The Care Center Of Honolulu
THE CARE CENTER OF HONOLULU in HONOLULU, HI — inspection on August 15, 2024.
Found 24 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
Observation was made on 08/13/24 at 09:16 AM in R415's room.
While R415 was talking to State Agency (SA), Certified Nurse Aide (CNA) 62 was observed pulling one of the privacy curtains near the entrance of the room/R415's bed and pulling it towards the window to provide privacy to the resident near the window. In doing so, CNA62 exposed R415 to the hallway, since R415's bed was next to the door. R415 was exposed to staff, residents, and visitors walking in the hallway. R415 had her legs elevated and was wearing a gown and adult briefs.
Her legs were open, therefore exposing her adult briefs. R415 stated, you see what I mean, pointing at the door. R415 remained exposed for 20 minutes, until CNA62 was informed by SA.
Interview with CNA62 was conducted on 08/13/24 at 09:36 AM in R415's room. CNA62 agreed that she should have adjusted the curtains to provide privacy for R415.
Interview was conducted with the Director of Nursing (DON) on 08/13/24 at 03:30 PM in her office.
DON was informed of the observation made by SA. DON stated that normally the staff closes the door when providing personal care to a resident in the room. DON confirmed that CNA62 should have closed the door.
A review of the facility policy titled, Resident Rights, with a revised date of 02/2021 was conducted.
The policy documented, Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
125019 08/15/2024
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
Review of R138's care plan (last reviewed 05/01/24) did not contain documentation that the resident preferred to have his meal plate remain on the cafeteria like trays while eating in the 1st floor dining room. 2) On 08/12/24 at 12:19 PM, observed five residents in a common dining room area eating lunch with their meals on top of a meal tray that was not removed when the meal was served.
A second observation was done on 08/14/24 at 08:10 AM, observed three residents in a common dining room area eating breakfast with meals on top of a meal tray that was not removed when the meal was served.
On 08/15/24 at 11:27 AM, an interview with Registered Nurse (RN) 40 was done.
Inquired if RN40 eats on meal trays when at home, he stated he does not but uses a place mat.
Further inquired if he does not use meal trays when eating at home, would it be a homelike environment for residents in the dining room to eat with meal trays, RN40 stated, .it would seem it would not.
On 08/15/24 at 11:29 AM, an interview with Assistant Administrator (AADM) was done. AADM reported he does not eat his meals with meal trays at home.
Inquired if it would be homelike for residents to use meal trays when eating their meals in the dining room at the facility, AADM stated it depends on the resident and if they prefer to eat with meal trays.
Further inquired if this would be in resident care plans, AADM reported it should be in their care plan.
125019 08/15/2024
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
During the interview, DON stated an investigation was conducted into R31's allegations.
Requested to review the DON's full investigation complete with witness statements. DON initially stated the investigation was in the Human Resource office and did not provide any documentation on 08/14/24. On 08/15/24, the DON submitted typed, Timeline of Events 7/31/24 which documented Resident had a care concern for the attitude of a night shift CNA [Certified Nurse Aide (AP)] and gave him [R31] attitude about turning up the temperature .
Union Meeting held . on 08/02, and included an unidentified staff member (no ledger on form) reporting that CNA48, CNA2, and Registered Nurse (RN)11 did not report anything related to the incident on 07/31/24.
The investigation notes did not address AP confronting R31, and intimidating him after finding out the resident had filed a complaint.
125019 08/15/2024
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
Review of a progress note written by SSD on 08/14/24 at 03:14 PM revealed that Social Service Assistant (SSA)5 and SSD had met with R31 in the social service office, where R31 verbalized, I am not feeling safe unless you transfer me to another facility or let him (AP) go.
Resident agreed to be transferred to another floor in the facility.
125019 08/15/2024
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
Review of R31's Electronic Health Records (EHR) documented a Minimum Data Set (MDS) admission assessment with an Assessment Refence Date (ARD) of 07/18/24, Section C.
