The Care Center Of Honolulu

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