statement of deficiencies and plan of …...08/16/16, rev 09/09/16 1 office of health care assurance...

08/16/16, Rev 09/09/16 1

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 6 and 7, 2018 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.

YOUR PLAN OF CORRECTION MUST BE SUBMITTED WITHIN TEN (10) WORKING DAYS. IF IT IS NOT

RECEIVED WITHIN TEN (10) DAYS, YOUR STATEMENT OF DEFICIENCIES WILL BE POSTED ONLINE,

WITHOUT YOUR RESPONSE.

2

RULES (CRITERIA) PLAN OF CORRECTION

Completion

Date

§11-100.1-13 Nutrition. (i)

Each resident shall have a documented diet order on

admission and readmission to the Type I ARCH and shall

have the documented diet annually signed by the resident’s

physician or APRN. Verbal orders for diets shall be

recorded on the physician order sheet and written

confirmation by the attending physician or APRN shall be

obtained during the next office visit.

FINDINGS

Resident #2 – No documented diet order within the past

year.

PART 1

DID YOU CORRECT THE DEFICIENCY?

USE THIS SPACE TO TELL US HOW YOU

CORRECTED THE DEFICIENCY

3


Completion

Date

§11-100.1-13 Nutrition. (i)

Each resident shall have a documented diet order on

admission and readmission to the Type I ARCH and shall

have the documented diet annually signed by the resident’s

physician or APRN. Verbal orders for diets shall be

recorded on the physician order sheet and written

confirmation by the attending physician or APRN shall be

obtained during the next office visit.

FINDINGS

Resident #2 – No documented diet order within the past

year.

PART 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR FUTURE

PLAN: WHAT WILL YOU DO TO ENSURE THAT

IT DOESN’T HAPPEN AGAIN?

4


Completion

Date

§11-100.1-13 Nutrition. (l)

Special diets shall be provided for residents only as ordered

by their physician or APRN. Only those Type I ARCHs

licensed to provide special diets may admit residents

requiring such diets.

FINDINGS

Resident #1 – Diet order on 9/4/2018 states, “finely chopped

texture with nectar thickened liquids.” However; diet order

incomplete as it does not specify the type of diet, i.e.,

regular, diabetic, etc…

PART 1




5


Completion

Date

§11-100.1-13 Nutrition. (l)

Special diets shall be provided for residents only as ordered

by their physician or APRN. Only those Type I ARCHs

licensed to provide special diets may admit residents

requiring such diets.

FINDINGS

Resident #1 – Diet order on 9/4/2018 states, “finely chopped

texture with nectar thickened liquids.” However; diet order

incomplete as it does not specify the type of diet, i.e.,

regular, diabetic, etc…

PART 2

FUTURE PLAN




6


Completion

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 – 1/8/2018 medication order for Oseltamivir

states, “75 mg po qd for 10 days.” Another order for the

same medication from 1/22/2018 states, “75 mg po qd,”

without a specific time frame. Medication administration

record (MAR) reflects medication being given from

1/23/2018 to 1/29/2018; seven (7) days. Medication orders

not clarified, and medication not given as prescribed.

PART 1

Correcting the deficiency

after-the-fact is not

practical/appropriate. For

this deficiency, only a future

plan is required.

7


Completion

Date





FINDINGS

Resident #1 – 1/8/2018 medication order for Oseltamivir

states, “75 mg po qd for 10 days.” Another order for the

same medication from 1/22/2018 states, “75 mg po qd,”

without a specific time frame. Medication administration

record (MAR) reflects medication being given from

1/23/2018 to 1/29/2018; seven (7) days. Medication orders

not clarified, and medication not given as prescribed.

PART 2

FUTURE PLAN




8


Completion

Date





FINDINGS

Resident #1 – 1/8/2018 medication order for Acetaminophen

changed to, “500 mg – two (2) tabs po tid.” Medication

order not updated on MAR until 2/4/2018.

PART 1





plan is required.

