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Graves v Arpaio Expert Report on Medical Compliance at Maricopa County Jail Apr 2011 Partb

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Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 17 of 65

Overall compliance
compliance was
was 94.3%
94.3% in
in November
November 2010
2010 compared
compared
Overall
to 77.3% in Apri12010.
April 2010.
2010.
to 77.3% in April

7. Since
Since August
2010, Dr.
Dr. Alvarez
led and facilitated
August 2010,
Alvarez has
has led
facilitated aa
7.
system-wide multidisciplinary
CQI
team to
to measure
measure and
and
cQr team
system-wide
multidisciplinar CQI
to inmate
inmate Health
improve processes
Health Care
Care Requests
Requests
improve
processes related to
A computer-supported
database
(HCR). A
computer-supporteddata
base was
was established
established as
as
(HCR).
2010. In
of October
1,2010.
In December
2010, there
there were
were 6,990
6,990
of
October 1,
1,2010.
December 2010,
HCR's, of which
which 4,849
4,849 were
were related to medical issues.
The
issues. The

HCR's, of

average time period between the
the time
time CHS
CHS received
received these
these
requests and the time that
that the
the requests
requests were
were triaged
(screened
Based
(screened and
and assigned
assigned an
an action)
action) was
was 14.1
14. 1hours.
hours. Based
NCCHC pre-survey team, the
on recommendations from the
the NCCHC
several revisions designed
designed to
improvement
team has
has made
made several
improvement team
to triage.
triage.
decrease the time
time to
Quality Improvement
Improvement Annual
CHS Continuous Quality
8.
8. The
The current
current CHS
the following
Plan
Plan is
is well-structured
well-structured and
and includes
includes the
following elements:
elements:
CQI
Scope;
Scope;Structural
Structural Framework and Communication; CQI
CQI Initiatives for
Council;
Quality Oversight
Oversight Committee,
Committee, CQI
Council; Quality
FY
Performance Measures;
FY2010-2011;
2010-2011; Performance
Measures; Measurement
Measurement and
and
Methodology;
Methodology;Education
Education and
andTraining;
Training; Confidentiality;
Confidentiality;
Annual
Annual Evaluation;
Evaluation;and
and Resource
ResourceInformation.
Information. The
The current
current
Annual
Plan is
Annual Plan
is consistent
consistent with
with the requirements
requirements for
for
accreditation
accreditation of
of the
the National Commission
Commission on
on Correctional
Correctional
Health
Health Care.
Care. It is also comparable
comparable in
in its
its content
content and scope
scope
cQr
with
with CQI
CQIplans
plansassociated
associated with
with major
major community-based
community-based
health
health care
care organizations.
organizations.

13
13

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 18 of 65

9. CHS/MCSO
CHSjMCSO 2010 monthly
monthly statistical
statisticalreports
reports also
also show:
show: a)
a)
9.
average Daily
Daily Census
(ADC)in
in the
the LBJ
Infirmary was
47.7
average
Census (ADC)
LBJ Infirmary
was 47.7
days; b)
b) average
average Length-of-Stay (LOS)
(LOS) for
in the
the
days;
for patients in
LBJ Infirmary
Infirmary was 19.8
19.8 days.
days.
LBJ
10. CHS/MCSO
CHSjMCSO2010
2010monthly
monthlystatistical
statisticalreports
reportsalso
alsoshow:
show:
10.
a) average number
numberof
ofmonthly
monthly offsite
offsite Specialty
Specialty
a)
Appointments was 227 of which
which 207
207 (91.2%)
(91.2
(91.2°;0)
(91.2%) were
were kept;
kept; b)
b)
%

Appointments was 227 of

)

among the average
average monthly number
number 20
20 Specialty
Specialty
Appointments not kept,
kept, 5.8
5.8 were
were classified
classified as canceled
canceled by
by
the outside
outside provider,
provider, 6.0 to being in Court, and 2.7
2.7 to
to
MCSO issues.
11.
CHSjMCSO2010
2010 monthly
monthlystatistical
statisticalreports
reportsalso
also show:
show:
11. CHS/MCSO
a)
emergency service
a) average
averagemonthly
monthly offsite emergency
service transports
transports
were 150.7, of which 76.8
76.8 were
were transported
transported by
by non-MCSO
non-MCSO
were 150.7, of

staff;
staff; b)
b) among
among the
the average
average number
number of 76.8
76.8 of patients
patients

outside
transported by non-MCSO staff, 71.2 were by outside
transported by non-MCSO staff, 71.2 were by

ambulance from CHS
CHS and
and 4.5 by the Phoenix Fire
Department
Department from
from CHS.
CHS.
12.
CHSjMCSO 2010
2010 monthly
monthly statistical
statisticalreports
reports also
also show:
show:
12. CHS/MCSO
a)
a) average
average monthly
monthly number
number of Health
Health Care Grievances
Grievances was
was
153.8,
Average Daily
153.8, which
which is
is aa rate of 0.68 per 1000 Average
Daily
Population
(ADP); percent
Population (ADP);
percent of
of Health
Health Care Grievances
Grievances
Resolved
Resolvedwithout
withoutSustained
Sustained of
ofPartially
PartiallySustained
Sustained outcome
outcome
was
99.630/0
was 99.63%
99.63%

