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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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 an Abbreviated Complaint Survey completed on November 27, 2024, it was determined that Jameson Nursing and Rehab Center was not in compliance with the following 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:

483.25 REQUIREMENT Quality of Care:

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.

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of clinical records and staff interviews, it was determined that the facility failed to transcribe physician's orders for an anticoagulant (medication to thin your blood to prevent blood clots) medication and dressing change to a surgical incision for one of four residents reviewed (Resident R1).

Findings include:

Resident R1's clinical record revealed an admission date of 10/25/24, with diagnoses that included anemia (a reduction in red blood cells resulting in symptoms such as fatigue and weakness), atelectasis (when part or your entire lung collapses resulting in symptoms such difficulty breathing, wheezing, and cough), and fractured right hip.

Resident R1's clinical record contained a document from an area hospital entitled "Patient Summary" dated 10/25/24, which identified a list of medications Resident R1 was to continue while at the facility. The Patient Summary indicated that Resident R1 was ordered Lovenox (injectable anticoagulant medication) 40 milligram (mg) per 0.4 milliliters (ml) - give 0.3 ml subcutaneous (sq) daily for 30 days. Resident R1's physician's orders and Medication Administration Record (MAR) lacked evidence that the facility transcribed and administered Lovenox as ordered on 10/26/24 and 10/27/24.

During an interview on 11/26/24, at approximately 2:15 p.m. the Nursing Home Administrator confirmed the facility failed to transcribe Resident R1's admission orders to include Lovenox resulting in the Lovenox not being administered as ordered.

Resident R1's clinical record also contained a document from an area hospital entitled "Ortho - Final Progress" dated 10/25/24, that revealed under "Incision / Wound Care" that Resident R1 was to have a dry dressing change completed daily until completely dry for two days, then it was okay to leave incision open to air. Review of "Nurse to Nurse Admission Report" revealed the area hospital informed the facility that Resident R1 had a dressing to her leg. Review of Resident R1's "Admission Assessment" completed by the facility on 10/25/24, Section I entitled "Skin Condition and History" revealed a right thigh surgical incision with two dressings present. Review of Resident R1's physician's orders and Treatment Administration Record (TAR) lacked evidence that the facility transcribed and changed the right hip dressing as ordered.

During an interview on 11/26/24, at approximately 3:00 p.m. the Director of Nursing confirmed the facility failed to transcribe the dressing change order regarding Resident R1's right hip and failed to provide evidence that if clarification was needed, that the facility contacted the primary care physician and/or surgeon to obtain clarification so care could be provided.

28 Pa. Code 211.5(f)(i)(ii) Clinical Records

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 12/24/2024

"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."

The facility cannot correct the transcription error related to the missed Lovenox and dry dressing change for resident R1. There were no adverse resident effects.
All licensed nursing staff will be re-educated on the Medication and Treatment Order Policy.
The Director of Nursing/ Designee will complete an audit on all new admissions with a 30-day look-back period.
The Director of Nursing/Designee will audit all new resident admission orders during clinical meeting for 4 weeks, then weekly for 2 weeks, then monthly for 2 months.
Outcomes of audits will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

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