Kona Community Hospital

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 39853 Based on observation, interviews, and document review, the facility failed to have a proactive approach and effective pest management plan to keep a pest free environment for patient safety. This deficient practice has the potential to affect any patient in the facility. Findings include: 1) The OHCA received an anonymous complaint on 07/11/2025 regarding an infestation of gnats in the operating room at the Hospital. 2) Reviewed the facility’s Event log for the time period of May 1, 2025 to current. There were two reported events of insects. Review of the “Quality Assurance Communication Healthcare Event Reporting Forms,” revealed the following: On 06/23/2025, the Operating Room (OR) reported “A gnat was spotted in the OR1 by the surgical tech (technician)...during a case and I (Registered Nurse) killed it. ...The report indicated the sighting occurred “After the procedure (incision) had already started but before procedure ended (closed).” The staff documented there was a “Break in sterile technique.” On 07/09/2025, the OB (obstetrical) department reported “gnats noted in LR2 (Labor Room) and LR3 alive and dead.” The description of the event was “gnats found in overhead lights, infant radiant warmers, window seals, shower, and flooring. Facilities, Housekeeping, CNE (Chief Nurse Executive), Infection Prevention, andNursing Supervisor notified. Rooms closed for terminal cleaning or until advised.” 3) Reviewed the Infection Committee Meeting Minutes dated 06/25/2025. The minutes included the “Operating Room Report,” which documented the following timeline of events of flying insects in the OR: - “Week of May 26th. We noticed more than one flying insect in the OR suite over the week. Sightings were random and isolated. Response: EVS (environmental services) was involved and two additional bug lights were installed (one in the OR hallway and one by the entrance to the OR from OB). That gave a total of 3 inside and outside of the substerile area. We continued to monitor with EVS. 5/27- a fly got into the OR and we had to break down the room/delay a case.” - “June 6th. We discovered a cluster of several, small gnats outside OR3. ...Response: OR3 was closed and a barrier was put up to seal off the area outside OR3. The area was treated/sprayed and we were unable to determine the source of the gnats. ...Infection Control, ...and Ecolab (pest management vendor) were all brought into the fold.” - “June 9th- Gnats were still found in the space. Facilities continued regular inspections of the ceiling space and located a crack in the building leading directly outside. The hole was sealed and the area was re-treated. Barriers remained in place and OR3 remained closed.” - June 13th. OR3 reopened. - “The past two weeks (no specific dates provided): the cluster of gnats still had not reappeared, but we are still seeing insects getting into the unit. We believe they are piggybacking into the unit when doors are opened/closed.” - “Ongoing efforts to mediate the situation include:” “Daily cleaning. spraying by EVS in stairwell/near hospital entrance.” “Continues inspection by Facilities in ceiling tiles, roof etc.” “Frequent cleaning of OR break room by EVS.” “OR staff ensuring food is not left out in breakroom or in locker room areas.” “Limited traffic between OB and OR.” “An additional Fly Light is being installed in the hallway outside the surgical unit.” “Bleach was poured down the drains in all the sinks on the unit.” “Automatic door “open time” was adjusted (reduced from 12 seconds to 5 seconds).” “Continued consultation with Ecolab.” “Daily tracking-shows more activity later in the day and gnats seem worse when it rains and locations are random.” “Daily messaging is going out to medical staff to keep them updated in real time.” “SOP (Standard Operating Procedure) is being created to outline our response. for the future.” 4) On 07/31/2025 at 11:30 AM, interviewed the Infection Preventionist (IP), who said she was first notified of flying insects in the OR on June 6, 2025. She said it seemed they were getting in from outside in the hallway by OR3. The IP went on to say by June 9, it seemed they figured it out, as they found and sealed a gap in the “expansion joint” of the buildings. On June 19th, there was an email from one of the surgeons that they were still seeing gnats. She said “at one point an email was sent with an extensive list of bulleted things to look at.” She said everyone that lived in the area had gnats at home and they were being found throughout the hospital. Additional things put in place included looking at the roof for standing water, decreased traffic going into the OR, a light on the roof was turned off at night, a plastic barrier was put up, and another gap was sealed. There were ongoing assessments of the perimeter and a request was made from Senior leadership for written guidelines. The IP said she, the Infection Prevention Medical Director (IPMD) and Operating Room Nursing Director (ORD) did exhaustive searches regarding insects in the OR and impact on infection. She went on to say ECOlab was at the facility several times to treat areas. The IP said the draft guidelines were completed and scheduled to go to the next Department of Surgery for approval. When asked if there was any other policy or plan for insect management, she said Environmental Services (EVS) had something. 