14
14

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 19 of 65

13. CHS/MCSO
CHS/MCSO2010
2010monthly
monthlystatistical
statisticalreports
reportsalso
alsoshow:
show:
13.
a) average
average monthly
monthly number
numberof
ofOccurrence
OccurrenceReports
Reportsreceived
received
a)
was105.2,
105.2,which
whichisisaa rate
rate of
of 0.43
ADP; b)
b) average
average
was
0.43 per
per 1000
1000 ADP;
monthly number
number of
of inmate
inmate injuries
injuries associated
associated with
with
monthly
Occurrence Reports
Reports was
was 15.2.
15.2.
Occurrence
14. The
TheCHS
CHSClinical
ClinicalGuidelines
Guidelinesfor
forDiabetes
Diabeteswere
wererevised
revised as
as
14.
of September
September 29,2010.
Duringmy
myrecent
recent site
site visits,
visits, II
of
29,2010. During
with Dr.
Dr. Alvarez
Alvarez the
the need
need to add routine
routine
discussed with
dental/ periodontal evaluation
evaluation to
to the
the list
list of
of actions
actions
dental/periodontal
for all
all patients
patients diagnosed
diagnosed with
necessary for
necessar
with diabetes.
diabetes. II will
wil
also be discussing
discussing with
with Dr.
Dr. Alvarez
Alvarez the
the need to crossreference the diabetes
diabetes clinical
clinical guideline
guideline with the guideline
guideline
for hypertension.
The reason
reason for
for doing this in because
for
hypertension. The
targets
for blood
blood pressure
control need
targets for
pressure control
need to
to be
be more
more stringent
stringent
than those for patients whose
whose only
only cardiovascular
cardiovascular risk
risk
factor
factor is hypertension.
15.
Reviewofof the
the 4th
4 th Avenue
Intake Pre-Booking
Refusals for
for
15. Review
Avenue Intake
Pre-Booking Refusals
January
andFebruar
February
demonstratesthat
that
that.CHS
eRS
CRShas
has aa active
active
Januar and
demonstrates
patient
place to refer
patient safety program in place
refer to
to outside
outside medical
facilit.ies
facilities
facilitiesthose
those persons
persons needing
needing immediate
immediate further
further
Over the
evaluation
evaluation and
and treatment
treatment prior
prior to
to booking.
booking. Over
the two
two
month
offsite
month period, fifty-five
fifty-fivesuch
such patients
patients were referred to offsite
medical
4 th Avenue
medical facilities
facilities prior
prior to
to booking
booking at
at the 4th
Avenuefacility.
facilty.
Clinical
Clinical reasons
reasons for
for these
these pre-booking
pre-booking refusals
refusals and
and offsite
offsite
medical
medicalreferrals
referralswere
werevaried.
varied. They
Theyincluded
includedaa spectrum
spectrum of
of
traumatic
traumatic injuries,
injuries, uncontrolled
uncontrolled diabetes,
diabetes, hypertensive
hypertensive

15
15

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 20 of 65

emergencies, delirium
delirium tremens,
tremens, drug
drugwithdrawal
withdrawal
emergencies,
syndromes, infections,
infections, cognitive
cognitive impairment
impairmentand
andother
other
syndromes,
neurologic deficits.
deficits. The
Thevolume
volumeand
andtimeliness
timelinessof
ofthese
these
neurologic
pre-bookingrefusals
refusalsand
andoffsite
offsitemedical
medicalreferrals
referralsare
are
pre-booking
consistentwith
withthe
therequirements
requirementsofofParagraph
Paragraph66of
ofthe
theSAJ.
SAJ.
consistent
16. CHS
CHSrecently
recentlyconducted
conductedpatient
patientsatisfaction
satisfactionsurveys
surveys in
in
16.
all of
of its
its outpatient
outpatient clinic
clinic locations.
locations. The
The survey
survey
all
methodology preserved
the questions
questions
methodology
preserved patient
patient anonymity
anonymity ~d
and the
were appropriate and consistent
consistent with
withthose
those employed
employed in
in
were
patient satisfaction
satisfaction surveys
surveys by
by community-based
community-based health
health
patient
care organizations.
organizations. While
While the
the results
resultswere
were specific
specific to
to each
each
care
of seven CHS locations, the overall levels of patient

of seven CHS locations, the overall

satisfaction were
were positive.
The highest
highest rates
rates of
of positive
positive
satisfaction
positive. The
responses
98°/0)
"1 feel
feel the
the
responses (87
(87 to
to 98%)
98%) were
were to
to the
the question,
question, "I
medical
Somewhat lower
lower rates
medical staff
staff treat
treat me
me with
with respect."
respect." Somewhat
rates
of
(72 to
"1
"I am
of positive
positive responses
responses (72
to 900/0)
90%) were
were to
to the
the question,
question, "I
am
able
someone from
staff in
timely
able to
to see
see someone
from the
the medical
medical staff
in aa timely
manner
have aa medical
manner when
when II have
medical problem."
problem."
17.
reviewof
of average
average mortality
mortality rates
17. AAreview
rates for
forpersons
persons in
incustody
custody
of
of the
the Maricopa
Maricopa County
County Jail
Jail system
system shows
shows aa significant
significant
decline
declinein
in death
death rates
ratesfor
for2008-2010
2008-2010 in
in comparison
comparisonwith
with the
the
previous
previous three
three to
to seven
sevenyears.
years. These
These average
averageannual
annual
mortality
mortalityrates
rates are
are expressed
expressed per
per 100,000
100,000 local
local jail
jail inmates,
inmates,
which
fif1y
which is
is the
the convention
convention used
usedto
to compare
comparethe
thefifty
fiftylargest
largestjail
jail
jurisdictions
jurisdictions by
by the
the U.S.
U.S.Bureau
Bureauof
ofJustice
JusticeStatistics.
Statistics. For
For
example,
example,there
therewere
weresix
sixdeaths
deathsof
ofpersons
personsin
injail
jailcustody
custodyin
in
16
16

