Nursing Investigation Results -

Pennsylvania Department of Health
JAMESON CARE CENTER, INC
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
JAMESON CARE CENTER, INC
Inspection Results For:

There are  46 surveys for this facility. Please select a date to view the survey results.

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JAMESON CARE CENTER, INC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification, Civil Rights Compliance, State Licensure Survey and an Abbreviated Survey in response to a complaint, completed on October 10, 2019, it was determined that Jameson Care Center, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


















 Plan of Correction:


483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at 483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:


Based on observations and staff interview, it was determined the facility failed to maintain privacy of confidential information during medication administration for one of two wings (B Wing).

Findings include:

Observation on 10/10/19, at 11:29 a.m. revealed Licensed Practical Nurse (LPN) Employee E1 performing resident medication administration and left the medication cart and the computer screen open with resident information visible to anyone passing by in the corridor. During an interview at the time of the observation, LPN Employee E1 acknowledged the lack of privacy with resident information on the computer screen.

Observation on 10/10/19, at 12:28 p.m. revealed two medication carts along side B Wing nurses station not attended to by staff with both computer screens open and visible to anyone passing by in the corridor.

28 Pa. Code 211.5(b) Clinical records






 Plan of Correction - To be completed: 11/30/2019

To protect the privacy and confidentiality of all residents, Employee E1 and all RN's and LPN's will be educated by the Staff Development Coordinator on personal Privacy/Confidentiality of records, specifically regarding leaving the medication cart with the computer screen open and visible with resident information. The DON will monitor the medication carts 3 X week for 4 weeks, then 2 X week for 4 weeks, and 1 X a week for 4 weeks and report at the QAPI meeting.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during the use of a blood glucose meter (BGM-a device to collect and measure the level of glucose [sugar] in the blood) for two of 19 residents observed during the administration of medications (Residents R41 and R225).

Findings include:

The facility policy entitled "Blood Glucose Meter" dated 9/24/19, indicated that staff are to clean the meter before and after each resident use, utilizing a Sani-Cloth wipe per manufacturer's recommendation.

Observation on 10/7/19, at 3:52 p.m. revealed that Licensed Practical Nurse (LPN) Employee E3 removed the BGM from the case without cleaning it, he/she proceeded to obtain a blood glucose sample from Resident R41. LPN Employee E3 then laid the BGM on top of the medication cart without cleaning it. At 3:56 p.m. he/she then proceeded to take the same BGM and obtained a blood glucose sample from Resident R225. LPN Employee E3 then replaced the BGM into the case at the nurse's station without cleaning it.

During an interview on 10/7/19, at 4:00 p.m. LPN Employee E3 indicated that night shift cleans the BGM's and performs the Quality Control checks every night.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
Previously cited 11/15/18







 Plan of Correction - To be completed: 11/30/2019

The Infection Control Nurse (ICN) educated employee E3 on cleaning the blood glucose monitor with a Sani-Cloth before and after each resident use and allowing the glucometer to air dry between residents. All other licensed nurses are being provided an education in-service presented by the ICN. Licensed nurses will be observed by the ICN when doing Blood Glucose Monitoring for a period of 3 X a week for 4 weeks, then 2 X a week for 4 weeks, and 1 X a week for 4 weeks. The results will be submitted to the DON and reported at the monthly QAPI meeting.

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long-Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of clinical records, facility policies, and staff interviews, it was determined that the facility failed to develop and/or update individualized care plans for four of 19 residents (Residents R38, R40, R52, and R68).

Findings include:

The "Comprehensive Care Plans" policy, dated 9/24/19, indicated that care plans should be updated as the resident's status changes.

Resident R38's clinical record revealed an admission date of 4/27/16, with diagnoses that included high blood pressure, dysphagia (difficulty swallowing), acute kidney injury, repeated falls, and muscle weakness. Clinical notes indicated that Resident R38 fell on 2/2/19 and 2/12/19.

Resident R38's care plan entitled Risk for Falls created on 5/28/19, revealed that the facility failed to develop a care plan to address Resident R38's falls until 5/28/19.


Resident R40's clinical record revealed an admission date of 11/16/17, with diagnoses that included fractured femur (thigh), fractured vertebra, repeated falls, diabetes visual loss- both eyes, dementia, moderate kidney disease, and anxiety. Clinical notes indicated that Resident R40 fell on 9/9/19 and 9/10/19.

Resident R40's care plan entitled History of Falls created on 8/2/18, revealed that the facility failed to update the care plan with new interventions following the incidents on 9/9/19 and 9/10/19.


Resident R52's clinical record revealed an admission date of 11/29/17, with diagnoses that included fractured arm, peripheral vascular disease, peripheral artery disease, muscle weakness, and tremors. Clinical notes indicated that Resident R52 fell on 4/21/19, 4/29/19, 8/24/19, 9/1/19, 9/9/19, and 9/10/19.

Resident R52's care plan entitled Risk for Falls created on 11/19/17, revealed that the facility failed to update the care plan with new interventions following the incidents on 4/21/19, 4/29/19, 8/24/19, 9/1/19, 9/9/19, and 9/10/19.


Resident R68's clinical record revealed an admission date of 10/14/16, with diagnoses that included anxiety, dysphagia (difficulty swallowing), dementia, high blood pressure, coronary artery disease, pressure ulcer of the sacrum (lower back), and cellulitis (skin infection). Clinical notes indicated that Resident R68 fell on 3/30/19, 6/12/19, 6/23/19, 7/24/19, 8/6/19, 8/17/19, 9/6/19, and 9/7/19, sustained a skin tear while transferring on 5/26/19, and a bruised, swollen hand on 5/17/19.