Cognitive Patterns the resident scored a 15 out of 15 on the Brief Interview for Mental Status, indicating the resident's cognition is intact, and that he is a reliable source of information.
Section GG- Functional Abilities and Goals documented the resident is dependent (helper does ALL the effort) on staff for oral hygiene, toileting, upper and lower body dressing, putting on footwear, and personal hygiene (combing hair, shaving, washing and drying face and hands).
During an interview on 08/12/24 at 10:06 AM, R31 reported he made a complaint to the facility regarding how AP treated him when he requested assistance with the temperature of the air conditioner.
After filing the initial complaint with the facility, R31 was assured that AP had been instructed not to have any form of contact with him.
Following this assurance, R31 reported AP verbally confronted and intimidated him while he was alone in his room, causing him to be fearful of staff, feel afraid and anxious, and he began having violent nightmares of physically defending himself from AP. R31 stated he informed AADM that AP came into his room and confronted him for making the initial complaint.
During an interview on 08/14/24 at 11:10 AM with the Administrator and AADM, the Administrator confirmed she was not informed that R31 reported to AADM that AP had confronted and intimidated him following the initial complaint. AADM confirmed although he was informed, he did not identify AP confronting R31 about the initial complaint as having the potential for abuse. As a result of not conducting an investigation and following up with R31, the facility was unaware of R31's nightmares and new feelings of anxiousness and feeling unsafe.
Review of SA's Aspen Complaints/Incidents Tracking System did not include a report from the facility of AP confronting R31 after the resident filed a complaint of AP's treatment of him.
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The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
Review of SA's Aspen Complaints/Incidents Tracking System did not include a report from the facility
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The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
The surveyor confirmed with MDSC1 that R56 was not coded with a stage 3 pressure ulcer on the 07/18/24 quarterly assessment and that R56 was diagnosed with a stage 3 pressure ulcer at the time of the look back period. MDSC2 joined the interview stating, we will correct the error on the MDS assessment.
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The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
days documented R218 was laying in bed.
125019 08/15/2024
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
Observation and interview with R126 in his room on 08/12/24 at 09:04 AM. R126 was in his bed on his back with the head of bed up 45 degrees. R126 said that he used to walk pretty well before but now I'm in bed all the time.
The surveyor asked R126 if he is able to get the help he needs from the staff? R126 said, I have a sore on my back that's infected and pretty deep. I'm supposed to be turned every two hours but there isn't always enough staff available. It takes two Certified Nurse Aides (CNA)'s to do it, and one CNA can't do it by themself. I take antibiotics because I have an infected sore. I wish I could turn or get a pillow.
When they came in to change the bed, they moved the extra pillows and I didn't get them back, they must be in short supply.
Record Review (RR) of the Minimum Data Set (MDS) annual review 07/09/24. R126 is cognitively intact.
Dependent on staff for toileting, bathing and dressing and requires partial to moderate assistance to roll left and right and dependent on staff for bed to chair transfer. R126 has a stage four pressure ulcer present on admission.
RR of Care plan 07/15/23 cross reference to F-F656.
RR of Infection note 8/10/24.
Wound noted to have deteriorated on 8/2 where last week resident was in his wheelchair exceeding four hours.
Noted with green drainage and foul odor .
Observation and interview with the wound Nurse Practitioner (NP) from the wound clinic on 08/14/24 at 08:45 AM.
The surveyor asked the NP how R126's the pressure ulcer is healing. He stated R126 has medically complex issues, and he is declining, his Chronic Obstructive Pulmonary disease (COPD) (a lung disease) has gotten a lot worse, and he's not able to do too much outside of his bed.
When he came in a year ago, he was able to actually get up and walk a bit.
His wounds were all completely closed then, 126 had a pretty bad skin tear that reopened the wound. He went to acute care for a cardiac procedure and was laying on a hard table for a long period of time, when he came back the wound had opened and progressed to a stage four wound on his sacrum. It's getting a little better, today were going to take a sample for a culture after we clean the wound.
The surveyor asked the NP if the resident is able to reposition himself off of the wound.
