Inspection Reports for Yukio Okutsu State Veterans Home
1180 Waianuenue Ave, Hilo, HI 96720, United States, HI, 96720
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% worse than Hawaii average
Hawaii average: 8.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 15, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide competent nursing services for one resident (R166), specifically related to delayed action in responding to the resident's respiratory distress.
Complaint Details
The complaint investigation found that nursing staff did not take timely action to transfer Resident R166 to the emergency room despite low oxygen saturation levels and family requests. The family reported the resident was struggling to breathe, looked pale, and was coughing. The Registered Nurse and Director of Nursing acknowledged delayed response and insufficient intervention.
Findings
The facility failed to take immediate action and seek a higher level of care for Resident R166's respiratory distress, resulting in the resident being at risk of more than minimal physical harm. Oxygen saturation levels were critically low, and nursing staff delayed transferring the resident to the emergency room despite family concerns and documented low oxygen levels.
Deficiencies (1)
Failure to provide competent nursing services for Resident R166, including delayed action in responding to respiratory distress and failure to seek higher level of care promptly.
Report Facts
Oxygen saturation levels: 83
Oxygen saturation levels: 84
Oxygen saturation levels: 91
Oxygen saturation levels: 92
Oxygen liters: 4
Oxygen liters: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN3 | Registered Nurse | Interviewed regarding delay in providing higher level of care for Resident R166 |
| DON | Director of Nursing | Present during interview with RN3 and confirmed normal oxygen saturation range and delayed action |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Nov 15, 2024
Visit Reason
The inspection was conducted as a recertification and annual survey of the Yukio Okutsu State Veterans Home to assess compliance with regulatory requirements and standards of care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, honoring food preferences, timely notification of transfers, comprehensive care planning for pain, appropriate medical care for bowel management, dialysis care, medication administration errors, food service sanitation, binding arbitration agreements, and vaccination documentation.
Deficiencies (10)
Facility failed to ensure resident's right to a dignified existence; staff referred to a resident as a feeder.
Facility failed to facilitate resident self-determination through support of food preferences; resident served disliked foods.
Facility failed to provide timely notification of transfer or discharge to resident, representative, and ombudsman.
Facility failed to develop a comprehensive care plan for pain including non-pharmacological interventions.
Facility failed to provide appropriate medical care for bowel management and diarrhea for a resident.
Facility failed to provide safe dialysis care by not ensuring fluid restrictions were followed as ordered.
Facility failed to ensure medication error rate was less than 5%; two medication errors observed.
Facility failed to clean and maintain food serving equipment and utensils in a sanitary condition.
Facility failed to ensure Binding Arbitration Agreements included residents' right to rescind within 30 days.
Facility failed to document resident refusal and education regarding influenza immunization.
Report Facts
Medication errors observed: 2
Residents agreeing to Binding Arbitration Agreement: 42
Fluid intake above ordered restriction: 5
Milk containers in resident refrigerator: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN6 | Registered Nurse | Named in dignity deficiency and dialysis care findings |
| DON | Director of Nursing | Confirmed multiple deficiencies including dignity, food preferences, care planning, bowel management, and vaccination documentation |
| LPN2 | Licensed Practical Nurse | Named in medication error findings for improper medication administration |
| D1 | Dietitian | Confirmed food preference errors and food warmer sanitation issues |
| AP1 | Attending Physician | Named in bowel management and stool sample delay findings |
| DA1 | Dietary Assistant | Named in dishwasher sanitizing solution testing findings |
| RN99 | Registered Nurse | Responsible for obtaining consents and refusal forms related to vaccination |
| SS2 | Social Service Staff | Confirmed transfer/discharge notice was not sent to Ombudsman |
| Administrator | Facility Administrator | Confirmed lack of written transfer notification and arbitration agreement deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 30, 2023
Visit Reason
The inspection was conducted following a complaint and incident report regarding a mechanical lift malfunction that caused injury to a resident.
Complaint Details
The complaint investigation was substantiated. A mechanical lift malfunction on 06/29/23 caused Resident 161 to fall from approximately three feet, resulting in multiple acute fractures. The CNA operating the lift was alone, contrary to facility policy requiring two staff members. The CNA was placed on administrative leave during investigation.
Findings
The facility failed to ensure safe use of a mechanical lift, resulting in a resident sustaining multiple fractures after a fall caused by lift malfunction and improper staff operation. The facility implemented mandatory staff training, skills validation, and monitoring to prevent recurrence.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents related to mechanical lift use.
Report Facts
Date of incident: Jun 29, 2023
Date of report submission: Jun 29, 2023
Date of report completion: Jul 7, 2023
Height of fall: 3
Date of last maintenance inspection before incident: Jun 14, 2023
Date of maintenance transition: Jul 6, 2023
Date of mandatory training completion: Jul 27, 2023
Monitoring period: 90
Date of interview: Oct 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) | Operated mechanical lift alone during incident; placed on administrative leave | |
| Restorative Aide (RA) 2 | Interviewed on 10/27/23 confirming two staff members are required for mechanical lift use |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Oct 30, 2023
Visit Reason
The inspection was conducted as part of the annual survey of the Yukio Okutsu State Veterans Home to assess compliance with regulatory requirements and standards of care.