5) On 07/31/2025 at approximately 01:00 PM, conducted an interview with the EVS Superintendent (EVSS) and Supervisor. The EVSS said she was responsible for the Pest Management Plan. When asked her to summarize the content of the plan and EVS role, she said when an insect is found, the EVS department is contacted. She went on to say their role is to notify Ecolab if necessary, and to terminally clean the area. “When they see bugs, they call me and I call Ecolab.” The EVSS said they have a monthly service with Ecolab for inside and outside treatments, and in addition she had called them “three or four times regarding the gnats.” On 07/31/2025 at 02:49 PM, conducted an interview with the IPMD, who said he was first notified of the gnats on June 6. He said there was no formal policy, so all sightings were to be reported to OR Leadership. The IPMD said there was little guidance in the literature and could not locate data of risk in the surgical suite. He said the Chief of Surgery was involved and consensus was to continue monitor and allow the surgeon to determine to proceed with a case or not. On 07/31/2025 at 03:10 PM, conducted an interview with the Chief Medical Officer (CMO), who was a surgeon. He said on 06/06/2025, gnats were found outside the OR. At that time OR3 was closed and efforts were made to determine the source. He went on to say, cracks were sealed and they gathered best practice. He said there was a surge of insects reported on 06/19/2025, and the activity waxed and waned June through July. The CMO said the decision was made to discourage implants, but that in general the risk was low if mitigation efforts were kept up. He said personally, he chose to inform his patients. On 07/31/2025 at 03:45 PM, conducted an interview with the Chief Operating Officer (COO), who had oversight of Surgical Services, Facilities and Environmental Services. She said they were using the interim protocol for flying insects in sterile areas, which was scheduled to go to the Surgical Department in September. The COO said they “should conduct regular inspections to identify and address potential entry points for flying insects and other pests.” She said there was an immediate reduction of insects after putting construction barrier up, spraying the roof and sealing the expansion joint. All staff were asked to report any sighting, alive or dead, to the manager. The COO said after a lot of discussion, it was agreed that it was “nuance issue,” and we weighed the risk of not doing surgery and closing the entire area for terminal clean, over the potential of an unstudied thing (surgical site infection). She said of all the sightings of gnats, they were all outside the OR room, or before a procedure, except one, when an insect was not discovered until someone was already in the OR. She said she recalled Ecolab “basically did everything they could think to do, and was hesitant to do anything overly aggressive. They did not feel it was an infestation.” The COO said yesterday they found one (gnat) in the hallway, and none the previous day. She went on to say “ The pest control plan should be under the EOC (Environment of Care), with standard maintenance. The COO said in the long term, over the next 12 months, the plan was to move the foliage away from the building to reduce access points. 5) Reviewed the draft,”Interim Protocol for Flying Insects in sterile areas,” dated 07/18/2025. The Purpose of the policy was “Established protocols for managing insects (flies, gnats, moths, mosquitoes) and other insects in the Surgical Services Department and specifically inside the OR suites.” Policy background included: “Key points to remember are that the presence of insects in the operating room should never be considered normal and a proactive approach to pest prevention is crucial to maintaining a safe and sterile operating environment. The protocol regarding insects in the operating room (OR) and other sterile areas is to immediately address any pest sighting to prevent contamination and maintain a sterile environment. This includes a rapid response, investigation, and thorough cleaning or pest control treatment of the affected area. The protocol provided steps for immediate staff response. The protocol included post incident actions, which included, but not limited to: - “During terminal clean special assessments/investigation as to the potential source of insect penetration should be completed by the EVS and Facilities team. 1. HVAC (heating, vacuum, air conditioning), water intrusion. construction projects and breaches in building, sinks, trash/roof, ceiling spaces, electrical and water penetrations not sealed, fresh air intakes, drains and pooling water. 2. Assessment should also include all adjacent spaces and other hospital departments for similar incidents. 3, Assessment of the following environmental impacts should also be completed. Foliage, parking lot drainage,drainage grates, outside trash moved away from building entrances, dead animals around building, birds’ nests, proper rain gutter management, pooling water on roof, roof vent overs and intakes are covered. ...” - “Review and reinforce pest prevention protocols. 1. Review the facilities pest management program and protocols, including sanitation, exclusion and education for staff on reporting insect sightings ...” -“ Review and reinforce pest prevention protocols. 1. Review the faculties pest management program and protocols, including sanitation, exclusion and education for staff on reporting insect sightings ... 