The NP stated, no, he needs help to turn and reposition.
The wound was observed to be deep with yellow slough.
After the NP removed the dressings and cleaned away the dead tissue. He said to R126 it's really important to keep the pressure off of the wound.
The surveyor asked the NP for clarification, turning the resident every two hours is really important, he said yes, it's very important to keep the pressure off of the wound.
125019 08/15/2024
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
Observation of R218 in her room on 08/12/24 at 10:15 AM. R218's laying on her back with her bed flat, her right leg started shaking.
Facial grimacing noted and an adhesive patch on her left knee.
Observation of R218 on 08/12/24 at 2:33 PM.
The resident was observed on her back in bed, with a contracture of her left arm, non-verbal, moaning and grimacing, and when asked if she was having pain, she moaned with her eyes wide open.
Trapeze in place over the bed, when asked if she can use this, she moaned and shook her head no.
The surveyor asked Registered Nurse (RN) 7 if R218 can use the trapeze bar, RN7 said we encourage her to reposition herself. (RR) of the Minimum Data Set (MDS) quarterly review 05/23/24: Resident is moderately cognitively impaired, has an impairment on one side of her upper body (left side).
Resident has an impairment on her lower part of her body on both sides.
Dependent in toileting, showering and mobility.
Care plan (CP) 02/19/24 reviewed.
Cross reference to F-F656.
RR of physician orders: Up to wheelchair daily at 10:30 am and have patient up in wheelchair until lunch time use HOYER (a mechanical lift to assist with transfer) one time a day 4/4/2024.
RR of plan of care (POC) dated 08/02/24 to 08/14/24.
Turn and reposition (right side, left side, back, chair. R218 was documented up in the chair on 08/03/24 at 2:13 PM and 08/10/24 at 12:19 PM.
The rest of the days document R218 was laying in bed.
Interview with Restorative Nurse Aide (RNA) 4 on 08/15/24 at 12:29 PM the surveyor asked RNA4 if R218 was receiving restorative care. RNA4 stated that R218 is working with an outside rehabilitation agency.
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The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
way that maximizes each resident's well being.
competencies necessary for resident safety.
This deficient practice has the potential for harm.
Findings include: On 08/14/24 at 09:00 AM, while waiting to check a medication cart on Unit 4, observed Registered Nurse (RN)10 dispose of a medication tablet in the trash bin (unlocked, unsecure) located on the side of the medication cart.
The medication landed on the top of other trash which was visible and accessible to anyone passing the medication cart.
Inquired if it was okay to dispose of the medication tablet in the trash bin at the side of the medication cart which was unsecured and unable to be locked. RN10 stated she would have to check on how she was supposed to dispose of that medication. RN10 confirmed she disposed of a tablet of Aspirin 81 mg (milligrams) on the side of the medication cart and remained unsure of how to properly dispose of the medication. As RN10 and this surveyor were discussing RN10 disposing of the medication in an unsecure/unlocked trash bin, and the potential opportunity for a resident to retrieve the medication from the cart, Resident (R)140 independently and unsupervised, wheeled himself past the medication cart with the Aspirin 81 mg tablet exposed.
On 08/15/24 at 12:20 PM, conducted an interview with Unit Manager (UM)8 and informed her of an observation of staff disposing a tablet of Aspirin 81 mg in the trash bin on the medication cart. UM8 confirmed disposal of non-controlled medication should be in the sharps or another closed system and should have not been disposed of in the trash on the medication cart.
125019 08/15/2024
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
clear and in an identifiable and prominent place. As a result of this deficient practice, residents and
Findings include: 1) On 08/13/24 at 10:55 AM, conducted observations of daily staff posting at the entrance of the building and on all four (4) units.
Near the entrance of the building, after the screener's station, Daily Staff Posting is posted on a bulletin board along with the employee clock in/out system, a Stay up to Date with your Covid Vaccine poster, Cover your Cough poster, August 2024 Employee Calendar, Mandatory CNA (Certified Nurse Aide) Meeting, and a list of employees who need to see the Director of Nursing (DON) prior to starting the shift.
