Palm Garden Retirement Home & Dementia Care

Maintain physician order documentation in resident record

87608 Postural Supports (a)Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care...Postural supports may be used under the following conditions (3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.This requirement is not met as evidenced by: Based on interviews and records reviewed, Licensee did not submit exception requests for resident that require full bed rails, which poses a potential health, safety or personal rights risk to persons in care.

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety...This requirement is not met as evidenced by: Based on interviews and records reviewed, R1’s right arm was stuck between bed rails and bed. Staff did not seek medical attention until two days after incident, which poses immediate health, safety or personal rights risk to persons in care.