Nuuanu Hale

In the surveyor’s words

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

• Immediate jeopardy, isolatedF880Aug 17, 2021

  Based on observation, interview, and record review, after identifying a person under investigation (PUI), with a fever of 102.3 degrees at 03:38 PM on 08/11/21, the facility failed to ensure appropriate protective and preventive measures for COVID-19 and other communicable diseases and infections were executed, as evidenced by the facility failing to revise, follow and implement their infection prevention and control policies and procedures, including the transmission-based precautions of their COVID-19 Plan to control and prevent the spread of infections. […]

• Actual harm, isolatedF689Mar 8, 2024

  Based on observations, interviews, and record review, the facility failed to ensure the resident's environment remains free of accident hazards for one resident (R)8 sampled. The facility implemented interventions to allow the resident to self-transfer from the bed to the floor mattress, but did not evaluate, analyze, identify, or address any environmental hazards which existed once R8 self-transferred to the floor mattress prior to implementing this intervention. Also, after implementing the did not monitor the effectiveness or safety for the floor mattress. As a result of this deficient practice, R8 sustained multiple skin tears, bruising, and wounds on both lower legs. […]

• Actual harm, isolatedF686Feb 6, 2023

  Based on observation, record review, and interview with staff members, the facility failed to ensure 2 (Residents 11 and 16) of 5 residents sampled with pressure injuries received preventative care to avoid the development of pressure ulcers. The facility failed to ensure accurate weekly skin assessments were done for Resident (R)16, resulting in delayed treatment to prevent the development of a Stage 3 pressure injury. The facility also failed to develop interventions for R11 to prevent the recurrent development or pressure injuries related to contractures. Findings include: 1) Resident (R)16 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Feb 6, 2023

  Based on observations, record review, and interviews with staff members, the facility failed to implement interventions, including adequate supervision, to reduce the risk of accidents for two of six sampled residents, Residents 23 and 36. As a result of this deficient practice, Resident (R)36 had multiple falls, with a fall resulting in the resident being taken to the emergency department for evaluation. Finding include: Resident (R)36 has an extensive history but not limited to hereditary musculoskeletal disease, blindness to the left eye secondary to a ruptured globe (repaired). Recurring depression/anxiety, cognitive decline with behavioral disturbances. […]

• Actual harm, isolatedF684Dec 22, 2022

  Based on interviews and record review, the facility failed to ensure the accurate assessment, upon admission, for existing behavioral disorders that may indicate a psychiatric condition for one of three (Resident (R)3) residents sampled. R3 did not receive adequate treatment to address the resident's severe psychological needs. R3 was transferred to the Emergency Department (ED) after the resident's behavior escalated to physical and verbal aggression toward residents and staff. R3 was transferred between the facility and the Hospital (H)3 twice by ambulance, then waited in the ED for three days before receiving services. R3 did not receive skilled nursing services or a psychiatric evaluation while in the ED. […]