statement of deficiencies and plan of correction€¦ · office of health care assurance state...

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Office of Health Care Assurance

State Licensing Section

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

Facility’s Name: Kina Ole Estate Ekolu, LLC

CHAPTER 100.1

Address:

45-219 William Henry Road, Kaneohe, Hawaii 96744

Inspection Date: September 29 & 30, 2016 Annual

THIS PAGE MUST BE SUBMITTED WITH YOUR PLAN OF CORRECTION. IF IT IS NOT, YOUR PLAN OF

CORRECTION WILL BE RETURNED TO YOU, UNREVIEWED.

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Rules (Criteria) Plan of Correction Completion

Date

§11-100.1-8 Primary care giver qualifications. (a)(6)

The licensee of a Type I ARCH acting as a primary care giver

or the individual that the licensee has designated as the

primary care giver shall:

Have at least one year experience working full time or its

equivalent providing direct nurse aide care as an employee of

a state licensed and approved intermediate care facility,

skilled nursing facility, home health agency, or hospital or

demonstrate competency equivalence through completion of a

program approved by the department;

FINDINGS

Primary care giver (PCG) does not have one year experience

working full time or equivalent providing direct nurse aide

care as employee of a state licensed and approved

intermediate care facility, skilled nursing facility, home health

agency or hospital. Nurse aide program completed 5/20/14;

however, PCG is not a certified nurse aide.

Part 1

DID YOU CORRECT THE DEFICIENCY?

USE THIS SPACE TO TELL US HOW YOU

CORRECTED THE DEFICIENCY

3


Date

11-100.1-8(a)(6) Part 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR

FUTURE PLAN: WHAT WILL YOU DO TO

ENSURE THAT IT DOESN’T HAPPEN AGAIN?

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Date

§11-100.1-9 Personnel, staffing and family requirements.

(e)(4)

The substitute care giver who provides coverage for a period

less than four hours shall:

Be trained by the primary care giver to make prescribed

medications available to residents and properly record such

action.

FINDINGS

Substitute care giver (SCG) #1 - No documentation of

training to make prescribed medication available to residents.

Part 1




5


Date

11-100.1-9(e)(4) Part 2

FUTURE PLAN




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Date

§11-100.1-15 Medications. (e)

All medications and supplements, such as vitamins, minerals,

and formulas, shall be made available as ordered by a

physician or APRN.

FINDINGS

Resident #1 - "Calcium-citrate 600 mg vitamin D 800 IU I tab

po one time per day" ordered 8/31/16; the medication record

reflected "Take 4 hours before or after multivitamin dose."

The medication record reflected the calcium-citrate and

multivitamins are taken at 8 a.m.

Part 1




7


Date

11-100.1-15(e) Part 2

FUTURE PLAN




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Date




physician or APRN.

FINDINGS

Resident #1 - "Sennosides docusate sodium (Senna S) 1 tab

po 2x/day Hold for loose BM" ordered 8/31/16. The

September 2016 medication record reflected "as needed for

constipation."

Part 1




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Date

11-100.1-15(e) Part 2

FUTURE PLAN




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Date




physician or APRN.

FINDINGS

Resident #1 - "Raloxafine (Evista) 60 mg 1 tab po 1 x/day"

ordered 8/31/16; however, last dose given 9/16/16. There was

no physician order to discontinue, no clarification with the

physician.

Part 1




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Date

11-100.1-15(e) Part 2

FUTURE PLAN




12


Date




physician or APRN.

FINDINGS

Resident #1 - "Ketorolac 0.5% ophth soln (Acular) 1 drop to

each eye 3 times daily as needed for eye itch/allergies"

ordered 8/11/16; the label reflected "Instill 1-2 drops." The

medication record noted "1 drop."

Part 1




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Date

11-100.1-15(e) Part 2

FUTURE PLAN




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Date




physician or APRN.

FINDINGS

Resident #2 - "Permethrin 5% cream apply from head to toe at

bedtime; rinse off in am. Repeat in 1 wk." ordered 12/30/15;

however, no documentation that the second application was

applied.

Correcting the deficiency

after-the-fact is not

practical/appropriate. For

this deficiency, only a

future plan is required.

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Date

11-100.1-15(e)

Part 2

FUTURE PLAN




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Date




physician or APRN.

FINDINGS

Resident #2 - "Permethrin 5% cream apply head to toe, repeat

in 1 week" ordered 4/21/16; however, no documentation that

the second application applied.






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Date

11-100.1-15(e) Part 2

FUTURE PLAN




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Date




physician or APRN.

FINDINGS

Resident #2 - "Carvedilol 6.25 mg 1 tab orally twice daily.

