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Based on record review, staff interview and review of policy, the facility failed to follow food/liquid preparation guidelines for one Patient (P)1 of three sampled. As a result of this deficient practice, P1 sustained skin burns from re-heated coffee.

Findings include:

Review of Electronic Health Record (EHR) showed P1 was admitted on 06/29/21 with diagnosis including Benign Prostatic Hyperplasia, Adjustment disorder, Hypothyroidism, Dementia, Primary Cancer of Skin.

Facility Reported Incident (FRI), dated 03/27/24, read that P1 was sitting in the day room watching TV. P1 requested and was served hot coffee and accidently spilled it on abdomen sustaining 1st and 2nd degree burns.

Staff interview on 12/04/24 at 09:40 AM, Staff Nurse 2 revealed during the incident previously mentioned, after P1 requested the coffee to be reheated, staff reheated the coffee in the microwave. Staff did not know that only the kitchen staff supposed to reheat food/liquids so they could monitor the temperature.

Review of EHR showed Physician Note, dated 03/27/24, read patient seen for burns to chest and abdomen from spilled hot coffee ... Reporting increased pain ... Silvadene with Adaptic dressing and will follow closely ...

Review of EHR showed Advanced Practice Registered Nurse Note, dated 04/08/24 read patient denies any pain or discomfort. Burns healing well ... Nursing reported no issues with pain during dressing changes ...

Facility policy on Food Preparation read the following: Purpose, to provide guidelines to the Critical Access Hospital element of Kohala Hospital's dietary staff on proper food preparation. Policy, standardize recipes are used for all food preparation. Food service manager and dietary department are responsible for the preparation and maintaining the quality and safety of patient and staff meals. Standardization of recipes, maintaining the recipe file, and supervising their use is overseen by the food service manager. Procedure, High standards of sanitation in followed for defrosting, preparing and cooking food products as well as in the serving of food products ... The cook II checks the temperature of food for safety using a stem thermometer ...

Based on record review, staff interview and review of policy, the facility failed to recognize and thoroughly investigate possible abuse for one Patient (P)1 of three sampled. As a result of this deficient practice, P1 was at increased risk for potential abuse or mistreatment.

Findings include:

Review of Electronic Health Record (EHR) showed P1 was admitted on 06/29/21 with diagnosis including Benign Prostatic Hyperplasia, Adjustment disorder, Hypothyroidism, Dementia, Primary Cancer of Skin.

Facility Reported Incident (FRI) dated 10/15/24 read staff found multiple bruise to left forearm and big bruise to left upper arm measured 4x2cm prior to giving shower.

Staff interview on 12/05/24 at 11:00 AM, Nurse Manager (Mgr)3 acknowledged that the facility did not further investigate possible abuse for P1.

Review of EHR showed Nurse Note, dated 10/14/24, read alert charting, continue to monitor for multiple fading bruises on the left forearm, no changes noted ...

Review of EHR showed Nurse Note, dated 10/17/24, read ... alert for bruise to left forearm ...

Facility policy on Patient/Resident Abuse read the following: Purpose, to establish guidelines for the prevention, identification and protection of patients/residents right to be free from abuse and establish the standard for a "no tolerance" for patient and resident abuse ... To effect early identification and reporting of suspected dependent adult abuse and neglect cases to DHS-Adult Protective Services ... To conform to OBRA requirements requiring reporting of any bodily injury to any dependent adult eighteen (18) years of age or older. To conform to the Medicaid contract and Administrative Rules requiring reporting of any bodily injury. To conform to 42 CFR 483.13 and 483.15, there must be evidence that all alleged violations are thoroughly investigated, and that action(s) have been taken to prevent further potential abuse while the investigation is in progress ... Procedures; Identification, any instance of suspected abuse must be thoroughly investigated following hospital and legal policies and procedures, including reporting to local law enforcement agencies as required ... All threatened or alleged incidents of patient/resident abuse shall be thoroughly investigated and documented. Incidents of unwitnessed patient/resident injury will be considered possible patient abuse cases ... The CNE or designee will conduct the initial abuse investigation and local law enforcement will pursue their own investigation ...