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 21 of 65

Maricopa County
County in
in 2008,
2008, during
duringwhich
whichthe
theaverage
averagedaily
daily
Maricopa
jailpopulation
population was
was 9,236.
9,236. The
Thecalculated
calculateddeath
deathrate
ratewould
would
jail
then be 64.96 per 100,000 localjail
jail inmates.
inmates. These
These
then be 64.96 per 100,000 local

aggregate death
death rates
rates encompass
encompass deaths
deaths due
due to
to all
all causes,
causes,
aggregate
homicide. Based
including illnesses,
illnesses, suicide, accidents and homicide.
Based
including
the Bureau
Bureau of
on information
information for
for 2007
2007 from
from the
ofJustice
Justice
on
U.S jails
jails
Statistics, 51.4%
51.4% of
of deaths
of people
people in custody
custody in
in U.S
U.Sjails
deaths of

Statistics,

includingAIDS;
were due to ilnesses,
illnesses, not
not including
AIDS;3.9%
3.9%
3.90/0to
to AIDS;
AIDS;
were
25.90/0 to
intoxication; 1.6%
25.9%
to suicide;
suicide; 7.2%
7.2% to
to drug
drug or
oralcohol
alcohol intoxication;
1.6%
25.9°!c>
7.20/0
25.9%
%
1.8
accidents; 1.8%
1.8%
1.8°!c>
8.3% to other or
or
to accidents;
to homicide; and 8.3%
unknown causes.
causes. The
average MCJ
for
The average
MCJ total mortality rate for
unknown
the three year period of 2005-2007 was
was 152/100,000

the three year period of

compared
61
/ 100,000 the
the three
three year
year period of 2008compared to
to 61/100,000
61/100,000
2010.
This60%
600/0 decline
decline in
is
2010. This
in mortality
mortality is
is remarkable.
remarkable. It
It is
likely
with
likely associated
associated in
in part
part 'with
with improvements
improvements in
in health
health care
care
quality and access,
access, although
although other as
as yet
yet unidentified
unidentified
factors
factors may
may have
have contributed.
contributed.
18.
Timeline for
for Implementation
Implementation of
of Pharmacy
Pharmacy and
18. Timeline
and
Electronic
Electronic Health
Health Record
Record Systems
Systems-- Please
Please refer
refer to
to Part
Part E,
E,
CAP-lOaf
CAP-10
CAP- 1 0 of
ofthis
thisSixth
Sixth Report.
Report.

Part
CHS
Part CC-- CRS
CHSUpdate
Updateon
onNursing
NursingStaffing
Staffing
On
Thomas Tegeler,
Tegeler, CHS
OnMarch
March 22,2011,
22,2011, Thomas
CHS Executive
ExecutiveDirector,
Director,
provided
providedme
mewith
withthe
thefollowing
followingsummary
summaryconcerning
concerningwork
workthat
that
17
17

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 22 of 65

he and
and Katie
Katie Wingate
Wingate are
are doing
doing to
to improve
improve the
thescope
scope and
and
he
ofCHS
CHS nursing
nursing services.
services. IIhave
quality of
have chosen
chosen to include
include their
their
quality
complete analysis
analysis in
in this
reportfor
this report
forthe
thefollowing
followingreasons.
reasons.
complete
First, itit contains
contains aa useful
usefuldescription
descriptionof
ofthe
thecomplex
complex processes
processes
First,
in order
that must
mustbe
be completed
completed in
order to
to expand
expand the number
number of
of
that
Second, itit reflects
reflects the
the knowledge
available nurses.
knowledge and insight
insight
available
nurses. Second,
that Mr.
Mr. Tegeler
Tegeler and Ms.
Ms. Wingate are applying as they identify
identify
that
respond to
challenges in
to challenges
in improving
improving nursing
and respond
nursing care
care services.
services.
and
specific actions proposed in their
Finally, aa number
of the specific
Finally,
number of
analysis and plan
plan are
are appropriate
appropriate for
for inclusion in the
included in
in this
this Sixth
Corrective
Plan that
that II have
Corrective Action
Action Plan
have included
Sixth

Report.
is as
as follows:
follows:
The
staffing is
The CHS
CHS analysis
analysisin
in nursing
nursing staffng

"CHS
"CHS staffs
staffs 66jails
jails and
and 99 health care
care facilities
facilities in the Maricopa
the workforce
workforce at
CHS is
County Jails
system. Currently
at CHS
Jails system.
Currently the
FTE Registered
comprised
Registered Nurses,
FTE Licensed
comprised of 88.3 FTE
Nurses, 58.6 FTE
Practical
Practical Nurses,
Nurses, 63
63 FTE
FTE Correctional
Correctional Health Technicians,
Technicians, and
coverage at
one
one discharge
discharge planner
planner (RN).
(RN).Staff
Stafffunding
funding for
for 24/7
24/7 coverage
allowing for
coverage at
the
the clinics
clinics was
was reduced in 2005 allowing
for 24/7
24/7 coverage
at
Housing
Unit,
Infirmary,
the
following
clinics:
Mental
Health
the following clinics: Menta Health Housing Unit, Infirmar,
and
and Intake.
Intake. Due to an increase
increase in
in medically complex patients,
the
the majority
majority of
of clinics
clinicshad
had no
no choice
choicebut
but to
to expand
expand back
back to
to
expansion
occurred
with
24/7
coverage.
Unfortunately
this
24/7 coverage. Unfortunately
expansion occurred with no
no
additional
nurses,
which
has
added
a
burden
to
the
existing
additional nurses,
added a burden to the existing
staff,
particularly
in
providing
staff, particularly in providing the
the necessary
necessar nursing
nursing support
support
during
the
day
shift.
Registry
costs
have
escalated
to
ensure
during the day shift. Registry costs have escalated to ensure
coverage.
coverage.Recently,
Recently,CHS
CHSsurveyed
surveyednursing
nursing staff
staff to
to gauge
gauge
increase
interest
interest in
in 12
12 hours
hours shifts which would allow us to increase
coverage
coverageand
andatatthe
the same
same time
timereduce
reduceregistry
registrycosts.
costs. The
The
results
results indicated
indicated that
that a significant number of nurses
nurses were
were
18
18

