KAPOLEI, HI - Federal inspectors documented several significant violations at Ka Punawai Ola nursing home during an April 2025 inspection, including improper pressure ulcer prevention protocols, incorrect pain medication dosing, and unsecured medication storage that could lead to drug diversion.
Pressure Ulcer Prevention Failures Put Residents at Risk
The most serious violation involved the facility's failure to properly prevent and treat pressure ulcers, also known as bedsores. Inspectors found that staff at Ka Punawai Ola were not following established protocols for repositioning residents who are at high risk for developing these painful and potentially dangerous wounds.
The inspection revealed that while staff documented repositioning a resident every two hours over multiple days, a nursing aide admitted that the resident "always refuses to be moved or repositioned." Despite this repeated refusal of care, staff failed to report the situation to nursing supervisors for 12 days, only alerting them after discovering an open wound on the resident's tailbone area on March 31.
This breakdown in communication represents a critical failure in basic nursing home care protocols. Pressure ulcers develop when sustained pressure on the skin reduces blood flow to tissue, causing cell death and open wounds. These injuries are particularly dangerous for elderly residents with limited mobility, as they can become infected and lead to serious complications including sepsis.
Medical protocols require that when residents refuse repositioning - a common occurrence due to pain, confusion, or other factors - staff must immediately notify nursing supervisors to develop alternative prevention strategies. These may include specialized pressure-relieving mattresses, more frequent skin assessments, or working with the resident to find comfortable positioning alternatives.
The facility's Director of Nursing confirmed during the inspection that staff should report resident refusals to be repositioned, highlighting that this was a known requirement that was not being followed. This type of communication failure can have serious consequences, as pressure ulcers that develop in nursing homes often indicate inadequate care and can result in prolonged healing times, increased medical costs, and unnecessary pain for residents.
Medication Errors Compromise Pain Management
A separate medication violation involved incorrect pain medication dosing that could have resulted in either inadequate pain relief or potentially dangerous over-medication. Inspectors observed a registered nurse administering the wrong strength of pain medication to a resident reporting moderate pain levels.
The incident occurred when a resident reported a pain level of "six out of 10" but received a stronger dose of hydrocodone-acetaminophen (10-325 mg) that was intended for severe pain rated seven to 10. The resident should have received the lower-strength medication (5-325 mg) designated for moderate pain levels.
Pain management in nursing homes requires precise assessment and medication administration because elderly residents often have multiple medical conditions and take several medications simultaneously. Giving too strong a dose can lead to excessive sedation, falls, respiratory depression, or dangerous drug interactions. Conversely, under-treatment of pain can significantly impact quality of life and healing.
The nurse involved acknowledged the error when questioned by inspectors, stating that the resident "should have been given Hydrocodone-Acetaminophen 5-325 mg since her pain level was only at six and considered moderate." This admission suggests the error was due to a misunderstanding of the facility's pain management protocols rather than a deliberate action.
Proper pain management protocols require nurses to carefully assess pain levels, match the assessment to the appropriate medication order, and document their decision-making process. This systematic approach helps ensure residents receive adequate pain relief while minimizing the risk of over-medication.
Unsecured Medications Create Security Risk
Inspectors also documented a significant medication security violation when they observed a medication cart left unlocked and unattended in a hallway with multiple staff members present. This situation creates serious risks for medication theft, tampering, or accidental access by unauthorized individuals.
The incident occurred during morning medication administration when a registered nurse was using one cart while preparing medications from a second cart operated by another nurse. After the nurse left to administer medications to a resident, the cart remained unlocked with three other staff members walking around the hallway.
Federal regulations require that all medication storage areas, including mobile carts, remain locked when not actively attended by authorized personnel. This requirement exists because nursing home medications often include controlled substances such as opioids, which have high potential for abuse and street value.
When confronted about the violation, the nurse stated she "did not notice it since she did not open the cart, only used it to prepare the medications and document on the computer." However, the facility's own policy clearly states that "medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access."
Medication security breaches can lead to drug diversion, where staff or visitors steal medications for personal use or sale. This not only deprives residents of needed medications but can also result in criminal charges and loss of professional licenses for involved staff.
Additional Issues Identified
Beyond these major violations, inspectors documented other concerning practices that impact resident care quality:
Food Allergy Management Failures: A resident with a documented egg allergy was served scrambled eggs on two separate occasions despite having this allergy clearly noted in their medical record. The facility's Food Service Director acknowledged the error, stating "it should not have been given to resident." Food allergies in elderly residents can trigger serious reactions and must be strictly managed.
Broken Equipment: A wall clock in a resident's room remained non-functional for multiple days despite the resident informing staff about the problem. While seemingly minor, working clocks help residents maintain orientation to time, which is particularly important for those with cognitive impairments or stroke-related conditions.
These violations collectively demonstrate gaps in the facility's quality assurance systems and staff training programs. Each issue represents a failure to follow established protocols designed to protect resident safety and well-being.
The inspection findings underscore the importance of robust oversight systems in nursing homes, where vulnerable residents depend on staff to provide safe, appropriate care. Effective nursing home operations require consistent adherence to medical protocols, proper staff training, and systems to identify and correct problems before they impact resident safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ka Punawai Ola from 2025-04-03 including all violations, facility responses, and corrective action plans.
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