Nuuanu Hale
NUUANU HALE in HONOLULU, HI — inspection on February 6, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The facility failed to identify pressure ulcers (PUs) to bilateral heels on R21's Minimum Data Set (MDS) Quarterly Assessment after R21 returned to the facility from being hospitalized .
The facility failed to develop and implement a care plan to provide treatment and monitoring of R21's PUs on his heels.
3) Cross-reference to
Review of R56's quarterly admission Minimum Data Set (MDS) with assessment reference date of 01/06/25 found in Section GG.
Functional Abilities and Goals, R56 is dependent in self-care and has impairment on one side for upper and lower extremity range of motion.
125024
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 125024 B.
Wing 02/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817
F-F676 Activities of Daily Living (ADLs)/Maintain Abilities.
Despite identifying upon admission that her primary language was not English, the facility failed to develop and implement a Communication/Language Barrier care plan for R24.
125024
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 125024 B.
Wing 02/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817
F-F684 Quality of Care for R32 despite identifying and documenting an ongoing pruritic skin condition since September 2024, the facility failed to develop and implement a care plan that effectively monitored and addressed R32's itching.
6) Cross-reference to
The facility failed to provide R54 necessary treatment, consistent with professional standards of practice to promote healing of a stage 4 pressure injury.
potential for actual harm R54 was admitted to the facility on [DATE]. R54's diagnoses include, not limited to, stage 4 pressure ulcer of sacral region, posterior reversible encephalopathy syndrome, local infection of the skin and subcutaneous
of right leg above knee, type 2 diabetes mellitus with hyperglycemia, non-pressure chronic ulcer of other part of right lower leg with necrosis of bone, pain, and infection of amputation stump of right and left lower extremity.
Review of R54's quarterly Minimum Data Set (MDS) with assessment reference date of 12/17/24 found R54's Brief Interview for Mental Status (BIMS) scored a 15 (cognitively intact). In Section GG.
Functional Abilities and Goals, under Mobility, R54 needs substantial/maximal assistance to roll left and right, is dependent sit to lying and lying to sitting on the side of bed.
On 02/03/25 at 08:59 AM, observation and interview with R54 was done. R54 reported she has a pressure injury on her coccyx and had it for a while.
The wound team reportedly informed her on their last visit that the wound was getting bigger. R54 expressed that she was frustrated because she tries to do the turning and positioning herself by using the bed rails to hold on to and offload but cannot do it for long because it is sore and becomes more painful. R54 stated she must ask staff to be repositioned but if she doesn't ask, they do not help or reposition her.
Observed resident attempt to reposition herself by using her arm strength and holding on to the bed rail lifting herself up, for less than thirty seconds, before going back to a flat on her back position. No pillows or wedges were observed to be used to help reposition her.
During a second observation and interview with R54, on 02/04/25 at 08:36 AM, R54 was observed lying flat on her back and stated her arm was sore when turning herself.
Inquired if the facility offered a wedge to help reposition so she does not have to hold on to the bed rail and lift herself up, R54 reported she has a wedge, but it is a hard foam and every time they put it behind her back it is uncomfortable, so she takes it off. R54 reportedly requested for pillows instead to reposition, and staff tell her they will look but never come back with pillows.
On 02/06/25 at 03:28 PM, concurrent record review and interview with UM1 and Infection Preventionist (IP) was done.
Concurrent review of R54's EHR documented R54 has a stage 4 pressure injury. UM1 stated residents with pressure injuries or are at risk and are not able to turn themselves should be turned every two hours and may use a wedge to assist residents in repositioning. IP reported R54 uses her arm to turn herself and has a wedge and pressure mattress but R54 refuses the wedge because it is too hard.
Staff had offered covering the wedge with a blanket. UM1 stated if a resident refuses treatment, nursing staff should educate and reapproach or offer different interventions as well as education of risk and benefits.
Refusals should be documented in the progress notes. UM1 confirmed refusals were not documented.
Review of R54's CP, UM1 confirmed the resident's CP was not updated to reflect R54's pressure injury status, did not include person-centered intervention, to aid with turning and positioning every two hours and to use pillows/wedges or other devices to assist with turning and positioning and should have been care planned.
125024
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 125024 B.
Wing 02/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817
The facility failed to ensure R56 with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion, and ensure treatment provided was evaluated by therapy, physician ordered, and/or care planned.
R56 was admitted to the facility on [DATE] with diagnoses, not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, vascular dementia, history of occlusion and stenosis of unspecified cerebral artery, muscle weakness, and contracture of muscle right upper arm and right lower leg.
Review of R56's quarterly admission Minimum Data Set (MDS) with assessment reference date of 01/06/25 found in Section GG.
Functional Abilities and Goals, R56 is dependent in self-care and has impairment on one side for upper and lower extremity range of motion.
Review of R56's CP reviewed/revised on 01/25/25 documented R56 .has impaired range of motion to right arm and right leg r/t [related to] previous stroke and contractures .will have no unaddressed complications related to limited range of motion through the review, .Monitor for presence of pain, intolerance, or muscle spasm during range of motion .OT/PT [Occupational Therapy/Physical Therapy] to eval [evaluation] and treat as indicated.
Encourage to follow guidelines set from therapy.
Multiple observations of R56 in bed were done on 02/03/25 at 08:41 AM and 11:35 AM, 02/04/25 at 08:05 AM, and 02/05/25 at 08:41 AM and 12:59 PM. R56's arms were observed to be bent to chest with closed fists holding rolled hand towels in both hands.
Right leg was bent, knee toward stomach and left leg was positioned straight.
Review of R56's Electronic Health Record (EHR) found no documentation that range of motion was done including monitoring for pain, intolerance, or muscle spam during range of motion as indicated in the CP.
Documentation for hand towels on both hands recommended and assessed by therapy, physician ordered, and in CP was not found.
On 02/05/25 at 02:11 PM, an interview with Director of Nursing (DON) was done. DON reported the facility does not have a Rehabilitation Nursing Aide (RNA) program so the Certified Nurse Aids (CNA) are encouraged to do passive range of motion (PROM) for residents. DON confirmed there was no documentation in R56's EHR because there is no place for the CNAs to document and do not have a way to keep track of residents receiving PROM services.
Inquired if R56 was assessed to use hand rolls, if it was physician ordered, and care planned, DON stated she did not see the treatment in R56's EHR.
125024
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 125024 B.
Wing 02/06/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Nuuanu Hale 2900 Pali Highway Honolulu, HI 96817