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 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 26 of 65 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 Filed 04/06/11 Page 27 of 65 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 Filed 04/06/11 Page 28 of 65 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 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 30 of 65 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 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 32 of 65 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