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Nursing home inspection form
 

Nursing home inspection form

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Ka Punawai Ola, a nursing home in Kapolei, was inspected May 29, 2013, using a CMS form 2567.

Ka Punawai Ola, a nursing home in Kapolei, was inspected May 29, 2013, using a CMS form 2567.

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    Nursing home inspection form Nursing home inspection form Document Transcript

    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0159 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some <b>Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.</b> Based upon staff interview and review of resident's personal funds, the facility failed to manage personal funds for residents that utilized salon services arranged by the facility. Findings include: On 5/22/13 at 12:45 P.M. review of residents' personal funds was done with the Receptionist and Business Office staff member. Inquired what is the process for residents to request money from their personal funds account. The Receptionist reported that the resident will fill out a slip and sign for receipt of the petty cash. A review of Resident #135's account found that the facility withdrew funds to pay for a haircut on 4/5/13 for $12.50. A request was made to review the documentation that accompanied the withdrawal to pay for the resident's haircut. At this time the Business Office staff member provided assistance. The staff members provided an invoice from the stylist requesting payment for services for Resident #135 and other residents of the facility. There was no documentation by the resident that she approved of the payment to the stylist. Inquired how does the facility ensure that the resident approved the payment and received the service. The staff members reported that this stylist did not follow the process of acquiring the resident's signature on the request slip for haircuts. The stylist was submitting an invoice for all the residents who received services for remittance. The Receptionist reported that this stylist is no longer contracted through the facility. Inquired how long was this stylist on contract. The Receptionist replied, he was on contract from January 2012 through April 2013. Interview with the Business Office Manager (BOM) was done 5/28/13 at 8:30 A.M. The BOM reported that when a resident/family member requests a haircut, a slip is completed and signed by the resident or nurse/aide to confirm the service was provided. However, the slips are not being attached to the residents' account information. A policy and procedure related to paying contractors for services provided was requested. On 5/28/13 at 9:30 A.M., the BOM reported that the facility does not have policy and procedures for paying contractors (i.e. haircuts). The facility did not have a system in place to ensure that salon services were provided to residents with personal funds before remittance. F 0160 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of personal fund accounts and staff interview, the facility failed to ensure upon the death of a resident with a personal funds account, the facility conveyed within 30 days a final accounting of those funds to be provided to the appropriate individual for 1 of 3 accounts reviewed. Findings include: Resident A expired on [DATE]. The resident's personal fund account was closed on [DATE] and the balance was provided to the representative on [DATE]. The facility did not ensure the personal funds account for Resident A was conveyed within 30 days to the individual managing the resident's estate. On [DATE] at 12:45 P.M. a review of personal fund accounts and interview with Receptionist and Business Office staff member was done. A request was made to review the account of a deceased resident who had an account managed by the facility. The staff members provided documentation for Resident A. Resident A expired on [DATE] and the account was closed on [DATE] with a check payable to a family member of $476.53. Inquired how many days does the facility have to convey the funds. The staff members replied that the facility has 30 days to reconcile the account and release any remaining funds to the appropriate recipient. Inquired what happened with this account, the staff members replied that the BOM was on maternity leave at that time and the person assisting them did not come in frequently enough to reconcile the resident's account for closing. On [DATE] at 8:30 A.M. an interview and concurrent review of the account was done with the BOM. The BOM explained that the resident received automatic direct deposit subsequent to his expiration. The ledger notes a deposit was made on [DATE] and these monies had to be returned, which was done on [DATE]. The cost share for March also had to be refunded to the account which was done on [DATE]. On [DATE] the approval to close the account was made and the refund check was dated [DATE]. F 0224 Level of harm - Actual harm Residents Affected - Few <b>Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, family and staff interviews, and a review of the facility's policy and procedure, there was a failure to provide services necessary to avoid mental anguish and a potential for a decline in health status for 1 of 32 residents included in the Stage 2 sample. Findings include: Cross-reference to additional and related findings at F226, F241, F242, F309, F312 and F323. During an interview with Resident #161 on 5/20/13 at 10:55 A.M., the resident stated she felt afraid because of the way she and/or other residents were treated. The resident conversed both in Japanese and English and said she was admitted to the facility for short term rehabilitation following a surgical procedure. She said, I have asthma and that there was an incident with her breathing which made her fearful and afraid since. The resident said one night she had chest pain/discomfort and could not breathe good. The night nurse just gave her some pain medication and told her, Good night, you can go sleep and never came back to check on her. The resident said her chest felt painful, but said it was because of the asthma. She said in Japanese, Tasukete, iki dekinai kara or Help me, because I cannot breathe and said she had to plead to a male nurse aide who came into the room. She told him, I need inhaler, something, I cannot takey my breath. She said the pain killer did not do anything because it was not the problem. She felt the nurse just wanted her to sleep. The resident said, How can be a nurse? and shook her head during the interview. The resident also said the male aide did tell the nurse and only then did that nurse return after 35-45 mins later to give her a breathing treatment. The resident said she felt really, really afraid because she could not breathe. The resident also stated during the interview that some staff have no feeling towards her. She said at night after toileting, when she has to lay back down, the staff do not assist or help her back to bed. She said they just leave her at the bedside and it was mostly the female staff. The resident said there were some staff who cared, but others were not and rude in their manners. She said her roommate was a new admission and about 4-5 nights ago around 3:00 A.M., her roommate started crying out for help. She said they both used their call lights, but the staff who came into the room said, Wow, wow! The resident said she told the staff her roommate needed help, but was told, No, she's okay, although her roommate could not sleep. The resident said she felt sorry for her and because she was also coughing, she called the nurse again. She asked the nurse if she could give her neighbor something for the cough, and this made her think how bad it was when the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 1 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0224 Level of harm - Actual harm Residents Affected - Few (continued... from page 1) staff did not seem to care. She said, patient so new--they don't even take care. I cannot sleep too--I worry for her, but cannot speak to her (language barrier). In addition, the resident said even though her family member meets with the staff about the issues related to her care, the communication was not good and did not feel clear answers were being provided. She stated she did not even know how she was doing with her illness and felt saddened by it. She stated, I just likey go home already and dabbed her eyes with tissue. Clinical record review on 5/22/13 found the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's 14 day MDS assessment with an ARD of 5/8/13 noted her BIMS was not done in Section C, but Section B coded the resident as having clear speech, made self understood, able to usually understand and had adequate vision. The resident was also capable of hearing and responded appropriately to surveyor's questions during the 5/20/13 interview with her. On 5/24/13 at 2:10 P.M., during an interview with the resident's family member, the family member stated one problem was the Administration. He/she stated, there's no communication--it's the little things that's not being reported. There's no communication. The family member also gave an example regarding a shower incident involving the resident and said, (resident) didn't even have a chance to clean up well after the shampoo was dumped on her head. Another instance the aide didn't wipe her down well. And the staff says to her, 'I'm doing my best!' in a heightened tone of voice. Different nurses come in and say what can she do? What?! So, they don't even know her level of care? It's just the communication, lots of improvement needed. And a lot of staff are rude, grouchy, but this is their job, their profession they chose. It shouldn't be like this. F 0226 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some <b>Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with staff and review of facility's documents, the facility failed to implement policies and procedure to identify, investigate and report allegations of mistreatment, neglect, and abuse of residents and misappropriation of resident property. Findings include: 1) During the abuse prohibition review, a request was made of the facility's listing of incident reports from the previous certification survey. The facility produced two incidents related to falls. A review of the resident council minutes found documentation of the Help Us To.Serve You Better Concern & Comment Form reports which is utilized to document residents' concerns/complaints. On 1/31/13, Resident B reported to the Activities Director that a male associate took his watch and was rough during care. The facility investigation and response was that the resident could not recall any concerns with staff, resident was not fearful and per resident's daughter, the resident did not have a watch. The action taken was the DON educated staff about proper care of resident with activities for daily living. Another report noted Resident C informed the Activities Director on 1/31/13 that (name) C.N.A. requested money from the resident to buy lunch and a C.N.A. was rough during care. The facility interviewed the resident and spoke with the resident's son. Both the resident and her son wanted the facility to follow up on the concern. The action taken was the DON educated staff and spoke with them about inappropriateness of requesting things (money) from residents and gentle care during activities of daily living. Upon request of specific reports related to Stage 2 sample residents, there was also a report of roommates, Residents #162 and #172 got into a screaming match on 2/4/13 resulting in Resident #172 feeling uncomfortable being in the same room. The follow up by facility included interviewing the residents and residents admitting that they do not like each other and would not meet to talk about the situation. Subsequently, Resident #172 moved to another room on 3/22/13. During the Quality Assessment and Assurance meeting on 5/28/13 at 1:35 P.M., the aforementioned concern and comment forms were reviewed with the team. Administrator #1 reported that if concerns related to abuse were identified the process for investigating concern and comment forms would go beyond what is required to process the facility's concern and comment forms. The administrator also acknowledge that this is a system that needs to be worked on. On 5/29/13 at 8:45 A.M. an interview was conducted with Administrator #2. Inquired whether the information shared from the Help Us To.Serve You Better Concern & Comment Form cards during the QA&A interview regarding rough handling by Certified Nurse Aides required further investigation. Administrator #2 replied, moving forward these are issues that should have been investigated further then what was required to process the concern and comment form. The facility failed to identify and investigate allegations of abuse as identified in the Help Us To.Serve You Better Concern & Comment form submitted by residents and family members. The facility also failed to report allegations to the State Agency. 2) Cross-reference to additional and related findings at F224, F241, F242, F309, and F323. Clinical record review on 5/22/13 found Resident #161 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's 14 day MDS assessment with an ARD of 5/8/13 noted her BIMS was not done in Section C, but Section B coded the resident as having clear speech, made self understood, able to usually understand and had adequate vision. The resident was also capable of hearing and responded appropriately to surveyor's questions during the 5/20/13 interview with her. During a follow-up interview with the resident on 5/21/13, she stated there was a problem with one of the CNAs (CNA #5). The resident said she was on a different unit when she was admitted and argued with CNA #5 about how cold the shower felt. She also said when she requested a shampoo, the CNA put shampoo just to one side of her head and did not help her shampoo. She ended up with the shampoo all over her body and felt like she had taken a shower with shampoo. The resident said she was upset because of this, and reported it to a nurse. The resident said CNA #5 came to tell her sorry but she (CNA #5) did it right. The resident said all CNA #5 did was control the shower head and spray her. She did not give her enough time to wash herself with soap and said, no more soap, only shampoo. The resident reiterated that CNA #5 told her, Sorry, I do my best and walked out. The resident said, She say I'm sorry, but she not sorry--the way she say it! I know. The resident stated she felt more upset afterward and no one really took care of the problem. This was also told to the surveyor by the resident's family member. On 5/23/13 at 2:35 P.M., an interview of CNA #5 was conducted. She has worked almost three years at the facility this June and started working morning shifts from November 2012. She was familiar with Resident #161. CNA #5 recalled the last time she showered the resident, she told me I did not help her do everything. She said just like rinsing everything, face towel, rub on her body and she told me I did not help her. But for me, I help her, I give her 2 towel and I use the other towel for her back and eveything. CNA #5 was asked how capable the resident was in doing her ADLs and she replied the resident was limited assistance but still needed help. She said she shampooed the resident's hair and the shower took about 10-15 minutes. She said the resident also liked hot water, and you can only make it only so hot and told the resident that. She said the family member was okay, but the resident is the one who making trouble. The nurse told me after break the resident said I didn't help her so I went with her to say I'm sorry, I did everything to help you. (Resident) told me, 'Oh no you don't even help me', but the (family member) said 'no, she help you', but (resident) said, 'no she don't help.' CNA #5 said she did not work with the resident thereafter because the resident moved to a different room and did not request for any more showers either. CNA #5 said there was no incident report written up, but a licensed nurse (LN #5) asked her questions about it. CNA #5 said, Only now someone is complaining. On 5/23/13 at 2:58 P.M., an interview with LN #7 revealed the resident told her CNA #5, she just put shampoo on her hair and then only on this side (top of head), and she wanted it all around, but CNA only showered in front. LN #7 said CNA #5 denied showering the resident as the resident claimed. LN #7 told the resident she would find out and wrote it on a blue form and told the charge nurse (LN #3) about what happened, but did not know anything more. LN #7 said she was concerned about the way CNA #5 shampooed the resident. That's why right away I have to investigate it. As long as I done talking with (CNA #5), I talk to my charge nurse. LN #7 said she apologized to the resident and told her she would talk to the CNA about it as well. On 5/24/13 at 1:25 P.M., during an interview with the DON, she stated she was away when the shower incident occurred between Resident #161 and CNA #5. She said a family member also brought it to her attention upon her return and asked that CNA #5 not shower the resident anymore. The family member did not like the action of the CNA squirting shampoo on her hair. The DON asked if the resident was hurt and the family member said no. However, the DON said she did not ask the resident about it and only asked LN #7 about what happened. The DON stated she did not have documentation on it as well. She said her expectation was there should be documentation about the incident, such as a concern and comment card, but there was none. On 5/24/13 at 3:42 P.M., the DON said she talked to LN #7 about the shower incident again. She reconfirmed the details and included that the shampoo they use was a shampoo and body wash combination. The DON stated she did not think the resident was informed of this and said she should have inquired more into this. At 3:53 P.M. the Registered Dietitian (RD) said she would be going to see the resident to explain that it was an all in one type of body wash/shampoo they used. Per interview with MDSC #1 on the morning of 5/24/13, she said if a situation involved a staff to resident issue, such as a concern or lack of an appropriate shower the resident received, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 2 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0226 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some (continued... from page 2) there would be an incident report generated. MDSC #1 said staff would also be addressed, and she would remove the staff from the unit until the investigation was completed. Per the guidelines at ?483.13(c) of Appendix PP of the State Operations Manual: Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (42 CFR 488.301). The facility's policy and procedure regarding the Protection of Residents: Reducing the Threat of Abuse & Neglect (Rev. 2/09), stated, All personnel will promptly report any incident or suspected incident or resident abuse and/or neglect, including injuries or unknown origin.10. Following the report of suspected abuse and/or neglect, the administrator will designate a resident advocate (i.e., social services), to support the resident through his/her feelings about the incident and his/her reaction to their involvement in the investigation. The designated resident advocate will coordinate development of care planned interventions as necessary to assist the resident in successfully dealing with the occurrence of abuse and/or neglect. There was no documentation or evidence that the facility followed their own policy and procedure nor further investigated the resident's concerns related to the shower incident with the CNA, despite being aware of it. F 0241 Level of harm - Actual harm Residents Affected - Some <b>Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, the facility failed to maintain the dignity and respect for 15 of 24 residents. Findings include: Interviews and observations were made during both Stages 1 and 2 of the Quality Indicators Survey (QIS) and revealed a multitude of issues/concerns related to dignity and respect. 1) Interview of a Resident, R #333, on the morning of 5/21/13 revealed that a Certified Nurses Aide, CNA #7, treated the resident roughly and was rude to her. During the interview on 5/21/13, R #333 was alert and oriented to person, place, and time. The R #333 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident stated, When I first came, I couldn't walk. I couldn't even move off the chair. The CNA was so rough, she pushed me around to make me move. I couldn't. She forced me to go to bed. She's short tempered. She complained that I was too demanding. I didn't demand anything. She's just mean and nasty. The resident further explained that this occurred every night that CNA #7 was on duty. The R #333 stated that she would use her call light to go to the bathroom and would wait long periods of time before the CNA would tend to her. The R #333 stated she was in the Day Room on the Keolamau unit one evening when she wanted to return to her room to go to bed. The resident stated the CNA #7 was sitting at the nurse's station, drinking water, and took her sweet time. The R #333 stated she waited approximately 30 minutes before the CNA #7 got up to assist her back to her room. The R #333 stated the CNA #7 was caring for her when she stated (in Filipino), You're a pain in the neck. Every time I come here you make more work for me. The resident was upset and stated to the surveyor, I don't want her near me. I don't want her taking care of me anymore. The R #333 stated that she was planning on talking to someone about this. As of 5/21/13, the resident did not share these concerns with any other staff members. The resident stated the CNA #7 hadn't worked over the past 2 evenings. The R #333 reasoned that the CNA #7 was likely to return that night (5/21/13) since she had been off the past 2 nights. She stated, I think she's coming back tonight and I refuse to let her touch me. I don't want her near me. The R #333 stated she wasn't afraid of the CNA and that she would tell her to leave her alone. The resident was able to describe what the CNA looked like: Body frame, Ethnicity, height. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 5/21/13 during the afternoon of 5/21/13 found R #333 had a Brief Interview for Mental Status (BIMS) score of 15/15. The resident was able to tell the surveyor where she was (facility), the city where her home was located, the reason for admission to the facility (rehabilitation), and how long she had been in the facility (7 days). Interview of the Administrator and Director of Nursing (DON) on the afternoon of 5/21/13 revealed the Administrator recently started working at the facility and had only been on the job for one week. The DON and Administrator both stated they were unaware of R #333's allegations of abuse. The DON and Administrator stated they would immediately investigate the allegations. The Administrator and DON interviewed R #333 on the afternoon of 5/21/13, during which the resident spotted the alleged perpetrator and was able to verbalize, You stay away from me. I don't want you touching me. The Administrator and DON stated she was pointing to CNA #7. The CNA #7 was immediately suspended pending investigation. Interview of the Adminstrator, Interim Administrator, DON, Chief Nurse Executive (CNE) on the afternoon of 5/22/13 revealed they were almost done with their abuse investigation. They had to interview the alleged perpetrator, CNA #7, and a rehab therapist was writing a statement. The DON expressed her shock at the fact that CNA #7 was being accused, as the CNA was recommended by a family member for outstanding performance. The Adminstrator further expressed that the resident, needed re-education on appropriate transfer techniques. The Administrator consulted the Physical Therapist, who informed her that the resident needed frequent reminders about proper transfer technique. The CNA #7 was interviewed by the DON on evening of 5/22/13, when the CNA denied the allegations. According to the DON, the CNA #7 was inconsistent with her stories. The facility substantiated abuse. The CNA #7 submitted a letter of resignation on the morning of 5/23/13. 2) Interview of R #333 on the morning of 5/21/13 revealed that she was admitted on [DATE] and still hadn't received a shower. Record review confirmed that R #333 did not receive a shower since her admission. The Montly Flow Report revealed R #333 received sponge baths on the evening and night shifts on 5/14/13; Day, evening and night shifts on 5/15/13; Day, evening and night shifts on 5/16/13; Evening and night shifts on 5/17/13; Day, evening and night shifts on 5/18/13; Day and Night shifts on 5/19/13 and 5/20/13; and Night shift on 5/21/13. Interview of the Assistant Director of Nursing, ADON, on the afternoon of 5/23/13 revealed that showers were usually given shortly after breakfast or soon after the evening shift began. Unless a resident requested, the night shift usually didn't provide showers. Their night shift was from 11 P.M. to 7 A.M. The ADON explained that sponge baths included a head to toe wipe down in bed. When asked whether the night shift provided sponge baths to residents, the ADON responded, Yes, probably. The DON and MDS-Coordinator (MDS-C #1) were notified on the afternoon of 5/21/13 that R #333 had not received a shower since her admission. The DON stated she would look into it. On 5/22/13 at 12:45 P.M., R #333 stated she still hadn't received a shower. She stated, I feel dirty. I want to take a shower. The resident didn't receive a shower until the late afternoon on 5/22/13, 8 days after she was admitted to the facility. The facility had a Bath List for Keolamau which indicated R #333 was supposed to receive showers on Wednesdays and Saturdays. The Bath List noted, Please don't make any changes unless approved by (DON) or (staff nurse). On the afternoon of 5/23/13, the ADON stated that residents had the ability to choose the frequency of their showers. If they wanted daily showers, they would try to accomodate them. 3) A Unit Clerk, #1, wheeled R #333 out to the lanai on the morning of 5/21/13 to meet with the surveyor. While being wheeled out, R #333 asked the Unit Clerk #1 if she could get a newspaper to read. The Unit Clerk #1 informed the resident that the Activities staff went over the current events with residents in the Day Room and she could get the paper after they were done with it. Interview of R #333 revealed that she was purchasing her own newspaper over the past week since she was admitted but the resident has since run out of money. The R #333 stated she had loose change in her bedside table but ran out so she now had to wait for her daughter to buy her a newspaper. Interview of the MDS-C #1 on the afternoon of 5/21/13 revealed that the resident was entitled to receiving a newspaper if she requested one. The MDS-C #1 stated the staff should have provided the R #333 with a newspaper. 4) On the morning of 5/21/13 interview of R #328 found that she was disrespected and felt her dignity was compromised. The resident explained that she previously went to the dining room for meals but stopped because of the way she was treated. The resident explained that while in the dining room, the staff would provide her with her food tray after everyone else got served. The resident stated the staff would bring the trays to persons who required assistance with eating, and uncover all their food items then walk back to the food cart to pass out the remainder trays without feeding them first. The R #328 stated she and another resident were the last to receive their trays. She stated that she asked to get served earlier but was ignored. By the time she received her tray, the hot food had already cooled off and the cold items weren't cold. The R #328 stated that she asked for toast one day and was told, No. She stated that she didn't have any dietary restrictions that would prevent her from a liberal diet. She stated, Now I stay in my room. I don't want to make a scene. I feel more comfortable and my TV is on. Record review for R #328 revealed a physician order [REDACTED]. Interview of the ADON on the afternoon of 5/23/13 found that residents were able to receive additional food items per their requests if within their dietary restrictions. 5) Interview of Resident, R #334, on the morning of 5/21/13 revealed she experienced long wait times for the call light to get answered. She stated that she looked at her clock and she often waited 15-20 minutes for assistance. The R #334 stated that 15-20 minutes is really long when you have to go the bathroom. The resident stated that she told the facility staff that they're slow. The R #334 told facility staff, We paying big money. They tell us they have other patients. They take so long to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 3 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0241 Level of harm - Actual harm Residents Affected - Some (continued... from page 3) come. Sometimes they're outside laughing. Sometimes you don't know what they're saying because they're talking Filipino. The R #334 stated that during the late morning one day last week they had something (ex. movies or other activity) in the Day Room on Keolamau. The R #334 and 3 other residents were waiting in the Day Room for approximately 30 minutes for the staff to take the resident back to her room. The resident observed one staff member walking back and forth. The R #334 went to the nurse's station and said something to the staff about ignoring the residents in the day room and making them wait for long periods of time. The resident stated that one resident was sleeping in the Day Room. One of the CNAs just stood there and looked at her. It wasn't in an intimidating way. Another staff member took them back to their rooms. The resident stated she often had to use her call light to assist her roommate, who was not alert and oriented. Record review for R #334 on the afternoon of 5/22/13 revealed a Brief Interview of Mental Status score of 15/15, indicating she was alert and oriented. The resident was admitted for rehabilitation and was being discharged on [DATE]. 6) During an interview with Resident #161 on 5/20/13 11:33 A.M., she stated when the staff approached her, they don't tell who and what going to do. She said for instance, CNA #4 who came to take her to bathroom, just started to comb her hair while she was sitting on the toilet. Resident #161 also stated when she used her call light, the staff failed to answer in a timely manner, but when they did, her sense was that staff were uncaring or unfriendly and did not properly introduce themselves. Resident #161 also stated she had a problem with one of the CNAs about her showers. Cross-reference to findings at F226 and F224. 7) Observation of Resident #326 on 5/21/13 at 9:36 A.M. found the resident sitting in his wheelchair (W/C) with head in his hands. He was situated by the foot of his bed with the privacy curtain drawn. The resident declined to be interviewed, but said, I like go home, I like go home, and teared up. It was also observed his call light was not within his reach. It was hung on an IV pole at the head of his bed. A social worker (SW) consultant passing by was asked to come see the resident and when she did, the SW failed to fully assess the resident's condition/needs when he sat there with his hands to his face, stating he wanted to go home. Instead the SW consultant told the resident that the therapist, who had walked in to talk with the resident's roommate, was going to schedule the resident's next therapy appointment. The resident acknowledged that; however, as the SW was going to leave his side, surveyor asked about his call light. The SW said, oh yeah, saw the call light hanging on the IV pole, obtained it and told the resident she was going to clip it to his shirt. CNA #4 walked in then and the SW told her the call light had been hung on the pole and then left the room. The SW did not tell CNA #4 anything about how she found the resident. CNA #4 kneeled down next to the resident and asked him in his native dialogue, Who put you here? and the resident replied he did not know. CNA #4 said, We usually don't put him here by himself. She said the resident tries to get up by himself and was not supposed to have been placed there with no call light within reach. After a few more questions, the resident said he wanted to go to bed and the CNA assisted him to bed. 8) During multiple random observations of Resident #329, the resident was found dressed in a white tee shirt and blue adult briefs. On 5/24/13 at 8:28 A.M., the resident was observed from the doorway laying in bed wearing blue adult briefs and a white tee shirt. The resident's right hand was in his brief and did not have a blanket or sheet covering him. The resident was in full public view from the doorway. Interview with CNA #6 revealed the therapist had just finished working with the resident. CNA #6 said, oh no, he no like sheet. Surveyor explained the resident was visible to the public, but then CNA #6 opened up the folded white bedsheet and immediately covered him and said, Someone maybe don't like, and drew the privacy curtain around the bed. At 9:00 A.M., therapist #2 said CNA #6 told him he did not cover the resident after working with him. Therapist #2 acknowledged with the resident being in blue adult briefs and visible to public view was not dignified. He was asked if there were shorts that the resident could wear, and he said, Oh yeah. However, in the afternoon, the resident still had the blue adult briefs and his thighs and legs were fully exposed. He did not have any shorts or other type of undergarment to cover the adult blue briefs. 9) Cross Reference to F353. Interview with residents during the survey found residents' reporting that they did not receive the assistance they require for toileting and managing pain. A) Interview with Resident #172 was done on 5/21/13 at 9:50 A.M. The resident reported that there has been times when she uses the call light for assistance to use the restroom and will have to wait a long time for assistance. Inquired how long she has to wait, the resident responded sometimes an hour or she has to wait so long that she forgets what kind of assistance she needs. She also reported that sometimes she waits so long that she loses the urge to use the toilet. The resident also shared that the staff will tell her that its okay if she wets the bed/urinate in her personal brief; however, the resident stated that after 3 to 4 times it gets uncomfortable. Record review done on 5/24/13 at 2:00 P.M. found an Initial Data Collection Tool/Nursing Service dated 12/19/12 documenting the resident is continent of bowel and bladder and occasionally incontinent. Review of the quarterly Minimum Data Set with assessment reference date notes the resident is frequently incontinent of urine and always continent of bowel. Resident #172 requires extensive assistance with one person physical assist for toileting and is not steady and only able to stabilize with staff assistance for moving on and off the toilet. B) Resident #44 was interviewed on the morning of 5/21/13. When asked whether the staff treats him with respect and dignity, he replied no. He reported that there is not enough staff available to assist him when he wants to use the toilet and he has to yell for help. Review of the resident's annual MDS with assessment reference date of 1/21/13 notes he requires extensive assistance with one person physical assist to use the toilet. The resident was also noted to be always incontinent of urine and frequently incontinent of bowel. The subsequent quarterly evaluation with assessment reference date of 4/8/13 notes the resident is always incontinent of urine and bowel. Resident #44 scored 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). C) Resident #292 was interviewed on 5/21/13 at 10:15 A.M. The resident reported that when his legs are sore and he asks for help, the staff doesn't come right away. He stated he is told there's plenty patients beside me, so they come when they get a break. They say, yeah, yeah we coming, we coming. But when they say they gonna come back, by the time they come, I'm suffering already. On 5/22/13 at 10:30 A.M., Resident #292 reported that he sometimes has to wait for medicine a long time and he gets mad when staff tell him they will be right back and two hours later they come back. He shared that he has burning and needs help to reposition himself or no longer wants to sit and staff tell him to take a deep breath. The resident commented that this is bull[***]. While interviewing the resident, the resident's wife arrived and requested to add her comments to the interview. The resident's wife reported that although her husband presses the red button nobody comes, it takes a very long time. The resident's wife also reported that her husband had to ring the call light for his roommate when he fell . D) During resident interview done on 5/21/13 at 8:00 A.M., Resident #162 responded that she has to wait a long time for staff to receive care and assistance that she needs. The resident clarified that sometimes she has to wait so long for staff to assist her with toileting that she will pee in her pampers. Record review found a quarterly MDS with assessment reference date of 3/11/13 noting Resident #162 scored a 13 (cognitively intact) on the BIMS. She was noted to require extensive assist with two plus person physical assist for toileting. She was also noted to be occasionally incontinent of urine and frequently incontinent of bowel. E) During interview with Resident #135 on 5/20/13 at 11:00 A.M. the resident reported that she sometimes has to wait two hours for assistance. She reported that at night it is really bad and the facility is short of staff and the people out there don't want to work and say they are very busy. Resident #135 reported that her bed gets wet. Record review done on the afternoon of 5/24/13 found an annual MDS with assessment reference date of 4/2/13 documenting the resident scored a 15 (cognitively intact) on the BIMS. Resident #135 requires extensive assist with one person physical assist to use the toilet. She was also noted to be frequently incontinent of urine and always incontinent of bowel. 10) On 5/21/13 at 7:30 A.M. observed Residents #12, #186 and #162 seated on their unit with bath towels wrapped around their upper body, covering their chest and back. Interview with Resident #162 found that she wears the towel because she is cold. Inquired whether she has a sweater, she responded that she has a sweater; however, it is in the laundry. Observation on 5/22/13 during breakfast found the three residents having breakfast in the dining room with the bath towels wrapped around their upper body. On the morning of 5/28/13 Licensed Nurse #5 was asked why the residents have towels draped on their upper body. LN #5 replied it is because they are cold. Inquired whether these residents have sweaters. The licensed nurse responded that they have sweaters and would look into why they are not wearing their sweaters. 11) On 05/21/13 at 8:04 AM during Stage 1 of the survey, R#165 was interviewed. When asked the QIS question, Has staff yelled or been rude to you? The resident answered, Yes. The resident further elaborated that staff are impolite sometimes, and that he/she felt hurt when staff said, This is your medicine, you supposed to take it. The resident stated that he/she is educated and not a moron that doesn't know things. Med record review on 5/22/13 at 8:45 AM revealed that R#165 was admitted to the facility on [DATE] for a short-term course of physical and occupational therapy, to improve functional FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 4 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0241 Level of harm - Actual harm Residents Affected - Some (continued... from page 4) status. The resident's previous lifetime career was in insurance sales. R#165 was prescribed an anti-depressant with behavior monitoring for, sad mood, and sad face, and in the Month of May 2013, a 0 was written each day to document that the resident did not display signs and symptoms of depression. On 05/22/13 a facility, Concern and Comment, card was completed by LN#3, due to R#165 becoming upset that LN#3 wanted to provide insulin by subcutaneous injection while he/she was eating breakfast. The outcome of the facility investigation concluded that LN#3 would no longer provide services to R#165, as resident requested, (He does not understand me.); and, LN#3 was provided education on appropriate treatment times. 12) On 5/21/2013 at 8:00 AM during Stage 1 of the survey, interviewed R#327 for QIS interview. The resident stated that the staff cleans his/her dentures daily, but not if he/she was to ask as needed. The resident related that on 05/20/13 in the evening, he/she wanted to rinse dentures in the bathroom sink, and requested assistance from the CNA that delivered the dinner tray. The CNA's reply to R#327 was that he/she was too busy with the dinner meal service. The resident resorted to rinsing his/her dentures in hot miso soup that was on the dinner tray and gargled with water to rinse. The resident stated that had to do whatever could be done for him/her self; because There are a lot of, ' Schwarzenegger ' s, ' that work here. When asked to clarify, R#327 stated that whenever he/she requests help from staff their reply is, I'll be back. The resident was a quadriplegic and admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R#327 required extensive assistance for all activities of daily living, (ADL), due to generalized weakness. The resident's May 2013 monthly flow sheet for daily care documented under the Dentures Cleaned, section, that there were no check marks between and on the days of 5/18-20/2013. F 0242 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some <b>Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, record reviews, and staff interviews, the facility failed to provide 5 of 40 residents the ability to choose their preferred shower schedules. Findings include: 1) Interview of Resident #333, R #333, on the morning of 5/21/13 at approximately 9:00 A.M., revealed the resident had not received a shower since she was admitted to the facility on [DATE]. Interview of the resident on 5/22/13 at 12:45 P.M. revealed the R #333 still hadn't received a shower. She stated, I feel dirty, I want to take a shower. The resident finally received a shower in the late afternoon of 5/22/13. Record review on the afternoon of 5/22/13 found that R #333 was admitted to the facility on [DATE]. The facility was in the process of completing the Minimum Data Set (MDS) and the completed portions were reviewed. The Brief Interview for Mental Status (BIMS) revealed that R #333 had a score of 15/15, indicating her ability to appropriately recall items, colors, and numbers after a brief period of time. The MDS further indicated the resident was not experiencing problems with her mood and did not have problems with behavior. On the afternoon of 5/22/13, a review of R #333's Activities of Daily Living (ADL) flow sheets revealed the resident did not receive a shower since her admission on 5/14/13. The ADL flow sheets revealed the resident received a sponge bath on various shifts on these dates: 5/14/13 (evening & night); 5/15/13 (day, evening, & night); 5/16/13 (day, evening, & night); 5/17/13 (evening & night); 5/18/13 (day, evening, & night); 5/19/13 (day & night); 5/20/13 (day & night); and 5/21/13 (night). Review of the Bath List For Keolamau, Evening Shift on the afternoon of 5/22/13 found that R #333 was supposed to have received showers on Wednesdays and Saturdays, twice per week. The Bath List For Keolamau, Evening Shift also noted, Please don't make changes unless approved by (DON) or (staff name), Thank you. Interview of the Assistant Director of Nursing (ADON) on the afternoon of 5/23/13 at approximately 1:30 P.M. revealed that residents were given the ability to choose when/if they shower. If the resident wanted daily showers, the facility would try to accomodate them. The ADON explained that a sponge bath included a head to toe cleansing with a washcloth. The ADON was asked whether the night shift (11:00 P.M. to 7:00 A.M.) were actually providing residents with sponge baths. The ADON responded, Yes, probably. The ADON stated that aside from the nurses' quarterly review of CNA records, the nurses were not providing oversight of CNA documentation. 