The 24-hour-Daily Staff Posting form was printed on what appeared to be an 11-inch (in) x 13 in paper.
The print was small, and this surveyor was unable to clearly read the form until standing approximately two (2) feet away from the form.
There was no larger sign clearly indicating the form was the 24-Hour-Daily Staff Posting. A visitor approached the main exit doors and this surveyor inquired if she knew where the daily staff posting was located.
The visitor confirmed she did not know where it was despite standing approximately 3-4 feet away from the posted form.
On each of the four units, the names of the staff working are written on a dry erase board which is set in the back of the nurses' station, over 10 feet from the entrance to the nurses' station.
The entrance of the nurses' station is noted by a high counter/desktop, which is where any resident or visitor would be stopped prior to entering the nurses' station.
The dry erase board was difficult to identify the location the units were listing, or the individual staffing census.
On 08/14/24 at approximately 02:10 PM, inquired with the Director of nursing where the daily staffing information was posted. DON confirmed daily staffing is written on the whiteboards on each unit and at the entrance of the building.
Informed DON on initial observation, the listing was not identifiable or highly visible when entering into the building due to the form being posted on the employee notification board, it appears like information for staff.
On 08/15/24 at 11:37 AM, observed Resident (R)315 and multiple family members (FM), walk past the nursing station at a slow rate, then into the resident's room.
Inquired with FM99, who was a young adult male (25-[AGE] years old), confirmed he does not need or use glasses and has great eyesight, if he was aware where the daily staffing was posted for the unit and for the facility. FM99 confirmed he has never seen any daily staffing form or information, and stated, Nope, I don't know where it is, and staff never told me where it was at.
At 11:40 AM, inquired with R138's FM if she knew where the facility's daily staffing information for R138's unit and for the entire facility was located. FM confirmed she did not know where that information was and has never seen the form. 2) On 08/12/24 at 08:24 AM, during an initial observation of Unit 3, the daily nursing staffing posting with total number and actual hours worked per shift for nursing staff responsible for resident care was not found.
125019 08/15/2024
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
Observation was conducted on 08/14/24 at 07:38 AM at the nurses' station on the second floor.
Registered Nurse (RN)24 was observed preparing medications for a resident.
The medication cart she was using was unlocked and RN24 was accessing the medications contained in the medication cart.
A review of the facility's document titled, Controlled Item Checklist, dated August, was conducted on 08/14/24 at 07:49 AM.
The sheet did not contain the outgoing night shift nurse and the incoming day shift nurses' signatures for August 14, 2024, in the 07:00 AM boxes. RN24 was informed of the missing signatures. RN24 stated that it should have been signed earlier with the outgoing night shift nurse.
On 08/14/24 at 07:57 AM, RN24 and RN20 were both observed signing the facility's, Controlled Item Checklist, form.
Interview was conducted with RN20 on 08/14/24 at approximately 08:20 AM. RN20 stated that she was the only nurse on the unit on night shift and after performing the narcotic count with RN24, she did not sign off on the controlled item sheet.
Instead, RN20 stated that she did her final rounds and used the restroom.
She didn't want RN24 to wait on her to start her morning medication administration, so she handed off the medication cart prior to signing the narcotic count sheet. RN20 confirmed that the normal process is to count the narcotics and once verified, the outgoing and incoming nurses sign the sheet.
125019 08/15/2024
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
Administration Record].
There was no documentation found for either the physician or nursing staff
On 08/15/24 at 11:48 AM, an interview and concurrent record review with License Practical Nurse
would be administered through the feeding tube.
Concurrent review of the MAR for APAP, sorbitol, insta-glucose, and iron found the order for APAP: Give 650 mg by mouth .; insta-glucose (discontinued on 08/14/24, 11 months after the recommendation): Give 24 gram by mouth .; and for iron: Give 1 tablet by mouth . LPN2 reported the medication orders should not say by mouth and should have been changed to administer via G-Tube.