Hold for SBP ˂ 105 or HR ˂ 60" ordered 8/11/16, 6/2/16,

2/1/16. The medication record reflected the medication was

given as follows for September 2016:

DATE TIME BP HR

9/2/16 8 a.m. 114/63 57

9/2/16 6 p.m. 141/69 55

9/7/16 6 p.m. 123/78 51

9/8/16 8 a.m. 116/82 52

9/9/16 6 p.m. 152/95 54

9/14/16 8 a.m. 123/75 59

9/14/16 6 p.m. 134/82 51

9/17/16 8 a.m. 122/72 50

9/17/16 6 p.m. 139/95 59

9/20/16 6 p.m. 142/65 59

9/21/16 8 a.m. 173/60 (?) 50

9/22/16 8 a.m. 87/50 53

9/23/16 8 a.m. 113/87 36

9/24/16 6 p.m. 139/78 50

9/28/16 6 p.m. 141/88 53






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Date

11-100.1-15(e)

Part 2

FUTURE PLAN




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Date

§11-100.1-15 Medications. (g)

All medication orders shall be reevaluated and signed by the

physician or APRN every four months or as ordered by the

physician or APRN, not to exceed one year.

FINDINGS

Resident #2 - No documentation medications were

reevaluated and signed by the physician prior to 2/1/16.

There was a Physician Order Sheet (POS) signed by the

physician but was dated 10/2/16. The inspection was

conducted on 9/29 & 30/16.

Part 1




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Date

11-100.1-15(g) Part 2

FUTURE PLAN




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Date

§11-100.1-15 Medications. (l)

There shall be an acceptable procedure to separately secure

medication or dispose of discontinued medications.

FINDINGS

Resident #2 - "Amlodipine" discontinued February 2016; the

Amlodipine was not disposed of; was with current

medication.

Part 1




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Date

11-100.1-15(l) Part 2

FUTURE PLAN




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Date

§11-100.1-17 Records and reports. (a)(1)

The licensee or primary care giver shall maintain individual

records for each resident. On admission, readmission, or

transfer of a resident there shall be made available by the

licensee or primary care giver for the department’s review:

Documentation of primary care giver's assessment of resident

upon admission;

FINDINGS

Resident #1 - Admission assessment was incomplete as it did

not reflect ADLs, mental status, vital signs, diet or

medications.

Part 1




25


Date

11-100.1-17(a)(1) Part 2

FUTURE PLAN




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Date

§11-100.1-17 Records and reports. (b)(3)

During residence, records shall include:

Progress notes that shall be written on a monthly basis, or

more often as appropriate, shall include observations of the

resident's response to medication, treatments, diet, care plan,

any changes in condition, indications of illness or injury,

behavior patterns including the date, time, and any and all

action taken. Documentation shall be completed immediately

when any incident occurs;

FINDINGS

Resident #1 - No documentation that the physician was made

aware that there was a "metoprolol" shortage. No medication

available 9/18/16 p.m. dose to 9/23/16 a.m. dose (10 doses).






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Date

11-100.1-17(b)(3)

Part 2

FUTURE PLAN




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Date

§11-100.1-17 Records and reports. (f)(2)

General rules regarding records:

Symbols and abbreviations may be used in recording entries

only if a legend is provided to explain them;

FINDINGS

Resident #2 - No legend for initials (JF) on the September

2016 medication record.

Part 1




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Date

11-100.1-17(f)(2) Part 2

FUTURE PLAN




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Date

§11-100.1-19 Resident accounts. (d)

An accurate written accounting of resident's money and

disbursements shall be kept on an ongoing basis, including

receipts for expenditures, and a current inventory of resident's

possessions.

FINDINGS

Resident #2 - Inventory of resident's possessions was not

current. Last updated 10/13/14.

Part 1




31


Date

11-100.1-19(d) Part 2

FUTURE PLAN




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Date

§11-100.1-20 Resident health care standards. (c)

The primary and substitute care giver shall be able to

recognize, record, and report to the resident's physician or

APRN significant changes in the resident's health status

including, but not limited to, convulsions, fever, sudden

weakness, persistent or recurring headaches, voice changes,

coughing, shortness of breath, changes in behavior, swelling

limbs, abnormal bleeding, or persistent or recurring pain.

FINDINGS

Resident #1 - No documentation that the physician was

notified of the following elevated BPs:

• 9/14/16 BP = 150/106

• 9/15/16 BP = 164/112

• 9/16/16 BP = 149/121

• 9/24/16 BP = 148/123

Part 1




33


Date

11-100.1-20(c) Part 2

FUTURE PLAN




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Date

§11-100.1-21 Residents' and primary care givers' rights and

responsibilities. (a)(1)(A)

Residents' rights and responsibilities:

Written policies regarding the rights and responsibilities of

residents during the stay in the Type I ARCH shall be

established and a copy shall be provided to the resident and

the resident’s family, legal guardian, surrogate, sponsoring

agency or representative payee, and to the public upon

request. The Type I ARCH policies and procedures shall

provide that each individual admitted shall:

Be fully informed orally or in writing, prior to or at the time

of admission, of these rights and of all rules governing

resident conduct. There shall be documentation signed by the

resident that this procedure has been carried out;

FINDINGS

Resident #1 - No documentation that the resident was

informed of his/her rights and responsibilities.

