OIG auditors discover training, staffing and maintenance issues at nursing facility

The OIG Audit and Inspections Team recently conducted an unannounced site visit to the Matagorda House Healthcare Center as part of an annual risk assessment for Texas nursing facilities.

Auditors concluded that though there were areas of compliance with applicable health and safety requirements, the 120-bed facility did not meet standards set for direct care staffing and training, including:

  • Confirming all direct care staff are properly trained.
  • Retaining staffing records to verify compliance with staff-to-resident ratios.
  • Maintaining direct care staff records to verify compliance with pre-employment qualifications. 

The audit detailed that failing to ensure sufficient staff coverage with properly trained and qualified providers jeopardizes the health and safety of residents with Alzheimer's or related disorders.

Additionally, auditors noted that several areas around the facility's exterior had fallen into disrepair. For example, roof supports had rotted in the weather, and fencing in the resident courtyard was rusting and broken. Auditors also found locks and gates that would not secure properly. 

Also left unsecured on the day of the site visit was a medication destruction box used to hold expired or unneeded pills. Inappropriately securing medication before its collection and destruction increases the risk of misuse. 

In addition to staffing and security concerns, Matagorda House failed to provide required Alzheimer’s disclosure statements to prospective residents or those assisting potential residents. As a facility certified to provide care for Alzheimer's patients, the facility must provide this documentation before resident admission to inform decision-makers about the facility's level of care. 

The OIG audit team recommended several changes that the Matagorda House management team can implement to comply with applicable health and safety requirements for a licensed nursing facility in Texas. Specifically, facility operators should:

  • Ensure facility and temporary agency staff complies with applicable training requirements, including receiving all required training. 
  • Ensure staff-to-resident ratios comply with requirements and retain documentation to support daily nurse staffing levels. 
  • Perform all required pre-employment checks. 
  • Identify and address maintenance concerns promptly to ensure the exterior areas of its nursing facility are secure and free of safety hazards. 
  • Ensure the medication destruction box is secure and train staff in medication security. 
  • Securely store overflow resident medications and perform medication reconciliations. 
  • Ensure prospective residents and individuals assisting potential residents receive Alzheimer's disclosure statements before admission.

After auditors concluded the site visit and developed recommendations, Matagorda House was purchased by Trinity Healthcare and renamed Colonial Living and Rehabilitation of Bay City. The new management team accepted the audit results, agreeing to complete necessary changes.

For the full audit, visit the OIG website.