2) Interview of R #328 on the morning of 5/21/13 found that she wasn't given a choice for her shower days. She stated she would prefer showers every other day, not only Tuesdays and Fridays (her current schedule). The R #328 was alert and oriented to person, place and time. Record review for R #328 on the afternoon of 5/22/13 found documentation of the resident refusal for showers on: 5/7/13 night shift; 5/12/13 night shift; 5/14/13 night shift; 5/15/13 night shift. Interview of R #328 on the afternoon of 5/23/13 found that she never refused a shower. Interview of the Minimum Data Set-Coordinator #1, MDS-C #1, on the afternoon of 5/23/13 revealed that residents were allowed to choose their shower preferences and the facility would accomodate them. The MDS-C #1 was informed that R #328 preferred showers every other day. The MDS-C #1 stated she would note the changes and begin providing showers every other day for the resident. Observation on the morning of 5/24/13 found R #328 in the hallway with her hair wet. The resident stated she just received a shower and, It feels good. 3) During an interview with Resident #161 on 05/20/13 at 10:43 A.M., she said she did not have a choice in how many times a week she had a shower, but it was once every 4 days. She recalled once she was sweating a lot and asked for a shower, but was told by a staff that her scheduled shower days were once every 4 days. She was not offered a shower, but said she had really wanted a shower then. Review of ADL flowsheets showed the day, evening and NOC shift CNAs marked the May 2013 monthly flow sheet as having given the resident sponge baths and/or refused bathing. In addition, the resident's shower days documented a span of 7 days from one shower day to the next (5/10 and 5/17). During that period, it was marked that the resident also received up to 2 sponge baths daily. On 5/22/13, during a follow-up interview with the resident, she said when she counted her shower days, in my head--one time every 4 days. At 2:42 P.M., during an observation of an interview conducted by MDSC #1 with the resident, the resident stated she showered every 4 days and a sponge bath was given 50-50. The resident also said she never had gotten a shower at night and the staff also never wiped her down at night. The resident stated she perspired a lot and the most staff would do was to take off her shift and just wipe off her back, just change clothes, sometimes no even wipe off, towel? No, I don't think so. At 2:55 P.M., with the RD as the interpreter, the resident stated she had never received a head to toe sponge bath in her bed and did not even know what it was until it was explained to her by the RD. The resident also restated she had never been asked nor given a sponge bath by the night shift (NOC). Per an interview with MDSC #1 on 5/28/13, she said the documentation regarding the NOC shift was inaccurate. Per MDSC #1, she confirmed the NOC CNA never asked the resident about a sponge bath or that the resident refused a bath. MDSC #1 said the CNA marked off that it was done when it was not. MDSC #1 stated, I will be looking into how we are going to investigate about the CNAs not providing the service. She said given the number of sponge baths documented in the flowsheet, the staff should have offered more showers instead of those sponge baths, which the resident stated she never received. During a re-interview with Resident #161 on 5/23/13 at 9:15 A.M., she said regarding all the questions asked of her about the sponge baths and bathing, she did not even know what a sponge bath was until they explained it to her. The resident reiterated, Here, don't know what, who--they come in, no say nothing. The resident also said on the evening on 5/22/13, after all the discussion about the sponge bath, a social worker came to see her. Why all of sudden asking all kinds questions? I don't know. I likey go home already. 4) Cross Reference to F353. A family interview was done on 5/20/13 at 11:30 A.M. The family member reported that Resident #179 does not receive the same number of baths or showers in a week based on past preference. The family member shared that at home, Resident #179 received a bath daily and at the facility receives a bath twice a week. The family member reported although Resident #179 received a bath/shower daily at home, the preference would be for a bath/shower three times a week. A review of the resident's care plan for Activities of Daily Living notes to assist with bath or shower 2 times weekly, more often as desired. The Monthly Flow Sheet noted for the month of March 2013, the facility missed two showers and received a total of seven showers and for the month of April 2013, the facility missed five showers and received a total of four showers for the month. 5) On 05/21/13 at 7:53 AM on Stage 1 of the survey, R#165 was interviewed. When the resident was asked whether he/she could choose how many times a week to take a bath or shower, R#165 answered, No. The resident further elaborated that he/she used to take a shower 1-2 times a day at home, but at the facility, he/she was on a schedule and given a shower every 4-5 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 5 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0242 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some (continued... from page 5) The resident stated that he/she would want to bathe more often. The resident further stated that no one ever asked him/her how many times he would like to bathe, and didn't think of asking because facility had a schedule for baths. ON 05/22/13 at 5:23 AM reviewed R#165's Monthly Flow Report for the month of May 2013, that the CNA staff would check off for each day an ADL task was performed. The Daily Care Monthly flow sheet for May 2013 had a check mark under the shower section on 5/4, 5/8, 5/11, 5/16, and 5/18 in the evening shift row. Sponge baths were checked off from 5/01-5/21 if provided during the day, evening or night shift, and on some days R#165 received a sponge bath each shift. The Bathing Refused section had check marks during the night shift for May 2013, with the exception of 7 days left blank. On 5/22/13 at 7:44 AM interviewed R#165, who stated that a shower was provided only once a week, and his/her last shower was 8 days ago. According to R#165, the facility staff provided no explanation on why cannot shower more often but instead informed him/her that baths are scheduled. Reviewed R#165's care plan (CP), dated 4/27/13 for, ADL Self-care deficit: Requires asst w/ADL care, due to resident's inability to perform test for balance while standing without physical support. The CP approaches included: Asst with bath or shower 2 times a week or more often as desired; Explain all procedures and purpose prior to performing task and encourage self performance. F 0247 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>Give notice to the resident before a room or roommate change.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with resident and staff member and record review, the facility failed to ensure a resident received notice before the resident's roommate in the facility is changed. Findings include: Interview with Resident #135 was done on 5/20/25 at 11:00 A.M. The resident reported that she was not notified of receiving a new roommate. Resident #135 explained that new roommates are just brought into the room, introduced to her and then they just stay there. Interview with the Ward Clerk was done on the morning of 5/22/13. The clerk reported that Resident #135 had a new roommate in April; however, this resident has been discharged . Review of the new roommate's record noted that she was admitted on [DATE]. Review of Resident #135's record could not find documentation that the resident was notified of the new roommate. Interview and concurrent record review was done with the Assistant Director of Nursing (ADON) on 5/22/13 at 2:27 P.M. The ADON reported that social services usually document and notify residents of roommate change. Documentation could not be found in the record and the ADON was agreeable to follow up. At 2:45 P.M. the ADON returned and reported that the resident should have been provided documentation Room Transfer Notification by social services. The ADON confirmed that notification was not provided to Resident #135. F 0250 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>Provide medically-related social services to help each resident achieve the highest possible quality of life.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with family and staff and record review, the facility failed to: provide medically-related social services to attain the highest practicable psychosocial well-being for and discharge planning for 2 of 32 sampled residents in Stage 2. Findings include: 1) Cross Reference to F329 and F319. Resident #292 was admitted to the facility on [DATE] from an acute hospital. The resident presented with signs and symptoms of depression as indicated in the Social Service Assessment and administration of the Geriatric Depression Scale related to decline in activities of daily living and overwhelmed by the stress caused by his illness. Resident #292 also reported to social services that it would be better if he wasn't around. Record review and interview with Administrator #1 could not find documentation that social services were provided to address the resident's depression and the problems the resident was experiencing related to adapting to changes in his life's circumstances. 2) During an interview with Resident #329's family member on 5/22/13 at 9:30 A.M., the family member stated they have not been informed about any discharge plans for the resident and feared mentioning anything during the initial care plan conference for fear of being kicked out too soon. The family member was unaware the facility was a long term care facility and thought the resident was only here for rehab. The family member believed the resident was going to be discharged sometime soon, but did not know what was going to happen. The family member began to cry and stated the adjustment has been great stress. The family member stated at the care conference they discussed the resident's current situation/condition, but nothing about what was going to happen in the near future. The family member cried during the interview and stated the anxiety of not knowing was difficult to deal with. On 5/23/13 at 1:00 P.M., a discussion with MDSC #2 revealed that discharge (d/c) planning started when residents were admitted . LN #1 stated however, that d/c planning usually was done two weeks before discharge. She said the post-discharge plan was not done until the resident was closer to d/c when the type of services the resident needed was determined. LN #1 said the social worker would follow up with the family and for Resident #329, they already completed the initial intake. Per the Interim Administrator (IA), he stated there were weekly discharge planning progress notes. He also said a staff in payroll/billing was currently helping with the intake questions for social services as the facility recently lost their SW and two social service designees. Interview with the business account staff (AR #1) stated on 5/13/13 found she spoke to the resident's family members. She noted one family member would leave their job in the event the resident was discharged . However, AR #1 confirmed she left a section regarding the anticipated discharge/transfer blank and that should have filled it out. In addition, AR #1 marked Unknown about whether the resident had family capable of and willing to provide assistance post-discharge. There was no further documentation that the IDT reviewed progress toward discharge during weekly discharge meetings.assist with referrals to community resources prior to discharge, assist with paperwork process, as stated in the discharge care plan. In addition, the IA was asked to produce documentation regarding the weekly discharge meeting as outlined in the resident's discharge care plan of 5/7/13. The Interim Administrator stated it was too early to know. The IA later confirmed he did not have any additional documentation about the resident's discharge planning, except for what the therapist noted on 5/14/13. On 5/24/13 at 10:40 P.M., during a reinterview with a family member, the family member said he/she had not been informed about any discharge process and reiterated he/she wanted to know, What's going to happen? He's a human. I don't know who to ask. I don't even know what's really happening to him. The doctor told me he has a stroke, but I already know that. That's not what I want to know. What's going to happen to him? The family member said no resources have been provided to them and that no social service representative has met with them to go over things. Review of the facility's policy and procedure, Discharge Plan (Rev. 6/17/08), it stated, Social Services staff, as members of the interdisciplinary care plan (ICP) team, participate in developing a discharge plan for residents with potential for discharge to a private residence.and care home. The discharge plan is used to assist the resident in preparing for discharge and to address continuing care needs after discharge. When the ICP team determines that a resident has potential for discharge in the next quarter, Social Services staff address the following. Necessary supportive relationship in the community to meet emotional needs, The cost of needed services and financial resources necessary to pay for services, Education needed by the resident and/or family about available community resources and how to access those services, Needs for emotional support to assist in adjustment to the new living environment. The need for a discharge plan is assessed upon admission. The discharge plan is incorporated into the resident's ICP. The interviews with the resident's family members revealed this was not implemented for the resident in accordance with the facility's policy on discharge planning. On 5/28/13, the Regional Chief Nurse Executive (CNE) met with the family as per the family member's request, and because the resident had a recent change in his condition. The CNE informed the surveyor that, from now on, there will be ongoing discussions with family about the discharge planning process. F 0253 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>Provide housekeeping and maintenance services.</b> Based on observation and interview with staff member, the facility failed to provide housekeeping services necessary to maintain a sanitary interior. Findings include: On 5/20/13 during the initial tour of Wailani, observation in the men's shower across Room 202 found a bucket with black substance scattered on the inside of the bucket. Interview and concurrent observation was done at 8:25 A.M. with C.N.A. #1. The aide identified the bucket as the catchment for the commode and when asked what the black substance was in the bucket, the aide replied probably poop and apologized. F 0280 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>Allow the resident the right to participate in the planning or revision of the resident's care plan.</b> <b>Allow the resident the right to participate in the planning or revision of the resident's care plan.</b> FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 6 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0280 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few (continued... from page 6) **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the residents' care plans were revised and/or updated to reflect the residents' current status for 2 of 32 residents in the Stage 2 sample. Findings include: 1) Cross-reference to findings at F312. For Resident #329, the facility failed to update the plan of care related to the resident's oral health and failed to ensure the staff delivered the oral care/hygiene regimen in a consistent manner. Cross-reference to findings at F312 for additional details. Resident #329 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's BIMS score coded on the 5 day PPS MDS assessment was 5. The resident also required extensive assistance in his activities of daily living (ADLs). A care plan for ADL self-care deficit as evidenced by a need for extensive to total dependence due to his medical condition had been developed. On 5/24/13, although LN #1 reported the ST made a clarification to the order, she acknowledged the resident's care plan had not been updated nor revised to reflect the ST's oral care regimen of 5/14/13. LN #1 confirmed it had not been communicated to the nursing staff nor the physician. Thus, as it was not implemented in the care plan, the staff failed to follow and deliver the treatment/services to maintain the resident's optimum oral health and hygiene. 2) Resident #292 did not have a history of falls before his admission to the facility. On 4/14/13 he fell from his wheelchair. Based on an assessment to address the identification of causal factors, the resident's care plan was not revised to prevent subsequent falls. Interview with licensed nurse was done on 5/20/13 at 12:30 P.M. The licensed nurse reported that Resident #292 fell on [DATE]. Interview and concurrent record review was done with MDSC #1 on 5/22/13. A progress note documents that on 4/14/13 at 12:25 P.M., an alarm was heard and Resident #292 was found on the floor. The resident fell from his wheelchair while seated in front of the television by the nurses station. He sustained a skin tear on the right forearm. The ADON interviewed the resident and he stated that he was trying to reposition himself while seated on the wheelchair. On 5/22/13 at 10:45 A.M., the resident's wife commented that her husband fell out of the wheelchair while in the activity area and can't see how that would happen when there are people around him. Record review found a care plan for falls (onset date of 3/28/13) related to limitations in mobility, unable to perform test for balance while standing without physical support and admission [DIAGNOSES REDACTED]. times; assess for participation in the falling star program as needed, apply hip protector at all times as needed, except during showers; and assess for pain and offer pain medication as ordered. Also noted on the care plan was a handwritten note 4/14/13 Actual Fall. Under the approaches column a handwritten note was added for hip protector. Interview was done with LN #1 on 5/23/13 at 10:30 A.M. Inquired who updates the resident's care plan after a fall, the nurses or MDSC? LN #1 reported she would check with MDSC #1. On 5/23/13 at 10:40 A.M. LN #3 was interviewed. Inquired who updates the resident's care plan after a fall. LN #3 responded the person who found the resident or the nurse in charge of the resident. The LN #3 clarified that a hip protector will protect the resident's hip if he should fall again. At 10:47 A.M., MDSC #1 joined the interview. The MDSC reported that the clip alarm has been added, concurrent review of the care plan found that this was not added to the care plan. Also, informed her that he already had a clip alarm at the time of the fall as the staff member reported to hear the alarm, responded and found the resident on the floor. Also of note was that the hip protector was already included in the resident's care plan. Inquired what causal factors were identified that contributed to the fall with a reminder that the resident reported he was repositioning himself when he fell out of the wheelchair. The MDSC #1 updated the resident's care plan to include the clip alarm. On 5/23/13 at 11:00 A.M., the ADON was interviewed and concurrent review of the resident's record was done. The ADON reported that the resident is not able to position himself in the wheelchair related to left sided weakness. The ADON was not sure whether positioning in the wheelchair was addressed in rehab and would have to follow up with them. The ADON confirmed that the care plan was not revised to include evaluation by rehab for positioning. On 5/23/13 at 11:15 A.M., the facility provided a copy of the Rehabilitation Services, Post-Fall Screening Tool. The document notes the resident reported that he was attempting to reposition himself due to anal pain and fell out of the wheelchair. The Falls Committee suggestions included: wheelchair pressure alarm and bed pressure alarm and resident to only be up in wheelchair for 2 hour periods until wound heals. F 0281 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some <b>Make sure services provided by the nursing facility meet professional standards of quality.