, which require specific antifungal medications to resolve. The combination of moisture and fungal organisms creates an environment where skin breakdown can rapidly worsen.
Care Plan Failed to Address Identified Needs
The resident's care plan, initiated on March 18, included the goal that "the resident's MASD will heal by review date" with a target date of June 14, 2025. However, the plan's interventions were limited to avoiding scratching, keeping body parts from excessive moisture, and increasing out-of-bed activity as tolerated.
Despite clear documentation of fungal infection by the wound care nurse on March 26, the care plan was not updated to include antifungal treatment protocols. This represents a fundamental failure in the care planning process, which should be revised whenever a resident's condition changes.
Delayed Response After Inspector Interview
The treatment gap only ended after federal inspectors interviewed the Director of Nursing (DON) about the resident's worsening MASD on April 3. The DON initially stated the resident had "Baza ordered" for daily application, but subsequent record review revealed this antifungal cream order was not placed until 11:07 AM on April 3 - just hours after the inspector's interview.
The care plan was also updated on April 3 to reflect "MASD to sacrum with fungal rash related to incontinence" with interventions to "apply treatment as ordered by MD." This update occurred only after the inspection team highlighted the gaps in care.
Clinical Standards for MASD Management
Proper management of moisture-associated skin damage requires prompt identification, moisture control, and appropriate topical treatments. When fungal infection is suspected or confirmed, antifungal medications should be initiated promptly to prevent progression and promote healing.
Standard protocols call for regular assessment of wound dimensions and characteristics, with care plan updates when conditions change. Delays in treatment can lead to increased pain, prolonged healing times, and risk of secondary complications including bacterial superinfection.
Additional Range of Motion Violations
The inspection also identified failures in maintaining resident range of motion for another resident, who did not receive appropriate treatment, equipment, and services to prevent decline. Inspectors documented inconsistent application of splints and range of motion exercises, putting the resident at risk for further contractures.
Range of motion exercises and proper positioning are essential components of nursing home care, particularly for residents with limited mobility. Failure to maintain these interventions can result in permanent loss of function and increased care needs.
Federal Oversight and Standards
The violations were classified as causing "minimal harm or potential for actual harm" affecting few residents. However, the failures in care planning and treatment delays represent systemic issues in clinical oversight and staff communication that could affect other residents.
Federal nursing home regulations require facilities to develop comprehensive care plans that address each resident's needs and are updated when conditions change. The regulations also mandate that residents receive necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
The inspection findings highlight the critical importance of timely clinical decision-making and proper care coordination in nursing home settings. When staff identify changes in a resident's condition, protocols must ensure rapid implementation of appropriate treatments to prevent deterioration and promote healing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Care Center - Honolulu, LLC from 2025-04-03 including all violations, facility responses, and corrective action plans.
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