The orders for APAP, insta-glucose, and iron routes of administration were not changed to feeding tube or by G-Tube despite the pharmacist recommending the facility clarify the administration directions on 09/11/23.
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The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
Review of the facility's policy and procedure, Food and Nutrition Services revised in October 2017 documented Meals and/or nutritional supplements will be provided per scheduled meal time or by request, and in accordance with the resident's medication requirements .Reasonable efforts will be made to accommodate resident choices and preferences.
125019 08/15/2024
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
Review of the facility policy titled, Food Receiving and Storage, with a revised date of 10/2017, was conducted.
The facility policy documented, Food shall be received and stored in a manner that complies with safe food handling practices. 2) Concurrent observation and interview were conducted with the Dietary Aide (DA) 1 on 08/12/24 at 08:53 AM. DA1 was observed checking the dishwasher sanitizer with a quality assurance strip.
When asked if she logs the results, DA1 stated that kitchen staff only logs the temperature for the dishwasher and there was no log for checking the dishwasher sanitizer.
Interview was conducted on 08/12/24 at 01:28 PM with DD. DD confirmed that the facility did not have a log for the dishwasher sanitizer quality assurance checks.
A review of the facility policy titled, Dishwashing Machine Use, with a revised date of 03/2010, was conducted.
The facility policy documented, A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution after filling the dishwashing machine and once a week thereafter.
Concentrations will be recorded in a facility approved log.
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The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
agreed that she should have logged off prior to leaving the computer unattended.
04/2014, was conducted.
The policy documented, A user may not leave his/her workstation or
log off at the end of his/her work shift.
125019 08/15/2024
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
During a concurrent review of a copy of the signed BAA and being asked if she recognized it, FM3 reported that she believed it was a form in a bunch of forms that had been sent to her to sign once when R63 was being re-admitted from the acute care hospital.
FM3 also reported that she could not recall the form being explained to her and stated that she wasn't sure what it was for.
After the state agency (SA) explained the BAA form to her, FM3 stated that she was sure the form had not been explained to her before, because if it had, she would not have signed it.
When shown the Voluntary Arbitration Program Information Sheet and asked if it had been read to her by a facility representative, FM3 responded that she did not recall seeing the Information Sheet before, nor did she remember it being read to her. FM3 stated that she did receive a phone call about the admission Packet forms but was only asked if there were any changes.
When she responded that there were no changes, FM3 stated that she was asked to review and sign the forms.
On 08/14/24 at 02:19 PM, an interview was done with the Director of Medical Records (DMR) outside of the Administrator's Office.
The DMR confirmed that the BAA would have been sent to FM3 for e-signatures with about 27 [other] forms in the admission Packet [all requiring signatures].
The DMR also confirmed that the social services representative that had signed off as reviewing the BAA information with FM3 no longer worked for the facility.
125019 08/15/2024
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
During R126 sacral wound dressing change, the nurse didn't sanitize hands after removing dirty gloves and before putting on clean gloves.
This failure could place the resident at risk for infection.
Findings include: 1) On 08/12/24 at 08:38 AM, during an observation of R85's room, observed R85 on oxygen, oxygen contractor running, and the humidifier bottle had broken off tape around it and was taped on the bottom sticking to the ground.
The rubber band that secured the humidifier bottle to the concentrator was broken and there was tape around the concentrator. R85 reported the humidifier bottle was taped to the concentrator this morning but it fell off and he had issues with his oxygen tube soon after, .there was a kink in the machine and the tubing was changed right after. R85 reported the rubber band holding the humidifier bottle had been broken for a while but could not provide how long or the date when he first noticed it broken.
On 08/15/24 at 10:39 AM, an interview with Infection Preventionist (IP) was done.
Inquired if an oxygen humidifier bottle on the floor would be acceptable. IP stated no because the floor is not sanitary with possible germs, bile, and infectious diseases on the floor. IP admitted this could put the resident at risk of infection. 2) R126 is a [AGE] year-old male admitted to the facility on [DATE] with primary diagnoses that includes heart failure; septicemia; wound infection and an unhealed stage four pressure ulcer of the sacral region, per Record Review (RR) of the face sheet.
