Hilo Benioff Medical Center

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections were implemented. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (additional infection control measures used when patients already have confirmed or suspected infections) by wearing the proper personal protective equipment (PPE) and adhered to standard precautions by performing proper hand and glove hygiene. In addition, the facility failed to have a surveillance plan for infections acquired outside of the facility. As a result of these deficient practices, staff and patient safety was compromised.

Inspectors wroteBased on record review and interviews, the facility did not assure staff members received training for dementia management and resident abuse prevention, understanding expressions or indications of distress of residents to prevent abuse from occurring. This deficient practice has the potential to place at risk of resident-to-resident or staff to resident abuse.

Inspectors wroteBased on record review and interview, the facility failed to protect the residents' rights to be free from physical abuse by another resident. The facility did not assure residents with a history of distressed behaviors were identified to be at risk for abuse. The facility did not ensure staff were provided with training to assess potential situations that may result in abuse (Cross Reference to F943 - Abuse, Neglect, and Exploitation Training). The facility did not assure residents with a prior incident were supervised and monitored on the lanai. The facility submitted reports alleging resident-to-resident abuse involving a cognitive resident (Resident 44) that had two incidents as the alleged perpetrator, one with a cognitively impaired resident (Resident 33) and a cognitive resident (Resident 3). There were two incidents involving Resident (R)44 and R33. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure all medications used in the facility were labeled in accordance with professional standards. In addition, the facility failed to ensure all medications used in the facility were securely stored in locked compartments in 3 of 4 medication carts. Proper storage and labeling of medications is necessary to promote safe administration practices, and to decrease the risk of medication errors and diversion of resident medications.

Inspectors wroteBased on confidential interview and record review, the facility failed to treat each resident with respect and dignity for one of one sampled resident reviewed for dignity. This deficient practice caused the resident distress and affected his mood.

Inspectors wroteBased on observations and interview, the facility did not ensure a resident's right to a safe and homelike environment was provided for one of one residents that expressed concern regarding their home environment. This deficient practice affects the resident's comfort and safety.

Inspectors wroteBased on interviews and record review, the facility did not ensure the resident was apprised of the progress toward resolution of a filed grievance and prompt efforts were not made to resolve a grievance for one (Resident 1) of one residents that filed a grievance. This deficient practice resulted in the resident being unaware of the outcome of the grievance; therefore, five months have passed and Resident (R)1 continues without knowledge of the results of her grievance and an iPad.

Inspectors wroteBased on observations, record review, and interview, the facility failed to develop a baseline care plan that provided effective and person-centered care for 1 of 4 new admissions in the sample. Specifically, despite identifying that Resident (R)151 had psychotropic medication (medications that affect the mind, emotions, and behavior) needs, the facility failed to develop and implement a behavior-monitoring care plan. As a result of these deficient practices, the facility placed R151 at risk for avoidable declines or injury.

Inspectors wrote2) Cross Reference to F692 (Nutrition Status Maintenance) and F710 (Resident's Care Supervised by a Physician). The facility failed to revise R10's care plan to reflect individualized preferences for foods and snacks. Record review found R10 had a significant weight loss. On 01/31/25 at 10:50 AM an interview was conducted with the Registered Dietitian (RD). RD confirmed significant weight loss occurred. Following identification of significant weight loss, RD reported she met with the resident to inquire what are his food and snack preferences are and discussed the use of dietary supplement. RD acknowledged the care plan was not updated to include the resident's preference as well as the interventions that were discussed. Based on record review and interview, the facility failed to review and revise the Comprehensive Care Plan (CP) for 1 of 1 resident (R) sampled for falls. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not assure one (Resident 10) of one resident who is unable to carry out activities of daily living (ADL) receives the necessary services to keep his fingernails clean. This deficient practice has the potential to result in unsanitary practice which may lead to infections.

Inspectors wroteBased on observations, record review, and interviews, the facility did not ensure a resident receives appropriate treatment and services to prevent further decrease in range of motion (how far a joint or muscle can be moved in various directions) for one (Resident 2) of four residents in the sample for residents with limited range of motion. The facility failed to apply soft posey splint and did not have an individualized program to perform passive range of motion. This deficient practice affects the resident's ability to obtain and maintain his highest functional goal.

Inspectors wroteBased on observation, record review, and interview, the facility failed to assure one (Resident 10) of two residents reviewed for significant weight loss was evaluated by his physician and his care plan was revised to include person-centered interventions. This deficient practice has the potential to result in continued weight loss and the inability of the resident to maintain acceptable parameters of nutritional status.

Inspectors wroteBased on observations, interviews, and record review the facility failed to label resident's nasal cannula with a date when first used for one of one resident in the sample. This failure has the potential to result in illness due to bacterial/viral buildup in the plastic tubing.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident's physician of a significant weight loss for one (Resident 10) of two residents sampled for significant weight loss. This deficient practice resulted in the lack of physician oversight to evaluate and manage causes of the resident's weight loss, inability to contribute to the resident's assessment and care planning, and ensure resident is maintaining acceptable parameters of nutritional status.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the pharmacy recommendations were addressed for one (Resident 27) of five residents reviewed for unnecessary medication when the physician did not respond to the pharmacist's recommendation for dose reduction of psychotropic medications. This deficient practice could potentially result in residents receiving unnecessary medication.

Inspectors wroteBased on observations, record review, and interview with staff members, the facility did not assure their infection control program for enhanced barrier precautions (an approach to expand the use of personal protective equipment, the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multidrug-Resistant Organisms [MDRO] to staff hands and clothing) were implemented.

Inspectors wroteBased on record review and interview, the facility failed to ensure an environment free of accident hazards for one resident (Resident (R)32) and/or receives adequate supervision to prevent accidents for one resident (R142) sampled. As a result of this deficiency, both residents had falls and R142 experienced harm that required the resident to be transported to an acute hospital on another island and had emergency neurosurgery (brain surgery) and a long hospitalization with further complications.

Inspectors wroteBased on observation and interview, the facility failed to provide meals that were at the desired temperature based on the resident's preferences. As a result of this deficiency, there is the potential to affect the resident's nutritional status, hydrations status, and could exposure the residents to food-borne illness and has the potential for harm.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident's wishes and preferences were considered in the exercise of the rights of the representative for 1 (Resident (R)10) of 2 residents sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure was the comprehensive person-centered care plan (CP) was implemented to maintaining the resident's highest practicable physical well-being for one (1) resident (Resident (R)32) sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure was the comprehensive person-centered care plan (CP) was revised after multiple falls to include interventions relevant to maintaining the resident's highest practicable physical well-being for one (1) resident (Resident (R)32) sampled.

Inspectors wroteBased on observation and interviews, the facility failed to ensure drugs storage was locked.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the entirity of a resident's Advance Health Care Directive (AHCD) was included in the electronic health record (EHR) for one 1 (Resident (R)8) of 3 residents sampled.