9


Completion

Date





FINDINGS

Resident #1 – 1/8/2018 medication order for Acetaminophen

changed to, “500 mg – two (2) tabs po tid.” Medication

order not updated on MAR until 2/4/2018.

PART 2

FUTURE PLAN




10


Completion

Date





FINDINGS

Resident #1 – Hydrocortisone 1% cream on MAR from

7/6/2018; however, no record of medication order until

9/4/2018.

PART 1





plan is required.

11


Completion

Date





FINDINGS

Resident #1 – Hydrocortisone 1% cream on MAR from

7/6/2018; however, no record of medication order until

9/4/2018.

PART 2

FUTURE PLAN




12


Completion

Date





FINDINGS

Resident #1 – 9/4/2018 medication order for Preservision

states, “one (1) soft gel po qd.” MAR and medication label

state, “(one) 1 soft gel po bid.” Medication order does not

match label or MAR.

PART 1




13


Completion

Date





FINDINGS

Resident #1 – 9/4/2018 medication order for Preservision

states, “one (1) soft gel po qd.” MAR and medication label

state, “(one) 1 soft gel po bid.” Medication order does not

match label or MAR.

PART 2

FUTURE PLAN




14


Completion

Date





FINDINGS

Resident #1 – Calcium Citrate available for resident and

documented on MAR, however; no record of medication

order within the past year.

PART 1




15


Completion

Date





FINDINGS

Resident #1 – Calcium Citrate available for resident and

documented on MAR, however; no record of medication

order within the past year.

PART 2

FUTURE PLAN




16


Completion

Date





FINDINGS

Resident #1 – 8/1/2018 medication order for Quetiapine

states, “25 mg po qhs.” MAR and medication label state,

“25 mg – ½ tab po qhs.” Medication order does not match

label or MAR.

PART 1




17


Completion

Date





FINDINGS

Resident #1 – 8/1/2018 medication order for Quetiapine

states, “25 mg po qhs.” MAR and medication label state,

“25 mg – ½ tab po qhs.” Medication order does not match

label or MAR.

PART 2

FUTURE PLAN




18


Completion

Date





FINDINGS

Resident #2 – Last medication order available from

2/27/2018 states, “Senexon-S 8.6-50 mg - 1 tab po q evening

prn.” MAR and label state, “1 tab po bid prn at 9am &

5pm.” Medication order does not match label or MAR.

PART 1




19


Completion

Date





FINDINGS

Resident #2 – Last medication order available from

2/27/2018 states, “Senexon-S 8.6-50 mg - 1 tab po q evening

prn.” MAR and label state, “1 tab po bid prn at 9am &

5pm.” Medication order does not match label or MAR.

PART 2

FUTURE PLAN




20


Completion

Date





FINDINGS

Resident #2 – Medication order for stool softener states,

“100 mg po qd prn.” MAR and label state, “100 mg bid

prn.” Medication order does not match label or MAR.

PART 1




21


Completion

Date





FINDINGS

Resident #2 – Medication order for stool softener states,

“100 mg po qd prn.” MAR and label state, “100 mg bid

prn.” Medication order does not match label or MAR.

PART 2

FUTURE PLAN




22


Completion

Date





FINDINGS

Resident #2 – Two (2) conflicting medication orders for

Acetaminophen from 12/1/2017. One order states,

“Acetaminophen 325 mg, 1-2 tabs po q 8 hours prn pain.”

The other medication order states, “Acetaminophen 325 mg

1-2 tabs po q 6 hours prn pain.” Orders do not match.

PART 1





plan is required.

23


Completion

Date





FINDINGS

Resident #2 – Two (2) conflicting medication orders for

Acetaminophen from 12/1/2017. One order states,

“Acetaminophen 325 mg, 1-2 tabs po q 8 hours prn pain.”

The other medication order states, “Acetaminophen 325 mg

1-2 tabs po q 6 hours prn pain.” Orders do not match.

PART 2

FUTURE PLAN




24


Completion

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 #1 – Medications reevaluated but not signed by a

physician or APRN every four (4) months.

PART 1




25


Completion

Date


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 #1 – Medications reevaluated but not signed by a

physician or APRN every four (4) months.