Wound care team observed on 08/14/24 at 08:45 AM.
Licensed Practice Nurse (LPN) 3 and Registered Nurse (RN) 22 started the dressing change on R126's stage four sacral wound.
During the dressing change, observed LPN3 clean the wound and remove her dirty gloves then put clean gloves on without sanitizing her hands.
The surveyor asked LPN3 if she should sanitize her hands after removing the dirty gloves and before putting on the clean gloves. LPN3 said yes and proceeded to remove the gloves, apply the hand sanitizer, and replaced with the clean gloves.
Wound Care policy and procedure, 2001 MED-PASS, Inc. (Revised October 2010) reviewed. 7.
Cleanse wound with ordered wound cleanser . 8.
Pull glove over and discard into appropriate receptacle.
Wash and dry your hands thoroughly or may use alcohol-based sanitizer as an alternative . 9. DON new gloves.
Review of R31's Electronic Health Records (EHR) documented a Minimum Data Set (MDS) admission assessment with an Assessment Refence Date (ARD) of 07/18/24, Section C.
Cognitive Patterns the resident scored a 15 out of 15 on the Brief Interview for Mental Status, indicating the resident's cognition is intact, and that he is a reliable source of information.
Section GG- Functional Abilities and Goals documented the resident is dependent (helper does ALL the effort) on staff for oral hygiene, toileting, upper and lower body dressing, putting on footwear, and personal hygiene (combing hair, shaving, washing and drying face and hands).
After filing a complaint with the facility regarding the Alleged Perpetrator's (AP) treatment of R31, AP was informed not to have any form of contact with the resident. R31 reported AP verbally confronted and intimidated the resident causing the resident to be fearful of staff, feel afraid and anxious, and started having violent nightmares of physically defending himself from AP.
During an interview on 08/14/24 at 11:10 AM with the Administrator and AADM, the Administrator confirmed she was not informed that R31 reported to AADM that AP confronted and intimidated the resident after the resident complained to the facility's management of the staff. AADM confirmed he did not identify AP confronting the resident about his complaints as having the potential for abuse. As a result of not conducting and following up with R31, the facility was unaware of R31's nightmares and new feeling of anxiousness and feeling unsafe.
125019
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 125019 B.
Wing 08/15/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
Review of R31's Electronic Health Records (EHR) documented a Minimum Data Set (MDS) admission assessment with an Assessment Refence Date (ARD) of 07/18/24, Section C.
Cognitive Patterns the resident scored a 15 out of 15 on the Brief Interview for Mental Status, indicating the resident's cognition is intact, and that he is a reliable source of information.
Section GG- Functional Abilities and Goals documented the resident is dependent (helper does ALL the effort) on staff for oral hygiene, toileting, upper and lower body dressing, putting on footwear, and personal hygiene (combing hair, shaving, washing and drying face and hands).
During an interview on 08/12/24 at 10:06 AM, R31 reported he made a complaint to the facility regarding how AP treated him when he requested assistance with the temperature of the air conditioner.
After filing the initial complaint with the facility, R31 was assured that AP had been instructed not to have any form of contact with him.
Following this assurance, R31 reported AP verbally confronted and intimidated him while he was alone in his room, causing him to be fearful of staff, feel afraid and anxious, and he began having violent nightmares of physically defending himself from AP. R31 stated he informed AADM that AP came into his room and confronted him for making the initial complaint.
During an interview on 08/14/24 at 11:10 AM with the Administrator and AADM, the Administrator confirmed she was not informed that R31 reported to AADM that AP had confronted and intimidated him following the initial complaint. AADM confirmed although he was informed, he did not identify AP confronting R31 about the initial complaint as having the potential for abuse. As a result of not conducting an investigation and following up with R31, the facility was unaware of R31's nightmares and new feelings of anxiousness and feeling unsafe.