2. Professional pest management may be required to inspect and treat the area, ...or other pest management strategies. ...” The protocol included “C. Prevention: a. Healthcare facility should have an established and documented integrated pest management program that focuses on prevention, monitoring and control. b. Conduct regular inspections to identify and address potential entry points for flying insects and other pests. Maintain strict sanitation practices throughout the facility to include proper disposal of waste and regular cleaning of ... d. train staff on the importance of pest prevention and how to report insect sightings promptly.” In addition, the protocol included “ During any period of heightened insect activity, consistent monitoring and reporting will come from the OR management/Senior leadership....ii. Any incident that would reasonably be considered a “sentinel event,” or “near miss (i.e.: insect in the sterile field during a procedure) should be logged in ...event software ... iii. OR manager ...will maintain and track insect activity. iv. COO (Chief Operating Office) ...will coordinate and track mitigation activity. ...” Reviewed the Policy Reference # 1260, titled “Insect and Vermin (refers to wide scope of organisms, including rodents, cockroaches, termites, bedbugs and more) Containment - Guidelines for Management,” last review date 01/25/2022. This was the only current policy that addressed pest management. The owner of the policy was the EVS Superintendent. The purpose statement was “To provide an environment free of potential for injury or infection by insects, vermin or vectors, for patients, visitors, ...” The policy included: - “Policy ... Appropriate departments are notified promptly, with the management of incidents monitored by the Environment of Care Committee.” - “Procedures: ...5c) Need for additional measures, such as extermination, trap setting, etc. will be recommended to Senior Management by the Environmental Services Director in consultation with the Infection Control Practitioner. ... ...7. Problem management and resolution is monitored in the Environment of Care Committee and Infection Control Committee. ...” This document provides direction for staff should they see a “Insect or Vermin,” and addresses some follow-up, but does not include any mitigation or prevention strategies. 6) Reviewed the Environment of Care (EOC) Committee Minutes from meeting dated 07/30/2025. The agenda included updates to the 1) Environmental Safety Management (Mgmt.) Plan, 2) Security Mgmt. Plan, 3) Medical Equipment Mgmt. Plan, 4) Utility Systems Mgmt. Plan, 5) Fire Safety Mgmt. Plan, and 6) Hazardous Materials and Waste Mgmt. Plan. The discussion under the Environmental Safety Mgmt. plan read “Environmental safety/hazard incidents - Issues we are having with gnats. We are moving in the right direction as maintenance has setup screens, sticky mats, bug traps and pressure washed areas and cleaned up the landscaping where could have been their breeding area. Some days we get reports of 0 gnats getting in.” There were no recommendations and/or follow up documented. Reviewed the documents provided, which revealed there were two versions of Reference (Ref) # 1191, Version 3 titled “Safety Program Management Plan with last reviewed date of 04/28/2025 and Ref # 1191 Version 4 titled “Environmental Safety Management Plan. Version 4 had a titile change and had not yet been approved. The Version 4 draft included the following: - “A. Scope 1. The ESMP is designed to address the safety risks the environment ...presents to patients, staff and visitors. The program is also designed to assure compliance with applicable codes and regulations.” - “C. Objectives 1. EOC rounds are conducted regularly of the buildings, grounds, equipment ... and work environment ...” 2. The analysis system for accidents, incidents, and occurrences is used to identify key casual [sic] elements of those incidents, and organizes the information for the Environment of Care Committee. ...7. The ESMP includes inspections of grounds and facilities at least annually.” - “E. Processes of the Safety Program 1. EOC rounds ...d. The results of the rounds are used to create new and revised policies and procedures, identify new hazard surveillance elements ... and indicators and /or short-term mitigation of identified hazards or potential hazards. ...3. On Going Examination of Safety Issues a. The chair of the EOC Committee manages the processes for examining safety issues and distributing resultant information. 7. Grounds and Equipment a. The Facility Director is responsible for managing the hospital grounds ... The facility director is responsible for scheduling and performing maintenance of hospital grounds. ... b. Hospital grounds include lawns, shrubs and trees, ... Contractors or KCH staff does preventive maintenance . Corrective maintenance is performed on an as - needed basis. ...” The EOC conducts quarterly rounding on departments, and uses the following to document findings: - “EOC Checklist: General EOC Overview” to check specific things such as oxygen cylinders, alarm pulls etc. - “EOC Checklist: Staff NPSG (National Patient Safety Goals/Joint Commission) Knowledge & PHI (Protected Health Information) Surveillance. Staff are interviewed to test their knowledge on several topics. - “EOC Checklist: Medication & Crash Cart Safety.” - “EOC Checklist: Patient Room Safety.” Included call light, privacy curtains, etc. EOC rounding did not include any routine inspection for pests, or identification of structural or environmental issues such as foliage, or shrubs that could potentially contribute to breeding. In addition, EOC staff knowledge check did not include any questions about pest management. 7) Reviewed the Hospital “Performance Improvement -Patient Safety Quality Plan Ref # 1287 last review date 05/18/2025. The Plan included: - “It is our policy to prevent, minimize, identify and resolve any breakdown in systems and processes that may occur and result in suboptimal patient care and/or safety issues. ...” - “The CEO (Chief Executive Officer): ...Reports to the Board matters related to performance improvement, quality, risk management, infection control and patient safety. ...” Review of the “Clinical Quality Meeting” Minutes for June 12, June 26, and July 10, 2025 revealed there was no discussion regarding gnat activity in the facility. 