Facility Evaluation Report

Licensing Program Manager (LPM) Kelly Burly, Licensing Program Analysts (LPA’s) Jenny Olson and Erika Miller conducted a Case Management - Deficiencies visit to the facility above. LPM and LPAs met with Administrator, Chris Patton and explained the purpose of the visit. These deficiencies were observed by Department of Developmental Services during a visit conducted 12/20/23. CCL and Regional Center staff were also present during the visit.

According to records, Client 1 (C1) had no recorded bowel movements (BMs) from 11/18/23 to 11/26/23 and 12/1/23 to 12/9/23. C1 has a PRN order for “Dulcolax 5mg 2 tabs by mouth daily as needed for constipation. Max 1 dose/24 hour.” There was no PRN given in November, and the facility’s PRN sheet for December does not have the order for Dulcolax. C1’s medication was not given as prescribed.

According to records, Client 2 (C2) C2 had no BM’s recorded between 11/7/23 to 11/14/23 and 11/29/23 to 12/09/23, yet no PRNs were given. C2 had a PRN order “give Magnesium Citrate one bottle for 2 days if no BM’ and “Polyethylene Glycol Powder give 17gm by mouth at bedtime as needed for no BM for 2 days.” No PRN was given in the month of November and December, therefore C2’s medication was not given as prescribed. Side effects for C2’s Clozapine 100 mg PO daily indicate constipation as a side effect. Staff interviewed stated they had no training or knowledge of residents’ bowel issues or PRN orders, or adverse side effects to medications to watch for.

Client 3 (C3) had a physician’s order for “Polyethylene Glycol 17gm mix with 1 capful water/juice/tea given by mouth daily for constipation.” However the facility wrote it in their MAR and PRN sheet as a PRN order, instead of a daily medication.