Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on June 3, 2022, it was determined that Twinbrook Healthcare and Rehabilitation Center was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Licensure Regulations.

 Plan of Correction:

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.

Based on a review of nursing schedules, it was determined that the facility failed to provide the minimum number of general nursing care hours of 2.7 hours of direct resident care hours per resident in a twenty-four hour period for one of 21 days reviewed (5/15/22).

Findings include:

During a review of nursing schedules between 5/1/22 through 5/07/22, 5/15/22 through 5/21/22, and 5/25/22 through 5/31/22, it was revealed that the hours of direct resident care was below the 2.7 minimum per patient day (PPD) on the following date:

5/15/22PPD 2.53

During an interview on 6/01/22, 11:44 a.m. the Director of Nursing confirmed that the facility did not meet the 2.7 minimum hours of direct resident care on the 5/15/22.

 Plan of Correction - To be completed: 06/30/2022

1. A daily staffing meeting including the NHA, DON, Staffing Coordinator, HR, or designees, is in place to monitor projected and final PPD 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. Facility will continue practice of not accepting admissions when staffing is projected to be below state minimum. Facility has hired many nursing staff over the past several weeks, and continue to actively recruit and advertise to new and former employees.

2. Staffing Coordinator will be educated by DON/designee to document efforts of procuring sufficient staff.

3. Audits of nursing staffing will be conducted by Director of Nursing or designee daily x 2 weeks, weekly x 4 weeks, and monthly x 3 months, with incidents of staffing under 2.7 reported to DOH.

4. Results of audits with recommendations for changes will be submitted to QAPI committee.

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