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 23 of 65

interestedin
inexploring
exploring alternative
alternative scheduling
schedulingincluding
including12
12
interested
hour shifts.
shifts. Clinics
Clinics that
thatare
are currently
currentlyoperating
operating 24/7
24/7include
include
hour
theInfirmary,
Infirmary,Mental
MentalHealth
HealthHousing
HousingUnit,
Unit,Lower
LowerBuckeye
Buckeye
the
JailOutpatient,
Outpatient,4th
4 th Avenue
Avenue Intake,
Intake, Durango
Durango and
andEstrella.
Estrella.We
We
Jail
anticipate that
thatthe
therevised
revised staffing
staffing patterns
patterns for
forthese
these clinics
clinics
anticipate
willinclude
include12
12hour
hourshifts
shiftswhenever
wheneverpossible
possibleto
to help
help stabilize
stabilize
wil
RN coverage.
12 hour
hour shift
shift
RN
coverage. Plans are underway to expand to 12
coverage at Tents and
and Towers,
Towers, eurrently
currently staffed
staffed on
on dayshift
dayshift for
for
coverage
10 hours. CHS
CHS plans
plans to
to convert
convert the
the 4th
4 th Avenue
Avenue Outpatient
10
Outpatient
Clinic to
to 24/7
24/7coverage
coverage in
that
Clinic
in the
the future.
future. It
It is calculated
calculated that
additionalLPN's
LPN's will
willbe
beneeded
needed to
to receive
receive medications
medications
additional
delivered'directly
medication rooms
of the clinics
clinics as
delivered 'directly
rooms of
as
directly to the medication
opposed to a central
central drop
drop off
off location
redistribution along
along
location and redistribution
with aa transition
transitionfrom
from stock
stock medication
medication to
to patient
patientspecific.
specific.
with
This change
change will
will be
be necessitated
necessitated by
by Federal
Federal and
and State
State
This
regulations."
regulations."
delivered

Proposed Nursing
Nursing Staffing
Proposed
Staffng

"For budget year FY12,
FY12, we
proposed adding
adding 11
11 FTE's
FTE's
we initially
initially proposed
including
RN, 2 LPN,
LPN, and
including 66 RN,
and 33 CHT.
CHT. The
The additional positions
will allow us to partially
partially staff
staff the
the Self
Self Surrender Unit, which
currently diverts nurses from LBJ Outpatient when self
surrender numbers are
are overwhelming or when the one
dedicated
dedicated Self
Self Surrender
Surrender nurse
nurse is off duty.
duty. Further,
Further, we are
are
proposing
RN coverage
proposing that RN
coveragebe
beexpanded
expanded in
in the
the Self
Self Surrender
Surrender
Unit
to handle
those patients
patients as
Unit to
to 24/7
24/7 to
handle those
as well
well as
as ICE
ICE
coordination.
coordination. To
Toaddress
address discharge
discharge planning
planning needs,
needs, these
these
nurses
will
be
responsible
for
coordinating
this
activity
at LBJ
nurses wil be responsible for coordinating this
Intake
Intake since
since Westside
Westsideclinic
clinic patients
patients are
are transported
transported there
there for
for
discharge
or
transfer
to
other
facilities,
including
the
state
discharge or transfer to
facilities, including the state
prison.
Full
time
coverage
for
Self
prison. Full time coverage for SelfSurrender
Surrenderwill
wil probably
probably
necessitate
adding
additional
staff.
Recently
the
CHS
necessitate adding additional
CHS Medical
Medical
Director
shared
plans
to
expand
physician
coverage
at
Director shared plans to
coverage at Intake
Intake
that
that will
wil require additional staff, including providers
providers as
as well
well as
as
clinical
clinical and
and administrative
administrative support.
support. Maintaining
Maintaining the
theflexibility
flexibility
to
to respond
respondquickly
quickly to
to evolving
evolving clinical
clinical needs
needs balanced
balancedwith
with the
the
constraints
constraints of the
the county
county budget is aa challenge
challenge for
for CHS,
CHS,both
both
clinically and
and administratively.
administratively. In
In the
the past
past two
two budget
budget cycles,
cycles,
clinically

19
19

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 24 of 65

CHS has been fortunate to
to see
see an increase in clinical
clinical staff,
staff,
CHS
including99 medical
detention offces
offices to
medical detention
to assist
assist with
with patient
patient
including
transportswithin
theclinics.
clinics.As
Aswe
withinthe
we move
move forward,
forward, a standstandtransports
alone supplemental
supplementalrequest
requestfor
forFY12
FY12 funding
funding wil
will be
be
alone
submitted to
to address
address the
the staffing
staffing needs
not addressed
addressed in
in the
the
needs not
submitted
initial budget.
budget. In
In addition,
addition, data
datais
isbeing
being collected
collected to
to support
support
initial
the level
level of staff
forexpanding
expandingcoverage
coverage and
and
the
staff necessary
necessar for
emergent processes."
processes."
emergent

Proposed Timeline
Timeline
Proposed
"Upon the
start of
of Fiscal
Fiscal Year 2012 which begins July 1,
1,2011
"Upon
the start
2011
recruitment process.
CHS HR
begin the recruitment
process. Typically
Typically it takes
CHS
HR will
wil begin
1-2
applications, another 22 weeks
weeks to
to complete
complete
1 -2 weeks
weeks to
to get
get applications,
interviews, selection,
credentialing process.
process. We
We anticipate
interviews,
selection, and credentialing