8) Reviewed Ecolab (pest management company) invoices from January 1, 2025 to current. The invoices included the following documentation: 01/06/2025: Monthly service “Structural concerns that could cause pest problems; Kitchen Area- Interior--hole/gap noted behind dish machine. Splash guard and caulking comin [sic] loose seal to prevent pest entry or harborage.” 01/09/2025: Monthly service “Sanitation issues that could cause pest problems: Exterior Area-- trees/shrubs are contacting the facility creating a path for pests to enter. Trim back this vegetation to eliminate contact.” 02/03/2025: Monthly service; Additional service report. Actions taken: ...Interior treatment for flying insects performed. “Structural concerns that could cause pest problems; Kitchen Area- Interior--hole/gap noted behind dish machine. Splash guard and caulking comin [sic] loose seal to prevent pest entry or harborage.” 02/06/2025: Monthly service “Sanitation issues that could cause pest problems: Exterior Area-- trees/shrubs are contacting the facility creating a path for pests to enter. Trim back this vegetation to eliminate contact.” 03/03/2025: Monthly service “Structural concerns that could cause pest problems; Kitchen Area- Interior--floor drains in need of cleaning. Please clean in and around drains frequently to help prevent breeding sites.” 03/05/2025 Monthly service “Sanitation issues that could cause pest problems: Exterior Area-- trees/shrubs are contacting the facility creating a path for pests to enter. Trim back this vegetation to eliminate contact.” 04/04/2025 Monthly service Sanitation issues that could cause pest problems: Exterior Area-- trees/shrubs are contacting the facility creating a path for pests to enter. Trim back this vegetation to eliminate contact.” 04/07/2025 Monthly service “Structural concerns that could cause pest problems; Kitchen Area- Interior--hole/gap noted behind dish machine. Splash guard and caulking comin [sic] loose seal to prevent pest entry or harborage.” 05/01/2025 Monthly service “Structural concerns that could cause pest problems; Kitchen Area- Interior--hole/gap noted behind dish machine. Splash guard and caulking comin [sic] loose seal to prevent pest entry or harborage.” 05/20/2025 Monthly service “Sanitation issues that could cause pest problems: Exterior Area-- trees/shrubs are contacting the facility creating a path for pests to enter. Trim back this vegetation to eliminate contact.” 06/06/2025 Monthly service “Sanitation issues that could cause pest problems: Exterior Area-- trees/shrubs are contacting the facility creating a path for pests to enter. Trim back this vegetation to eliminate contact.” 06/06/2025 Second Invoice Additional Actions taken: “...Inspected OR rooms for gnat entry points. ...pest activity found during this service. Conditions found/Actions taken: Roof -Exterior -Gap at the bottom of roof entry door needs to be sealed. Please address structural concern.” 06/09/2025 Service: Interior insect. Actions taken: Inspected OR for gnats. Pesticide applications were made to the following room (s)/area(s) Spot treated hallway loading dock for gnats.” Escorted by EVSS. 07/02/2025 “Sanitation issues that could cause pest problems: Exterior Area-- trees/shrubs are contacting the facility creating a path for pests to enter. Trim back this vegetation to eliminate contact.” 07/07/2025 Second Invoice “Sanitation issues that could cause pest problems: Exterior Area--excess water noted. Very damp areas throughout the entire property. Keep area dry. Reduce plant watering to help eliminate pest infestations.” 07/17/2025 Actions taken: “Exterior areas was treated for control of gnats.” Ecolab invoices identified multiple times that the vegetation was an issue that could cause a pest problem, as well as some kitchen issues. There was a lack of evidence that the facility addressed these issues in a timely manner. 9) On 08/01/2025 at 09:00 AM, during an interview with the Facilities Director (FD), he said EVS was responsible for the pest management plan and worked with Ecolab for services. He said he had done one walk around with the Ecolab representative who made some recommendations regarding the grounds for pest control. When inquired what kind of routine or preventive maintenance was done to areas that may contribute to pests such as cutting back shrubs, power washing areas of the building including the roof, he replied they had “recently done work, but it is on an as needed basis.” The FD did not know how many times Ecolab had been called by EVS, outside the monthly visit, for pest issues. A request was made for work orders related to the issue. Review of work orders provided included: - July 2, 2025 and July 30, 2025: “Pressure wash 1st floor roof” - July 9, 2025: “Cleaned out gnats and wiped down lens from surgical light covers in Rm 2,3,6, & 7.” - July 14, 2025: “mats installed inside or (OR) door inside pacu (post anesthesia care) office and both locker rooms (to mitigate any gnats on people’s shoes).” - July 16, 2025: “removed gnats and cleaned lights in labor rooms 123, and 5” Later received a typed document from FD listing mitigation efforts facilities did related to the insects. The list included: “6/05 installed additional bug light in OR” “6/09 ...found gap in expansion joint above the ceiling in the storage between OR3 and OR2, he sealed from the inside” “7/7 sprayed area around generator for weeds and cleaned any potential moss off the concrete” “7/9 sealed the expansion joint from the outside to ensure there was no gap” “7/9 placed sticky mats at entrances to OR” “7/9 cleaned lights of gnats in OB” “7/11-7/18 cleaned roof to remove any possible le organic matter that would be a breeding ground for insects” “7/14 installed screen over elevator entrance in the ambulance bay” “7/15 sealed all gaps in ceiling tiles as needed” “7/21-7/23 installed additional bug light” “Other items addressed throughout: Checked and replaced filters as needed in AHU’s, verified exhaust fans working as designed, removed vegetation that may have been contributing to favorable breeding conditions, repair and inspect any potential water sources above ceiling in the OR suite, multiple inspections,completed by facilities for potential abatement and sources of contribution to breeding and food sources.” Hand written on the document was “Other mitigation includes:” - “List from EVS” - “Closed breakroom/removed trash cans” - “Limited access to hall by ‘closing’ stairwell entrance by OR, and access points between OB/OR to reduce potential sources” - “Increased trash removal and increased cleaning.” 