KAPOLEI, HI - A Hawaii nursing home has been cited for failing to prevent pressure ulcer development in a resident who was identified as high-risk upon admission. Ka Punawai Ola faced federal scrutiny after inspectors found staff failed to follow basic skin care protocols for a rehabilitation patient.
Inadequate Repositioning Led to Skin Breakdown
The incident involved a female resident who entered the facility for short-term rehabilitation services with diagnoses including muscle weakness and malnutrition. According to the inspection report, the resident had no skin problems upon admission but developed a pressure ulcer on her tailbone area within 12 days.
The resident's family member, who visited daily for up to six hours, reported observing that staff did not reposition the resident every two hours as required by medical standards. The family member noted the resident frequently refused to be moved, which presented care challenges for the nursing staff.
Medical records showed the facility had properly identified the resident as at-risk for pressure ulcers. Her admission assessment documented brown discoloration on the tailbone area, and a Braden Scale assessment conducted on March 26th yielded a score of 12, categorizing her as high risk for pressure ulcer development with "very limited" mobility.
Staff Failed to Follow Protocol for Resistant Residents
When federal inspectors interviewed nursing staff, significant gaps in care protocols emerged. A Certified Nurse Aide acknowledged that while staff were supposed to reposition the resident every two hours, "she always refuses to be moved or repositioned."
The aide confirmed that when residents refuse repositioning, staff should report the refusal to a licensed nurse. However, the aide admitted that the resident's consistent refusals were not reported to nursing supervision until an open skin area was discovered on March 31st - 12 days after admission.
The Director of Nursing confirmed during interviews that there was no documentation showing the resident had been repositioned every two hours, nor any records of the resident's refusals to be repositioned. She acknowledged that nursing aides should have repositioned the resident every two hours but failed to do so.
Physical Therapy Notes Document Ongoing Resistance
Physical therapy treatment records from March 25th through April 1st painted a picture of a resident with significant resistance to care. Documentation showed the resident was "resistive to sitting edge of bed" and "combative" when staff attempted to help her stand.
The therapy notes described the resident as exhibiting "heightened anxiety with activity" on multiple occasions. However, by April 1st, therapists noted some improvement, reporting she "was agreeable for therapist to assist with mobility but then would resist movement or want to return to bed."
Medical Significance of Pressure Ulcer Prevention
Pressure ulcers represent a serious medical concern, particularly for residents with limited mobility and nutritional deficiencies. When individuals remain in one position for extended periods, continuous pressure on bony prominences like the tailbone restricts blood flow to the skin and underlying tissues.
For residents identified as high-risk using the Braden Scale, repositioning every two hours is considered the gold standard for prevention. This protocol allows blood circulation to return to compressed areas, preventing tissue death that leads to open wounds.
Residents with muscle weakness and malnutrition face elevated risks because they lack the strength to reposition themselves and may have compromised tissue integrity. The combination of these factors with prolonged immobility creates conditions where pressure ulcers can develop within hours.
Facility Policy Required Different Response
The facility's own policies outlined specific requirements for pressure ulcer prevention that were not followed in this case. According to the nursing home's written procedures, skin assessments should be performed weekly by licensed nurses, with any changes or open areas reported immediately to nursing staff.
The policy also specified that residents should be repositioned "at least every 2-4 hours," a standard that clearly was not met for this resident. When residents refuse care, proper protocol requires documentation of the refusal and alternative interventions to protect skin integrity.
Regulatory Framework for Skin Care
Federal nursing home regulations require facilities to ensure residents receive care and services to prevent pressure ulcers unless clinically unavoidable. This means that even when residents resist repositioning, facilities must implement alternative strategies and document their efforts.
Acceptable approaches for resistant residents include family involvement in care planning, pain management before repositioning, use of pressure-relieving devices, and frequent monitoring by licensed nurses. The facility's failure to report refusals prevented supervisory staff from implementing these alternative interventions.
Impact on Quality Measures
Pressure ulcer development in nursing homes is tracked as a quality indicator by federal regulators. Facilities are expected to maintain low rates of new pressure ulcers, particularly for residents who enter without existing skin problems.
This citation represents a failure in one of the most fundamental aspects of nursing home care. Pressure ulcer prevention requires coordination between nursing aides, licensed nurses, and rehabilitation staff to ensure vulnerable residents receive appropriate care regardless of their cooperation level.
The inspection findings highlight the critical importance of communication and documentation in nursing home care, where failure to report resident refusals can result in serious medical complications that could have been prevented with proper oversight and intervention.
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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