Dreier's Nursing Care Center
DREIER'S NURSING CARE CENTER in GLENDALE, CA — inspection on June 11, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a concurrent interview and record review on [DATE] at 3:36 PM of the facilities QUAPI/QAA (/Quality Assurance and Performance Improvement- data driven and proactive approach to quality improvement/Quality Assessment and Assurance - A Committee is responsible for identifying and responding to quality deficiencies that are identified in the facility) plan with Administrator (ADM) and Director of Staff Development (DSD).
The DSD stated the facility had not identified or implemented any adverse event into facility ' s QAPI Program.
The DSD stated the cause of death of Resident 53 was not investigated to determine if there were quality deficiencies and measures to address in the QAPI.
The DSD confirmed current facility ' s QAPI was only for Fall reduction.
The DSD stated the facility only relied on the [NAME] 3 (Minimum Data Set 3.0 Quality Measure Reports) report to identify issues to implement into their QUAPI/QAA plan and the only issue they had identified was related to falls.
The ADM stated he had not been involved the facilities QAPI/QAA program oversight since last year.
The ADM stated it had been the facilities Director of Nursing who had been in charge of the oversight, and he was unaware the facility failed to have a system other than relying on [NAME] 3 to identify and address and analyze adverse events.
The ADM stated the DON resigned on [DATE] and he is currently hiring a replacement.
A review of the facility ' s policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Plan with a revision date of [DATE] indicated The QAPI program overseen by the QAPI committee is designated to identify and address quality deficiencies though analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level.
555839
During an interview on [DATE] at 3:32 PM, LVN 1 stated during the 3 PM to 11 PM shift on the night of [DATE], Resident 53's family member (Family) 1 requested for LVN 1 to administer pain medication to Resident 53 because, Resident 53 was crying a lot, moaning, and fidgeting with her hands. LVN 1 stated she asked Resident 53 about her pain level, but the resident moaned and moved her arms around. LVN 1 stated she took Resident 53's vital signs (VS), but she did not document the VS and she could not recall what they were. LVN 1 stated she did not notify Physician 1 when she observed Resident 53 moaning. LVN 1 stated she gave Resident 53 a pain medication Tylenol and the resident stopped moaning. LVN 1 stated she did not document Resident 53's behavior of moaning, but she should have.
During a concurrent interview and record review of the VS records on [DATE] at 4:37 PM with LVN 1, LVN 1 stated Resident 53's last blood pressure was at ,d+[DATE] on [DATE] at 5:47 PM. LVN 1 stated she did not notify Physician 1 or monitored and rechecked the BP when Resident 53's BP was trending down and lower from baseline BP, which could have been the cause of the significant change in the resident's condition. LVN 1 stated on [DATE] at around 9 PM, she assessed Resident 53 and Resident 53 was having pain at a evel of 7 out of 10. LVN 1 stated she administered Tylenol to Resident 53, which was ordered by the physician for the resident's pain level of ,d+[DATE]. LVN 1 stated she did not notify Physician 1 about Resident 53 having the pain level of 7 out of 10 even when Resident 53 did not have any physician order for pain medication stronger than Tylenol at the time. LVN 1 also stated Family 1 was content with the Tylenol and the results of the Tylenol. LVN 1 stated she could not recall why she did not notify Physician 1.
During a telephone interview with Physician 1 on [DATE] at 9:20 AM, Physician 1 stated if a resident's blood pressure continues to decrease, he would expect to be notified by the facility's staff.
Physician 1 stated the staff should have monitored Resident 53's blood pressure.
Physician 1 stated he could not recall if he was informed that Resident 53's pain level went above a 3 on the pain scale.
The Physician 1 stated if Resident 53's pain was not controlled, he would expect to be notified by the facility staffs.
Physician 1 stated if there were other things happening while Resident 53 was observed with pain like if resident's heart was going up from 60 bpm to 100 bpm, Physician 1 stated he would expect to be notified.
555839
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555839 B.
Wing 06/11/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Dreier's Nursing Care Center 1400 West Glenoaks Blvd Glendale, CA 91201