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview and review of the facility's policies and procedures, the facility failed to ensure professional nursing standards of practice were followed for 4 of 32 residents in the Stage 2 sample. Findings include: 1) During an observation of Resident #161 on [DATE] at approximately 7:52 A.M., she stated, I don't feel too good and her legs were visibly shaking. LN #4 came in to assess the resident and proceeded to take the resident's blood pressure (BP) and oxygen saturation level. She then told the resident, I'd encourage you to eat your breakfast. The resident's legs were still shaking. Surveyor asked LN #4 if the resident's blood sugar was taken. LN #4 replied, around 5 minutes ago and it was 72. The resident told LN #4 she did drink some juice earlier. LN #4 however, proceeded to assess the resident's lung status asked her if she wanted some cough syrup. Resident #161 restated she did not feel good. LN #4 did not respond to the resident about that, and also failed to notice the resident did not have a meal tray either. LN #4 then stepped out of the room and at 8:00 A.M., the RD came in. The RD asked the resident how she was and the resident said, I'm shaking, nervous. Sugar low that's why. RD informed her she was going to check with her nurse right away. At 8:03 A.M., the Medical Director (MD) came to assess Resident #161. He asked her to take some deep breaths, and the resident told him her sugar was low. The MD stated they were going to take care of it. The resident also said she had some cramping, just went shi-shi.go home, when? The MD stated, We gotta get you better first. We can't send you home like this. He said he would talk with the nurse, to get your blood sugar and breathing better. Keep taking deep breaths through your nose. The MD stepped out, spoke to the nurse and ordered a Mighty Shake to be given to the resident along with other orders. During a discussion with the MD at 8:55 A.M., the MD acknowledged there was an issue with the way the licensed staff assessed Resident #161 earlier. The MD affirmed a lot of had to do with the licensed nurse's assessment and critical thinking skills. Surveyor expressed concern that despite the resident stating she did not feel good and visibly shaking, LN #4 just encouraged the resident to eat something after assessing her, but failed to ensure the resident was provided with something to eat and failed to monitor the resident. He affirmed it was basic nursing care that was missed in this instance, and these issues were an on-going struggle with the licensed staff. In addition, review of the facility's policy and procedure on Diabetic Care, (Rev ,[DATE]), for Hypoglycemic Reaction.The nurse must use good clinical judgment in the treatment of [REDACTED]. The resident's care plan also included approaches to observe for signs and symptoms of unstable blood sugar levels, which included tremors, shaking, and to offer substitutes, supplements or alternative choices PRN. 2) Resident #161 had a [DATE] treatment order date for oxygen (O2) at 2 liter/min via nasal cannual (NC) for respiratory distress as needed. On [DATE] and [DATE], the resident was observed with O2 via a NC. During a review of Resident #161's treatment record (TAR) for [DATE], it showed there was no documentation marked on [DATE] and [DATE] for the resident's O2 use. In addition, a new entry on the TAR dated [DATE] noted, Change O2 tubing weekly with [DATE] marked as done. The next tubing change date was to be [DATE]. During the initial interview with Resident #161, she stated her NC had not been changed for approximately three weeks until an aide told her that was not right and changed it for her. In addition, on ,[DATE] and [DATE], during random observations of the resident, it was noted the sterile water connected to the resident's oxygen concentrator was not dated/initialed. On ,[DATE], the sterile water attached to the O2 concentrator was not dated/initialed. However, on [DATE], it was dated. On [DATE], during an interview with the DON, she said the humidifier (sterile water) had to have a date on it. She said however, the NC did not have to be dated. Yet, there was a new entry in the TAR dated [DATE] to change the O2 tubing weekly. Thus, it was not clear what the procedure was to ensure resident care items were monitored and replaced consistently. Within the TAR, there was another entry, Monitor O2 sat q 4 h prn per (family member) request). On [DATE] at 8:17 A.M., per LN #1, she said there was no physician's order for this and there were no parameters for it, such as to call the MD if the O2 sat was below a certain percentage. LN #1 confirmed with the missing documentation in the TAR, unlabeled items, and no physician's order, this did not meet the nursing standard of care practices nor for clinical documentation. She said, Yes, they (nurses and aides) need more education. LN #1 also confirmed for the use of pain medication, the assessment should include documentation for the effect of the intervention and the administering nurse has to follow-up with. 3) On [DATE] at 7:20 A.M., Resident #329 was observed in his room with two staff repositioning him. MDSC #3 confirmed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 7 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0281 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some (continued... from page 7) the resident's tube feeding (TF) closed system had a manufacturer's label, but was not filled out with the resident's name, type of enteral nutrition (EN) formula, start date and time and ordered rate. MDSC #3 said, it should have everything written on it and verified it was not done. She also said the tubing expired in 48 hours and there was no date when it was first used. She was unsure when the EN expired and thought it was to be used within 24 hours. However, with no start date/time written on it, she stated it should be discarded. On [DATE], surveyor observed the resident's name on the EN label with [MEDICATION NAME] 1.2 cal, room number, date, start time of 0500 and rate of 320 ml x 5 written on it. The tubing was also dated ,[DATE] 12 am and initialed. The water flush bag was dated ,[DATE] 12 pm with the resident's name and room number. On [DATE] at 9:55 A.M., LN #1 produced the facility's EN TF policy and procedure. She said it did not state what the licensed staff's responsibility included for labeling the EN bottle. LN #1 said however, it should include the resident's name and for all licensed staff, they are supposed to fill in the information on the label. LN #1 also said the tubing was to be labeled. The American Society for [MEDICATION NAME] & Enteral Nutrition (ASPEN), Enteral Nutrition Practice Recommendations, March/[DATE], Vol 33, No 2, ,[DATE], p. 129, noted for the labeling of enteral nutrition, To avoid misinterpretation, a label should be affixed to all EN formula administration containers (bags, bottles,.). The label should reflect the four elements of the order form and therefore contain the following: patient demographics, fomula type, enteral access delivery site/access, administration method, individuals responsible for preparing and hanging the formula, and time and date formula is prepared and hung.All EN labels in any healthcare environment shall express clearly and accurately what the patient is receiving at any time. Having standard components on a label decreases potential confusion when a patient is transferred to a different unit within a facility, or when a new staff member takes over a patient's care.Clear labeling that the container is 'Not for IV Use' helps decrease the risk for an enteral misconnection. Proper labeling also allows for a final check of that enteral formula against the prescriber's order. Care should be taken in developing a label that is clear and concise and of a size that fits neatly on the container. 4) On [DATE] at 11:10 A.M., LN #4 was observed passing medications to Resident #336. She stated he was a newly admitted resident and was going to give [MEDICATION NAME] for leg [MEDICAL CONDITIONS] and [MEDICATION NAME] for gout. After the resident took his medication, LN #4 asked the resident if he had any pain. Resident #336 replied yes and that his pain was 5 out of 10 on the pain scale described to him. LN #4 said okay, and was going to walk out of the room without further assessing his pain. Surveyor asked LN #4 if she was going to assess what the resident told her about his pain level, and LN #4 said, oh yeah. She went back to ask questions, and the resident said he had sharp pain that radiated down his legs. The resident stated he would accept Tylenol for pain relief. At the medication cart, LN #4 acknowledged she should have probed about the resident's pain instead of walking out. She said 5 out of 10 was, moderate pain and should not be ignored. At 11:17 A.M., the resident received Tylenol 325 mg, 2 tabs orally. It was also noted the resident had been transferred from an acute setting for which he was admitted with left popliteal pain. Review of the facility's, Competency-Based Position Description and Performance Review Registered Nurse (RN) (Rev [DATE]) produced by LN #1, stated, Specific Requirements - Must possess the ability to make independent decisions when circumstances warrant such action, Must be knowledgeable of nursing practices and procedures as well as the laws, regulations and guidelines governing nursing functions in the long-term care facility.Essential Functions - Must be able to knowledgeably and competently deliver basic nursing care to residents, Must be able to evaluate resident's needs through ongoing assessment and revised care plan based on changes in resident's condition,.Must be able to concentrate and use reasoning skills and good judgment. 5) On [DATE] at 10:14 AM observed LN#9 administer medication to R#152. The resident requested [MEDICATION NAME] and stated that his/her head was sore. The LN#9 provided one tab of [MEDICATION NAME] to R#152, and stated that resident would not be given routine [MEDICATION NAME] since provided [MEDICATION NAME]. The surveyor informed LN#3 that cannot provide advice, and that physician orders, (PO), should be followed. On [DATE] at 10 AM reviewed R#152's [MEDICATION NAME] prescription as written on the PO dated [DATE]; [MEDICATION NAME] 1 tab every 4 hours (hrs) for moderate pain and 2 tabs for severe pain. Inquired of LN#3, how staff would determine pain severity. LN#3 showed the Medication Administration Record, [REDACTED]. Reviewed the MAR form for [MEDICATION NAME] with LN #3 and on [DATE] when R #152 received the [MEDICATION NAME] tab for headache, there was no documentation why prescription was provided. LN#3 later found documentation written on [DATE] by LN#9 that [MEDICATION NAME] was provided to R #152 for bilateral lower extremity, (BLE), in the electronic medical record. On [DATE] at approximately 10:30 AM verified with R #152, reason he/she asked for [MEDICATION NAME] on [DATE] during the AM med pass and resident stated that he/she has migraines. Inquired where else does R#152 have pain that would ask for [MEDICATION NAME], and the resident stated, On my okole, (posterior), from the pressure ulcer, my back, and sometimes my left shoulder. Inquired if he/she has pain in the legs or feet and resident replied, No. R#152 further stated that the facility did not have [MEDICATION NAME] available, so asked for [MEDICATION NAME] instead. The resident further stated that he/she wants to talk to the Doctor to let him know that [MEDICATION NAME] does not help with the migraines. On [DATE] at 2:00 PM interviewed the Med Dir at the Keola Mau nursing unit regarding LN#9 not providing routine [MEDICATION NAME] due to the use of [MEDICATION NAME] for migraines. The Med Dir stated that the PO should be followed and LN#9 should not have made her own determination on use of pain med's. The DON listened in on the discussion, went to the med cart, and found the [MEDICATION NAME] blister pack for R #152 in the narcotic drawer. The [MEDICATION NAME] blister pack was dated [DATE] and according to the DON would have been available from that date.
    • F 0309 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some <b>Provide necessary care and services to maintain the highest well being of each resident</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and medical record reviews, the facility failed to ensure that 3 of 32 residents in the Stage 2 survey sample received the necessary care and services to help these residents attain or maintain the highest practicable level of well-being by preventing or managing pain. Also for one resident, the facility failed in managing the interchange of [MEDICAL TREATMENT] information. Findings include: Cross-reference to F 281 1) On 05/22/13 at 10:14 AM observed LN#9 administer medication to R#152. The resident requested [MEDICATION NAME] and stated that his/her head was sore. The LN#9 provided one tab of [MEDICATION NAME] to R#152, and stated to surveyor that resident would not be given routine [MEDICATION NAME] since provided [MEDICATION NAME]. The surveyor informed LN#3 that cannot provide advice, and that he/she should just follow physician orders, (PO). On 05/23/13 at 10 AM reviewed R#152 PO for [MEDICATION NAME] prescription as written on 05/17/13, [MEDICATION NAME] 1 tab every 4 hours (hrs) for moderate pain and 2 tabs for severe pain. Inquired of LN#3, how staff would determine pain severity. LN#3 showed the Medication Administration Record, [REDACTED]. Reviewed the MAR form for [MEDICATION NAME] with LN #3 and on 05/22/13 when R #152 received the [MEDICATION NAME] tab for headache, there was no documentation why prescription was provided. LN#3 later found documentation written on 05/22/13 by LN#9, that [MEDICATION NAME] was provided to R#152 for bilateral lower extremity, (BLE), in the electronic medical record. On 05/23/13 at approximately 10:30 AM verified with R #152, reason he/she asked for [MEDICATION NAME] on 05/22/13 during the AM med pass and resident stated that he/she has migraines. Inquired where else does R#152 have pain that would ask for [MEDICATION NAME], and the resident stated, On my okole, (posterior), from the pressure ulcer, my back, and sometimes my left shoulder. Inquired if he/she has pain in the legs or feet and resident replied, No. R#152 further stated that the facility did not have [MEDICATION NAME] available, so asked for [MEDICATION NAME] instead. The resident further stated that he/she wants to talk to the Doctor to let him know that [MEDICATION NAME] does not help with the migraines. On 05/23/13 at 2:00 PM interviewed the Med Dir at the Keolamau nursing unit regarding LN#9 not providing routine [MEDICATION NAME] due to the use of [MEDICATION NAME] for migraines. The Med Dir stated that the PO should be followed and LN#9 should not have made her own determination on use of pain med's. The DON listened in on the discussion, went to the med cart, and found the [MEDICATION NAME] blister pack for R #152 in the narcotic drawer. The [MEDICATION NAME] blister pack was dated 05/21/13 and according to the DON would have been available from that date. 2) On 05/23/13 at 2:00 PM also reviewed R152's medical record for the [MEDICAL TREATMENT] Communication form. The most current [MEDICAL TREATMENT] Communication form was dated 05/18/13, on which [MEDICAL TREATMENT] staff ordered that [MEDICATION NAME] be increased to 60 mg effective with that evening meal. Reviewed R#152's PO and could not find prescription for [MEDICATION NAME] at 60 mg. Interviewed the Med Dir on the [MEDICAL TREATMENT] communication process regarding the 05/18/13 prescription change of [MEDICATION NAME] by R#152's Nephrologist. The Med Dir looked at the resident's PO, MAR, progress notes, and his communication folder, and could not find documentation regarding the dosage increase for [MEDICATION NAME] on 05/18/13. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 8 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0309 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some (continued... from page 8) Med Dir conferred with LN#3, who stated that usually a copy of the [MEDICAL TREATMENT] Communication form would be placed in the Med Dir's communication folder when there are prescription changes. The Med Dir stated that he would review all prescription changes from the [MEDICAL TREATMENT] facility and would communicate to the LN. The PO would be transcribed to the PO and/or signed if it was via telephone order to the LN. The Med Dir further stated that if he did not agree with prescription changes would confer with the Nephrologist and document in progress notes. The Med Dir acknowledged that the [MEDICAL TREATMENT] communication process needed to be corrected; and, asked LN#3 to call LN#10, that received the [MEDICAL TREATMENT] Communication form on 05/18/13 to find out why he was not informed of prescription change. On 5/24/13 at 8:45 AM observed R#152 being transferred on a gurney for a MD appt., the resident stated that his/her catheter for [MEDICAL TREATMENT] came out last night. Went to review R152's medical record for the [MEDICAL TREATMENT] communication form and progress notes in the electronic medical records about the resident's internal jugular, (IJ), perma catheter, (cath), coming out and could not find documentation. Interviewed LN#1 at 10:14 AM who reported that she spoke with the RN that was on duty the evening of 05/23/13, (Thurs), and found out that the computer was down that night but staff has 48 hrs to document in progress notes. LN#1 stated that the [MEDICAL TREATMENT] facility had called the Med Dir the afternoon of 05/23/13, and informed him that the IJ Perma cath was still intact but coming loose. The Med Dir advised the [MEDICAL TREATMENT] staff to tape down the IJ perma cath, and he was to look at it when the resident returned to the facility. There was no [MEDICAL TREATMENT] Communication form in R#152's medical record and/or progress notes in the EMR pertaining to the resident's IJ Perma cath becoming loose. According to LN#1, the RN that was on duty the evening of 05/23/13, had planned to document incident on the afternoon of 05/24/13, which is within the 48 hr timeframe to document. On 5/24/13, (Fri), at 3:51 PM reviewed the Med Dir progress notes dated 05/24/13 at 12:18 PM, that documented that R#152 was assessed by the Med Dir upon return from [MEDICAL TREATMENT] on 05/23/13, and that the [MEDICAL TREATMENT] facility had already scheduled the 05/24/13 MD appt. to replace the IJ perma cath. The Med Dir documented that the resident ' s IJ perma cath became loose during [MEDICAL TREATMENT], was secured with tape but came out completely the evening of 05/23/13 when he/she returned to the facility. The Med Dir Also assessed the resident's complaint of headaches and how pain med provided no relief. The Med Dir diagnosed R#152 with cluster type headaches and prescribed a new medication that the resident was willing to try. On 05/28/13, (Tues), at 10:37 AM reviewed R152's medical record, and looked at the nursing notes dated 05/25/13, (Sat), at 8:47 PM that documented that the resident returned to the facility from [MEDICAL TREATMENT] at 5:30 PM with his/her perma cath to the left chest intact and dry. The nursing note further documented that R#152 complained of a migraine and she was given a tab of [MEDICATION NAME]. Interviewed LN#3 and asked how staff would be alerted of a prescription change by a physician to treat migraines. According to LN#3, the MD would transcribe in the PO to alert LN of change. There was no PO for the prescription change for migraines as noted in the Med Dir assessment done on 05/23/13. The resident was administered [MEDICATION NAME] for complaints of headache throughout the 3 day Memorial Day weekend. On 05/29/13 at 7:45 AM, interviewed the Med Dir regarding prescription change for R#152 for migraines, and the Med Dir stated that the PO was written on 05/28/13 at 10:45 AM because the resident returned to the facility at 5:30 PM on 05/24/13 (Friday). Also discussed that there was no [MEDICAL TREATMENT] Communication form on 05/23/13 when the resident's IJ perma cath became loose and late documentation for critical information regarding resident's lifeline. The Med Dir acquiesce that communication and documentation between the facility and [MEDICAL TREATMENT] center could be improved. The DON provided the facility's policy and procedures, (P&P), for [MEDICAL TREATMENT] with the heading of Clinical Services Policies & Procedures, Nursing Volume 1, Treatments, and Chapter 10. In this P&P, it is noted under the Procedure section for Post-[MEDICAL TREATMENT], 3. Transcribe any diet, medication, and/or orders received with resident from the [MEDICAL TREATMENT] facility; and, 7. Maintain [MEDICAL TREATMENT] transfer form in the resident's medical record - do not destroy. Under the General Guidelines section, 6. Document in the clinical nursing record: [MEDICAL TREATMENT] treatment completed, order changes, condition of shunt site, complaints from resident (if applicable), and whether physician was notified. The P&P for physician's orders [REDACTED]. Receiving a written order: a. Physician or other licensed independent practitioners must write order on order sheet.3. Transcribing the orders: a. Write order with black ballpoint pen on Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].5. When an order is changed, treat old order as if it has been discontinued. Write the change order in a new block and treat it as a new order. Never cross out or alter any part of an order. Both P&P's did not provide a timeframe, (e.g. within 48 hrs), for transcribing changes to the PO from the [MEDICAL TREATMENT] communication form, or when a physician changes a medication order. 3) On 5/22/13 at 7:23 A.M., LN #3 was observed taking Resident #161's O2 sat and it showed to be 97% on room air. The resident was dressed in her night clothes, had a towel wrapped around her head and was conversant. She stated although her chest felt tight, felt a little better after a rough night due to her breathing problems. LN #3 said the resident had been complaining of being unable to breathe. A family member also present, then asked LN #3 if there was anything to relieve the resident's complaints of knee pain. LN #3 said he would have to check and left the room. It was noted that LN #3 did not ask nor assess the resident at that time for any complaints of knee pain. After he left, the resident said, Ahh, I likey go home already, shook her head and then stated in Japanese, how tired she felt being here and uncertain of the care she was receiving. At 7:35 A.M., the family member said LN #3 hasn't brought anything yet for the resident's knee pain. At 7:37 A.M., LN #3 was observed during the change of shift counting medications with the day nurse. At 8:05 A.M., LN #8 said LN #3 only endorsed that Resident #161 was given a medication at night to help with breathing, but did not receive any endorsement related to pain. At 8:10 A.M., surveyor queried LN #3 what the status was about checking on the resident's knee pain. He said he did not forget and personally was going to check, thus did not endorse it to the day nurse. He thought there was an ointment and at that time, went to get her chart. After reviewing the resident's chart and 40 minutes later, LN #3 said there was nothing ordered for knee pain. LN #3 acknowledged he did not assess the resident for the knee pain after the family member requested something for it, and said he did not know if the resident actually had the knee pain when he left her side at 7:23 A.M. LN #3 also confirmed this was something he should have done, but now it was now 45 minute later and the resident nor family had any response yet. At 8:17 A.M., LN #3 went to assess Resident #161, who told him she has dull pain to her kneecap, and said, Oh I cannot tell you how high or low, I think weather change time, dull pain. LN #3 said he would have to check with the doctor and at 8:28 A.M., LN #3 said the in-house physician was going to see the resident. The facility's policy on Pain Management produced by LN #1 on 5/28/13 with Handout #2 attached, stated, What do we do to care for resident's who cannot report pain, due to.or communications difficulties?.Always remember to evaluate resident's by touching, moving and looking at our resident's in detail, to confirm that the signs and symptoms are due to pain. Further review of the May 2013 MAR for Resident #161 noted for two entries on 5/7/13 and 5/10/13, the follow-up assessment time and result of the pain medication administeration were not documented. 4) For Resident #336, cross-reference findings to F281.