PART 2

FUTURE PLAN




26


Completion

Date


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 – Medications not reevaluated or signed by a

physician or APRN every four (4) months. Last medication

reevaluation was on 2/27/2018, more than six (6) months

ago.

PART 1




27


Completion

Date


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 – Medications not reevaluated or signed by a

physician or APRN every four (4) months. Last medication

reevaluation was on 2/27/2018, more than six (6) months

ago.

PART 2

FUTURE PLAN




28


Completion

Date

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

During residence, records shall include:

Annual physical examination and other periodic

examinations, pertinent immunizations, evaluations,

progress

notes, relevant laboratory reports, and a report of annual re-

evaluation for tuberculosis;

FINDINGS

Resident #2 – Report of annual reevaluation for

tuberculosis states the date the TB skin test was

administered; however, there is no date for when the skin

test was read.

PART 1




29


Completion

Date



Annual physical examination and other periodic

examinations, pertinent immunizations, evaluations,

progress

notes, relevant laboratory reports, and a report of annual re-

evaluation for tuberculosis;

FINDINGS

Resident #2 – Report of annual reevaluation for tuberculosis

states the date the TB skin test was administered; however,

there is no date for when the skin test was read.

PART 2

FUTURE PLAN




30


Completion

Date



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 – Progress notes did not include observations

of the resident’s response to nectar thickened liquids.

PART 1





plan is required.

31


Completion

Date



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 – Progress notes did not include observations of

the resident’s response to nectar thickened liquids.

PART 2

FUTURE PLAN




32


Completion

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 not

updated since admission, over one (1) year ago.

PART 1




33


Completion

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 not updated

since admission, over one (1) year ago.

PART 2

FUTURE PLAN




34


Completion

Date

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

(c)(2)

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:

Develop an interim care plan for the expanded ARCH

resident within forty eight hours of admission to the

expanded ARCH and a care plan within seven days of

admission. The care plan shall be based on a comprehensive

assessment of the expanded ARCH resident’s needs and shall

address the medical, nursing, social, mental, behavioral,

recreational, dental, emergency care, nutritional, spiritual,

rehabilitative needs of the resident and any other specific

need of the resident. This plan shall identify all services to be

provided to the expanded ARCH resident and shall include,

but not be limited to, treatment and medication orders of the

expanded ARCH resident’s physician or APRN, measurable

goals and outcomes for the expanded ARCH resident;

specific procedures for intervention or services required to

meet the expanded ARCH resident’s needs; and the names of

persons required to perform interventions or services required

by the expanded ARCH resident;

FINDINGS

Resident #1 – No nutrition care plan developed for this

resident with nutrition risks, i.e., significant weight changes,

special diet, and nutrition supplement.

PART 1




35


Completion

Date

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

(c)(2)

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:

Develop an interim care plan for the expanded ARCH

resident within forty eight hours of admission to the

expanded ARCH and a care plan within seven days of

admission. The care plan shall be based on a

comprehensive assessment of the expanded ARCH

resident’s needs and shall address the medical, nursing,

social, mental, behavioral, recreational, dental, emergency

care, nutritional, spiritual, rehabilitative needs of the

resident and any other specific need of the resident. This

plan shall identify all services to be provided to the

expanded ARCH resident and shall include, but not be

limited to, treatment and medication orders of the expanded

ARCH resident’s physician or APRN, measurable goals and

outcomes for the expanded ARCH resident; specific

procedures for intervention or services required to meet the

expanded ARCH resident’s needs; and the names of persons

required to perform interventions or services required by the

expanded ARCH resident;

FINDINGS

Resident #1 – No nutrition care plan developed for this

resident with nutrition risks, i.e., significant weight changes,

special diet, and nutrition supplement.

PART 2

FUTURE PLAN




36

Licensee’s/Administrator’s Signature: _________________________________________

Print Name: __________________________________________

Date: __________________________________________

statement of deficiencies and plan of …...08/16/16, rev 09/09/16 1 office of health care assurance...

Documents