Resident R68's care plan entitled Risk for Falls created 6/27/17, revealed that the facility failed to update the care plan with new interventions following the incidents on 3/30/19, 6/12/19, 7/24/19, 8/17/19, 9/6/19, 9/7/19, 5/26/19, and 5/17/19.

During an interview on 10/09/19, at 1:45 p.m., Registered Nurse Employee E3 confirmed that the fall care plans were not initiated and/or updated for Residents R38, R40, R52, and R68.


28 Pa. code 211.5(f) Clinical records

28 Pa Code 211.11(d) Resident care plan

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 11/15/18


 Plan of Correction - To be completed: 11/30/2019

R 38's open chart was reviewed and updated to ensure his care plan included Risk for Falls.
R 40's chart was reviewed, and the care plan was updated to include fall prevention interventions.
R 52's chart was reviewed, and the care plans updated to include fall prevention interventions.
R 68's Chart was reviewed, and the care plans updated to include fall prevention interventions.
On 10/10/2019 and 10/11/2019 all resident care plans were reviewed to ensure interventions updated as appropriate.
The DON or designee will monitor fall risk care plans for interventions and updates on four residents a week for four weeks, then two resident a week for four weeks, then one resident a week for four weeks.
The result of this monitor will be reported at the QAPI meetings.

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:

Based on review of the Minimum Data Set (MDS-federally-mandated assessments of a resident ability and care needs) User's Manual, clinical records and staff interviews, it was determined that the facility failed to ensure that the MDS assessments were completed within the required time frame for two of 19 residents reviewed (Residents R7 and R22).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing MDS assessments, dated October 2017, indicates that the Assessment Reference Date (ARD-the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type and is to be completed no later than the ARD plus 14 calendar days.

Resident R7's clinical record revealed an admission date of 9/9/15, with diagnoses that included dementia, dysphagia (difficulty swallowing), muscle weakness, anxiety, depression, and cystitis (inflammation of the bladder).

Resident R7's MDS records revealed that a Quarterly MDS had an ARD of 5/29/19, with no additional MDS scheduled or completed for a period of 134 days after the previous assessment and 42 days past due.

Resident R22's clinical record revealed an admission date of 2/26/19, with diagnoses that included pneumonia, diabetes, stroke, Whipple's Disease (rare bacterial infection that most often affects your joints and digestive system).

Resident R22's MDS records revealed that a Quarterly MDS had an ARD of 5/26/19, with no additional MDS scheduled or completed for a period 137 days after the previous assessment and 45 days past due.

During an interview on 10/9/19, at 10:45 a.m. Registered Nurse Assessment Coordinator Employee E2 confirmed that Residents R7 and R22 MDS assessments were not completed within the required time frame.

28 Pa. Code 211.12 (c)(d)(5) Nursing services
Previously cited 11/15/18







 Plan of Correction - To be completed: 11/30/2019

The Assessment Review Date (ARD) for R7 was set for 10/11/19 and completed on 10/14/19.
The Assessment Review Date (ARD) for R22 was set for 10/9/10 and completed on .10/16/19.
All quarterly and annual assessments for all our in-house residents were reviewed and found to be completed. A long-term care assessment worksheet was compiled to reflect resident last assessments and the next due date.
This long-term care assessment worksheet will be updated with each resident assessment.
The RNAC or designee will monitor assessments on four residents a week for four weeks, then two resident a week for four weeks, then one resident a week for four weeks
The result of this monitor will be reported at the QAPI meetings.

483.10(e)(4)-(6) REQUIREMENT Choose/Be Notified of Room/Roommate Change:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement.

483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.
Observations:

Based on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure that in preparation for a room change, the resident's responsible party received written notice before the resident's room was changed for one of three residents with a room change reviewed (Resident R22).

Findings include:

Resident R22's face sheet documented an admission date of 2/26/19, with diagnoses that included disorientation, communication deficit and weakness.

A tour of the facility on 10/7/19, revealed that Resident R22 no longer resided in Room 39, and was observed to have been moved to Room 43.

There was no documentation to indicate that Resident R22's responsible party received any written notice regarding the room change.

During an interview on 10/10/19, at 1:05 p.m. the Director of Nursing confirmed that Resident R22 was moved to a different room, but that written notification regarding the room change was not provided prior to the room change.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/15/18 and 7/24/19

28 Pa. Code 201.29(j) Resident rights





 Plan of Correction - To be completed: 11/30/2019

I hereby acknowledge the CMS 2567-A, issued to JAMESON CARE CENTER, INC for the survey ending 10/10/2019, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

Resident R22 wife was approached to confirm she had verbal notification of resident room change and was presented with a written notice of confirmation of room change. Social Services will verbally inform and provide written documentation to the Resident/Residents family of the room change, and the reason for the change before the residents' room or roommate is changed. A copy of the informed written documentation of the room change will be placed in the residents' medical record. Nursing to be educated by the Staff Development Coordinator on documentation of room changes. We identify other residents having the potential to be affected by not being informed of a room change by having Social Services do monthly checks on a minimum of 10 resident rooms each month for a period of three months and will report this information to the DON for the monthly QAPI meetings.
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long-Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.



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