    • F 0312 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with family members, residents and staff members, and record reviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene for 3 of 3 residents whom were sampled for ADL care in Stage 2. Findings include: 1) Observation of Resident, R #272, on the afternoon of 5/21/13 found she was dependent on staff to provide her with personal care to include showers and oral hygiene. On the morning of 5/22/13, a review of the May 2013 Monthly Flow Report noted the resident received sponge baths on all 3 shifts: day, evening, and nights from 5/7/13 to 5/21/13. The R #272 was scheduled to receive showers on Mondays and Thursdays. From 5/1/13 to 5/5/13, the resident did not receive any showers. A shower was provided on 5/6/13 (Monday), 7 days later on 5/13/13 (Monday); and 8 days later on 5/21/13 (Tuesday). There was no documentation to show the resident refused showers. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/13 found the resident was totally dependent on staff with bathing and required 2 person assistance. A review of the MDS with ARD of 4/20/13 found the same, total dependence and required 2 person assistance. Interview of the MDS-Coordinator, MDS-C #1, on the afternoon of 5/23/13 found that the resident should have received additional showers. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 9 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0312 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few (continued... from page 9) MDS-C #1 stated the Rehabilitation staff were also working with the resident and may have provided the resident with showers for home training. However, the documentation was separate and not part of the Monthly Flow Report. The MDS-C #1 was able to show documentation from Rehabilitation staff that she did receive an additional shower on 5/8/13. The MDS-C #1 stated the same Certified Nurses Aide (CNA) was on duty when she didn't get her showers. 2) For Resident #329, the facility failed to ensure the resident's oral health/hygiene was maintained by failing to provide the services as evidenced by the clinical documentation, family and staff interviews. Resident #329 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's BIMS score coded on the 5 day PPS MDS assessment was 5. The resident also required extensive assistance in his activities of daily living (ADLs). A care plan for ADL self-care deficit as evidenced by a need for extensive to total dependence due to his medical condition had been developed. The goal was for the resident to participate as able in his daily ADLs with staff assistance. One approach listed on the ADL self care deficit care plan was for oral care to be provided by nurse aides or licensed staff twice daily and as needed with a suction toothbrush. However, during an interview with different family members on 5/21/13 at 8:55 A.M. and on 5/22/13 at 9:30 A.M., both family members stated the resident's oral care was inadequate and it was dependent on which staff performed it. One family member said their concern was that certain staff did not provide the routine oral care for the resident. The family member stated some staff were trained by the speech therapist (ST) on how to use the suction machine to clean the resident's teeth and mouth, but not all. The family member said about 2-3 days ago, there was a staff who told the family member she did not know how to use the suction toothbrush and thus, did not do the oral care. The family member stated the resident's lower lip was stuck to his teeth and there was brownish build up. The family member said they felt, very bad for (resident) when I saw him. So disappointed that they cannot do for (resident). That's not good. A review of the resident's oral assessment dated [DATE] showed he did not have dentures and had some missing upper teeth and lower teeth. During an interview with MDSC #1 on 5/22/13 at 10:24 A.M., she said the ADL plan was the comprehensive care plan and staff who were trained signed off on it. On 5/23/13 at 10:45 A.M., LN #1 said the resident's oral care should be done with the nurses every shift as needed or when the resident was being suctioned. A concurrent review of the ST's 5/14/13 note stated the resident required oral care every 2 hours and were to use the suction toothbrush with peroximint min 2x/day. If unsure as to how to use suction toothbrush speech therapist can train you. Two licensed nurse, one occupational therapist and one CNA had signed off as being trained from 5/14 - 5/15/13. LN #1 said, This is what the nursing staff should be doing. LN #1 said since it was from the ST, it was also to be in the physician's orders [REDACTED]. This way everybody knows, not just those who were trained to do it. Review of the resident's Monthly Flow Report for Daily Care for May 2013 revealed the section which the CNAs documented Teeth Brushed did not have an entry for 5/8/13 for the day and evening shift to indicate that resident's oral care was completed. There were an additional 6 entries between 5/11 - 5/13/13 for the day and evening shifts and an evening shift entry on 5/20/13, which indicated oral care was not done. All of the night shift entries were not marked, which LN #1 said it meant that oral care was not done on the night shift. 5/23/13 at 2:27 P.M., CNA #4 said the ST told her, do toothbrush suction at least twice day to make sure his mouth not dry. He easily get dry skin on lips inside mouth, tongue--we use toothettes. CNA #4 said she did the resident's oral care with toothbrush suction first and inbetween if tongue or mouth dry, I use the toothettes and moisturizer for the lips. Peroximint is for suction toothbrush. She also said, I know evening shift doing it (suction toothbrush) and night shift doing toothettes. I not sure if night doing suction. Regarding the ST note, she said the toothettes should be used every 2 hours and the suction toothbrush was 2x day. CNA #4 restated the evening and night shifts should do, every 2 hour care using the toothettes. On 5/24/13, although LN #1 reported the ST made a clarification to the order, she acknowledged the resident's care plan had not been updated nor revised to reflect what was supposed to have been done to ensure the resident received the proper oral care. This had not been communicated to the nursing staff nor the physician and thus, had not been implemented to ensure services to maintain the resident's oral care/hygiene was being delivered accordingly. 3) A family interview was conducted on 5/21/13 at 11:30 A.M. The family member reported that she has mentioned to the facility that oral care is not being provided to her parent (Resident #179) as evidenced by bad breath and there are times when there is a build up of saliva on her mother's lips. Observation on 5/24/13 at 8:00 A.M. found Resident #179 in bed with her eyes open. There was an indistinct odor in the room and the resident had two white lines on her lower lip. At 8:10 A.M. concurrent observation was made with the ADON. Inquired what these white lines were on the resident's lip. The ADON took out a swab and assessed that this was dry skin on the resident's lip as the resident is a mouth breather. The ADON reported that she did not want to attempt to remove the dry skin as she did not want to tear the resident's lip. Record review noted Resident #179 requires extensive assist with two person physical assist for personal hygiene. The care plan for Activities of Daily Living notes resident has ADL self-care deficit as evidenced by: requires 1-2 person total dependence with daily care; impaired mobility r/t left [MEDICAL CONDITION]; and impaired cognition r/t [MEDICAL CONDITION]. The approaches include oral care every shift and prn. A review of the Monthly Flow Report notes oral care was not provided during the night shift for: March 2013 (x7); April 2013 (x2); and from 5/1/13 to 5/23/13 (x3). F 0314 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that it were unavoidable for 1 of 2 sampled residents of the 32 residents who were included in the Stage 2 sample. Findings include: Record review done on 5/22/13 notes Resident #292 was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. Review of the 30 day MDS with assessment reference date of 4/29/13 documents the resident had a Stage 2 pressure ulcer to the coccyx. A review of the Pressure Ulcer Status Record notes a Stage 2 pressure ulcer was first observed on 4/17/13. The measurement was 1.8 (L) x 3 (W) cm. On 4/24/13 the measurement was 4 (L) x 3 (W) cm. On 5/3/13 an entry notes the wound extended to upper left buttock. On 5/13/13 the pressure ulcer was documented as healed. Interview was done with the Wound Nurse (WN) on 5/23/13 at 11:00 a.m. The WN confirmed that the resident acquired the pressure ulcer in the facility. Inquired what contributed to the break down, the WN replied it would be moisture and pressure. The WN reported that the resident wanted to stay in bed to offload pressure from sitting down. The WN confirmed that this resident is being seen in rehab. The WN reported that the Occupational Therapist noticed the open area on the buttocks while assisting the resident to the toilet. At 1:20 P.M. the WN was asked whether the pressure ulcer was avoidable. The WN reported that the pressure ulcer could have been avoidable as the resident was known to have had difficulty with repositioning himself. F 0319 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>Give the right treatment and services to residents who have mental or psychosocial problems adjusting.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview of staff members, the facility failed to ensure that 1 of 32 sampled residents in Stage 2 received appropriate services to address psychosocial adjustment difficulty. Findings include: Cross Reference to F329 and F250. The facility failed to provide appropriate services to address Resident #292's adjustment to the recent changes in his life's circumstances (i.e. decline in activities of daily living, anxious about having another stroke, signs/symptoms of depression) to maintain his highest level of mental and psychosocial functioning. There was no documentation of support services provided by the social worker(s) or referral made to an appropriate source. Also, this resident was not reviewed by the behavior committee. Interview with Resident #292 was done on 5/22/13 at 10:30 A.M. The resident reported that he sometimes feels afraid, inquired whether he is afraid of staff members, he replied no. Then he reported that he worries that he may have another stroke. Record review done on 5/22/13 at 7:25 A.M. noted Resident #292 was admitted to the facility on [DATE] from an acute hospital. A review of the physician's orders [REDACTED].#292 became tearful. Subsequent documentation dated 5/18/13 NP documented that the resident's depression has improved on [MEDICATION NAME] but still has frequent crying spells and becomes easily fatigued. The NP [DIAGNOSES REDACTED]. to 20 mg. Review of the admission MDS with assessment reference date of 4/4/13 noted in Section D. Mood, the mood interview was conducted and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 10 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0319 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few (continued... from page 10) the resident yielded a total severity score of 11 (moderate depression). The symptoms that the resident presented with nearly every day included: feeling down/depressed, feeling bad about himself, and moving or speaking so slowly that other people could have noticed or being so fidgety or restless that he was moving around a lot more than usual. The resident also presented with feeling tired or having little energy and poor appetite or overeating for several days. A review of the Care Area Assessment (CAA) noted Resident #292 presents with depressive symptoms related to [DIAGNOSES REDACTED]. Also noted that the resident's depressive symptoms were compounded by nursing home placement and the plan was to monitor the resident's adjustment to a new environment. A review of the 30 day assessment with assessment reference date of 4/29/13 found that there was no improvement in the resident's mood, the resident continued to yield a total severity score of 11 (moderate depression). A review of the Social Service Assessment completed by the Social Services Assistant (SSA) noted the resident scored 15 out of 15 on the Geriatric Depression Scale on 4/3/13. In the section for Mood/Behavior Status the social worker assessed that the resident was showing signs of depression/anxiety. The instruction to the assessor is to describe and indicate interventions used and this was not addressed by the social worker. The social worker further notes that the resident reports to feeling down, tired, bad about self, poor appetite and moving/speaking so slowly that other have noticed. The spiritual assessment was completed on 4/3/13 by the SSA. The resident responded that he is overwhelmed by the stress caused by his illness/treatment. Then in response to his feeling regarding living in a nursing facility, he replied, I think it would be better if I wasn't around. A review of the care plan for Mood notes the following problems: 3/28/13 alteration in mood status related to [DIAGNOSES REDACTED]. Approaches included: consultation with psychological/psychiatric services based upon resident/responsible party approval and MD orders; discuss way to utilize present coping skills to deal with situation that arise (provide regular opportunity for physical activity, decision making, stimulation, socialization, leisure activities consistent with interests; encourage and allow open expression of feelings; encourage frequent contact with family and friends; observe effectiveness/side effects of medications as ordered; promote homelike environment; report to physician changes in mood status; support strengths and coping skills; review in behavior committee prn; and administer medication as ordered. Interview with Administrator #1 was done on 5/4/13 at 1:30 P.M. The Administrator confirmed that he would address questions regarding social services as the social worker(s) left a week prior to the start of this survey. The Administrator was asked how did social services support Resident #292 and whether the resident was reviewed by the behavior committee. The Administrator was agreeable to follow up. At 2:35 P.M. the Administrator provided a Social Service Note dated 4/3/13 documenting the social service assessment was done and an explanation of the role of the social worker was given to the resident. The progress note also recognized that during the meeting the resident was emotionally strained and made random comments about being better if I wasn't around any longer. There was no subsequent visits/support provided by the social worker/services. The Administrator reported there is no documentation that Resident #292 was discussed by the behavior committee. F 0322 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and review of the facility's nursing standard of practice, the facility failed to ensure labeling of the enteral nutrition (EN) formula was complete and accurate for 1 sampled resident who received tube feedings (TF) of the 32 residents in the Stage 2 sample. Finding includes: Resident #329 was admitted to the facility for short term skilled rehabilitation therapy status [REDACTED]. Review of the resident's September 2012 Physician order [REDACTED]. Cross-reference to findings at F281. Resident #329's EN tube feeding was not accurately labeled and this was confirmed by MDSC #3 on 5/21/13. F 0323 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents</b> Based on interviews, the facility failed to ensure residents were free from accidents as is possible for 1 of 32 residents in the Stage 2 sample. Finding includes: During an interview with Resident #161's family member on 5/24/13 at 2:10 P.M., the family member stated one evening, the resident's tray was delivered to her with a fork that had one of the four prongs bent up. The family member stated that was unacceptable and fortunate the resident did not immediately use that fork to eat, or otherwise it could have torn the top of her mouth. The family member said however, when it was brought to the attention of the staff, they replied, Oh, we'll just replace it, as if it meant nothing to them. The family member said it was also brought to the attention of the IA as the family member was upset about. The family member had a phone picture of the fork and said, nothing ever came out of it, to ensure these types of things do not happen. During an interview with IA on 5/22/13, the newly hired Administrator, other administrative staff and two physicians at 3:40 P.M., the newly hired Administrator stated, the incidents aren't really written down, but from now on we'll start doing concern and comment cards. Regarding Resident #161's fork incident, the IA said he addressed it but did not keep any documentation on it. He said dietary staff were inserviced. On 5/24/13 at 3:53 P.M., the RD verified she did the inservices and was made aware of it through the IA. She stated she should have filled out concern and comment card but did not. She was asked about their system, such as whether the IA who knew about it before her, could have initiated it first. The RD acknowledged it and said, I see, uh-huh and nodded. The facility was informed the resident and family members did not feel it was resolved and the fork given to the resident was an accident hazard. The family also felt the staff did not seem to seriously consider the ramifications of it, with no clear or prompt resolution nor documentation of it. F 0329 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to ensure 1 of 10 sampled residents drug regimen was adequately monitored. Findings include: The facility did not monitor Resident #292's mood from the inception of the use of an antidepressant, [MEDICATION NAME]. Record review done on 5/22/13 at 7:25 A.M. found a physician's orders [REDACTED]. Review of the Nurse Practitioner (NP) note dated 5/18/13 documents the resident's depression has improved on [MEDICATION NAME] but still has frequent crying spells. The NP's [DIAGNOSES REDACTED]. to 20 mg. daily. On 5/23/13 at 10:35 A.M. LN #3 was interviewed. LN #3 confirmed the resident receives [MEDICATION NAME] and his mood/behavior is monitored in the Medication Administration Record. The LN #3 provided the Behavior/Intervention Monthly Flow Record for May 2013 to monitor for sad mood and crying. Review of the flow sheet for May 2013 found missing documentation for the following: 5/8/13 (day shift); 5/9/13 (night shift); 5/10/13 (day shift); 5/11/13 (evening shift); 5/12/13 (day shift); 5/13/13 (day, evening and night shift); 5/16/13 (night shift); 5/17/13 (day shift); 5/18/13 (evening shift); 5/20/13 (evening shift); and 5/22/13 (day shift). Inquired whether there is a flow record for April 2013 as the order date of the medication was 4/11/13. The LN #3 reported that it should be filed in the resident's chart. Concurrent review of the resident's chart confirmed there was no flow record in the resident's chart. On 5/24/13 at 10:45 A.M. inquiry was made with LN #1 for the flow record for the month of April. The LN #1 agreed to check medical records as the flow record was not in the resident's chart. On the afternoon of 5/24/13 the staff member in medical records confirmed that there was not a flow record for Resident #292 in the thinned chart. Prior to exiting the facility, a Behavior/Intervention Monthly Flow Record for April 2013 was not produced. F 0334 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some <b>Develop policies and procedures for influenza and pneumococcal immunizations.