Graves v Arpaio Expert Report on Medical Compliance at Maricopa County Jail Apr 2011 Partc
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Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 33 of 65 function and and also also take take any any actions actions that thatare are appropriate appropriate function regarding the the allegation allegation of ofabusive abusive actions actions by by correctional correctional regarding staff on 12/05/10. 12/05/10. staff 12. I reviewed II reviewedthe themedical medicalrecord recordofofaa28 28year yearold oldwoman woman 12. (MCJ # # 719570) 719570) who (MCJ who died diedin in the the Estrella EstrellaJail Jail on on 12/07/10, 12/07/10, after she she collapsed collapsed in in aa shower shower and and was was non-responsive non-responsive after despite cardiopulmonary resuscitation efforts. efforts. She She had had despite cardiopulmonar resuscitation been screened oni oni2/01/ 2/01/ 10,reported reported having having asthma and and been on 12/01/10, being on multiple medications. She was was noted noted to to have have being medications. She markedobesity. obesity. AA "Pre-Booking Medical marked "Pre-Booking Assessment Assessment Medical Clearance Report" 10 showed showed normal blood Clearance Report" dated dated 12/01/ 12/01/ 10 normal blood pressure, pulse rate, respiratory respiratory rate rate and and blood blood oxygen oxygen levels. 12/02/10,she she submitted submitted aa request request to to be be seen seen levels. On 12/02/10, for severe severe persistent She was then seen seen by a a persistent headaches. headaches. She nurse on 12/04/10 12/04/ 12/04/10 10at atwhich whichtime timesystolic systolicblood blood pressure pressure was moderately mni moderately elevated elevated at at 151 151 mm mm Hg. Hg. The nurses' nurses' assessment note indicates indicates that the patient described her I'sudden headache "same as as headache both both as as "sudden "sudden onset" onset" and the "same as usual". usual". The The nurse nurse recommended recommended aspirin aspirin and and because because the the patient patient said been drinking the water water in the the jail, gave gave said she had not been water water and and encouraged encouraged her her to to drink drink water water as as usual. usuaL. On On 12/06/ 10, the patient submitted submitted another request to be 12/06/10, be seen seen for forheadache. headache. A A nurse nurse sent sent aa written written response response recommending administration of Tylenol headache. Tylenol for for the headache. recommending administration of The The Thepatient's patient's sudden sudden death death occurred occurred later later that that day. day. The report report of of an an autopsy autopsy was was not not complete complete as as of ofMarch March 1, 1, 2001, 2001, 29 29 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 34 of 65 butthe thecause causeof ofdeath deathaccording according to to the the death deathcertificate certificatewas was but subarachnoidhemorrhage hemorrhage due due to to rupture ruptureofofone oneof ofthe the subarachnoid arteries supplying supplying the the brain. brain. This Thistype typeof ofcerebrovascular cerebrovascular arteries catastrophe is is rare rare in inaa young young person person and and was was likely likely catastrophe unrelated to to this thispatient's patient'sother othermedical medicalproblems problen~s problenlsof ofobesity obesity unrelated and asthma. asthma. The The patient's patient'sheadache headache symptoms symptomsmay mayhave have and been associated associated with aneurysm (out-pouching); (out-pouching); been with an arterial arterial aneurysm however, this is speculative, speculative, lacking lacking full full results results of of the the however, this is autopsy. The Thesystolic systolicblood bloodpressure pressure elevation elevation was was not not severe and not likely likely to cerebral arterial arterial severe and not to have have caused caused aa cerebral aneurysm or The patient patient apparently apparently did not aneurysm or rupture. rupture. The of neck pain or stiffness stiffness whieh which is often often present complain of with the the onset onset of a a subarachnoid hemorrhage. with hemorrhage. Other observations of care are observations regarding regarding quality of are not appropriate without additional information, including the final final autopsy report. It is for CHS to review review its its report. It is appropriate, appropriate, however, however, for CHS to nursing protocol with with nursing protocol with respect respect to to evaluation evaluation of of patients patients with sudden sudden onset onset of of severe severeheadache. headache. II will wil discuss discuss this this recommendation Dr. Alvarez recommendation with with Dr. Alvarez and and offer offersuch such advice advice as as helpful. may helpfu1. may be helpfuL. Among Amongthe theother other medical medical records records that that were reviewed reviewed and and critiqued 2011 by byPlaintiffs' Plaintiffs'Counsel, Counsel, there there are are critiqued in in January Januar 2011 numerous numerous other other examples examples of ofdeficiencies deficienciesininquality quality and and documentation documentation of ofcare. care. II agree agree with withPlaintiffs PlaintiffsCounsel Counselthat that 30 30 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 35 of 65 can logically manyof ofthese these deficiencies deficiencies can logicallybe be placed placed into intothe the many categories: following categories: following Delaysinincare care and andstabilzation stabilization of of incoming incoming(Intake (Intake .