Review of SA's Aspen Complaints/Incidents Tracking System did not include a report from the facility of AP confronting R31 after the resident filed a complaint of AP's treatment of him.
125019
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 125019 B.
Wing 08/15/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
Review of documented MRRs uploaded in the resident's EHR found the MRR for 07/31/24 was not uploaded in the EHR.
Review of hard chart at the nurse's station found the MRR 07/31/24 was not in the file.
On 08/14/24 at 08:57 AM, an interview with Director of Medical Records (DMR) was done.
Inquired where the facility keeps residents' MRRs. DMR reported it would be uploaded in the EHR or put in a binder. DMR was observed to look for the binder at the nurses' station but was not able to locate it. DMR further stated she will have to look for it in the medical records office.
On 08/15/24 at 09:25 AM, an interview and concurrent record review was done with DMR.
Review of R67's MRR dated 07/31/24 from the pharmacist to the attending physician documented: To help optimize pain management for this resident, please consider adding: .
For severe pain not managed by PRN [as needed] APAP [Acetaminophen] to the PRN oxycodone order.
Under physician's response, a handwritten note on the signature line documented: No new order.
The note was dated 07/31/24, and was not signed.
The bottom of the MRR form was noted to have a print date of 08/05/24.
Inquired why the physician did not sign the document. DMR reported the physician was called, and the response was not to change the order.
Requested for DMR to provide documentation the physician was called and notified, as well as documentation of the physician's rationale for not making the recommended change in the order.
Review of R67's progress notes found no documentation the physician was notified of the recommendation and the physician's response or rationale.
The documentation requested on 08/15/24 was not provided by the facility or DMR.
2) During review of R110's EHR under the pharmacist note in progress notes, the pharmacist documented for MRR between 09/01/23 and 09/30/23 to see report.
Review of documented MRRs uploaded in the resident's EHR found the MRR was not uploaded in the EHR.
Review of hard chart at the nurse's station found the MRR was not in the file.
125019
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 125019 B.
Wing 08/15/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The Care Center of Honolulu 1900 Bachelot Street Honolulu, HI 96817
During random observations of Resident (R)126 in his room on the following days and times:
08/12/24 at 09:07 AM and 2:00 PM;
08/13/24 at 09:15 AM; 11:30 AM; 2:00 PM and 3:45 PM;
08/14/24 at 08:45 AM, 11:38 AM, 1:45 PM, and 3:14 PM,
noted R126 laying on his back with the head of the bed elevated, watching television.
Record Review (RR) of R126's Care plan (CP), started 07/15/2023, noted the following:
R126 has limited physical mobility related to pain, wounds, deconditioning secondary to sepsis.
Stage four to sacrum.
Will show signs of healing without complications through the next review date.
The resident will not develop any further complications related to immobility .
2) R218 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that includes depression, hemiplegia, and hemiparesis (weakness) per Record Review (RR) of face sheet.
Cross reference to
Observation and interview with R126 in his room on 08/12/24 at 09:04 AM. R126 was in his bed on his back with the head of bed up 45 degrees. R126 said that he used to walk pretty well before but now I'm in bed all the time.
The surveyor asked R126 if he is able to get the help he needs from the staff? R126 said, I have a sore on my back that's infected and pretty deep. I'm supposed to be turned every two hours but there isn't always enough staff available. It takes two Certified Nurse Aides (CNA)'s to do it, and one CNA can't do it by themself. I take antibiotics because I have an infected sore. I wish I could turn or get a pillow.
When they came in to change the bed, they moved the extra pillows and I didn't get them back, they must be in short supply.
Record Review (RR) of the Minimum Data Set (MDS) annual review 07/09/24. R126 is cognitively intact.
Dependent on staff for toileting, bathing and dressing and requires partial to moderate assistance to roll left and right and dependent on staff for bed to chair transfer. R126 has a stage four pressure ulcer present on admission.
RR of Care plan 07/15/23 cross reference to
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.