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with staff members and review of the facility's policy and procedures, the facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 11 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0334 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some (continued... from page 11) develop policies and procedures that ensure that each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period for 2 of 5 residents in the sample. Findings include: Resident #12 was admitted to the facility on [DATE]. The resident signed the Informed Consent for Influenza Vaccine form to decline administration of flu vaccine on 1/17/12. Resident #135 was admitted to the facility on [DATE] and signed the form to decline administration of flu vaccine on 10/27/10. There was no further documentation that the flu vaccine was offered and declined or determined to be medically contraindicated during subsequent flu seasons (October 1 through March 31). Interview and concurrent record review was done with the Assistant Director of Nursing (ADON) on 5/24/13. The ADON reported that the flu vaccine is offered to the resident upon admittance and if they refuse then the flu vaccine is not offered thereafter. A review of the policy and procedure provided by the ADON on 5/24/13 at 2:35 P.M. The policy entitled Influenza Vaccine, Pneumococcal Vaccine, and Flu Outbreak Management notes under procedure for influenza vaccine: 1. Starting in October (unless another month is recommended by the Department of Public Health) and extending to March 31 (or check with local Health Department), residents are offered the influenza vaccine. Education is provided to the resident and/or representative regarding benefits and side effects or risks. Interview with the ADON was done at 3:40 P.M. The ADON clarified that on admission, the facility gets consent for flu and pneumococcal vaccine, if the resident is agreeable to the vaccine then the physician makes a standing order and the vaccine is administered every year. The ADON reported a new consent is not obtained. If the resident declines the vaccine, the vaccine is not offered during the flu season. However, if the resident requests the flu vaccine then a new consent is obtained. F 0353 Level of harm - Actual harm Residents Affected - Some <b>Have enough nurses to care for every resident in a way that maximizes the resident's well being.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to provide sufficient nursing staff based on the staff's inability to provide needed care to residents that enable them to reach their highest practicable physical, mental and psychosocial well-being. The survey was extended due to substandard quality of care. Findings include: Cross to F 224 Based on observation, record review, resident, family and staff interviews, and a review of the facility's policy and procedure, there was a failure to provide services necessary to avoid mental anguish and a potential for a decline in health status for 1 of 32 residents included in the Stage 2 sample. Cross to F 226 Based on interview with staff and review of facility's documents, the facility failed to implement policies and procedure to identify, investigate and report allegations of mistreatment, neglect, and abuse of residents and misappropriation of resident property. Cross to F 241 Based on observations, resident and staff interviews, the facility failed to maintain the dignity and respect for 16 of 24 residents. Cross to F 242 Based on resident interviews, record reviews, and staff interviews, the facility failed to provide 5 of 40 residents the ability to choose their preferred shower schedules. Cross to F 280 Based on observations, record reviews, and interviews, the facility failed to ensure the residents' care plans were revised and/or updated to reflect the residents' current status for 2 of 32 residents (Residents #292 and #329) in the Stage 2 sample. Cross to F281 Based on observations, record review, staff interview and review of the facility's policies and procedures, the facility failed to ensure professional nursing standards of practice were followed for 4 of 32 residents in the Stage 2 sample. Cross to F 309 Based on observations, resident and staff interviews, and medical record reviews, the facility failed to ensure that 2 of 32 residents in the Stage 2 survey sample, (R#152 and R#161), received the necessary care and services to help these residents attain or maintain the highest practicable level of well-being by preventing or managing pain. Also for R #152, the facility failed in managing the interchange of [MEDICAL TREATMENT] information. Cross to F 312 Based on observation, interviews with family members, residents and staff members, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene for 3 of 3 residents sampled for ADL care. Cross to F 314 Based on record review and interview with staff members, the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that it was unavoidable for 1 of 2 sampled residents of the 32 residents who were included in the Stage 2 sample. Cross to F 322 Based on observation, record review, staff interview and review of the facility's nursing standard of practice, the facility failed to ensure labeling of the enteral nutrition (EN) formula was complete and accurate for 1 sampled resident who received tube feedings (TF) of the 32 residents in the Stage 2 sample. Cross to F 329 Based on record review and intervview with staff members, the facility failed to ensure 1 of 10 sampled residents drug regimen was adequately monitored. Cross to F 368 Based on observation and interviews, the facility failed to ensure that snacks were offered to residents at bedtime daily for 1 of 32 residents in the Stage 2 sample. Cross to F 441 Based on observation, record review and interviews, the facility failed to ensure a safe, sanitary environment to help prevent the development and transmission of disease and infection, and failed to conduct data analysis toward detecting unusual or unexpected outcomes to determine the effectiveness of infection prevention and control (IC) practices. Cross to F 514 Based on record review and interviews, the facility did not ensure clinical records were maintained on each resident that were accurate and complete, in accordance with accepted professional standards and practices, including the facility's own policies and procedures. F 0368 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.</b> Based on observation and interviews, the facility failed to ensure that snacks were offered to residents at bedtime daily for 1 of 32 residents in the Stage 2 sample. Finding includes: During the Stage 1 review, Resident #161 stated she was not being offered an evening snack. During the Stage 2 review, the resident reiterated she was not being offered snacks at bedtime daily. She also said she was not being offered snacks between meals during the day as well. The resident stated the staff would give you something only if you asked for it. On 5/24/13 at 10:30 A.M., the resident's family member said no snacks or nourishments have been offered to the resident. The family member said the nurses gave medications, but did not offer anything else. The family said the resident was never offered a snack before bedtime. During an interview with the RD on 5/24/13, she said those residents who were diabetic were offered snacks. However, it was noted during an observation of the midday snacks that the resident did not have a labeled snack. One of the nurse aides stated the snacks came from the kitchen already labeled, which surveyor observed, so they knew which resident had a snack. Resident #161, who has diabetes mellitus, did not have a snack labeled with her name on it. Review of the Montly Flow Report for Diet documenting the resident's meals and snacks revealed the resident's AM snack, PM snack and HS snack intake from 5/1/13 to 5/23/13 was documented as 0%, with only a 50% intake noted for the morning snack on 5/5/13. Interview with the LN #1 on 5/23/13 found the areas not marked (gray boxes) indicated that snacks were not offered. Additional interview with the DON on 5/24/13 revealed they found out as a result of the query about Resident #161's snacks, that their flow report was not capturing the percentages accurately. Regarding whether the snacks were even being offered to the resident, the DON stated their corporate office was going to review their form, and no clear response was elicited. F 0371 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some <b>Store, cook, and serve food in a safe and clean way</b> Based on observations and interview with staff, the facility failed to ensure food was stored and served under sanitary conditions. Findings include: 1) Observation during the initial tour of the kitchen done on 5/20/13 at 7:55 A.M. with Assistant Manager found a sandwich stored in the four compartment refrigerator with no label on it. Inquired when the sandwich was made, the manager responded that she was not sure and would have to check. Also observed two containers of Thick and Easy containers that were opened with no label to indicate when it was opened. The manager confirmed that the sandwich and Thick and Easy containers should be labelled with the date it was opened and when the sandwich was made. Also FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 12 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0371 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some (continued... from page 12) observed in the lower compartment seven plastic containers of various colored fluids. The manager reported that these are containers of the juice concentrate for the dispenser. Inquired whether these containers need to be labelled with the date it was opened or when it is expired. The manager reported that she will need to follow up with the Dietary Manager. Follow up interview with the Dietary Manager (DM) was done on 5/21/13 at 10:10 A.M. The DM reported that she is doing a follow up with the vendor. The DM confirmed that there was no expiration date on the containers and they order the concentrate twice a week from the vendor and it is sent to them frozen. The AM provided information from the distributor on 5/22/13 at 2:50 P.M. The frozen concentrate has a shelf life of 36 months; once thawed, 45 days in the refrigerator or machine. Interview with the AM found product is delivered to the facility already thawed and not labelled as it is used within a week. Inquired how does the facility know when the product was thawed if it is not labelled. The facility does not have a system to monitor the storage and use of this product. 2) On 5/21/13 at 11:20 A.M. observed two lunch trays sitting in a multi-level cart. A kitchen staff member reported that these were early trays. One lunch tray for Resident #165 consisted of a tuna sandwich and a carton of milk. At 11:30 A.M. requested temperatures of the sandwich and milk be taken. The DM took the temperatures and found the tuna sandwich and milk was 80 degrees. The DM noted that the resident likes warm milk. Inquired if that's how the milk should be warmed out by leaving it on the tray. The DM stated that the milk should be heated up to 140 degrees. The DM threw out the tray and made a new tray for the resident. The second tray consisted of a sectioned plate containing pureed foods for Resident #18. Upon query for the temperatures, the DM asked a kitchen staff member to heat up the food in the steamer. The staff member put the food in the steamer. The surveyor requested that the food be removed and that the DM take the temperature of the food. The DM took the temperatures at 11:35 A.M. and found two portioned pureed items were at 100 degrees and the white pureed item was 80 degrees. The DM threw out the food and requested a new tray be made for the resident. The facility was not ensuring food and beverages were at the proper holding temperatures. F 0425 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and medical record reviews, the facility failed to ensure that 1 of 32 residents in Stage 2 of the survey sample was administered the correct dosage of medication, and routine medication as ordered by the physician. 1) On 05/22/13 at 10:15 AM observed R#152 being administered medications by LN#9 in hallway 600 of the facility. The resident stated that her head was sore and wanted Percocet for pain. The LN provided 1 tab of Percocet to R#152 and did not assess the resident for pain. The LN informed the surveyor that would not provide routine Tramadol because administered Percocet. Informed LN#9 that the surveyor does not give advice to LN, and should continue administering meds per physician order [REDACTED]. On 05/23/13 at 10 AM reviewed R#152's medical record and the pain medications as written on the PO were: 5/06/13 Give Percocet 1 tab prior to visit to MD; 5/17/13 Percocet 1 tab PO Q 4 hrs prn moderate pain. Percocet 2 tabs PO Q 4 hrs prn severe pain. NTE 4g/day; Tramadol 50 mg orally 2 x/day for pain. Asked LN#3 how moderate or severe pain was determined. LN#3 got the MAR from the hallway 600 med cart, and showed that the reason would be written on the back of the prescription's MAR form. There was no reason written on the back of the Percocet Mar form on 5/22/13 for R#152. The LN#3 then went into the EMR nurses progress notes and showed documentation by LN#9 that R#152 was given Percocet for bilateral lower extremity, (BLE) pain on 05/22/13. Interviewed R#152 on 05/23/13 at 10:30 AM and asked why he/she asked for Percocet on 5/22/13 in the AM, and the R#152 stated that he/she has migraines. Inquired where else does the R#152 have pain that would ask for Percocet and the resident stated, On my 'okole' (posterior) from the PU, my back, and sometimes my left shoulder. Inquired if R#152 had pain in his/her legs or feet, and resident replied, No. The resident further stated that they don't have the Tramadol so using Percocet instead and wants to talk to the Doctor to let him know that Percocet doesn't help his/her migraines. On 05/23/13 at 2 PM interviewed the Med Dir and informed him that R#152 wasn't administered Tramadol and that LN#9 stated giving Percocet instead. The resident also stated that Tramadol wasn't available. According to the Med Dir, Tramadol should have been given as prescribed and Percocet is as needed. The DON came and joined the discussion, then went to the med cart and found the Tramadol in the locked narcotic drawer that was dispensed on 05/21/13. The DON stated that LN#9 probably didn't look in the narcotic drawer. The Med Dir stated that LN#9 should not make any changes to the PO and should follow the PO as ordered. The Med Dir also showed documentation that R#152 was consulted with on 5/14/13 to address concerns about migraines, and prescription for migraines. The plan was to continue use of Tramadol and Percocet, and if no improvement would determine what migraine medication was used before. The Med Dir stated that he has time to talk with R#152 but he/she was at dialysis, so he will address later. 2) The afternoon of 05/23/13 at 2:00 PM reviewed R152's medical record and looked at the most current Dialysis Communication form dated 05/18/13, on which dialysis staff ordered that Sensipar be increased to 60 mg effective with that evening meal. Reviewed the PO for R#152 and could not find prescription for Sensipar at 60 mg. The facility's Med Dir was in the nursing unit and interviewed him on the dialysis communication process, and referred to the 05/18/13 prescription change of Sensipar by R#152's Nephrologist. The Med Dir looked at the resident's PO, MAR, progress notes, and his communication folder, and could not find documentation regarding the dosage increase for Sensipar on 05/18/13. The Med Dir conferred with LN#3, who stated that usually a copy of the Dialysis Communication form would be placed in the Med Dir's communication folder when there are prescription changes. The Med Dir stated that he reviews all prescription changes from the dialysis facility and would communicate to the LN by transcribing to the PO or by signing PO that was verbally communicated to a LN via telephone order . The Med Dir further stated that if he did not agree with prescription changes would confer with the Nephrologist and document in progress notes. The Med Dir acknowledged that the dialysis communication process needed to be corrected; and, then asked LN#3 to call LN#10, who was on duty on 05/18/13 and received the Dialysis Communication form. On 5/24/13, (Fri), at 3:51 PM reviewed R152's Med Dir notes dated 05/24/13 at 12:18 PM, that documented the resident was assessed by the Med Dir upon return from dialysis on 05/23/13, due to the residents IJ perma cath coming loose at the dialysis facility. The Med Dir also assessed the resident's complaint of headaches not being alleviated with use of the current pain meds. The Med Dir prescribed a new medication, (Imitrex), to treat the [DIAGNOSES REDACTED]. On 05/28/13, (Tues), at 10:37 AM reviewed R152's medical record, and looked at the nursing notes dated 05/25/13 at 8:47 PM that documented that the resident returned to the facility from dialysis at 5:30 PM with his/her perma cath to the left chest intact and dry. The nursing note further documented that R#152 complained of a migraine and was given a tab of Percocet. Interviewed LN#3 and asked how staff would be alerted of a prescription change by a physician to treat migraines. According to LN#3, the MD would transcribe in the PO to alert LN of change. There was no PO for the prescription change for migraines as noted in the Med Dir assessment done on 05/24/13. The resident was administered Percocet for complaints of headache throughout the 3 day Memorial Day weekend. On 05/29/13 at 7:45 AM, interviewed the Med Dir regarding prescription change for R#152 for migraines, and the Med Dir stated that the PO was written on 05/28/13 at 10:45 AM because he was awaiting the residents return from replacing the IJ perma cath on 05/24/13 a Friday and the resident returned to the facility at 5:30 PM. The DON provided the facility's policy and procedures, (P&P), for Dialysis with the heading of Clinical Services Policies & Procedures, Nursing Volume 1, Treatments, Chapter 10. In this P&P it is noted under the Procedure section for Post-Dialysis, 3. Transcribe any diet, medication, and/or orders received with resident from the dialysis facility; and, 7. Maintain dialysis transfer form in the resident's medical record - do not destroy. Under the General Guidelines section, 6. Document in the clinical nursing record: dialysis treatment completed, order changes, condition of shunt site, complaints from resident (if applicable), and whether physician was notified. The P&P for physician's orders [REDACTED]. Receiving a written order: a. Physician or other licensed independent practitioners must write order on order sheet.3. Transcribing the orders: a. Write order with black ballpoint pen on Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].5. When an order is changed, treat old order as if it has been discontinued. Write the change order in a new block and treat it as a new order. Never cross out or alter any part of an order. Both P&P's did not provide a timeframe, (e.g. within 48 hrs), for transcribing of medication and/or orders from dialysis facility, or when a physician changes a medication order. F 0441 Level of harm - Minimal harm or potential for actual harm Residents Affected - Many <b>Have a program that investigates, controls and keeps infection from spreading.