Health inspection·November 27, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm 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). Residents Affected - Few 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. Page 1 of 2 396049 396049 11/27/2024 Jameson Nursing and Rehab Center 3349 Wilmington Road New Castle, PA 16105

F 0684 28 Pa. Code 211.5(f)(i)(ii) Clinical Records Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(5) Nursing services Residents Affected - Few 396049 Page 2 of 2