Pu'Uwai 'O Makaha

In the surveyor’s words

From the most serious findings on record at Pu'Uwai 'O Makaha, in the surveyor’s own words.

• Actual harm, patternF689Aug 10, 2022

  Based on observations, interviews, record reviews, and review of policy, the facility: 1) failed to ensure Resident (R)26 remained free of accident hazards, 2) failed to keep R36's bed in the lowest position resulting in a fall and a laceration to R36's head that required stitches, 3) failed to collect/secure smoking material (lighter) from Resident (R)17, and as a result put R17 as well as all other residents at risk for accident hazards. Findings include: 1) On 08/03/22 at 11:36 AM, conducted a record review of R26's Electronic Health Record (EHR). R26 was admitted with diagnosis that include chronic [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], dysphagia, [CONDITION(S)], and contracture. The resident is unable to speak or move independently. On 04/26/22. […]

• Actual harm, isolatedF689Aug 31, 2023

  Based on interviews and record/document review, the facility failed to take immediate interventions and provide adequate supervision to one resident (R)1 after she attempted suicide. On 08/22/2023, R1 wrapped the call light cord around her neck in a suicide attempt. After R1 was found, the staff did not immediately remove all items that could be used to harm self, or provide adequate supervision. As a result of this deficiency, R1 was able to access cords and attempted to hurt herself again two times. At the time of survey, the staff was found to have addressed the deficiencies and were in compliance. […]

• Actual harm, isolatedF684Jul 28, 2023

  Based on observations, interviews, and record review, the facility failed to ensure one resident sampled (Resident (R)2) sampled received professional standard quality of care. R2 was readmitted to the facility on [DATE] from an acute hospital with an ostomy bag. The facility did not develop care plans, which drives the care of residents for malnutrition, pain, and prevention of pressure injury/pressure ulcer. On admission, the physician identified R2 to be at risk for malnutrition, R2 was not assessed by the Dietician until 9 days after admission when contacted by the facility due to R2's poor oral intake, refusing meals, and having a significant weight loss of 12.09%. […]

• Actual harm, isolatedF684Sep 17, 2021

  Based on interview with facility staff, and record review (RR), the facility failed to ensure that licensed nurses and other nursing personnel had the knowledge and competencies to promptly identify and address a resident's change in health status so that interventions could be applied to prevent the condition from worsening. Specifically, the facility failed to recognize signs of a potential urinary tract infection in a resident (R)1 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of this deficient practice, R1 suffered harm and was transferred to the Emergency Department (ED) in acute respiratory distress and admitted to intensive care on a respirator with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689May 17, 2021

  Based on interviews, record review, Policy and procedure, the facility failed to provide a safe environment for Resident (R) 174 which resulted in a fall with injury. R174 required hospitalization and surgery for her injury. Findings include: R 174 sustained a fall with injury while left unattended in the restroom during a shower. R174 has a history of cerebral infarction, [CONDITION(S)] affecting left nondominant side. dysarthria. She has generalized muscle weakness and is unsteady on her feet. Record review of a facility reported event report on 05/12/21 revealed that R174 requested to use a shower chair that was too small for her size, and insisted to the certified nursing assistant (CNA)1 to place 3 blankets on the chair to make her sit higher on the shower chair. […]