</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure a safe, sanitary environment to help prevent the development and transmission of disease and infection, and failed to conduct data analysis toward detecting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 13 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0441 Level of harm - Minimal harm or potential for actual harm Residents Affected - Many (continued... from page 13) unusual or unexpected outcomes to determine the effectiveness of infection prevention and control (IC) practices. Findings include: 1) On 5/28/13 at 11:00 A.M., interview with the Infection Control RN (IC RN) revealed Healthcare Associated Infection Summary Reports were completed monthly and reviewed by one of the Medical Directors. It was noted for January - March 2013, the facility's urinary tract infections (UTIs) were the highest for those months, followed by respiratory infections. The report documented there were either no significant trends or significance noted. For April 2013, it was reversed with respiratory infections being the highest and UTIs second highest. Although there was a section for the action taken related to the identified issues, there was no explanation of the data regarding residents who developed infections within the nursing home, and no comparison of the current infection control surveillance data (including the incidence or prevalence of infections and staff practices) to past data. Thus, the analysis failed to describe or tie-in the detection of unusual or unexpected outcomes, trends, effective practices, and performance issues and whether the facility needed to change its practices to enhance infection prevention to minimize the potential for transmission of infections. For example, the facility's February 2013 report showed residents having UTIs as the highest, without indwelling foley catheters. Respiratory infections ranked second highest and a noted increase in conjunctivitis was also seen, but without significant trends. However, in the actions taken related to their IC findings, they facility mentioned continued monitoring of proper hand hygiene from associates, monitoring residents for flu-like symptoms and offering of influenza/pneumococcal vaccines. However, there was no analysis regarding why the UTIs remained the highest by the second month in 2013 and for March 2013 as well. The IC RN confirmed there was no analysis related to the specific issue of infection trends identified for the months of Jan - April 2013 related to the incidence of UTIs being at the highest for Jan, Feb and March and second highest in April. She said they would consider things such as if it's poor pericare, etc., but found no documentation to support the analysis of the outbreaks as well as what measures were implemented, documented and tracked to resolve or change practices based on the data. 2) On 5/20/13 at 10:20 AM observed LN#2 administer medications to R#324 in hallway 600 of the facility. When the med pass was completed, R#324 signaled LN#2 for tissue so that he/she could cough up sputum into it. The LN did not have tissue on the med cart, went to the clean linen cart nearby to grab a washcloth, and gave it to R #324. Asked LN#2 why disposable tissues not used and he replied that it was an emergency. After the resident spat out sputum onto the washcloth, he/she handed it back to LN#2. The LN folded the washcloth up, held it in his right hand and wheeled R#324 back to the main hallway on the left side of the nursing station. After placing the resident in his/her wheelchair in the area, LN#2 went into the nursing station to speak with someone, then went to dispose of the soiled washcloth into the dirty linen hamper on hallway 600, and then went into room [ROOM NUMBER] to wash his hands. Informed LN#2 that observed that he carried the soiled washcloth while wheeling the resident back to the main hallway and into the nursing station. LN#2 stated that he probably should have disposed of the soiled washcloth into the dirty hamper and washed his hands instead of carrying it around the facility. 3) On 5/23/13 at 10:52 am observed LN#11 perform wound care on R#152. The LN washed her hands, donned clean gloves, removed the old dressing from the resident's pressure ulcer on the right ischial tuberosity, changed gloves, and proceeded to clean the wound site with normal saline and gauze. The LN then went into the bathroom washed her hands, returned to the bedside, donned clean gloves and completed wound care with the appropriate topical ointments and dressings. Inquired of LN#11 if should have washed her hands after removing soiled dressing from the wound and before donning clean pair of gloves. The LN stated that she should have done that. The DON provided the facility's P&P for Hand Hygiene with the heading Chapter 6: General Resident Care, A Guide to Infection Control, provided by Life Care Centers of America, Inc. Under the Policy heading it states, Hand washing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infections. Under the heading Waterless Hand washing Products, it states, If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations other than those under Hand washing above. F 0465 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few <b>Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.</b> The facility failed to ensure a sanitary environment for the residents on the Keolamau unit. Findings include: During initial tour of the facility on 05/20/13 observed that he ice machine in the nourishment room of the Keolamau unit, had areas of black colored substance at the top of the ice machine around the area of the ice dispensing spout. The Housekeeping Supervisor walked into the nourishment room and showed her that the ice machine had areas of black substance where the ice comes out. The HS stated that the ice machine is cleaned once a month. F 0490 Level of harm - Actual harm Residents Affected - Some <b>Be administered in an acceptable way that maintains the well-being of each resident .</b> Based on observations, resident interviews, staff interviews, and facility policy review, the facility failed to effectively maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: The survey team determined the facility was providing substandard quality of care and actual harm. An extended survey was initiated. During entrance conference on the morning of 5/20/13 the survey team determined that the Administrator was new to the position, with her just starting work at the facility the week before, 5/13/13. The facility was under the direction of the Interim Administrator (IA) over the past 10 months. The Director of Nursing (DON) was responsible for the Quality Assessment and Assurance (QAA) in addition to her other responsibilities. 5/22/13 INTERVIEW WITH KEY PERSONNEL: During an interview with key personnel: IA, Administrator, DON, and 2 Medical Directors on 5/22/13 at approximately 3:30 P.M., the IA explained that he was not involved in the QAA process since he was only temporary. He explained that he coincidently went home to another State when the QAA meetings were scheduled. He stated that he missed all but 2 QAA meetings. Interview of the DON revealed that she was left to manage all nursing staff and perform administrative duties and activities, including QAA meetings. On 5/22/13, the IA explained that the facility conducted a mock Quality Indicators Survey (QIS). Their mock survey results found many areas above the acceptable threshold. The areas which scored above the threshold included: Abuse, Admission/Transfer/Discharge, Choices, Nutrition, Care Plan, and Resident Property. When asked what the facility did with the survey information, the staff were unable to discuss interventions/plans to modify/improve the facility practices. When questioned about interventions for the Abuse (since threshold is 0%), the IA stated the residents were unable to give a specific date, time, or staff name. The facility concluded it's abuse investigation based on the fact that the residents were unable to provide more information. A root-cause analysis was not discussed regarding the mock survey results. The facility provided the survey team with a copy of the mock survey findings. Attached to the survey findings were 4 of the inconclusive abuse interviews of the residents. One resident's response noted that staff weren't rough but rowdy. When asked what rowdy meant, the resident responded that one staff member did things loudly and slammed doors. The staff asked that resident if he had been injured, to which the resident replied, No, I did not break any bone or hurt my muscle. No further intervention was was provided. During the interview with the key staff on 5/22/13, the IA stated they provide a Circle of Service, which provided residents with a mentor or coach who would provide one-on-one attention for the first 72 hours following admission. The Circle of Service provided staff with the ability to maintain contact with the resident and provided the facility with an understanding the residents' experience. After 72 hours, the facility followed up with the residents' needs during the Care Plan meeting 14 days following admission. The facility had no procedural ways to monitor a resident's adjustment to the facility. They typically had the Social Worker do an assessment followed by monitoring by 2 contracted Social Workers. The IA explained that the Director of Social Services had 2 Social Services Designees (SSD), 1 full time and 1 part time. The full time SSD walked out on the Director followed by the part time SSD. The SS Director resigned last week. The facility was in the process of hiring an SSD, who would start the following week. Please reference the following citations for more details: F224 F241 F353 F493 F520 F 0493 Level of harm - Actual harm Residents Affected - Some <b>1) Set up a group that is legally responsible for writing and setting up policies for leading and running the nursing home; or 2) hire a properly licensed administrator.</b> <b>1) Set up a group that is legally responsible for writing and setting up policies for leading and running the nursing home; or 2) hire a properly licensed administrator.</b> FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 14 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0493 Level of harm - Actual harm Residents Affected - Some (continued... from page 14) Based on observations, resident interviews, and staff interviews, the facility failed to designate a Nursing Home Administrator (NHA) to establish and implement policies to manage and operate the facility. Findings include: On the afternoon of 5/28/13, the current NHA stated he was the Interim Administrator (IA). He stated his position was temporary and month to month. The IA further determined that he really didn't want to dig my heels into anything big, and explained that he wouldn't be able to complete any projects. The Regional Director of Clinical Services, RDCS, indicated she was unaware the IA was on a month to month assignment. The IA further explained that the administrative oversight came from the Regional Executive Director, RED, who was located on another island and was not on sight daily. The IA stated the RED made visits to the facility weekly. The IA and the newly appointed Administrator were both licensed in other States and not with the State of Hawaii. Cross reference to: F241 F353 F490 F520 F 0501 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some <b>Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility.</b> Based on record review and interview, the facility did not ensure that the Medical Director of the Keolamau unit, identified, evaluated and addressed medical and clinical concerns/issues which affected resident care, medical care and/or the resident's quality of life, including the evaluation of resident care policies and procedures reflecting the current standards of practice. Finding includes: Cross-reference to additional and related findings at F241, F281, F309 and F353. On 5/24/13 at approximately 4:05 P.M., during a discussion with the Medical Director (MD) of the Keolamau unit, he acknowledged that there was a problem with the new licensed nurses related to the quality of care issues that surfaced during the on-going survey. He related they have hired and fired nurses, provided training/education, and stated for those who made it, they often got promoted and thus were no longer providing direct resident care. He acknowledged the Keolamau unit was a challenging unit, more a subacute unit with the majority of residents requiring skilled rehabilitation services. He acknowledged the quality of care and quality of life issues at this point in the survey and stated the facility needed licensed staff with a strong clinical background for that unit. He acknowledged too, that Administration was responsible for the concerns and the DON had added responsibilities which should not have been given to her. The MD stated they had a lot of work to do and verified they had care issues and policy review they would need to address. F 0514 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some <b>Keep accurate, complete and organized clinical records on each resident that meet professional standards</b> **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure clinical records were maintained on each resident that were accurate and complete, in accordance with accepted professional standards and practices, including the facility's own policies and procedures. Findings include: Cross-reference to various findings: 1) At F242 for Resident #161, per an interview with MDSC #1 on [DATE], she said the documentation regarding the NOC shift was inaccurate. Per MDSC #1, she confirmed the NOC CNA never asked the resident about a sponge bath and/or that the resident refused a bath. MDSC #1 said the CNA marked off that it was done when it was not. MDSC #1 stated she would, be looking into how we are going to investigate about the CNAs not providing the service. She also said given the number of sponge baths this resident had, the staff should have been able to offer more showers instead of all the sponge baths that was documented. 2) At F250 for Resident #329, AR #1 stated on [DATE] she spoke to the resident's family members and noted one family member would leave their job in the event the resident was discharged . However, AR #1 confirmed she left a section regarding the anticipated discharge/transfer blank and stated she should have filled it out. In addition, AR #1 marked Unknown for a question whether the resident had family capable of and willing to provide assistance post-discharge. There was no further documentation found in the record to assure the IDT reviewed progress toward discharge during weekly discharge meetings.assist with referrals to community resources prior to discharge, assist with paperwork process. 3) At F281 for Resident #161, she had a [DATE] treatment order date for oxygen (O2) at 2 liter/min via nasal cannual (NC) for respiratory distress as needed. On [DATE] and [DATE], the resident was observed with O2 via a NC. During a review of Resident #161's treatment record (TAR) for [DATE], it showed there was no documentation marked on [DATE] and [DATE] for the resident's O2 use. In addition, a new entry on the TAR dated [DATE] noted, Change O2 tubing weekly with [DATE] marked as done. The next tubing change date was to be [DATE]. During the initial interview with Resident #161, she stated her NC had not been changed for approximately three weeks until an aide told her that was not right and changed it for her. In addition, on ,[DATE] and [DATE], during random observations of the resident, it was noted the sterile water connected to the resident's oxygen concentrator was not dated/initialed. On ,[DATE], the sterile water attached to the O2 concentrator was not dated/initialed. However, on [DATE], it was dated. On [DATE], during an interview with the DON, she said the humidifier (sterile water) had to have a date on it. She said however, the NC did not have to be dated. Yet, there was a new entry in the TAR dated [DATE] to change the O2 tubing weekly. Thus, it was not clear what the procedure was to ensure resident care items were monitored and replaced consistently. Within the TAR, there was another entry, Monitor O2 sat q 4 h prn per (family member) request). On [DATE] at 8:17 A.M., per LN #1, she said there was no physician's order for this and there were no parameters for it, such as to call the MD if the O2 sat was below a certain percentage. LN #1 confirmed with the missing documentation in the TAR, unlabeled items, and no physician's order, this did not meet the nursing standard of care practices nor for clinical documentation. She said, Yes, they (nurses and aides) need more education. 4) At F309 for Resident #161's pain medication management, review of her [DATE] MAR noted for two entries on [DATE] and [DATE], the follow-up assessment time and result of the pain medication (i.e., effective or not) were not documented. LN #1 also confirmed for the use of pain medication, the assessment should include documentation as to the effect of the intervention which the nurse has to follow-up with. LN #1 also confirmed for the use of pain medication, the assessment should include documentation for the effect of the intervention and the administering nurse has to follow-up with. 5) At F312 for Resident #329, review of the resident's Monthly Flow Report for Daily Care for [DATE] revealed the section which the CNAs documented Teeth Brushed did not have an entry for [DATE] for the day and evening shift to indicate that resident's oral care was completed. There were an additional 6 entries between ,[DATE] - [DATE] for the day and evening shifts and an evening shift entry on [DATE], which indicated oral care was not done. All of the night shift entries were not marked, which LN #1 said it meant that oral care was not done on the night shift. 6) At F322 for Resident #329, the facility failed to ensure labeling of the enteral nutrition (EN) formula was complete and accurate. On [DATE] at 7:20 A.M., MDSC #3 confirmed the resident's tube feeding (TF) closed system had a manufacturer's label, but was not filled out with the resident's name, type of enteral nutrition (EN) formula, start date and time and ordered rate. MDSC #3 said, it should have everything written on it and verified it was not done. She also said the tubing expired in 48 hours and there was no date when it was first used. She was unsure when the EN expired and thought it was to be used within 24 hours. However, with no start date/time written on it, she stated it should be discarded. On [DATE] at 9:55 A.M, LN #1, produced the facility's EN tube feeding policy and procedure and said it did not state what the licensed staff's responsibility included for labeling documentation. LN #1 said it should include the resident's name however, and licensed staff, they are supposed to fill in the information on the label. LN #1 also said the tubing was to be labeled. 7) On [DATE], during a review of the medication storage area on the Keolamau unit, a concurrent review of the blood glucose monitoring log with LN #1 showed gaps in the documentation. LN #1 verified there were several days in the log without entries about the results of the control solutions. LN #1 said it meant it was not being tested every 24 hours and would produce the manufacturer's specifications or policy. Review of the manufacturer's User Form produced by LN #1 noted under Glucose Control Testing, Quality control testing must be performed a minimum of once every 24 hours, with each new box of test strips, and when test results are questionable. This was affirmed by LN #1 that it was not being performed during the [DATE] interview. 8) On [DATE], during the record review, Resident #161's [DATE] MAR revealed missing documentation for the administration of the accuchecks four times daily with [MEDICATION NAME]administration via sliding scale. There were 8 entries that were incomplete between ,[DATE] and [DATE]. On [DATE] at 9:45 A.M., during a concurrent review of the resident's MAR with the Regional CNE, she stated this was basic nursing 101 and said it was unacceptable that the documentation incomplete. She was also shown other holes or incomplete documentation in the May MAR and acknowledged these issues needed to be addressed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 15 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