12 hours
hours first.
first. Expanding
Expanding
Tents/Towers
converted to
Tents/Towers will
wil be converted
to 12
th
be
24/7 coverage
coverage at
the 4th
4 Avenue
Avenue Outpatient
at the
Outpatientclinic
clinic will
wil be
be needed.
needed. and
challenging
challenging since
since more
more nurses
nurses will
will be
and the status
beenfinalized.
finalized. LPNs
LPNs will
of the
has not
not been
the county budget has
wil be hired
as
quickly
as
possible
due
to
DEA
requirements.
Additional
as
as possible due to DEA requirements. Additional
early August.
RN and
staffing
August. RN
staffing at Self-Surrender is planned for early
expanded physician
physician coverage
coverage at
CHT
CHTpositions
positionstoto support
support the expanded
later
Intake
place after
no later
Intake will
wil take place
after recruitment
recruitment in
in July
July but no
than late August 2011."

Part
Part D - Medical Record Reviews
1.
MCP ## P713874 was screened
1. AA CHS
CHSpatient
patient with
with MCP
screened at
at the
the
th Avenue
44th
AvenueIntake
Intakeunit
unitatat11:29
11:29AM
AMonon11/09/10.
11/09/10. His
His

prior
prior medical
medical history
history included
included diabetes,
diabetes, seizures,
seizures,
His blood
hypertension,
hypertension, and
and eye
eye cataracts.
cataacts. His
blood glucose
glucose
(sugar)
(sugar)level
levelwas
waselevated
elevatedand
andhe
he received
receivedinsulin
insulin as
as well
well
as
asorders
ordersfor
for Neurontin
Neurontin (to
(to prevent
prevent seizures),
seizures),Simvastatin
Simvastatin
20
20

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 25 of 65

(for elevated
elevated blood
blood lipids)
lipids) and
aspirin. The
Thefollowing
followingday,
day,
(for
and aspirin.
he was
was seen
seenin
inthe
the4th
4 th Avenue
Avenue Jail
Jail Clinic.
Clinic. Throughout
Throughout the
the
he
day, he
he was
was treated
treated with
with insulin
insulin plus
plus intravenous
intravenousfluid
fluid
day,
for uncontrolled diabetes.
Subsequentblood
blood sugar
sugar
for
diabetes. Subsequent
measurements on
on 11(
11/11/10,11/12/10,11/13/10,
11/11/10,
measurements
11 (10, 11/12/10,
11/12( 10, 11/13/10,
11/13/10,
11/14/10,
11/15/10
continued
11(
14( 10, and 11(
15( 10 showed continued
uncontrolled diabetes.
diabetes. On
On1 11/15/10,
an
uncontrolled
1( 15( 10, the patient had an
apparent seizure
seizure likely due to low rather than
than high
high blood
blood
apparent
sugar. He
Hewas
wastreated
treated by
by aa nurse
should have
sugar.
nurse who
who should
have
informed a
a physician but did not
not do
do so.
so. The
The patient
patient had
had
other probable
probable seizures
seizures due to low blood sugar on
other
11/17/10
11/18/
11/18/10,
10, both
bothof
ofwhich
whichwere
weretreated
treatedby
by
11
¡i 7 ¡i 0 and 11
¡i 8( 10,
a nurse
did not
The patient
patient
a
nurse who
who did
not inform
inform aa physician.
physician. The
was
admitted to
was admitted
to the
theLBJ
LBJInfirmary
Infirmaron
on 11/20/10.
11(20(10. II
reviewed
the CHS
CBS
CHS Medical
reviewed this
this patient's record with
with the
Director, Dr. Jeffrey Alvarez,
Alvarez, who
who agrees
agreesthat
that this
this patient
patient
with
with Type
TypeIIinsulin
insulindependent
dependent diabetes
diabetes should
should have
have been
on the
day of
referred
Infrrmary
Infrrrnary
either on
the day
of his jail
referred to
to the
the LBJ
LBJInfirmary
Infirmar either
Dr. Alvarez
admission
Alvarez also
admission or
or on
on the
the following
following day.
day. Dr.
agrees
CBS
CHS nurses
agrees that
that the CHS
nurses who
who treated
treated this
this patient for
for
probable
probable hypoglycemic
hypoglycemic seizures
seizures on
on three separate
separate days
days
should
should have
have called
called aa physician
physician to
to evaluate
evaluate this
this patient.
patient.
As
be
As aafollow-up,
follow-up, II recommend
recommendthat
that this
this patient's record be
reviewed
reviewedwith
withthe
the nurses
nurses involved
involved to
to ascertain
ascertain why
why they
they
did
did not
not inform
informaaphysician
physicianand
and be
be counseled
counseled as
as
appropriate.
appropriate. Another pertinent recommendation
recommendationisisthat
that

