Pennsylvania Department of Health
JAMESON NURSING AND REHAB CENTER
Patient Care Inspection Results

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JAMESON NURSING AND REHAB CENTER
Inspection Results For:

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JAMESON NURSING AND REHAB CENTER - 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 March 15, 2024, it was determined that Jameson Care Center, was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


211.5(f)(i)-(xi) LICENSURE Medical records.:State only Deficiency.
(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to include the discharge summary in the closed record for two of three closed records reviewed (Closed Record Residents CR59 and CR61).

Findings include:

Review of Resident CR59's clinical record revealed an admission date of 12/11/23, with diagnoses that included
malignant neoplasm of lung (tumor on the lung) and muscle wasting.

Review of Resident CR59's clinical record revealed there was no discharge summary included in the record.

Review of Resident CR61's clinical record revealed an admission date of 11/30/23, with diagnoses that included multiple fractures of ribs of the right side and multiple fractures of the ribs on the left side.

Review of Resident CR61's clinical record revealed there was no discharge summary included in the record.

During an interview on March 14, 2024, at 2:30 p.m. the Medical Records Clerk Employee E1, confirmed that there was not a discharge summary in the closed records for Residents CR59 and CR61.






 Plan of Correction - To be completed: 05/08/2024

The physician completed the discharge summary on resident CR 59's clinical record on 3-15-2024 and completed this discharge summary on resident CR 61's clinical record on 3/15/2024. The medical records employee will review the last 30-day discharge records for completion of discharge summaries. The NHA will review the discharge chart check list at AM stand up meeting for the completion. Review every two weeks times 4 weeks then monthly times two months. And PRN / ongoing. Any deficient charts will be reported to the physician and the NHA.
The monitored results will be reported at the quarterly QAPI meeting.

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 the facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Nurse Aide (NA) per 20 residents for the overnight shift for two of 21 days reviewed (10/03/23 and 2/18/24).

Findings include:

Review of facility staffing ratio information from 10/1/23 through 10/7/23, and 2/18/24 through 3/10/24, revealed the following NA staffing shortages for the overnight shift where the NA ratios were not met:


10/03/23 census of 57 residents 2.00 NAs worked and 2.85 were required
2/18/24census of 61 residents3.00 NAs worked and 3.05 were required

Review of an email correspondence interview dated 3/27/24, at 11:56 a.m. revealed the Nursing Home Administrator confirmed the NA ratios were not met for the above dates and shift.




 Plan of Correction - To be completed: 05/08/2024

The facility will ensure that it meets the minimum nurse aide to resident ratio each day by calculating out projected ratios needed at current census levels.
The Nursing Home Administrator has reviewed and educated the Director of Nursing, and the Unit Manager and the schedular staff member on ensuring that the facility meets the minimum nurse aide to resident ratio.
We will institute the following system changes to ensure we meet the staffing ratios:

We will have a Staffing Schedular Computer Program that will predict our staffing needs. This program will alert staff of openings to meet staffing needs. Management staff or designee will review the potential admission numbers to ensure appropriate census levels are maintained. We will continue to offer additional time to our staff members which may include agency and continue to offer extra shift bonuses for current employees, ensure all our vacant positions are currently in recruitment and advertised appropriately.

The Director of Nursing or designee will audit to ensure that facility meets the required minimum number of nurse aide to resident staffing ratio by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance. Monitoring will be conducted once a week for one month, then two times a week for one month, then monthly for 2 months.

Monitoring will be reviewed at the quarterly QAPI Meeting and additional recommendations will be followed as deemed appropriate.

211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on review of the facility staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 25 residents for the day shift for seven of 21 days reviewed (10/1/23, 10/6/23, 10/7/23, 2/18/24, 2/24/24, 3/9/24, and 3/10/24; failed to ensure one LPN per 40 residents on the overnight shift for seven of 21 days reviewed (10/1/23 through 10/7/23).

Findings include:

Review of facility staffing ratio information from 10/1/23 through 10/7/23, and 2/28/24 through 3/14/24, revealed the following LPN staffing shortages for the day shifts where the LPN ratios were not met:

10/1/23 census of 58 residents 2.00 LPNs worked and 2.32 were required
10/6/23census of 56 residents2.00 LPNs worked and 2.24 were required
10/7/23census of 54 residents2.00 LPNs worked and 2.16 were required
2/18/24census of 60 residents2.00 LPNs worked and 2.40 were required
2/24/24census of 57 residents2.00 LPNs worked and 2.28 were required
3/09/24census of 60 residents2.00 LPNs worked and 2.40 were required
3/10/24census of 59 residents2.00 LPNs worked and 2.36 were required

Review of facility staffing ratio information from 10/1/23 through 10/7/23, revealed the following LPN staffing shortages for the overnight shift where the LPN ratios were not met:

10/01/23census of 59 residents1.00 LPNs worked and 1.48 were required
10/02/23census of 59 residents1.00 LPNs worked and 1.48 were required
10/03/23census of 57 residents1.00 LPNs worked and 1.43 were required
10/04/23census of 57 residents1.00 LPNs worked and 1.43 were required
10/05/23census of 57 residents1.00 LPNs worked and 1.43 were required
10/06/23census of 56 residents1.00 LPNs worked and 1.40 were required
10/07/23census of 54 residents1.00 LPNs worked and 1.35 were required

Review of an email correspondence interview dated 3/27/24, at 11:56 a.m. revealed the Nursing Home Administrator confirmed the LPN ratios were not met for the above dates and shift.





 Plan of Correction - To be completed: 05/08/2024

The facility will ensure that it meets the minimum nurse LPN to resident ratio each day by calculating out projected ratios needed at current census levels.
The Nursing Home Administrator has reviewed and educated the Director of Nursing and the Unit Manager and the schedular staff member on ensuring that the facility meets the minimum LPN to resident ratio.
We will institute the following system changes to ensure we meet the staffing ratios:

We will have a Staffing Schedular Computer Program that will predict our staffing needs. This program will alert staff of openings to meet staffing needs. Management staff designee will review potential admission numbers to ensure appropriate census levels are maintained. We will continue offer additional time to our staff members which may include agency and continue to offer extra shift bonuses for current employees, ensure all our vacant positions are currently in recruitment and advertised appropriately.

The Director of Nursing or designee will audit to ensure that facility meets the required minimum number of LPN to resident staffing ratio by reviewing the current working schedule and assignment sheets prior to the day and after the day is complete to ensure compliance. Monitoring will be conducted once a week for one month, then two times a week for one month and monthly for 3 months.

Monitoring will be reviewed at the quarterly QAPI Meeting and additional recommendations will be followed as deemed appropriate.


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