Observations:
Review of facility staffing ratio information from 11/19/23 through 11/25/23, 12/10/23 through 12/16/23, and 1/7/24 through 1/13/24, revealed that the facility failed to meet the Nurse Aide (NA) ratios for the day and evening shifts for one of 21 days reviewed (1/09/24).
Findings include:
Review of facility staffing ratio information revealed the following NA staffing shortages for the day shift where the NA ratios were not met:
1/09/24 census of 103 residents 8.50 NAs worked and 8.58 were required
Review of facility staffing ratio information revealed the following NA staffing shortages for the evening shift where the NA ratios were not met:
1/09/24 census of 103 residents 8.0 NAs worked and 8.58 were required
During an interview on January 24, 2024, at 12:35 p.m. the Interim Scheduler and Nursing Home Administrator confirmed the accuracy of the facility provided staffing information and confirmed the facility failed to meet the minimum NA ratio on the above day and shifts.
| | Plan of Correction - To be completed: 03/06/2024
This plan of correction is submitted in good faith and required by law. By submitting this plan of correction, Twinbrook Healthcare and Rehabilitation Center does not admit that the citations listed on the CMS 2567 exist nor does it admit to any statement, finding, facts or conclusion that forms the basis of alleged citations. 1. A daily staffing meeting including the Nursing Home Administrator, Director of Nursing, Staffing Coordinator, Human Resources, or designees, is in place to monitor projected staffing ratios, with staffing coordinator offering bonuses for vacant shifts to staff as well as reaching out to PRN staff and agencies to fill shifts for call offs. The facility has added an additional staffing agency provider in an attempt to provide additional staff. The facility will continue the practice of not accepting admissions when staffing is projected to be below state minimum. The facility will continue to actively recruit and advertise to new and former employees.
2. The Staffing Coordinator will monitor in-house resident census by shift to verify accuracy. The Staffing Coordinator will be educated by the Nursing Home Administrator on documenting all efforts in procuring sufficient staff. The Staffing Coordinator will continue to ensure that the nursing staff ratios of Certified Nursing Assistant are as followed:
1:12 for Day Shift/1:12 for Evening Shift/1:20 for Night Shift.
3. Audits of nursing staff ratios will be conducted by the Director of Nursing or designee daily x 2 weeks, weekly x 4 weeks, and monthly x 3 months.
4. Results of the audits will be submitted to the QAPI Committee for review and recommendations at the Quarterly meeting.
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