10) On 08/01/2025 at approximately 09:30 AM, interviewed the Operating Room Director (ORD) and the OR lead. They said they have kept a daily log to track and trend the activity of the insects. The ORD said they provide a report to the surgeon of the recent activity, and the surgeon makes the decision to do the case or not. He went on to say there were only two times an insect was found in the OR Room when a patient was in it, and these two events should have had an event reports made. At that time reviewed the event reports with the ORD, and confirmed that there was no report for the 06/20/2025 event. Reviewed the report of the 06/23/2025 report, and the ORD agreed it lacked important details of where specifically the insect was found and what immediate actions were taken. Although a request was made for the number of cases canceled or delayed, the data was not received prior to survey exit. Reviewed an email communication from OR Director to COO dated June 27, 2025 at 09:06 AM, that read “...They are seeing a large number of gnats in MS2 (medical/surgical inpatient unit) ...” The ORD said that area of the MS unit is fairly close to the OR. Reviewed the OR log of pest activity, which included, but not limited to the following entries: - 06/18/2025: OR3 (inside OR), Case moved/delayed, 1 gnat, Room open, no pt (patient) - 06/20/2025: OR3 (inside OR), Case in progress, 1 gnat, landed on sterile field - 06/23/2025: OR1 (inside OR), Case in progress. no comment recorded - 07/01/2025: OR hallway, outside OR3, 1 beetle like bug, found dead on mayo (small procedure table) stand - 07/04/2025: Outside OR3, 15 gnats dead and alive, maintenance called in to investigate - 07/05/2025: OR3 (inside OR) and hallway- all over ..., 30 ish dead and alive, Maintenance sealed off OR3 and hallway of OR 3 - 07/7/2025: OR charge station, led room, 10-20 dead and alive, canceled dental cases ...OR remained sealed. ...” - 07/07/2025: Scheduling office, 15 dead, ...Maintenance is working on it outside ...” - 07/08/2025: OR suite in the equipment room, 6 gnats, 3 alive - 07/08/2025: Break Room, 5 gnats, 1 dead - 07/09/2025: inside OR3, 1 live gnat, MD aware as it it his room, room shut down to be terminally cleaned, delaying his last case. - 07/10/2025: inside all OR’s, 6 total, was told this morning that they found gnats overnight in all the OR’s, they were terminally cleaned after. ...” - 07/11/2025: there were seven separate entries on 07/11/2025, with locations that included: OR suite hallway , outside of OR1, OR3 subroom, pre-op hallway by HUC office, cart in hallway by preop 3 and 4, Procedure room, OR chart area, a total of 10 live gnats - 07/12/2025: outside of OR3, and equipment room, 5 live gnats. MD canceled all of his cases due to last weeks gnats. 11) Reviewed a communication thread between the COO and the EVSS,which included: July 10, 2025 COO asked EVVS: “Can your teams please assist with morgue as well?” July 11, 2025 EVSS to COO: “Yes, ..., we will be cleaning up any dead gnats first thing in the morning, I also gave her (staff) a spray bottle to spay any gnats she sees flying around.” July 11. 2025 EVSS to COO: “ I’ve been doing morning rounds daily, spraying any live gnats found in the basement, stairwells, and entrances. there wasn’t much activity this morning. ...” 12) On 08/01/2025 at approximately 10:00 AM, toured the OR entrances and area with the OR Director and lead. Observed several of the mitigation strategies put in place, that included, blocked off entrance from OB to OR with tape (can access in emergency), blocked off entrance from locker room from hallway, insect lights installed in OR hallway, sign regarding no open food in break room, and sign limiting stairwell use, and the screen installed in front of the elevator by the ER entrance. Observed one dead gnat on the tape of one insect trap. On at 08/01/2025 at approximately 10:30 AM, escorted the Quality Director (QD) to an area located near the elevator, off the Emergency Department ambulance entrance, where had previously observed green growth on the ground. The QD agreed the area needed to be cleaned. 13) The facility’s response to pest management was focused on monthly treatments from Ecolab and responding when something was found, rather than a proactive approach. The plan was not effective and did not include 1) adequate preventive maintenance, 2) routine inspections internal and external to include foliage and drainage 3) an organized method to track overall insect activity and mitigation activities, 4) Staff education, or 5) monitoring of the amount of pesticide used. `”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 39853 Based on interviews and record review (RR), the Hospital (H)1 did not ensure an effective transition at the time of discharge for one patient (P)1 of a sample size of three. P1 was not competent to provide self-care for his diabetes management, which included checking blood sugars and administering insulin injections. H1 failed to ensure the designated care giver (CG) had the supplies and training required to immediately