Findings
The facility was found deficient in multiple areas including failure to provide written bed-hold notices at transfer, inaccurate resident assessments, incomplete and untimely care plans, inadequate pressure ulcer care, unsafe use of mechanical lifts resulting in resident injury, medication errors including crushing extended-release medications, improper medication refrigerator temperature monitoring, inadequate dishwashing temperature documentation, and failure to properly disinfect shared medical devices and maintain hand hygiene.
Deficiencies (9)
Failure to notify resident or representative in writing about bed-hold duration at hospital transfer.
Failure to provide accurate assessments for residents leading to incomplete care plans.
Failure to implement complete care plan interventions for fall prevention and timely revision of care plans.
Failure to provide consistent repositioning and pressure ulcer care for a resident with Stage 4 pressure ulcer.
Failure to ensure adequate supervision and safe use of mechanical lift resulting in resident injury with multiple fractures.
Medication errors including holding medications without parameters and crushing extended-release medications.
Failure to ensure appropriate temperature monitoring and documentation for medication refrigerators.
Failure to ensure dishes were properly sanitized with missing temperature log entries.
Failure to properly disinfect shared blood glucose meters and inadequate hand hygiene during meal delivery.
Report Facts
Falls: 9
Medication error rate: 5
Mechanical lift fall height: 3
Medication refrigerator temperature range: 36-46
Dishwasher temperature log entries missing: 1
Medication refrigerator temperature log missing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN4 | Registered Nurse | Named in medication error finding for holding medications without parameters and crushing extended-release medication |
| LPN2 | Licensed Practical Nurse | Named in care plan finding regarding hearing aid intervention follow-up |
| RN5 | Registered Nurse | Interviewed regarding care plan and disinfection of blood glucose meter |
| CNA11 | Certified Nurse Assistant | Named in care plan observation for fall prevention monitoring |
| CNA10 | Certified Nurse Assistant | Named in pressure ulcer care and hand hygiene findings |
| PT1 | Physical Therapist | Interviewed regarding pressure ulcer positioning |
| RA2 | Restorative Aide | Interviewed regarding mechanical lift safety procedures |
| DSD | Dining Services Director | Interviewed regarding dishwasher temperature log and sanitation |
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Oct 14, 2022
Visit Reason
The inspection was conducted as part of a regulatory annual survey to assess compliance with healthcare facility regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, care planning, infection control, staffing adequacy, medication management, pressure ulcer care, pain management, behavioral health services, and medical record accuracy. Several residents experienced inadequate care planning, untreated or poorly managed medical conditions, and insufficient staffing leading to delayed care and potential harm.
Deficiencies (16)
Failed to honor residents' rights to dignified existence, self-determination, communication, and exercise of rights, including failure to respond to grievances and provide communication aids.
Failed to provide residents with notice of rights, rules, services, and charges, and failed to ensure ongoing communication about rights.
Failed to provide residents with informational notice of how to contact the Ombudsman or State Agency.
Failed to allow residents to view nursing home survey results and communicate with advocate agencies.
Failed to maintain a clean, sanitary, and homelike environment, evidenced by urinals placed on bedside tables with food and hydration items, compromising resident safety.
Failed to develop and implement comprehensive, person-centered care plans for multiple residents addressing individualized needs including constipation, pressure injury prevention, behavioral health, and wandering behavior.
Failed to timely update care plans for residents to meet changing care needs, including behavioral health and wound care.
Failed to provide appropriate treatment and care according to orders and resident preferences, including management of constipation, weight monitoring, and treatment of skin rash.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in worsening and infected pressure injuries for residents.
Failed to provide adequate pain management for a resident with chronic pain syndrome, resulting in severe pain interfering with movement, mood, and appetite.
Failed to provide sufficient nursing staff to meet residents' needs, resulting in delayed care and unmet needs.
Failed to ensure medications were free from significant medication errors, including administration of expired insulin.
Failed to ensure drugs and biologicals were stored and labeled in accordance with professional standards, including improper storage of influenza vaccines and lab specimens with food.
Failed to conduct and document a facility-wide assessment to determine necessary resources to care for residents competently during day-to-day operations and emergencies.
Failed to safeguard resident-identifiable information and maintain medical records accurately, resulting in conflicting advance directives and unclear documentation of resident wishes.
Failed to provide and implement an infection prevention and control program, including failure to follow policies for PPE use, gown changes between residents, proper specimen handling, and COVID-19 outbreak management.
Report Facts
Deficiencies cited: 17
Residents affected: 19
Expired insulin days: 6
COVID-19 positive residents: 5
COVID-19 positive staff: 2
Influenza vaccine doses: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN5 | Registered Nurse | Named in medication error finding for expired insulin administration |
| ADON | Assistant Director of Nursing | Interviewed regarding pressure ulcer care and infection prevention |
| SSA1 | Social Services Assistant | Interviewed regarding behavioral health services and care planning |
| CNA1 | Certified Nurse Aide | Observed handling lab specimens improperly |
| LVN1 | Licensed Vocational Nurse | Observed and interviewed regarding PPE use and storage |
| IP | Infection Preventionist | Interviewed regarding COVID-19 outbreak and infection control practices |
| DON | Director of Nursing | Interviewed regarding medication storage and infection control |
Viewing
Loading inspection reports...
