Pennsylvania Department of Health
UPMC MAGEE-WOMENS HOSPITAL TRANSITIONAL CARE UNIT
Patient Care Inspection Results

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UPMC MAGEE-WOMENS HOSPITAL TRANSITIONAL CARE UNIT
Inspection Results For:

There are  47 surveys for this facility. Please select a date to view the survey results.

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UPMC MAGEE-WOMENS HOSPITAL TRANSITIONAL CARE UNIT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on December 28, 2023, at UPMC Magee-Women's Hospital TCU, it was determined that there were no federal deficiencies, related to the Health portion of the survey process, identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as it relates to the Health portion of the survey process; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one nurse aide per 12 residents during the day and evening shifts on four of 21 days (7/2/23, 11/21/23, 11/23/23, and 12/24/23).

Findings include:

Review of facility census data indicated that on 7/2/23, the facility census was 17, which required two nurse aides (NAs) during the evening shift.

Review of the nursing time schedules revealed one NA provided care on the evening shift on 7/2/23. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 11/21/23, the facility census was 17, which required two NAs during the evening shift.

Review of the nursing time schedules revealed one NA worked on the evening shift on 11/21/23. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 11/23/23, the facility census was 13, which required two NAs during the evening shift.

Review of the nursing time schedules revealed one NA worked on the evening shift on 11/23/23. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 12/24/23, the facility census was 16, which required two NAs during the day shift.

Review of the nursing time schedules revealed one NA worked on the day shift on 11/24/23. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 12/24/23, the facility census was 16, which required two NAs during the evening shift.

Review of the nursing time schedules revealed one NA worked on the evening shift on 11/24/23. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 12/28/23, at 9:09 a.m. the Director of Nursing confirmed the facility failed to provide a minimum of one nurse aide per 12 residents during the day and evening shifts on four of 21 days.


 Plan of Correction - To be completed: 02/16/2024

The NHA or designee will review all current schedules to ensure we have met the ratio requirement of one nurse aide per 12 residents on day and evening shifts without the need to round to the next number.

NHA or designee will educate TCU schedulers (DON, NHA and Charge Nurses) on the need to maintain appropriate staffing hours based on resident census.

NHA or designee will audit all daily schedules to ensure appropriate staffing ratios are met based on the regulation daily for 1 week, weekly for 4 weeks, then twice monthly for two months, or until substantial compliance is achieved.

Results will be reviewed at the Quarterly QA meetings.

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