21
21

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the CHS
CHS procedure for tracking and
and follow-up
follow-up of
of "man"manthe
down" events should be
be reviewed
reviewed to
that timely
timely
down"
to be
be sure that
communication with
with and
andfollow-up
follow-up by
by a physician
physician always
always
communication
occurs.
occurs.
A patient
with MCJ
MCJ # P629538 has
has severe
advanced liver
liver
severe advanced
2. A
patient with
disease. On
at 2:20
2:20 PM,
PM, the
the patient
patient
disease.
On 10/30/10
10/30/10 at
complained of "liver" pain
pain and
and had
had aa fever
fever with
temperature of
of 101.1.
101.1.
101. L He
He was
was evaluated
evaluated by
by a nurse
nurse who
who
did not inform
The patient
patient continued
continued to
to
inform aa physician.
physician. The
have abdominal pain and
and fever overnight and the
have
following morning.
7: 05 PM,
PM, aa physician was called
following
morning. At 7:05
and directed that the patient be sent to an outside
emergency department
hospital emergency
department where
where the patient was
admitted and had surgery for appendicitis.
appendicitis. He
He was
hospitalized for
for aa week
week before
before returning
returning to the LBJ
Infirmary
where his
his subsequent
care has
Infirmar where
subsequent care
has been
been
appropriate.
A patient
patient with
with MCJ
MCJ #
# P716240 was screened at
at the
the 4th
3.
4 th
3. A
Avenue
11/
18/ 10 and
and reported
reported being on
AvenueIntake
IntakeUnit
Uniton
on11/18/10
11/18/10
the Humulin form
His blood
blood sugar was
form of
ofinsulin.
insulin. His
moderately
had.
moderatelyelevated
elevatedand
andhe
hehad
had aa prior
prior history
history and
and an
an
episode
episodeof
ofdiabetic
diabetic ketoacidosis
ketoacidosis and
and Mallory-Weiss
Mallory-Weiss
syndrome
esophageal bleeding
syndrome (upper gastric
gastric or esophageal
bleeding from
from
arteries
extrelne
He
arteries that
that may
may rupture
rupture due to extreme
extreme vomiting).
vomiting). He
was
was treated
treated the
the following
following day
dayfor
for recurrent
reeurrent vomiting
vomiting and
and .
diabetes.
diabetes. Treatment
Treatment included
included intravenous
intravenous fluids
fluids and
and aa

22
22

Case 2:77-cv-00479-NVW Document 1966

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blood test
showed an
anelevated
elevated white
test showed
white blood
blood count
count and
and
blood
other results
results that
thatsuggested
suggestedpossible
Mter
possible dehydration.
dehydration. After
After
other
being sent
sent back
back to
his housing
unit, he
he was
was seen
seen the
the next
next
to his
housing unit,
being
day because
because of
of vomiting
vomiting bloody
bloody fluid.
He was
was then
then
day
fluid. He
assessed further
further and
referred to
andreferred
to an
an outside
outside hospital
hospital
assessed
was admitted
admitted for
for two
two days for treatment
where he was
treatment of
of
where
ketoacidosis. This patient's record illustrates,
as
diabetic ketoacidosis.
ilustrates, as
lapses in
the risk
risk of
of lapses
in
have multiple other prior cases, the
treatment and
and evaluation
evaluation of
ofpatients
patientswho
whoreceive
receive
treatment
in jail
intravenous hydration in
jailfacilities
facilities outside
outside of
of the
the LBJ
LBJ
Infirmary..
Infirmar
is aa 56
56 year
year old
old man
man who
who
4. A
A patient
patientwith
with MCJ
MCJ ## P704310
P704310 is
he was
gave
was
gave aa history
history of high blood pressure when he

screened at the 4th
4 th Avenue
AvenueIntake
IntakeCenter
Centeron
on10/06/10.
10/06/10.
were
medications were
Several
Several appropriate
appropriate anti hypertensive medications

ordered
orderedand
andgiven
givenonon10/07/10.
10/07/10. On
On 10/08/10,
10/08/10, aa
patient might
might be
physician
be exhibiting
exhibiting
physician observed
observed that
that the patient
him to
to aD
an
altered
altered mental
mental status and wanted to refer him

outside
outside emergency
emergency department
department for
for further evaluation.
of
However,
the patient
However, the
patient refused.
refused. Dosages
Dosages of

antihypertensive
antihypertensive medications
medications were
wereincreased
increased and
and the
the
drug
drug Neurontin
Neurontin (usually used
used for
for treatment of pain
pain or to
to
prevent
prevent seizures)
seizures)was
was prescribed
prescribed at
at aa higher
higher dose
dose based
based
on
prior to
to jail
on information
information from
fromthe
the patient's
patient's treatment prior
the patient
patient complained
entry.
10/16/10, the
entry. On
On 10/13
10/13 and
and 10/16/10,
complained

of
ofheadaches.
headaches. He
He was
was observed
observedto
to be
bedisoriented
disoriented on
on

23
23

Case 2:77-cv-00479-NVW Document 1966

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10/16/10and
andwas
wassent
senttotoan
anoutside
outsidehospital
hospitalwhere
where he
he
10/16/10
was admitted
admitted and
and treated
treated effectivcly
effectively for
for acute
acute kidney
kidney
was
failure. The
Theacute
acutekidney
kidneyfailure
failure may
may have
have been
been due
due to
to
failure.
toxicity from
from one or more of
of his
his medications
medications (Diovan
(Diovan and
and
toxicity
Neurontin) and inadequate
inadequate fluid
fluid intake
intake in
in the
thejaiL.
Based
jail. Based
Neurontin)
on retrospective
retrospective review of the medical record, it
it is
is clear
clear
on
that the
the intended
intended referral to an ED on
10/08/10was
was
that
on 10/08/10

medically indicated.
best
medically
indicated. Once the patient refused, the best
alternative course would
would have
patient
have been
been to
to send
send this patient
to the
Infirmaryfor
for more
moredetailed
detailed evaluation
evaluation
to
the LBJ
LBJ Infirmar
including timely
timely laboratory
laboratory tests
tests such
as aa basic
including
such as
basic

metabolic panel which
which was
was not
not drawn
drawn at the jail until
10/15/
10/15/10,
10/
15/ 10,one
one day
day prior
prior to transfer to
to the outside
10/15/10,
Thispatient's
patient'smedical
medicalconditions
conditionswere
were complex
complex
hospital. This
and he was
give the CHS
CHS physicians clear
was not able to give

information
information about
about his multiple medications
medications and prior
medical
However, review of this
medical history
history on intake. However,
this
patient's medical record
lapses in
record demonstrates
demonstrates multiple
multiple lapses
continuity
continuity and coordination of care;
care; need to be more
proactive
proactive in
in acquisition
acquisition of
of laboratory
laboratory results
results for
for such
complex
not well
well
complex patient's
patient's whose clinical conditions are not
understood
timely referrals
understood on admission to the jail; timely
referrals to
to
the
and more
more effective
effective procedures
the LBJ
LBJ Infirmary;
Infirmar; and
procedures and
and

systems
systemstototrack
trackand
andcare
carefor
forsuch
suchpatients.
patients. As
As such,
such, II
recommend
recommendthat
that this
this case
case be
be reviewed
reviewedand
anddiscussed
discussed
formally
formally with
with all CHS
CHS providers
providers in
in an
an appropriate
appropriate

