Hale Malamalama

In the surveyor’s words

From the most serious findings on record at Hale Malamalama, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 31, 2025

  Based on interview, record and document review, the facility failed to protect one resident (R)1 of two investigated for staff abuse/neglect. Specifically, Certified Nurse Assistant (CNA)2 was witnessed to make inappropriate, unsympathetic comments to R1, and willfully neglected to provide her the necessary services of toileting on more than one occasion. As a result of these willful acts, R1 suffered mental anguish and emotional harm. Findings include: 1) On 01/10/2025, the Office of Healthcare Assurance (OHCA) received an anonymous report of potential abuse of R1 (alleged victim/AV) by facility staff. The narrative account included but not limited to: - R1 was admitted to the facility on [DATE] for skilled nursing level of care after being hospitalized . […]

• Actual harm, isolatedF684Sep 15, 2023

  Based on observations, interviews, and record review, the facility failed to provide care to residents in accordance with professional standards of practice. Resident (R)89 is allergic to iodine (disinfectant) and the facility did not identify and provide a substitute for iodine. The staff member used alcohol pads to cleanse the area before inserting a catheter. This deficient practice had the potential to cause burning of the skin or pain. Finding includes: R89 was admitted to the facility on [DATE] with admitting diagnoses of rectal pain/anal fissure (tear in the thin, moist tissue that lines the anus) and unspecified dementia, unspecified severity, with other behavioral disturbance. Record review found a progress note dated, 09/15/23 at 01:37 AM. […]

• Actual harm, isolatedF689Sep 15, 2023

  Based on record review (RR), interview with family and staff, the facility failed to ensure one of two residents sampled were free from accidents. Resident (R) 7 had two avoidable falls. The facility failed to perform a root cause analysis and based on identification of probably contributing factors, develop interventions to prevent falls. The facility also implemented interventions that were not included in the resident's care plan. Findings include: Cross Reference to F657. Care Plan Timing and Revision. On 09/12/23 at 10:47 AM while introducing self to R7, who was resting sitting upright in his bed, observed he had multiple bruises and swelling to his face. When asked how he got the bruises on his face he reported I fell . […]

• No harm, potential for more than minimal, widespreadF867Sep 27, 2024

  Based on interviews and record review, the facility failed to create an annual Performance Improvement Project (PIP) that focuses on high risk or problem prone areas identified through the data collection and analysis. This deficient practice has the potential to negatively affect all the residents' overall wellbeing. Findings Include: Interview and facility document review were concurrently conducted on 09/27/24 at 10:33 AM with the facility Administrator. The facility's Quality Assurance and Performance Improvement (QAPI) binders did not contain documents on an annual Performance Improvement Project (PIP). Administrator confirmed that the committee met quarterly to discuss current facility issues and improvements but did not have an official PIP. […]

• No harm, potential for more than minimal, widespreadF563Sep 15, 2023

  Based on complaint report and interview, the facility failed to ensure residents of the facility had the right to receive visitors. Findings include: On 11/28/22, the Office of Health Care Assurance (OHCA) received a complaint alleging the facility was not allowing visitors due to identification of COVID-19 cases. The complainant provided photos of signage in the window which read, Please No Visitors At this time. Thank you. There was also a stand with a posted sign, COVID-19 cases have been identified in the facility. No visitors are allowed at this time until further notice. On 09/14/23 at 01:00 PM an interview was conducted with the Infection Control Coordinator (ICC). ICC reported the facility had a COVID-19 outbreak at the end of last year. […]