meet P1’s care needs upon discharge. Specifically, there was no order for the needles that attach to the insulin pen, so the medication could be administered, and P1 did not have a working glucometer. In addition, the CG did not receive sufficient inhospital training prior to discharge. As a result of this deficiency, P1 did not receive the insulin as ordered and went to the Emergency Department on 02/15/2024 for hyperglycemia (high blood sugar level). Due to the nature of the deficiencies, this resulted in a Condition Level deficiency in Discharge Planning. Findings include: 1) The Office of Healthcare Assurance (OHCA) received a report from an external agency on 02/21/2024, regarding allegations of self neglect by P1. The report included: “1. A vulnerable adult’s (P1) inability or failure, due to physical or mental impairment, to perform tasks essential to caring for oneself. ... “AV (alleged victim) was hospitalized at H1 from approximately from 12/30/2024 - 02/12/2024 after police did a wellness check and found AV naked/confused on the floor; H1 stated AV needed 24 hour care and would be waitlisted for ... but it is unknown why AV was discharged home instead without any plan for AV’s care. -Per H1, AV is suppose to take insulin and is unable to administer his own insulin or check his own blood sugars; ... 2. The vulnerable adult appears to lack sufficient understanding or capacity to make or communicate responsible decisions and appears to be exposed to a situation or condition that poses an immediate risk or death or serious physical harm. ...A. AV’s capacity to make decisions appears questionable because AV is not oriented to time or place and sometimes not oriented to person. B. AV may be at immediate risk for serious physical harm or death if his blood sugars are out of control. ...-Shortly before AV was hospitalized, he attempted to drive and backed into his neighbors parked car. ...” 2) P1 was a 75 year old male admitted to H1 on 12/30/2024. The Emergency Department Provider note revealed he had been found on the floor of his house after neighbors called for a welfare check. He lived alone and had not been taking his insulin for an unknown period of time. P1 was admitted to Intensive Care for diagnosis that included dehydration, hyperglycemia (high blood sugar), DKA (Diabetes ketoacidosis-a serious complication due to lack of insulin), and dementia. A family member (FM)1, was designated his Durable Power of Attorney (POA) for Healthcare decisions. P1’s medical condition improved, and his level of care (LOC) was changed to SNF/ICF (Skilled Nursing Facility/Intermediate Care Facility) level on 01/04.2023. He was discharged home with FM1 on 02/05/2024. On 02/15/2024, P1 returned to the Emergency Department for hyperglycemia. 2) Reviewed P1’s PT note dated 01/23/2024. The note included: “Interval History: Per discussion with case management and per chart review, current plan is to continue to work on LTC (Long term care) insurance for placement. Case management aware of discharge from PT today and transition to restorative aide program. ...Assessment: Pt reached a plateau with physical therapy, being limited mostly due to cognition. When pt given education or a task at hand, pt not able to remember the sequence, or is not sure of what to do next and needs spv/SBA (supervision/Stand By Assistance) with mobility to due this. ...” Reviewed P1’s Occupational Therapy Treatment note dated 01/23.2024. The note included: “...Assessment: Pt continues to require 1 P SBA (one person stand by assist) at times CGA (Care giver assist) for mobility and transfers related to ADL’s (Activities of Daily living, i.e. Ambulating, dressing, bathing). Due to memory challenges pt needs step by step cuing to initiate and complete ADL’s ... For safety reason, it is recommended that patient does not live by himself and engage in tasks such as cooking and driving. Pt needs assist to maintain his safety in mobility and ADL’s together with assist with DM (Diabetes Management) and medication management. ...Plan: ...the plan is to transition to restorative. Discharge Disposition Recommendations: 24/7 assist for needs in health management and safety during mobility and ADL’s and IADL’s (instrumental activities of daily living, i.e. cooking). ...” When P1 was discharged from PT/OT service, the plan was P1 would be going to another facility rather than home. 3) Reviewed the Case Management (CM) and Social Worker (SW) progress notes which included, but not limited to the following: 01/02/2024 CM note: “Discussed patient (P1) after IDT (interdisciplinary) meeting. Plan for SNF rehab (rehabilitation). ...” 01/03/2024 CM note: PT (physical therapy) recommending SNF. ...Pt Denies having wife or children. No family on island and lives alone. Monitor d/c (discharge) needs.” 01/05/2024 CM note: “...DC plan is for SNF. Referrals made to facilities. Awaiting accepting facility. ... “ 01/06/2024 SW note: “FM1 confirmed that there is limited support as FM1 is in Arizona and they have a cousin in Waimea. There is no one available to check on patient daily. ...FM1 hopes to fly out in a few days. ...” 01/11/2024 CM note: “...Patient is SNF LOC (level of care) and there is a problem with disposition. Patient aware that FM1 is coming to the island this weekend but unsure if FM1 will be able to stay with him after discharge. Patient is alert and aware that he needs to be independent with care before going home. ...” 01/15/2024 CM note: “...CM spoke with patient’s FM1. FM1 is concerned about patient inability to care for himself. FM verbalizes patient’s home is a “mess”. FM1 knows patient denies needing help but would like patient to be in a “care home” and to start process for LTC (long term care). ...” 01/15/2024 SW note: “... Plan is to sell patient’s home and get him into a care home in Hawaii. ...” 