Hilo Benioff Medical Center

In the surveyor’s words

From the most serious findings on record at Hilo Benioff Medical Center, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 24, 2022

  Based on record review and interview, the facility failed to ensure an environment free of accident hazards for one resident (Resident (R)32) and/or receives adequate supervision to prevent accidents for one resident (R142) sampled. As a result of this deficiency, both residents had falls and R142 experienced harm that required the resident to be transported to an acute hospital on another island and had emergency neurosurgery (brain surgery) and a long hospitalization with further complications. Findings include: 1) On 10/21/22 at 10:04 AM, reviewed the facility reported event that was received via email to the Office of Healthcare Assurance (OHCA) on 06/29/22 at 4:00 PM. […]

• Actual harm, isolatedF692Oct 28, 2021

  Based on observations, record review, and staff interviews, the facility failed to ensure adequate interventions were provided to establish proper nutrition for one (Resident (R) 17) of three reviewed for nutrition in a total sample of 14 residents. The facility failed to re-weigh R17 per facility policy when a significant weight loss was first identified, failed to immediately assess R17's nutritional status after a significant weight loss, and failed to immediately notify R17's physician of the significant weight loss. […]

• No harm, potential for more than minimal, widespreadF880Feb 7, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections were implemented. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (additional infection control measures used when patients already have confirmed or suspected infections) by wearing the proper personal protective equipment (PPE) and adhered to standard precautions by performing proper hand and glove hygiene. In addition, the facility failed to have a surveillance plan for infections acquired outside of the facility. As a result of these deficient practices, staff and patient safety was compromised. […]

• No harm, potential for more than minimal, widespreadF943Feb 7, 2025

  Based on record review and interviews, the facility did not assure staff members received training for dementia management and resident abuse prevention, understanding expressions or indications of distress of residents to prevent abuse from occurring. This deficient practice has the potential to place at risk of resident-to-resident or staff to resident abuse. Findings include: Cross Reference to F600 - Free From Abuse and Neglect. The facility submitted event reports alleging resident-to-resident abuse, there were incidents of residents striking out, throwing items, and engaging in altercations related to inability to cope with other residents' behaviors of distress. A review of facility reported incidents found four allegations of resident-to-resident abuse. […]

• No harm, potential for more than minimal, patternF600Feb 7, 2025

  Based on record review and interview, the facility failed to protect the residents' rights to be free from physical abuse by another resident. The facility did not assure residents with a history of distressed behaviors were identified to be at risk for abuse. The facility did not ensure staff were provided with training to assess potential situations that may result in abuse (Cross Reference to F943 - Abuse, Neglect, and Exploitation Training). The facility did not assure residents with a prior incident were supervised and monitored on the lanai. […]