Hawai'i nursing homes rarely are fined, even when poor care results in patient harm or puts a resident at risk of harm. Numerous unsanctioned cases can be found in the annual inspection reports for the nursing homes.

CASE 1

Facts: A resident who was unable to speak was observed by inspectors grimacing in pain after a caregiver lightly touched a boil on the patient’s right elbow in December 2008. The boil started to bleed, and the resident immediately pulled away the arm, prompting the caregiver to say, “Oh, it must be sore.” The caregiver dabbed the dripping blood with bed linen.

The resident’s chart warned about skin problems and indicated that pain medication should be given if any signs of pain, such as facial grimacing, appeared. Yet when the inspector later checked the patient’s records for that day, the nursing entry noted, “No signs of pain. Res appears comfortable.” From September to December 2008, the nursing entries reported the same assessment – no signs of pain – even though monthly summaries during that period noted the resident was moaning, grimacing and frowning. Not even Tylenol was given.

Outcome: Inspectors concluded the facility failed to adequately assess and treat the resident’s pain and didn’t provide sufficient care for four other residents among 19 cases checked. The institution completed a new pain assessment for the patient and provided training to staff on pain management. No sanctions were imposed.

CASE 2

Facts: A man whose primary language was Mandarin and who suffered from difficulty swallowing was put on a pureed diet because of the risk of choking. Yet an inspector saw the man’s wife feeding him chunks of banana and a cube-shaped substance and quickly alerted staff. Because no one was around who spoke Mandarin, the staff couldn’t learn what the man was eating or explain that he risked choking by having non-pureed foods. Two staff members unsuccessfully tried to pry the food from his mouth. The records did not indicate that the man’s condition had been fully explained to him in his primary language. They also didn’t indicate that family members who normally translate for him had been fully informed.

Outcome: The facility was cited for failing to adequately inform the patient and two other residents about their care because of language barriers. A social worker subsequently met with the man’s wife and son to explain the diet restrictions, and his care plan was revised to address the language issue. The institution also developed a list of interpreters to tap as needed. No sanctions were imposed.

CASE 3

Facts: A resident complained of pain in the left arm while sitting in a wheelchair. The resident was returned to bed with the arm propped on pillows and said, “I’m OK now.” The records show that no assessment of the pain was done. The following day, a doctor ordered X-rays. The results came back the next day — two days after the resident complained of pain. The X-ray indicated a “comminuted” fracture – bone shattered into many pieces.

Outcome: The institution did a comprehensive pain assessment of the resident and four others whose care was deemed lacking. No sanctions were imposed.