Lanai Community Hospital

Inspectors wroteBased on policy review and interview, the facility failed to review its infection control plan on an annual basis. The deficient practice inhibits the facilities ability to effectively implement its infection control prevention plan and has the potential to affect all of the residents in the facility by placing them at an increased risk for illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure that the personal information and clinical records of resident (R)12 were protected. As a result of this deficient practice, residents are at risk of their health information not remaining private. Findings Include:On 03/31/26 at 01:00 PM, observed the computer terminal (located on the left-side corner of the activities room) with R12's electronic health record (EHR) left open and accessible to any passerby. The screen included R12's flowsheets, diagnosis, and other healthcare information. Concurrent interview with Certified Nurse Assistant (CNA) 1 stated that she left the EHR open and forgot to exit out when passing resident food trays. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide written notice of the discharge to the hospital to the resident's representative and provide a written notice to the office of the Long-Term Care Ombudsman (LTCO) for one of one resident (Resident (R) 6) sampled for hospitalization. The deficient practice potentially affects the rights of the resident and resident's representative to ensure protections are in place; and facility practices related to transfer and discharge are known to the office of the LTCO.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop a person-centered comprehensive care plan for one of one resident (Resident (R) 7) sampled for dental services and skin conditions. Findings Include:Cross-reference to F791R7 is a [AGE] year-old female, admitted to the facility on [DATE] with a primary diagnosis but not limited to stroke, hemiplegia affecting right side and aphasia. On 03/30/26 at 10:00 AM, observed R7 in bed, awake, able to mumble words when spoken to. R7's right hand flaccid with notable right-hand contracture. R7 with brief on, with no visible indwelling catheter assessed. On 03/31/26 at 11:30 AM, interview with R7's family member (FM) 1, noted that R7 is prone to having skin issues. FM1 stated that for the last couple of months, R7 seemed to have some kind of skin problem. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to revise the care plan for one of two residents (Resident, (R), 7) sampled for limited range of motion (ROM). The facility did not revise the care to include the application of a towel splint for R7's right-hand contracture. This deficient practice puts R7 at risk for worsening contractures. Findings Include:R7 is a [AGE] year-old female, admitted to the facility on [DATE] with a primary diagnosis but not limited to stroke, hemiplegia affecting right side and aphasia. On 03/30/26 at 10:00 AM, observed R7 in bed, awake with noticeable right arm flaccidity and right-hand contracture. No hand or towel splint applied. On 03/31/26 at 10:00 AM, observed right-hand contracture with rolled towel in place. [...]

Inspectors wroteBased on interviews and record review, the facility failed to re-schedule a follow-up dental appointment for one of one resident (Resident (R), 7) sampled for dental services. This deficient practice has the potential to affect all residents currently residing in the facility. Findings Include:On 03/31/26 at 11:25 AM, interview with R7's family member (FM)1 noted that R7's teeth are getting worse and was not sure what could be done about it. FM1 stated she is worried that it will affect R7's eating. On 03/31/26 at 02:31 PM, interview with Charge Nurse (CN) confirmed that R7 did have an appointment with the health clinic on the island but initially refused. CN stated subsequent follow-up appointment could not be accommodated by the clinic, and the facility also failed to reschedule appointment. CN also acknowledged that R7's refusal and dental issues were not included in R7's care plan. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure all medications and blood glucose testing supplies were labeled in accordance with professional standards. Proper labeling is necessary to promote safe administration practices and decrease the risk for medication errors. Proper labeling of blood glucose testing supplies is necessary to ensure the efficacy of the supplies used to test the blood glucose meter for accuracy. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level I was completed accurately to determine if Resident (R)7 will have to be referred for a Level II evaluation. As a result of this deficient practice, there was a potential for R7 not receiving the appropriate care and services for his mental condition. Findings Include: Review of R7's medical records conducted. R7 was admitted to the facility on [DATE] for long term placement with a diagnosis of Dementia due to Pick's Disease. Review of the PASARR Level I Screen dated 12/11/20 under Part A revealed that for the second question, Does the SMI (Serious Mental Illness) individual have Dementia?, the box for No was checked. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure comprehensive person-centered care plans were developed and/or implemented for three residents (Resident (R)3, R4 and R6) in the sample. Specifically, care plans were not developed or implemented to monitor for adverse effects of medications taken for all three residents and to care for the vascular access (a way to reach the blood for hemodialysis) post hemodialysis (treatment to remove waste and excess fluids from the blood) for R3. As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide care consistent with professional standards of practice for the resident (Resident (R)3) who received hemodialysis (treatment to remove waste and excess fluids from the blood) treatments. Specifically, the facility did not provide post hemodialysis treatment care for R3's vascular access (a way to reach the blood for hemodialysis). This deficient practice could result in preventable vascular access complications that could cause serious adverse health conditions.

Inspectors wroteBased on record review and interviews, the facility failed to ensure adequate monitoring was done for three of five resident (Resident (R)3, R4 and R6) sampled for unnecessary medications. The facility was not documenting if R3 was being monitored for signs and symptoms of bleeding and if R4 and R6 were being monitored for adverse effects of psychotropic medications. As a result of this deficient practice, these three residents were put at risk for avoidable adverse health complications related to her health condition and the use of anticoagulants and antidepressants.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to be free from misappropriation of a resident's property for one Resident (R)9 sampled. The Alleged Perpetrator (AP) was an acquaintance with R9 prior to the resident's admission to the facility and worked in the business office. The AP used his/her position as the Patient Access Services Lead and is responsible for handling financial matters. AP used her position to gain access to R9's bank account and personal property. This deficient practice placed the residents in the facility at risk for misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to implement screening procedures to protect resident(s) from financial exploitation, report and thoroughly investigate an allegation of financial exploitation for one resident (Resident (R)9) sampled. The Administrator failed to report the allegation of financial abuse to the appropriate authorities and to the State Agency (SA). This deficient practice placed the residents in the facility at risk for financial exploitation.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an allegation of financial exploitation was reported immediately, but not later than 24 hours after the allegation is made, to the State Survey Agency (SA), Office of Health Care Assurance (OHCA)), Adult Protective Services (APS), and the authorities, or submit a completed report of all investigations in accordance with State law, to OHCA, within 5 working days of the incident for one Resident (R)9 sampled.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an allegation of financial exploitation was thoroughly investigated and reported to the State Agency, within 5 working days of the reported incident, for one resident (Resident (R)9) sampled. Legal counsel of R9's health care and Financial Power of Attorney (FPOA) reported an allegation of financial exploitation of the resident by a facility staff to the Administrator on 09/19/23. Review of the facility's investigation during the State Agency's (SA) recertification survey revealed the facility had not completed an investigation more than a month after the allegation was reported.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement policies for the feedback, data collection, monitoring, performance improvement for high-risk, high-volume, or problem-prone areas, and conduct an improvement project at least annually. The Administrator was unaware of the high-risk/high prone issues, how the facility was addressing identified issues such as adverse event reporting, and results or adjustments made to implemented measures in a good faith attempt to reconcile these issues related to the facility's Quality Assurance Performance Improvement (QAPI) program as a result of this deficient practice, residents are at a potential risk for physical, mental, and/or psychosocial harm.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the designated Infection Preventionist (IP) worked at least part-time at the facility. The facility's IP works full-time at another facility on another island and is not present at the facility at least half-time. As a result of this deficient practice, residents are at risk for more than minimal potential for harm.