• Delays Center) patients, patients, Center) Incompleteororincorrect incorrect nursing andlack lack of of .• Incomplete nursing assessments assessments and actual or or timely timely communications communications from from nurses nurses to to medical medical actual practitioners. practitioners. errorsofofcommission, Medicationerrors commission,omission omissionand and and and MAR MAR .• Medication documentation. It important to to note note that that the the records records summarized summarized above above It is is important were drawn from aa very very selective selective sampling sampling methodology methodology were drawn from requested Counsel. This sampling sampling methodology methodology requested by by Plaintiffs' Plaintiffs' CounseL. effectively adverse events effectively identifies adverse events associated associated with with care of complex complex patients, patients, most most of whom whom have have multiple multiple chronic chronic serious serious medical For example, example, the medical conditions. conditions. For the sample sample includes includes all all patients patients who who were were transferred transferred from from CBS CBS facilities facilities to to an outside hospital hospital or or emergency emergencydepartment department during during aa prior prior four four month month period. Furthermore, from from among among a a total of approximately 110 110 period. Furthermore, medical medical records records made madeavailable availablefor fortheir their review, review, Plaintiffs' Plaintiffs' Counsel Counsel forwarded forwarded to to me me aa list list of of thirty-five thirty-five written written summaries. do not not know know ifif Plaintiffs' Plaintiffs' Counsel Counsel reviewed reviewed other summaries. II do other records recordsand and ifif so, so, whether whether negative negative or or positive positive observations observations were weremade. made. Because Because of ofthe the sampling sampling methodology methodology used used to to identify identify these these cases, cases,ititisisnot not possible possibleto toextrapolate extrapolatethe theresults results 3131 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 36 of 65 of to to aa random random sample sample of of the the larger larger CHS CHS patient patient population population or or of even to CHS This even to the the entire entire CRS CHS population population with with chronic chronic illnesses. ilnesses. This ambiguity is major question will address address in in ambiguity is aa major question that that III wil subsequentrecord record reviews reviews conducted conductedin inconcert concertwith withCHS CHS as as subsequent described in the the Corrective Corrective Action Plan Plan detailed detailed in in Part Part E E of of this Sixth this Sixth Report. Report. Despite the the highly highly selective selective sampling methodology used in in reviewed recently by Plaintiffs' Plaintiffs' Counsel Counsel selecting the records reviewed these records records do do reflect reflect a higher than me, these than acceptable acceptable and me, context of of the prevalence of quality of care care deficiencies deficiencies in in the context SAJ. Plan Part E Action Plan E -- Corrective Action includes aa provision 3, 2009 includes Judge Judge Wake's Wake'sOrder OrderofofJanuary Januar 3,2009 3,2009 experts to for for the Court's appointed medical and mental health experts assist assist CHS CHS in in preparation preparation of aa Corrective Corrective Action Action Plan, Plan, ifif needed, needed, to to achieve achieve compliance compliancewith with pertinent pertinent requirement requirement of the Because compliance compliance with 7, and of . the SAJ. SAJ. Because withParagraphs Paragraphs6,6,7, and 88 of CBS the been achieved, the SAJ SAJ has has not not been achieved, and and CHS CHS has has agreed agreedthat that objectives, further further actions actions are are consistent consistent with with their their needs needs and and objeetives, CBS' executive II have have worked worked closely closely with with CHS' executive leaders leaders to to prepare prepare the the Corrective CorrectiveAction ActionPlan Planthat that is is detailed detailed in in the the following following of this plan largely substance of plan largely section sectionofofthis thisreport. report. The substance were proposed mirrors mirrors the the content content of of the the ten ten remedies remedies that that were proposed in in 32 32 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 37 of 65 my Expert's Expert's Report Reporton onCompliance Compliancewith withMedical MedicalProvisions Provisions my of Second Second Amended Judgment, Judgment, dated dated August August 202010. 