Lanai Community Hospital

In the surveyor’s words

From the most serious findings on record at Lanai Community Hospital, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF607Oct 27, 2023

  Based on interview and record review, the facility failed to implement screening procedures to protect resident(s) from financial exploitation, report and thoroughly investigate an allegation of financial exploitation for one resident (Resident (R)9) sampled. The Administrator failed to report the allegation of financial abuse to the appropriate authorities and to the State Agency (SA). This deficient practice placed the residents in the facility at risk for financial exploitation. Findings include: On 10/23/23 at 04:24 PM, the State Agency (SA) contacted the State Long Term Care Ombudsman LTCO assigned to the facility to inquire about any concerns. […]

• No harm, potential for more than minimal, widespreadF609Oct 27, 2023

  Based on interviews and record reviews, the facility failed to ensure an allegation of financial exploitation was reported immediately, but not later than 24 hours after the allegation is made, to the State Survey Agency (SA), Office of Health Care Assurance (OHCA)), Adult Protective Services (APS), and the authorities, or submit a completed report of all investigations in accordance with State law, to OHCA, within 5 working days of the incident for one Resident (R)9 sampled. Findings include: On 10/23/23 at 04:24 PM, the State Agency (SA) contacted the State Long Term Care Ombudsman LTCO assigned to the facility to inquire about any concerns. […]

• No harm, potential for more than minimal, widespreadF867Oct 27, 2023

  Based on interviews and record reviews, the facility failed to implement policies for the feedback, data collection, monitoring, performance improvement for high-risk, high-volume, or problem-prone areas, and conduct an improvement project at least annually. The Administrator was unaware of the high-risk/high prone issues, how the facility was addressing identified issues such as adverse event reporting, and results or adjustments made to implemented measures in a good faith attempt to reconcile these issues related to the facility's Quality Assurance Performance Improvement (QAPI) program as a result of this deficient practice, residents are at a potential risk for physical, mental, and/or psychosocial harm. […]

• No harm, potential for more than minimal, widespreadF882Oct 27, 2023

  Based on interviews and record review, the facility failed to ensure the designated Infection Preventionist (IP) worked at least part-time at the facility. The facility's IP works full-time at another facility on another island and is not present at the facility at least half-time. As a result of this deficient practice, residents are at risk for more than minimal potential for harm. Findings include: On 10/24/23 at 1:15 PM, conducted an interview with the Administrator regarding the facility's IP. The Administrator confirmed the IP works full-time on another island for another facility and primarily works remotely. Inquired as to when the IP is physically present at the facility. […]

• No harm, potential for more than minimal, widespreadF727Aug 11, 2022

  Based on interview and record review, the facility failed to provide a Director of Nursing (DON) on a full-time basis. The same staff member covers both the long-term care (LTC) facility and the Critical Access Hospital (CAH) as the DON. Findings include: On 08/10/22 at 01:45 PM, Administrator reported the facility's Director of Nursing (DON) oversees the LTC facility and the CAH. On 08/11/22 at 02:46 PM, the facility provided a job description for the LTC DON via secure email. The job title is Director of Nursing - Critical Access. […]