Hale Makua - Kahului
HALE MAKUA - KAHULUI in KAHULUI, HI — inspection on January 14, 2025.
Found 3 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 revise Resident (R)1's care plan following an incident of actual elopement and unsafe wandering (wandering into other residents' rooms).
The facility submitted an Event Report on 12/06/24 at 08:30 PM regarding R1's elopement. On 12/06/24, R1 was found outside near fence in back of unit. R1's WanderGuard (a system that provides wander management for those at risk of elopement) bracelet reportedly was in place and functioning at the start of the shift. No alarms were heard.
The final report was submitted on 12/10/24 at 02:35 PM.
The facility clarified, R1 was found outside of the building behind the activities center.
The House Supervisor saw the WanderGuard alert on another unit (North) and notified R1's unit (Pikake).
Another staff member saw R1 from the window of another unit (Ilima) and notified the Pikake unit.
The facility's investigation found the door to enter the activities department from the Pikake unit was not locked and R1 was able to enter the room and access the emergency exit door at the rear of the building.
The emergency exit door is equipped with a locking mechanism that will allow the exit door to open after being held for 15 seconds.
On 01/13/25 at 10:50 AM record review was done. R1 was readmitted to the facility on [DATE].
Diagnoses include but not limited to unspecified dementia, unspecified severity with anxiety; unspecified dementia, unspecified severity with agitation; nondisplaced intertrochanteric fracture of left femur (routine healing); cognitive communication deficit; aphasia (a language disorder that makes it difficult to understand or express language); and anxiety disorder.
125007
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 125007 B.
Wing 01/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Hale Makua - Kahului 472 Kaulana Street Kahului, HI 96732
Observation on 01/13/25 at noon saw R2 seated in a wheelchair in the hall next to the door of her room.
Observation at 01:00 PM, R2 was standing at a table with two other female residents and talking.
Subsequently, R2 was observed to follow staff around the unit. R2 was independently ambulatory.
Later R2 was observed sitting at a table by the nurses' station, watching television.
Later observed R2 seated in activities for volleyball, R2 was smiling.
On 01/13/25 at 01:39 PM a record review was done for R2. R2 was admitted to the facility on [DATE].
Diagnoses include but not limited to, Alzheimer's with early onset; dementia in other diseases classified elsewhere, unspecified severity, without behavior disturbance, psychotic disturbance, mood disturbance, and anxiety; chronic kidney disease, stage 2 (mild); wandering in diseases classified elsewhere; and other abnormalities of gait and mobility.
A review of the quarterly MDS with an ARD of 11/26/24 noted R2 was assessed with moderate cognitive impairment for decision making skills. R2 was also coded for wandering behavior, occurred one to three days during the assessment period.
The facility developed a care plan during the survey for R2 being at risk for elopement due to history of wandering and severe cognitive impairment.
Approaches included: if I am going toward unit exit, please help me back to my room where staff can supervise me; I use a WanderGuard for safety, please check the placement every shift; if I become agitated and difficult to redirect, I may require 1:1 supervision to manage my wandering; and please refer to my activity care plan for my preferences and things that interest me.
Prior approaches for wandering with a start date of 02/09/21 included but not limited to: 12/17/22 - WanderGuard to my dominant risk (right side) as I tend to wander around at night and attempt to leave the facility out of curiosity.
Monitor my WanderGuard is in place every shift; and 12/27/22 - Wandering/exit seeking, when observed redirect me to my unit/room, offer me something to eat/drink or offer me to use the bathroom, encourage me to engage in group activities every shift
125007
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 125007 B.
Wing 01/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Hale Makua - Kahului 472 Kaulana Street Kahului, HI 96732
Review of R1's quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 10/21/24 notes R1 yielded a score of 3 (severe cognitive impairment) when the Brief Interview for Mental Status was administered. R1 was also coded for wandering, occurring one to three days during the observation period. R1 requires supervision or touching assistance for walking 10 feet, walking 50 feet with two turns, and walking 150 feet.
A review of R1's progress notes from 11/29/24 to 01/12/25 found entries of R1 wandering into other residents' rooms: 11/29/24 at 02:41 PM, R1 wandered into another resident's room at night; 12/08/24, R1 sometimes walked into other residents' room looking for the toilet; and 12/15/24 at 08:55 PM, R1 was wandering a lot on the unit and was found in another resident's room.
Review of R1's care plan found approaches for wandering with a start date of 08/23/23.
Approaches/Interventions included: ask me if I need anything or offer me drink/food/toilet/lie down/activity; monitor my whereabouts; provide redirection and reorientation as needed, state what I should do not what I should not do; follow me for safety until I can be redirected, I was issued a WanderGuard device that locks exit door when I approach.
There were no care plan revisions to assess the efficacy of current approaches and/or to develop new approaches following actual event of elopement and incidents of resident entering other residents' rooms.
On 01/14/25 at 07:50 AM an interview and concurrent record review was done with the Unit Nurse (UN).
Inquired whether the facility revised R1's care plans after the wandering incident on 11/29/24. UN stated the team decided to place a Stop banner across the door of the room R1 entered. UN also stated it wouldn't be feasible to place these banners across all residents' doorways to prevent R1 from entering. UN was unable to confirm R1's care plan was revised.
125007
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 125007 B.
Wing 01/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Hale Makua - Kahului 472 Kaulana Street Kahului, HI 96732