Leahi Hospital

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 30, 2022

  Based on observations, interviews, and record reviews, the facility failed to properly assess and treat the mobility issues and provide for the dementia care needs of one resident (R)77 out of a sample of one, that could have potentially prevented R77's fall. This deficient practice has rendered harm to R77 who sustained a pelvic fracture that cannot be surgically corrected, with subsequent pain, decreased mobility, decreased appetite, and overall decreased quality of life. This has the potential to affect all residents with dementia and mobility issues in the facility who need timely rehabilitation (PT/OT) screening and individualized dementia care. Finding includes: On 09/27/22 at 09:48 AM, an initial observation of R77 was made. […]

• Actual harm, isolatedF552Sep 20, 2021

  Based on observations, interviews, and record reviews, the facility failed to ensure the resident's right to be informed of and participate in his/her care in a manner the resident can understand for one (1) resident, (R)335, sampled. Staff did not use auxiliary aids or written communication to inform R335, who has impaired hearing, that a medication would be administered rectally and was not informed of options and/or alternatives prior to staff administering the medication. As a result of not understanding medications would be administered rectally, R335 reported an allegation of sexual abuse to a family member (FM). […]

• Actual harm, isolatedF600Sep 20, 2021

  Based on interviews and record review, the facility failed to ensure the resident's right to be free from neglect and abuse for one resident, R335, sampled. Staff did not accurately assess the extent of R335's hearing impairment upon admission and was administered a rectal suppository without being fully aware and/or informed of the route of administration, reason for administration, or alternative choices prior to administration. After the rectal suppository was administered, R335 called FM crying and reported an allegation of sexual abuse. FM contacted the facility and reported the allegation to the NS4. NS4 spoke to the resident who was upset and crying, and the resident's blood pressure became elevated which required a medication intervention. […]

• Actual harm, isolatedF686Sep 20, 2021

  Based on observations, interviews and record reviews, the facility failed to implement interventions to prevent a pressure ulcer and provide necessary treatment to prevent infection for R73 who was at risk for developing pressure ulcer/pressure injury (PU/PI) due to the presence of contractures. This deficient practice caused R73 to develop an unstageable PU/PI which was avoidable if the facility provided proper care. Findings include: R73 is a [AGE] year-old admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R73 also presents with MASD to the GT site, buttock and labia and a left great toe unstageable ulcer that requires a daily dressing change. […]

• No harm, potential for more than minimal, widespreadF867Aug 1, 2024

  Based on interview, record review, facility document review and facility policy review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI). Specifically, the facility failed to ensure corrective action was implemented and maintained to ensure sustained compliance with reporting and investigating alleged allegations of abuse. This had the potential to affect all residents that resided in the facility. Findings included: The Department of Health and Human Services Center for Medicare and Medicaid Services [CMS] Form CMS-2567's, dated 09/20/2021, 09/30/2022, and 09/14/2023, revealed the facility received deficiencies for F609 and F610 each year. […]