24
24

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 29 of 65

conference so
so that
that all
all staff
staffcan
canbenefit
benefit educationally
educationally and
and
conference
participatein
inconsidering
consideringquality
qualityimprovement-related
improvement-related
participate
options.
options.
5. A
A patient
patient with
with MCJ
MCJ ## 670869
670869was
wasscreened
screenedatat4th
4 thAvenue
Avenue
5.
on 06/18/10
06/ 18/ 10atatwhich
whichtime
timehe
hewas
wasnoted
notedto
to have
have
on
abdominal, thigh
thigh and
andskin
skinsequelae
sequelaeof
ofsix
sixpreviously
previously
abdominal,
treated gunshot wounds. Over
Over the
the next
next two
two months,
months, he
he
treated
was seen
seen by
by CHS
CHS staff
staff for complaints of
of abdominal pain.
pain.
was
A CT scan of the abdomen was
10,
A
was requested
requested on
on 08/27
08/27// 10,
approved on 09/03/
09/03/10
10and
anddone
doneon
on09/
09/117/
7 / 10
10 at which
time the results
results identified
identified presence
presence of
of chronic abscesses
subcutaneous extraperitoneal abdominal tissues.
The
in subcutaneous
tissues. The
hospital where
where he was further
patient was sent to a hospital
evaluated and treatment
treatment with
with antibiotics
antibiotics was initiated.
This patient's condition was unusual
and subtle
subtle in
in some
some
unusual and
respects.
Nevertheless,
Nevertheless II believe
respects. Nevertheless,
believe itit would
would be
be worthwhile
worthwhile
l

for CHS
review why
why there
there was
was a three week
CHS to
to further
further review
delay
delay between
between the
the ordering
ordering and performance of the
abdominal
abdominal CT
CT scan.
scan.
6.
4 th
6. A
A patient
patient with
with MCJ
MCJ ## P712610
P712610 was
was screened
screened at the 4th

Avenue
AvenueJail
Jail on
on 11/05/10
11/05/ 10 and reported
reported taking
taking Coumadin
Coumadin
to
to prevent
prevent aa recurrence
recurrence of
of deep
deep venous
venous thrombosis
thrombosis in
in his
his
legs.
legs. Although
Although an appropriate dose of Coumadin
Coumadin was
was
ordered
orderedand
andadministered,
administered, the
the patient's
patient's medication
medication
administration
administration record
recordindicates
indicatesthat
that Coumadin
Coumadin was
was not
not
given
giventhe
thenext
nextthree
three days
daysafter
afterintake
intake and
and also
also on
on

25
25

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10. ItItisisunlikely
unlikely that
thatthe
theinitial
initialthree
threeday
daylapse
lapse
111/31/
1/31/ 10.
would have
have resulted
resulted in
in aa recurrence
recurrenceof
ofvenous
venous
would
thrombosis. However,
However, this
thismedication
medication error
errorisisindicative
indicative
thrombosis.
need for better
systems and staff
of the
the ongoing
ongoing need
better systems
staff
of
performance in documenting
documenting and assuring the reliability
reliability
reliabilityperformance
essential medications
of administration
administration of
of essential
medications including
including
of
Coumadin.
Coumadin.
was screened
7. A
A 43
43 year
year old
old patient
patient with
with MCJ
MCJ #
# P687337
P687337 was
screened
7.
th Avenue Jail on 08/13/10. He gave a history of
at the
the 4th
44th
at
Avenue Jail on 08/13/10. He gave a history of
treatment with
with
a prior stroke, left sided weakness
weakness and
and treatment
Dilantin and
Neurontin to
to prevent
prevent seizures.
seizures. Over
the
Dilantin
and Neurontin
Over the
10 days,
days, the patient manifested signs
next 10
signs of
of Dilantin
Dilantin
toxicity which
toxicity
which was
was confirmed
confirmed on
on aa blood
blood test
test on
stayin
medical
08/23/23.
During
daystay
inthe
the jail,
jail, medical
08/23/23. During
anan1818day
evaluation and management of this patient's
patient's
anticonvulsant
therapy failed
failed to
anticonvulsant therapy
to meet
meet an
an appropriate
appropriate
standard
of care.
standard of
8.
(MCP ## not
8. A female
female patient
patient (MCP
not available)
available) was
was treated
treated in
in the

Estrella
/ 31/
31 / 10
Estrella Jail
Jail for
for abscesses
abscesses of
of the
the hip
hip between
between 07
07/31/
and
01/
Several antibiotics were prescribed
and 01/10/
01/ 10/ 11.
1 1. Several
prescribed and
and
there
there is
is documentation
documentation in
in the medical record
record concerning
concerning
possible
possible allergy
allergytotoBactrim,
Bactrim,although
althoughthe
the patient's
patient's history
was
ty-pical
wasnot
nottypical
typical for
for such
such an
an allergy.
allergy. The
The patient
patient was
was
Spanish-speaking
Spanish-speaking and
and Plaintiffs
Plaintiffs Counsel
Counsel expressed
expressed
concern
concern about
about her
her knowledge
knowledgeof
ofthe
thepossible
possibleallergy.
allergy. On
On
two
two dates,
dates,the
thepatient
patient was
was cared
caredfor
for by
by Dr.
Dr. Alvarez
Alvarezwho
whoisis
2626