Part 1




35


Date

11-100.1-21(a)(1)(A) Part 2

FUTURE PLAN




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Date

§11-100.1-54 General operational policies. (2)

In addition to the requirements in section 11-100.1-7, the

Type II ARCH shall have general operational policies on the

following topics:

Medication administration;

FINDINGS

No facility policy and procedure for documenting medication

held due to parameters outside the range set forth by the

physician. The medication records did not consistently reflect

medications withheld (by circling the care giver initials) due

to low blood pressure or heart rate.

Part 1




37


Date

11-100.1-54(2) Part 2

FUTURE PLAN




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Date

§11-100.1-56 Physical environment. (c)(1)

Except as provided in subsection (a), Type II ARCHs shall be

in compliance with the requirements for Group I occupancies

as defined in the Uniform Building Code and as detailed in

applicable chapters of the NFPA 101 Life Safety Code

adopted by reference by the state fire code and respective

county fire codes. Compliance shall include but are not

limited to the following:

All exits in Type II ARCHs shall be lighted from sunset to

sunrise and under other conditions required by applicable

provisions of the state and county fire codes;

FINDINGS

No documentation of annual sprinkler check. Last completed

9/9/13. Submit copy with the plan of correction (POC).

Part 1




39


Date

11-100.1-56(c)(1) Part 2

FUTURE PLAN




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Date

§11-100.1-56 Physical environment. (c)(1)

Except as provided in subsection (a), Type II ARCHs shall be

in compliance with the requirements for Group I occupancies

as defined in the Uniform Building Code and as detailed in

applicable chapters of the NFPA 101 Life Safety Code

adopted by reference by the state fire code and respective

county fire codes. Compliance shall include but are not

limited to the following:

All exits in Type II ARCHs shall be lighted from sunset to

sunrise and under other conditions required by applicable

provisions of the state and county fire codes;

FINDINGS

No documentation of the Honolulu Fire Department

inspection which, by report, was conducted in the last six (6)

months. Submit copy with the POC.

Part 1




41


Date

11-100.1-56(c)(1) Part 2

FUTURE PLAN




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Date

§11-100.1-83 Personnel and staffing requirements. (1)

In addition to the requirements in subchapter 2 and 3:

A registered nurse other than the licensee or primary care

giver shall train and monitor primary care givers and

substitutes in providing daily personal and specialized care to

residents as needed to implement their care plan;

FINDINGS

Resident #1 - No documentation of substitute care giver

training by the case manager for seizure precautions and

aspiration precautions.

Part 1




43


Date

11-100.1-83(1)

Part 2

FUTURE PLAN




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Date

§11-100.1-84 Admission requirements. (b)(4)

Upon admission of a resident, the expanded ARCH licensee

shall have the following information:

Evidence of current immunizations for pneumococcal and

influenza as recommended by the ACIP; and a written care

plan addressing resident problems and needs.

FINDINGS

Resident #1 - No evidence of current influenza immunization.

Part 1




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Date

11-100.1-84(b)(4) Part 2

FUTURE PLAN




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Date

§11-100.1-88 Case management qualifications and services.

(c)(4)

Case management services for each expanded ARCH resident

shall be chosen by the resident, resident's family or surrogate

in collaboration with the primary care giver and physician or

APRN. The case manager shall:

Update the care plan as changes occur in the expanded ARCH

resident care needs, services and/or interventions;

FINDINGS

Resident #1 - Care plan was not updated to address services to

be provided for elevated BP on 9/14/16 = 150/106; 9/15/16 =

164/112; 9/16/16 = 149/121 and 9/24/16 = 148/123. The case

manager visited 9/26/16.

Part 1




47


Date

11-100.1-88(c)(4) Part 2

FUTURE PLAN




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Date

§11-100.1-20 Resident health care standards. (c)

The primary and substitute care giver shall be able to

recognize, record, and report to the resident's physician or

APRN significant changes in the resident's health status

including, but not limited to, convulsions, fever, sudden

weakness, persistent or recurring headaches, voice changes,

coughing, shortness of breath, changes in behavior, swelling

limbs, abnormal bleeding, or persistent or recurring pain.

FINDINGS

Resident #2 - No documentation that the facility reported

significant weight gain of 9 lbs from February 2016 (109.4

lbs) to March 2016 (118.8 lbs) to the physician.

Part 1




49


Date

11-100.1-20(c) Part 2

FUTURE PLAN




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Licensee’s/Administrator’s Signature: __________________________________________

Print Name: __________________________________________

Date: __________________________________________

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