01/16/2024 CM note: “...Patient verbalized and agreed that he needs “long term care.” Patient aware that FM1 will assist to get him a proper place. ..” 01/17/2024 CM note: “... DC plan: SNF. Barriers: 1. Lives alone 2. No LTC insurance 3. Over Asset d/t home owner. ..Chart Review: ...3. CM re-sent SNF referrals 1/16/24...” 01/18/2024 CM note: “Patient participating in PT/OT and recommends SNF. No accepting facility at this time. ...Patient to continue with PT/OT in acute setting unless there is accepting facility and safe discharge is determined. ...” 01/19/2024 CM note: “...Patient lives alone and unsafe. Patient needs assistance but no family or friend available to assist. Patient’s FM1 will be assisting with LTC process. ...” 01/22/2024 CM note: “...Discharge still mainly with LTC due to safety issue being home alone. ...Patient with Restorative aide with activities. ...” 01/23/2024 CM note: “...Possible downgrade to ICF (intermediate care facility/LOC) this week. CM/SW to continue working on LTC insurance for placement with patient’s FM1.” 01/26/2024 CM note: “...Pt will need LTC or Care Home Placement. ...” 01/31/2024 CM note: “...LOC ICF. Patient discussed in HIGH Risk meeting today. ...Per NP (Nurse Practitioner): a. Pt is forgetful ...” 02/01/2024 SW note: “...FM1 back on island. Would like to discuss a home plan. ...” 02/02/2024 at 10:04 AM, CM note: 1. ...Family meeting scheduled... 2. FM1 expressed wanting to take pt home to his house, ...b. FM1 will continue working on LTC after H1 discharge. ... 5. CM called & spoke with NP re:dc plan,=Monday 2/5/2024. 6. CM requested NP to include the following: 7. DC orders/summary to go home 8. DME (durable medical equipment) order re: FWW (front wheel walker)... 8. Home Health orders re: Med (medication) management and PT.” 02/02/2024 at 11:00 AM, SW note: “...FM1 would like to take patient home. SW and CM discussed the necessary steps to DC patient and take him home safely. ...-Patient and family teaching re: insulin/diabetes management - Referral to HH (home health) for medication management. FM1 will continue to work on selling patient’s home and then using funds to pay for a private care home. SW and CM explained that once Dc’d, a external SW will be assigned and will help patient and FM1 for LTC insurance once he qualifies. SW and CM will no longer be able to assist w/application and placement ...” 02/05/2024 CM note: “...DC home today with FM1. ...Update: “1. ...Outpatient SW: referral sent.” “2. Home Health PT & RN for education/meds: referral placed.” “4c. Possible admission with ....(HH) RN (Registered Nurse) on Wednesday 2/7/2024.” “5. CM spoke with RN: a. Requested pt teaching/education re: DM (glucometer/insulin dose & administration). “6. CM spoke with Restorative Therapy...confirmed SBA (stand by assist) re (regarding): ambulation. “9. FM1 planning to p/u (pick up) Rx (prescriptions) before picking pt up at H1 ...today. ...” “14. At 3:46pm -...FM1 re: arrived at pts beside with glucometer. a. RN called CM to re: family at bedside. b. CM/SW met FM1 with pt in hallway. c. RN asked pt to return to bed for privacy re:teaching/dc instructions d. Pt chose to stay in hallway. e. Pt explained and demonstrated proper technique to check blood glucose. f. CM instructed FM1 -best/safe practice to dispose used lancet into disposable plastic bottle and cap, prior to discarding in trash.” “15. CM/SW witnessed RN completing all DC instructions and DM teaching. ...” 5) RR of P1’s acute care admission revealed the following: 02/05/2024 at 10:55 AM, Registered Nurse (RN)1 progress note: “patient (P)1 is A&O x2-3, oriented but forgetful. ...Patient is to be discharged today to go to FM’s home (P1 actually went to his home with FM1) per CM (Case Manager). 02/05/2024 at 04:45 PM, RN1 progress note: “...Patient discharged from unit via wheelchair accompanied by Social Worker ...All DC (discharge) instructions/handouts given to patient. Patient and FM1 verbalized understanding of discharge education.” Review of P1’s “After Visit Summary (discharge instructions),” revealed instructions included “...Pick up your medications at ...Pharmacy... : “Atorvastatin (for cholesterol), Blood-Glucose Meter (to test blood sugar), insulin glargine-yfgn (long acting injectable insulin pen to control blood sugar), magnesium oxide (treat or prevent low magnesium), Metformin (oral diabetes medicine) and OneTouch Verio test strips (use with meter). RR revealed there was no documented discussion regarding P1’s dementia and cognitive status or education of how to manage behaviors when caring of him. In addition, there were no instructions provided that P1 should not be driving or cooking for safety reasons. 6) RR revealed documentation of follow up after discharge phone call made on 02/08/2024 at 11:57 by Quality Staff (1). The Note read “Contacted and spoke to Family Member (FM1) of patient (P)1, who is here from Arizona trying to assist patient, who notes that he is doing ok, seems a lot better (walking using his cane), but that he is NOT monitoring his blood sugars as instructed nor taking his insulin. She states both he and their brother manage their diabetes in their own way and FM1 feels like its not FM1’s place to tell him what to do, as they are adults. FM1 confirms that she did pick up the Rx at discharge and can confirm that she reminds him to take his pills and he has been compliant with them. HH (Home Health) did contact her and will be coming tomorrow to do evaluation. ... Discussed importance of regular MD follow up, medication compliance and plan of care. ...” 