Case 2:77-cv-00479-NVW Document 1966

Filed 04/06/11 Page 31 of 65

care
fluent in
in Spanish.
Spanish. Overall,
Overall,this
this patient's
patient's medical
fluent
medical care
sensitivitytest
test
was appropriate,
appropriate, although
although aa culture
culture and
and sensitivity
was
abscess is
of fluid
fluid from the abscess
is always
always helpful
helpful in
in aa jail
jail
of
detect the
the presence
of methacilin
environment to
to detect
presence of
methacillin
environment
resistant staphylococcus
staphylococcus aureus
aureus and,
and, ififpresent,
present, to
to
resistant
determine drug
drug sensitivity
sensitivitylevels.
levels.
determine
01/13/11,a apatient
9. From
12/23/10toto 01/13/11,
patient with
9.
From 12/23/10
with MCJ
MCJ ##
P725329 was
Jail with
with three
was treated
treated in
in the
the Estrella
Estrella Jail
three
P725329
anticonvulsant medications
medications -- Dilantin,
Dilantin, Valproic
Valproic acid
acid and
and
anticonvulsant
record for
Tegretol. The
The medication administration
administration record
for aa two
two
Tegretol.
of 136
136 drug
period is blank
blank for
for 30 out
out of
month period
Because this
thisisisaa relatively
relatively
administration actions. Because
recommend that
CHS review
recent record,
record, I recommend
that CHS
review itit carefully
in order to better understand
understand why
why there
there were
were so many
gaps
aspects of staff
gaps in
in care
care and
and to
to determine
determine what aspects
staff
and IIor
education and!
orsupervision
supervisionmay
maybe
bemerited.
merited. This is
education and

also
also another
another example
example of
of the
the importance
importance of near
near term
term
implementation
implementation of an
an electronic
electronic prescription
prescription order
order entry
entry
and
and medication
medication documentation
documentation system.
system.
P717801
10.
A patient
withMCJ
MCJ
wasbooked
bookedatat 4th
4 th
10. A patient
with
# #P7L780
1 was
Avenue
AvenueJail
Jail on
on 11/23/
11 /23/ 10
10 and gave
gave aa history
history of being
being on
on
Coumadin.
INR test
Coumadin. The initial INR
test (to
(to monitor
monitor and
and

determine
determine subsequent
subsequent safe
safe and
and effective
effective doses
dosesof
of
Coumadin)
Coumadin)was
was elevated
elevated above
abovesafe
safe levels
levelsand
and was
was below
below
effective
effectivetreatment
treatmentlevels
levelsthree
threedays
dayslater.
later. There
There was
was also
also
an
an initial
initialfailure
failuretotoaccept
acceptand
and activate
activate an
an order
order for
for
27
27

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Coumadin, aa failure
failure that
thatwas
wasdetected
detectedby
byCHS
CRS
CHS in
in an
an
Coumadin,
Occurrence Report.
Report. Subsequent
Subsequent monitoring
monitoringand
and
Occurrence
adjustmentofofCoumadin
Coumadinlevels
levelswere
were also
also substandard.
substandard.
adjustment
Considered in
in the
the context
context of
of recurrent
recurrent lapses
lapses in
inclinical
clinical
Considered
and medication
medication management
rnanagement of
of Coumadin therapy,
therapy, II
and
recommend that
thatCHS
CHS conduct
conductaa comprehensive
comprehensive review
review of
of
recommend
its practices,
practices, policies,
policies, documentation and tracking in this
this
its
regard. IIrecognize
recognize that problems in administration
administration and
and
regard.
safe management
management of
of high risk anticoagulation drugs,
especially Coumadin,
common in
care
especially
Coumadin, are
are eommon
in major
major health
health care
systems and
and facilities
facilities throughout
the country.
country. All
All such
throughout the
systems, including
including CHS,
CHS, need to implement more
more robust
and effective
effective methods
methods to enhance
enhance safety
safety for
for patients
patients on
these types of
of high risk medications.
11.
year
oldpatient
patient with
11. A 42A 42
year
old
with MCJ
MCJ ## P720402
P720402 was
was

screened
4 th Avenue
screened at the 4th
AvenueJail
Jailon
on12/04/10
12/04/10 at which
time
time no
no significant abnormalities or complaints were
noted.
On 12/10/10,
12/10/10,the
thepatient
patientrequested
requested to
to be
be seen,
noted. On
stating
he had
stating that
that he
had hand and
and back
back pain
pain due
due to
to "injuries
"injuries
due
while
due to
to abuse beating from
from guards
guards 'while
while handcuffed"
handcuffed" on
on
12/05/10.
X-rays of
of the
12/05/10. X-rays
the hand
hand and
and back
back were
were not
not done
done
until 12/22/
These x-rays showed
showed no
12/22/ 10.
10. These
no fractures
fraetures or
or
until

dislocation
dislocation except
except for
for aa flexion
flexioncontracture
contracture deformity
deformity of
of
the
the fifth
fifth distal
distal interphalangeal
interphalangealjoint,
joint, aa finding
findingthat
that was
was

thex-rays
x-rayson
on01/03/11.
01/03/11. II
identified after are-reading of the
identified after are-reading of

recommend
recommendthat
that CHS
CHSfurther
furtherevaluate
evaluatethis
thispatient's
patient's hand
hand
28
28

 

 

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