    • F 0514 Level of harm - Minimal harm or potential for actual harm Residents Affected - Some (continued... from page 15) 9) Cross Reference to F329. Resident #292 is prescribed [MEDICATION NAME] for depression. Record review found there is no documentation of the resident's mood via the Behavior/Intervention Monthly Flow Record for the month of [DATE]. Review of the flow sheet for [DATE] found missing documentation for the following: [DATE] (day shift); [DATE] (night shift); [DATE] (day shift); [DATE] (evening shift); [DATE] (day shift); [DATE] (day, evening and night shift); [DATE] (night shift); [DATE] (day shift); [DATE] (evening shift); [DATE] (evening shift); and [DATE] (day shift). 10) At F241, interview of R #333 on the morning of [DATE] revealed she didn't receive a shower since she was admitted to the facility on [DATE]. Interview of the R #333 on the afternoon of [DATE] revealed she still hadn't received a showers, despite the facility's awareness that she wanted a shower. The resident, on [DATE], stated she felt so dirty. R #333 reported she had not received a sponge bath. Record review found the Monthly Flow Report noted R #333 received a Sponge Bath on [DATE] (evening & night shifts), [DATE] (all 3 shifts), [DATE] (all 3 shifts), [DATE] (evening & night shifts), [DATE] (all 3 shifts), [DATE] (day & night shifts), [DATE] (day & night shifts), and [DATE] (night shift). Interview of the MDS-C #1 on the afternoon of [DATE] revealed that it was unlikely that the CNAs were not providing sponge baths on every shift. She stated they probably make an error in documentation. The MDS-C #1 further stated that there was no oversight of the CNAs' documentation. The MDS-C #1 and other nursing staff were likely to oversee their documentation when doing MDS updates, which occurred frequently upon admission then quarterly thereafter. Otherwise, none of the nursing staff reviewed the CNAs' documentation. 11) At F242, interview of R #328 on the afternoon of [DATE] found she never refused showers and yet the Monthly Flow Report demonstrated she refused bathing on the following dates: [DATE], [DATE], [DATE], and [DATE]. It was further documented that R #328 received a shower [DATE], when it was documented that she refused bathing on that day. 12) Interview of R #334 on the morning of [DATE] revealed that she never refused bathing. She also noted that she did not receive a sponge bath daily. She stated that the staff assisted her with cleaning up but primarily she received a shower almost daily. Record review on the afternoon of [DATE] found the Monthly Flow Report noted the R #334 refused bathing on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. In contrast the Monthly Flow Report noted that R #334 received showers on [DATE], [DATE], [DATE], [DATE], and [DATE]. The Monthly Flow Report also noted the resident received sponge bath on [DATE] (evening & night shifts), [DATE] (all 3 shifts), [DATE] (morning & night shifts), [DATE] (day shift), [DATE] (day & night shifts), [DATE] (evening shift), [DATE] (day & night shifts), [DATE] (day shift), [DATE] (day & evening shifts), [DATE] (day & night shifts), [DATE] (day shift), [DATE] (day shift), [DATE] (day shift), [DATE] (night shift), [DATE] (day & night shifts), [DATE] (night shift), and [DATE] (day shift). Interview of the MDS-C #1 on the afternoon of [DATE] revealed that the CNAs should not have documented refusal when the resident received a shower. She further stated it was highly unlikely that CNAs were providing a sponge bath daily and on more than one shift, when the resident received showers. 13) Cross to 309 for [MEDICAL TREATMENT] communication. On [DATE] at 2:00 PM reviewed R152's medical record for the [MEDICAL TREATMENT] Communication form. The most current [MEDICAL TREATMENT] Communication form dated [DATE], on which [MEDICAL TREATMENT] staff ordered that [MEDICATION NAME] be increased to 60 mg effective with that evening meal. Reviewed R#152's PO and prescription for [MEDICATION NAME] at 60 mg was not found. Interviewed the Med Dir on the [MEDICAL TREATMENT] communication process regarding the [DATE] prescription change of [MEDICATION NAME] by R#152's Nephrologists. The Med Dir looked at the resident's PO, MAR, progress notes, and his communication folder, and could not find documentation regarding the dosage increase for [MEDICATION NAME] on [DATE]. The Med Dir conferred with LN#3, who stated that usually a copy of the [MEDICAL TREATMENT] Communication form would be placed in the Med Dir's communication folder when there are prescription changes. The Med Dir stated that he reviews all prescription changes from the [MEDICAL TREATMENT] center and communicates to the LN by transcribing to the PO and/or by signing PO that was via telephone order to the LN. The Med Dir further stated that if he did not agree with prescription changes would confer with the Nephrologists and document in progress notes. The Med Dir acknowledged that the [MEDICAL TREATMENT] communication process needed to be corrected; and, asked LN#3 to call LN#10, that received the [MEDICAL TREATMENT] Communication form on [DATE] to find out why he was not informed of prescription change. On [DATE] at 8:45 AM observed R#152 being transferred on a gurney for a MD appt., the resident stated that his/her catheter for [MEDICAL TREATMENT] came out last night. Went to review R152's medical record for the [MEDICAL TREATMENT] communication form and progress notes in the electronic medical records about the resident's internal jugular, (IJ), perma catheter, (cath), coming out and could not find documentation. Interviewed LN#1 at 10:14 AM who reported that she spoke with the RN that was on duty the evening of [DATE], (Thurs), and found out that the computer was down that night but staff has 48 hrs to document in progress notes. LN#1 stated that the [MEDICAL TREATMENT] center had called the Med Dir the afternoon of [DATE], and informed him that the IJ Perma cath was still intact but coming loose. The Med Dir advised the [MEDICAL TREATMENT] staff to tape down the IJ perma cath, and he was to look at it when the resident returned to the facility. There was no [MEDICAL TREATMENT] Communication form in R#152's medical record and/or progress notes in the EMR pertaining to the resident's IJ Perma cath becoming loose. According to LN#1, the RN that was on duty the evening of [DATE], had planned to document incident on the afternoon of [DATE], which is within the 48 hr timeframe to document. On [DATE], (Fri), at 3:51 PM reviewed the Med Dir progress notes dated [DATE] at 12:18 PM, that documented that R#152 was assessed by the Med Dir upon return from [MEDICAL TREATMENT] on [DATE], and that the [MEDICAL TREATMENT] facility had already scheduled the [DATE] MD appt. to replace the IJ perma cath. The Med Dir documented that the resident ' s IJ perma cath became loose during [MEDICAL TREATMENT], was secured with tape but came completely out the evening of [DATE] at the facility. The Med Dir also assessed the resident's complaint of headaches and the use of current pain med's that did not provide relief. The Med Dir diagnosed R#152 with cluster type headaches and prescribed a new medication that the resident was willing to try. On [DATE], (Tues), at 10:37 AM reviewed R152's medical record, and looked at the nursing notes dated [DATE], (Sat), at 8:47 PM that documented that the resident returned to the facility from [MEDICAL TREATMENT] at 5:30 PM with his/her perma cath to the left chest intact and dry. The nursing note also documented that R#152 was given a tab of [MEDICATION NAME] due to a complaint of migraine headache. Interviewed LN#3 and asked how staff would be alerted of a prescription change by a physician to treat migraines. According to LN#3, the MD would transcribe in the PO to alert LN of change. There was no PO for the prescription change for migraines as noted in the Med Dir assessment done on [DATE]. The resident was administered [MEDICATION NAME] for complaints of headache throughout the 3 day Memorial Day weekend. On [DATE] at 7:45 AM, interviewed the Med Dir regarding prescription change for R#152 for migraines. The Med Dir stated that the PO was written on [DATE] at 10:45 AM because he was awaiting the residents return from replacing the IJ perma cath on [DATE] (Friday), and the resident didn ' t return to the facility until 5:30 PM. Also discussed that there was no [MEDICAL TREATMENT] Communication form on [DATE] when the resident's IJ perma cath became loose and late documentation for critical information regarding resident's lifeline. The Med Dir stated that communication and documentation between the facility and [MEDICAL TREATMENT] center could be improved. The DON provided the facility's policy and procedures, (P&P), for [MEDICAL TREATMENT] with the heading of Clinical Services Policies & Procedures, Nursing Volume 1, Treatments, Chapter 10. In this P&P, it is noted under the Procedure section for Post-[MEDICAL TREATMENT], 3. Transcribe any diet, medication, and/or orders received with resident from the [MEDICAL TREATMENT] facility; and, 7. Maintain [MEDICAL TREATMENT] transfer form in the resident's medical record - do not destroy. Under the General Guidelines section, 6. Document in the clinical nursing record: [MEDICAL TREATMENT] treatment completed, order changes, condition of shunt site, complaints from resident (if applicable), and whether physician was notified. The P&P for Physician's Orders/Transcription, revised on ,[DATE] with the heading, Clinical Services Policies & Procedures, Nursing Volume 1, Medical Records, Chapter 17, under the Procedure section, state, 1. Receiving a written order: a. Physician or other licensed independent practitioners must write order on order sheet.3. Transcribing the orders: a. Write order with black ballpoint pen on medication administration record or treatment record in the appropriate space and complete start order date.5. When an order is changed, treat old order as if it has been discontinued. Write the change order in a new block and treat it as a new order. Never cross out or alter any part of an order. Both P&P's did not provide a timeframe, (e.g. within 48 hrs), for transcribing changes to the PO from the [MEDICAL TREATMENT] communication form, or when a physician changes a medication order. F 0520 Level of harm - Actual harm Residents Affected - Some <b>Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.</b> FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 16 of 17
    • DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED:7/2/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER / SUPPLIER / CLIA IDENNTIFICATION NUMBER 125051 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______ B. WING _____ (X3) DATE SURVEY COMPLETED 05/29/2013 NAME OF PROVIDER OF SUPPLIER KA PUNAWAI OLA STREET ADDRESS, CITY, STATE, ZIP 91-575 FARRINGTON HIGHWAY KAPOLEI, HI 96707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0520 Level of harm - Actual harm Residents Affected - Some (continued... from page 16) Based on observations, resident and staff interviews, and policy review, the facility's Quality Assessment and Assurance (QAA) committee failed to identify quality deficiencies and failed to develop and implement appropriate plans of action to correct the deficiencies. Findings include: Part 2 of the Quality Assessment and Assurance (QAA) review was conducted on the afternoon of 5/28/13. In attendance were the IA, Administrator, DON, and the RDCS. The QAA Committee met monthly, was chaired by the DON, and included all department heads. The DON stated the IA worked with her to co-chair the QAA Committee. The IA was questioned as to his role as the Interim Administrator. The IA stated that everyone had a piece of the QAA and they discussed bigger facility concerns. The IA further stated that he had only attended 2 or 3 meetings over the past 10 months. He indicated that it was coincidental that the QAA meetings occurred while he returned home in another state. The IA stated he knew, for example, there was a concern about phone coverage after hours and so they talked about getting cell phones, what doctors bring up,.so stuff like that. The DON then went over a listing of areas reviewed during QAA meetings. Such topics included falls, pressure ulcers, indwelling foley catheters, tube feedings, physical restraints, nutrition, behaviors, psychoactive medications, pain management, blood thinning medication use, etc. The facility maintained that care area goals were enforced by the corporate office, which set thresholds for the facility. In reference to oversight of CNA staff, the DON stated they expect CNAs to do rounds every couple hours. The IA stated they also discussed the Interact Tools and the Medical Director and Corporate Office were interested in implementing it. The purpose of the Interact Tools was to assist nursing homes with Quality Assurance and Performance Improvement (QAPI). The Interact Tools were not being utilized during the survey period. The survey team coordinator shared some of the negative findings from the survey up until 5/28/13. The issues included: Communication between the nursing staff and the physicians; Dignity - food and shower preferences, call lights being answered in a timely manner and being respectful to residents; Choices; Nursing issues - clinical documentation, assessments, general resident care, physicians orders, incomplete documentation on Medication Administration Records (MARs); CNAs - Documentation (accuracy, supervision/oversight - actual sponge baths on every shift?) and supervision of CNAs; Social services - adjustment to the facility, discharge planning, psychosocial issues; Accidents; Unnecessary medication use - behavior monitoring; Hydration - no bedtime snacks being offered; Resident behavior and facility practice - Responses to complaints/concerns, accurate reporting, and documentation of incidents. Due to the abuse allegation, the Abuse Prohibition Review was triggered which required the facility to provide a minimum of 3 alleged violations since the last survey. The facility provided the only 2 alleged incidents reported. The fact that they only had 2 alleged incidents was inconsistent from the many complaints and general dissatisfaction expressed by residents, families, as well as observations/findings during survey. The survey observations found several reports of residents who got into verbal altercations with staff and residents/families expressing their dissatisfaction. Further investigation of the reports revealed the facility failed to document or demonstrate in writing what, if anything, had been done to remedy the issues/concerns. Interviews with involved staff members revealed the facility was made aware of the problems/concerns. The facility failed to show a good faith effort to resolving the problems. Refer to the following citations: F224, F226, F241, F242, F309, F353, F490, and F514. The IA responded by saying some of the concerns raised by the survey team should have been placed on the facility's Comment & Concerns Cards (CCCs). The purpose of the CCCs was to gather information from residents/families for quality improvement. The cards provided the administration insight into the residents' experiences and was used as documentation of how the facility addressed the issues. The IA further stated that some of the concerns have been very small and minor. He stated, So do I spend half my day writing these things down? But there are things we could have. He further stated, We do not have anything documented, because if we did we'd give it to you. We do not. The RDCS stated the facility worked to decrease falls and pressure ulcers. The Medical Director did rounds with the Wound Nurse to collaborate on skin care. The IA stated that when there were concerns brought to his attention, he would talk to family members and staff. He stated, In terms of bigger system things in place, but how much I've been able to oversee all this.(he trailed off).because I'm month to month. He worked with the DON on increasing admissions. A surveyor then asked if the DON was taking on the administrative and DON duties. The IA stated the DON had taken on a lot of things. The IA then said that some of the issues brought forth from the survey were new to him and not part of their QAA. He further indicated that they came up with action plans over the past week regarding communication. The IA said the facility conducted a mock QIS survey in April 2013. The survey triggered abuse. In response to the abuse allegations, the IA stated the residents who made allegations were unable to provide a time, staff name, or specify the incident. The mock survey also triggered above the thresholds for Admission/Transfer/Discharge, Choices, Nutrition, Care Plan, and Resident Property. The facility did not create or initiate an action plan to address the issues/concerns stemming from the mock QIS survey. The RDCS discussed the facility's dashboard which looked at various topics such as pressure ulcers, etc. and their associated thresholds. The facility utilized a red, yellow, green light system to determine how they would manage things. In conclusion, the facility failed to demonstrate a working system to identify and address concerns/issues, resulting in noncompliance with the QAA regulation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 125051 If continuation sheet Page 17 of 17