Inspection Reports for Good Samaritan Society – Pohai Nani
45-090 Namoku St, Kaneohe, HI 96744, United States, HI, 96744
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to investigate complaints related to failure in identifying and submitting significant changes in resident conditions, failure to provide respiratory care according to resident's choice, failure to secure treatment carts, and failure to implement proper infection prevention practices.
Complaint Details
The complaint investigation revealed failures in timely reporting of significant changes for Resident 21, inadequate respiratory care documentation and plan updates for Resident 19, unsecured treatment cart, and improper placement of urinary catheter bag for Resident 16.
Findings
The facility failed to identify and submit a significant change for one resident related to weight loss and injury, failed to provide respiratory care in accordance with a resident's daily oxygen use, failed to ensure a treatment cart was locked, and failed to assure proper placement of an indwelling urinary catheter bag off the floor. These deficiencies placed residents at risk of harm or infection.
Deficiencies (4)
Failed to identify and submit a significant change for one resident related to significant weight loss and decline in activities of daily living.
Failed to provide respiratory care in accordance with the resident's choice for one resident, resulting in risk of anxiety and discomfort due to lack of daily oxygen use documentation.
Failed to assure staff locked one treatment cart containing supplies and prescribed ointments, posing risk of inappropriate use.
Failed to assure staff placed an indwelling urinary catheter bag off the floor, placing resident at risk for infection.
Report Facts
Significant weight loss percentage: 7.4
Weight loss in pounds: 10.4
Oxygen flow rate: 1.5
Oxygen order flow rate range: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident care plans and treatment cart locking. |
| MDS Coordinator | Minimum Data Set Coordinator (MDSC) | Interviewed regarding missed significant weight loss reporting and care plan updates. |
| Registered Nurse 5 | Registered Nurse (RN) | Interviewed regarding documentation of oxygen use and treatment cart ownership. |
| Registered Nurse 2 | Registered Nurse (RN) | Interviewed regarding treatment cart ownership. |
| Learning & Development Nurse | Learning & Development Nurse (LDN) | Interviewed regarding training on urinary catheter care. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 9
Date: Feb 15, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding failure to provide written notification of transfer/discharge, incomplete and unimplemented care plans, inadequate assistance with eating, failure to implement fall prevention interventions, medication errors including excessive dosing of Lasix, inadequate monitoring of anticoagulant use, failure to perform hand hygiene between glove changes, and failure to monitor antibiotic use.
Complaint Details
The complaint investigation focused on multiple issues including failure to provide written notification of transfer/discharge, incomplete care plans, inadequate assistance with eating, failure to implement fall prevention, medication errors including excessive dosing of Lasix, inadequate monitoring of anticoagulant therapy, failure to perform hand hygiene between glove changes, and failure to monitor antibiotic use.
Findings
The facility was found deficient in multiple areas including failure to provide written transfer/discharge notification, incomplete care plans for residents, inadequate assistance with eating leading to prolonged meal times, failure to implement fall prevention measures after a resident's fall, medication errors resulting in excessive dosing of Lasix for one resident, inadequate monitoring of anticoagulant therapy for another resident with unexplained bruising, failure to perform hand hygiene between glove changes during catheter care, and failure to monitor antibiotic use for prophylaxis without an end date.
Deficiencies (9)
Failure to provide timely written notification to resident or representative before transfer or discharge.
Failure to develop and implement comprehensive care plans for residents' specific needs including catheter care, fall prevention, and bleeding precautions.
Failure to update comprehensive care plans within 7 days of assessment and by a team of health professionals.
Failure to ensure residents requiring maximum assistance with eating were fed in a timely manner.
Failure to implement fall prevention interventions after a resident's fall resulting in head injury.
Failure to ensure nursing staff had appropriate competencies to prevent medication errors resulting in excessive dosing of Lasix.
Failure to ensure residents' drug regimens were free from unnecessary drugs and to adequately monitor anticoagulant use.
Failure to perform hand hygiene between glove changes during perineal care for a resident with an indwelling urinary catheter.
Failure to implement a program that monitors antibiotic use, resulting in prolonged prophylactic antibiotic use without appropriate indication or end date.
Report Facts
Residents sampled: 35
Excessive Lasix doses: 35
Bruise size: 4.5
Bruise size: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NS36 | Nursing Staff | Entered erroneous medication orders for Lasix leading to excessive dosing for Resident R14 |
| P5 | Physician | Reviewed and confirmed excessive dosing of Lasix for Resident R14 and was unaware of order entry error |
| DON | Director of Nursing | Confirmed deficiencies in care plans, hand hygiene expectations, and antibiotic stewardship |
| RN28 | Registered Nurse / Facility Educator | Observed hand hygiene deficiency and provided education status |
| CN23 | Charge Nurse | Interviewed regarding monitoring of anticoagulant use and bruising for Resident R27 |
| LPN2 | Licensed Practical Nurse | Interviewed regarding bruising on Resident R27 |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 6
Date: Feb 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication management, food safety, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to follow up on residents' advance directives, incomplete and unupdated comprehensive care plans, unlocked medication carts, unsafe food storage and preparation practices, inadequate infection prevention and control practices including improper use and disposal of PPE, and improper handling of linens from residents under transmission-based precautions.
Deficiencies (6)
Failed to provide follow up documentation on Advanced Health Care Directive (AHCD) for one resident and failed to follow up with resident's right to update their AHCD.
Failed to develop and implement a complete care plan that meets all the resident's needs, including monitoring for bleeding related to Plavix medication and psychosocial wellbeing for a resident expressing desire to die.
Failed to revise a resident's comprehensive person-centered care plan after multiple falls to mitigate fall risk.
Failed to ensure one of two medication carts was locked or attended, increasing risk of unauthorized access to medications.
Failed to ensure food was stored and prepared in a safe and sanitary manner, including improper temperature control, expired products, unsanitary containers, and improper storage of brown sugar.
Failed to ensure infection control practices were implemented, including improper sanitization of reusable medical equipment, oxygen tubing not labeled or properly stored, improper use and disposal of PPE, failure to implement transmission-based precautions, and improper handling of linens from residents under transmission-based precautions.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: Many
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NS29 | Nursing Staff | Named in infection control deficiency related to improper sanitization of blood pressure device |
| DON | Director of Nursing | Acknowledged care plan deficiencies and improper disposal of PPE gown strap |
| CNA54 | Certified Nurse Aide | Confirmed resident removed personal alarm leading to falls |
| KS1 | Kitchen Staff | Confirmed food storage and preparation deficiencies |
| IP | Infection Preventionist | Confirmed infection control deficiencies and provided clarifications on proper procedures |
| MDSRN | Minimum Data Set Registered Nurse | Confirmed care plan revision deficiencies |
| CNA2 | Certified Nurse Aide | Observed not donning PPE when entering room under transmission-based precautions |
| CNA6 | Certified Nurse Aide | Observed improper handling of gown strap and linen from resident under transmission-based precautions |
| LS1 | Laundry Specialist | Explained laundry handling procedures and confirmed deficiencies |
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