20 2010. of Based on current circumstances, including includingaa new newCHS CHS Based current circumstances, leadership team, team, II have have made aa number of modifications modifications and and leadership additions in in the the content contentand andformat formatof ofmy mypreviously previouslyproposed proposed additions remedies. For For the the most most part, part, II think think these these changes changes are are in in line line remedies. with the and agreement agreementof of CHS CHSleadership. leadership.. with the understanding understanding and with any cate As is usually the case with any major health health care care organization organization As committedto to aa Continuous Quality Improvement (CQI) committed Continuous Quality Improvement (CQI) Program, further this Corrective Corrective Action Program, further adaptations within within this Plan may well be and appropriate appropriate going going forward be necessary necessar and over the 18 months. over the next 12 to 18 To and Defendants Defendants may To the extent that Counsel for Plaintiffs and disagree CAP, II ask disagree with with any aspect aspect of of this this CAP, ask that that they consider the the following following points: points: •. II will ofall all will be be intensively intensivelymonitoring monitoring implementation implementation of aspects of this plan with the expectation that positive that positive outcomes be evident in terms of accessibility, outcomes will wil be health care care and and aa coordination and continuity of health coordination and continuity of reduction reduction in potentially preventable preventable adverse adverse events events •. If If specific prove ineffective ineffective or specificaspects aspects of ofthe the CAP CAP prove or insufficient insufficient to to achieve achieve needed needed improvements improvements in in health health care care quality, quality, IIwill wil propose propose and and support support whatever whatever changes changes are are necessary. necessar. 33 33 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 38 of 65 willcontinue continue offertoto facilitate facilitate regular .• I I wil totooffer regular joint joint meetings meetings with CHS CHS leaders leaders and andPlaintiffs' Plaintiffs'and andDefendants' Defendants'Counsel Counsel with to discuss discuss implementation implementationof ofthe theCAP, CAP, joint jointreview review and and to discussion of medical records, records, policies of medical policies and and procedures procedures discussion and measures measures that thatmay be useful may be useful in in assessing assessing and compliance. compliance. The Corrective Action Plan I propose propose at time has has the the at this time following components components and Many and projected projected timelines. timelines. Many respect also be monitored and assessed assessed with with respect components will wil also as part part of ofCHS' CHS' their implementation implementationand andoutcomes outcomes as to their Plan. Continuous Quality Improvement Improvement Plan. Continuous Quality at the CAP 1: Physician CAP -- 1: Physician and and Provider Provider (PA (PA and and NP) NP) Staffing Staffng at the th 44th Avenue AvenueIntake Intake Center th Avenue Jail Intake Center, CHS will expand its At At the 44th Avenue Jail Intake Center, CHS wil professional professional coverage coveragetotoinclude include24 24 hour hour per per day presence of at least one (PA) or one licensed licensed physician, physician, physician assistant (PAl nurse practitioner (NP) (NP) qualified nurse practitioner qualified by by training, training, experience, experience, assess, treat and, licensure licensure or or certification certification to identify, assess, and, when when pretrial detainees detainees who all newly necessary, refer out, out, all newly received received pretrial necessar, refer who have haveor orare areat atrisk risk for for serious serious acute acuteor or chronic chronic illnesses, ilnesses, physical physical handicaps, handicaps,debilitation debiltation or other other vulnerabilities vulnerabilities All new associated associated with with their their physical physical or or mental mental condition. condition. All new physicians physicians employed employed to to provide provideexpanded expanded coverage coveragewill wil be be 34 34 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 39 of 65 Board- certified certified in in Internal InternalMedicine, Medicine, Family FamilyMedicine Medicine or or BoardEmergency Medicine. Physician Assistants Assistantsor orNurse Nurse Emergency Medicine. Physician Practitioners participating participating in in coverage coverage will be skiled skilled in in the the Practitioners wil be basic procedures procedures and andemergency emergency care care needed needed to to cover cover the the basic Department. They They wil will at at all Intake Department. all times times have have either either on-site on-site or or Intake telephonic back-up by by a physician. During the 168 168 hours hours telephonic comprising each each week, week, 80 hours will willbe be covered covered by physician physician comprising assistants and 88 hours by by physicians. physicians. Expanded Expandedweekday weekday be in night shift shift coverage coverage will in place place no later than than June June 1, 1, night wil be 2011. Weekend Weekend and and holiday holiday coverage coveragewill wil start start no no later than by shift on a August 1, 2011. CHS will 201 1. CHS wil document staffing staffng by to secure secure expanded expanded monthly taken to monthly basis basis and report actions taken physician physician coverage coverage Treatment Plans Plans at at CAP and Treatment CAP -- 2: 2: Timely Timely Assessment Assessment and Medical Problems Intake for Patients Patients with with Significant SignificantMedical Problems Simultaneous Simultaneous with with expansion of physician and PA/NP coverage the Intake Center, CHS CHS will coverageof ofthe will steadily steadily increase increase its capacity capacity to to complete complete medical medicalevaluations evaluationsand andinstitute institute treatment plans promptly promptly after after initial initial Reception