7) On 05/30/2024 at 09:30 AM, during an interview with the Nursing Director (ND), she said it would be the expectation diabetic management education would include “print out teaching materials,” as well staff demonstration and return demonstration of hands on by the patient and family of the tasks required, such as checking blood sugars using the glucometer and administering insulin injections. The ND reviewed the nursing progress notes and medical records and confirmed she did not see any documentation that FM1 demonstrated ability to use the glucometer, and there was no notation that FM1 or P1 received education or demonstrated ability to administer the insulin. The ND agreed it would be the standard of care if there was a designated caregiver that they would also be trained to assist with ADL/IADL needs and how to safely provide “Stand by assist/SBA” and review what P1’s functional ability was and the type of care FM1 needed to assist with. ND said the education should be documented, and if they have a hard time with the task or procedure, it should be repeated. ND said PT/OT would be the ones that do the caregiver training for ADL assistance. On 05/30/2024, at 11:00 AM, during an interview with the Case Manager (CM)1, she said they often will have a psychiatrist evaluation to determine competency, but did not see any documentation regarding his competency. Inquired if CG, FM1 had any training, and she said on the day of discharge, she observed P1 doing the glucose test. CM1 said she thought it was a brand new glucometer that FM1 brought in at the time of dicharge. She said she sent a referral to the HH agencym, who said they could possible do the admission at the home on 02/07/2024. CM1 said she had asked RN1 to do the teaching. On 05/30/24 at 12:00 PM, during an interview with the Social Worker (SW), when asked about the decision to discharge home rather than LTC, she said she thought the family decided they wanted to take him home and continue to pursue placement from the outside after selling the house. She said she thought P1 had a problem with remembering to take his insulin. SW said she recalled being the hallway and P1 was doing “the teach back” with the glucometer and FM1 was trying to help, but he wasn’t going to let her be any part of it. When inquired about his competency, she said “I assume he is not competent, as we were going through the POA.” On 05/31/2024 at 09:15 AM, interviewed the Registered Nurse (RN)1, who confirmed she discharged P1 on 02/05/2024. When asked about his cognitive status, she said “he would say things that would make me think he didn’t know exactly what was going on. He was hard to direct sometimes.” RN1 said she recalled saying hello to FM1. She said Case Management was present and talking to FM1, and “we were all in the hall.” RN1 said FM1 brought in a glucometer, but that “there was a problem with it.” She did not remember the exact specifics, but that she thought FM1 did not have the strips for that glucometer and the ones we had didn’t work in that meter, so they had to use the hospitals glucometer. “Something wasn’t working with the glucometer. I did show her how to do a blood sugar check in the hallway and we were able to get a BS (blood sugar) before he left.” RN1 said they usually provide education on how to do the insulin injection the same time they teach the glucometer, but had not done it that day. She said she thought maybe she had been thinking P1 was still going to a long-term care facility. 8) On 05/30/2024 at 11:15 AM, during an interview with Home Health staff (HH)1, HH1 said the initial admission visit to P1’s home was on 02/09/2024 (tentative date documented by CM was 02/07/2024). At that time, HH1 found out P1 had not been monitoring his blood sugar and had not been taking the insulin as prescribed. An inventory of supplies was done, and HH1 said there was no functioning Glucometer at the home to check blood sugar and no insulin pen needles to attach to the insulin pen, so it could be administered. HH1 went on to say FM1 said H1 did not teach her how to give the insulin. HH1 said she contacted the pharmacy and confirmed they had an order for the glucometer, but had not been picked up, but they did not have an order for the needles. HH1 facilitated the order. On 02/15/2024, HH1 made the second home visit and said P1’s “glucose was in the 400’s, and it was clear taking the insulin was still not a priority, so recommended P1 go to the ER (Emergency Room) immediately for treatment.” 9) On 05/31/2024, confirmed with the outside Pharmacy the following: On 02/05/2024 (day of discharge), the following six items were picked up: -Atorvastatin -insulin pens -magnesium oxide -Metformin -lancet supplies -test strips supplies There was no order for the needles that are needed to use with the insulin pens. On 02/09/2024, the following two items were picked up: - needles for the insulin pens - glucometer 10) Reviewed P1’s medical record of Emergency Department visit on 02/15/2024. Records included” 02/15/2023 at 02:14 PM: RN Triage Note: “Sent by ...home health agency for evaluation of elevated blood glucose, reading >600 mg/dl @ home.” 02/15/2024 at 02:35 PM: lab resulted Glucose 721(target 80-150 older adults with type 2 diabetes) 02/15/2024 at 04:51 PM, Provider notes: “... Patient recently discharged with new insulin schedule, he has not been taking his insulin as scheduled. ...Patient given fluids, IV (intravenous) insulin, education was performed on checking his blood sugar and administering his insulin both with the patient and the patients wife (P1 was not married, FM1 accompanied).” The clinical impression included “Hyperglycemia,” and Medication noncompliance due to cognitive impairment.” 02/15/2024 at 05:00 PM RN note: “Extensive education given to family and patient, demonstration of blood glucose with patient able to repeat multiple times on own in demonstration of glucometer and insulin administration.” 02/15/20224 at 05:06 PM, lab resulted Glucose of 366. P1 was discharged back home.”