Last February, two nurses with the Hawaiʻi Department of Health were wrapping up an inspection at a care home for adults in East Honolulu when they found something they weren’t expecting: a resident of that facility locked in a car parked on the curb. 

The resident, inspectors discovered, had been confined in the car with the front windows cracked for an hour and 20 minutes in the full midday sun. 

It was a coincidence that health officials discovered the troubling incident at ʻĀina Haina Adult Residential Care Home. That day, the nurses happened to be checking out an unrelated complaint at the facility for adults who require living assistance and, depending on the facility, some level of medical care. 

The original complaint was later dropped. But ʻĀina Haina ARCH was issued a $1,000 penalty for leaving the resident unsupervised and confined, a violation of state law that requires a caregiver to be present around the clock. 

The care home, which typically houses up to five residents, had a history of minor deficiencies, but most do. There was nothing in past inspections of ʻĀina Haina ARCH to indicate a more serious issue like this was brewing, according to officials from the Department of Health. 

But the system for identifying a pattern of minor problems that could point to a bigger issue is limited, something officials are eager to address. 

While it’s common for care homes to have problems, it’s incredibly rare for them to face financial penalties. Only six licensed adult residential care homes, known as ARCH facilities, have been issued an administrative penalty since 2018.   

John McDermott, the state’s long-term care ombudsman, was appalled to learn about the resident locked in the car in the sun.  

“If you saw a dog in a car with the windows all shut or almost all shut, I think almost anybody would call the police or be tempted to break the glass and save the dog,” he said. “So how was this person in the car for an hour and 20 minutes and nobody noticed?”

Tracking Worrisome Trends

It’s unclear why the resident was locked in the car that day. Health officials wouldn’t provide those details, nor would they give any information about the resident, citing privacy restrictions. The operator of ʻĀina Haina ARCH, Lan Chen, declined to answer questions. The resident was not hurt, according to officials.

In the months that followed the incident, health inspectors returned to the facility three times to check that residents weren’t being left unsupervised again. The facility also had its annual unannounced visit last June, about four months after the resident was found in the car.

But ʻĀina Haina ARCH had a long history of minor problems, according to inspection records dating back to 2015. In nine of the last 10 years, nurses who work with the state Office of Health Care Assurance, which is responsible for licensing and inspections of medical facilities, have flagged a number of concerns at the facility. 

The problems ranged from caregivers not adjusting residents’ diets to conform to updated orders from a doctor, failing to log whether new staff or residents had up-to-date tuberculosis documentation or improperly recording whether residents had adverse responses to medication. 

It’s common for care homes to have deficiencies flagged on their annual inspections, said Justin Lam, a supervisor at the Office of Health Care Assurance who leads the licensing section. Because the state is in the middle of transitioning its data systems, Lam wasn’t able to provide data on how many facilities have at least one issue flagged in their annual inspection. He estimates the figure is about 90% of the 484 licensed adult residential care homes.

“Having no deficiencies is actually kind of a rarity,” Lam said. Having issues “doesn’t necessarily mean that they’re not providing good care.”

It is rare that licensed facilities are given fines like the one ʻĀina Haina ARCH received for leaving the resident in the locked car, according to the Department of Health. The vast majority of actions are of unlicensed care homes, which represent two-thirds of the 19 ARCH facilities fined since 2018. In that timeframe, about $33,000 in penalties have been issued to licensed care homes, according to the Department of Health. 

Most of the time, care homes are flagged for minor concerns. Penalties are issued for serious infractions that put residents at risk, including housing more residents than allowed, denying inspectors access to the home or operating an unlicensed facility.

But the same minor issues did appear repeatedly at ʻĀina Haina ARCH over the last 10 years, pointing to challenges with assessing whether care homes are fixing their problems. 

Licensed care homes in Hawaiʻi are inspected every year. If health officials flag concerns, those are supposed to be fixed before the facility’s license can be renewed. Care home operators submit pictures or paperwork to show that the problems have been addressed and a plan to prevent them from happening again. Inspectors also conduct unannounced visits later in the year to check whether care home operators are following that plan. 

But the Department of Health relies too heavily on the word of care home operators that the problems have been addressed before reupping their license, according to a 2023 state report on the Office of Health Care Assurance. It can be anywhere from three to nine months before health inspectors go back into the home for a surprise visit to verify that the plan to keep issues from resurfacing has actually been implemented.

“I think that’s wholly inadequate,” said Dr. Laura Mosqueda, a specialist in geriatric care at the University of Southern California. “Once you’re seeing a series of things go wrong, you want to dig in deeper and do a more thorough, deeper inspection. And inspect it more frequently without notice.”

Lam says the staff at the Office of Health Care Assurance is trained to look for the root causes of problems. If they are inspecting a facility that’s known to have issues, they’ll look more closely. 

But right now, identifying trends in deficiencies over time is left to inspectors looking manually through in a care home’s inspection records.

Lam said repeat problems of the same type do raise a red flag. But nurses are only required to look at records going back a year, although they can go back further if they notice the same problem in consecutive years.

But if a particular deficiency skips a year or crops up sporadically, it won’t be flagged as a repeat issue. 

That’s something health officials want to fix, and they’re hoping a new data program set to go live later this year will help them do that. Lam hopes the improved data system, which will gather inspection data and allow officials to generate customized analysis, will enable the agency to spot trends in problems at a particular facility over longer stretches of time.

“The nurses wouldn’t have to manually track that. It’s something that could be written into the programming to where, like, if it’s a repeat deficiency, it’s automatically flagged,” he said.

The new data system will also help inspectors spot whether facilities run by the same people see similar problems.

Mosqueda says that it’s imperative that inspectors try to identify deeper problems at care homes.

“These are typically pretty vulnerable people. Especially if these are people who don’t have family, friends, people who love them looking after them, all they’ve got are these inspectors,” she said. “Who’s going to speak up for them?”