Reception Screening, treatment plans including including prescribing prescribing of ofessential essential medications, medications, for for all allpatients patients with with significant significantacute acute or or chronic chronic medical medicalconditions. conditions. The The objective objectiveisisfor for all all such such patients patients to have have aa "hands-on" "hands-on" assessment and examination examination and and completion completion of of an an initial initial assessment and plan plan to to include include the the ordering ordering of of medications, medieations,pertinent pertinent labs labs and and aa 35 35 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 40 of 65 foregoing scheduled follow-up follow-up specific specific to to their theirneeds. needs. The Theforegoing scheduled completed taskswil willbe becompleted cOlnpleted no no later laterthan than24 24hours hoursafter afterinitial initialjail jail tasks entry, and and in in most most instances instances much much sooner. sooner. The Theexpanded expanded entry, PAjNP CHS IntakeCenter Centerphysician physicianand andPA/NP coverage wil willenable enableCHS PA/NPcoverage Intake to fulfill fulfIll fulfillrequirements requirementsofofthe theRECEIVING RECEIVINGSCREENING SCREENING to 2008 Standards HealthServices Standard J-E-02 J -E-02 - E-02 of ofthe the 2008 Standardsfor forHealth Services in in Standard on Correctional Jails J ails of ofthe theNational National Commission Commission on Correctional Health Health Care Care Jails (NCCHC). Furthermore, Furthermore, CHS CHS will be better better prepared prepared to to (NCCHC). wil be first provide, no later than than the the first frrst24 24hours hoursafter afterReceiving Receiving provide, Screening, an initial health assessment for for all all persons persons Screening, an initial health assessment identified with with clinically clinically significant in compliance compliance identified signifcant findings in onINITIAL withinNCCHC NCCHC Standard Standard J-E-04 J-E-04 on INITIAL HEALTH HEALTH within ASSESSMENT. The ASSESSMENT. The foregoing foregoing services services will will be be implemented implemented between April practitioner staffing staffing As practitioner between April 11 and and August August 1, 1, 2011. 2011. As CRS increases in the the 4th 4 th Avenue Avenue Intake CHS will increases in Intake Center, Center, CHS wil steadily steadily proportion of achieve the proportion of patients with clinically clinically achieve increases increases in in the patients with significant findings who have health assessment assessment have their their initial initial health completed after Receiving Receiving Screening. Screening. completed within within 24 24 hours hours after CAP - 3: CAP 3:Timely Timely Referrals Referralsand and Transport Transport of of Intake Intake Center Center Patients Patients Needing Needing Infirmary Infirmary Care Care Expert's Report In 20, 2010 Expert's Report on on Compliance, Compliance, I In my myAugust August20,2010 20,2010 th Avenue Jail Intake Center adapt its proposed proposed that that the the 44th Avenue Jail Intake Center adapt its facilities facilities and and add addequipment equipmentand andstaff staffsuitable suitable for for patients patients who whoneed needan anInfirmary Infirmar level levelof ofcare, care,but butwho whocannot cannot be be 36 36 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 41 of 65 transferredto tothe theLBJ LBJbecause because of of pre-arraignment pre-arraignment status status or or transferred other reasons. reasons. I Iam ammodifying modifyingmy myoriginal originalrecommendation recommendation in in other thisregard regardfor forthe thefollowing followingreasons: reasons: this Onbehalf behalfof of the MCSO, Defendants have have responded responded that that .• On the MeSO, MCSO, Defendants pre-arraignment or or classification classification status status does does not not pose pose pre-arraignment significant obstacles obstacles to transferring transferring patients timely timely to to significant LBJ Infirmary. the LBJ Infirmar. TheMCSO Meso MCSO has hasagreed agreed to to expand expand the the proximate proximate space space .• The available to This expansion expansion of of space space available to the Intake Center. This will be be beneficial beneficial in in helping helping CHS CHS to better evaluate, evaluate, wil observe and more patients during the the first first 24 24 observe and treat more hours after after reception reception screening. screening. •. While Whilebeneficial, beneficial, additional additional available available space space proximate-to proximate to the Intake Center is not suitable for for conversion conversion to an infirmary level of of care. infirmar level Because Becauseof ofthe theforegoing foregoingconsiderations considerationsititwill willbe benecessary necessar for for CHS received patients CHS to to ensure ensure that that all newly received patients whose whose clinical clinical condition for an infirmary level condition indicates indicates need need for an infirmary level of ofcare care will wil be be transferred transferred to to the the LBJ LBJInfirmary Infirmar no no later later than than 24 24 hours hours after after booking. booking. CHS CHS will wil also also need need to to establish establish aa formal, formal, continuous continuous system system of of medical medicalrecord recordreview/monitoring review/monitoringtotoconfirm confirmthat that this feasible for this 24 24 hour hour timeline timeline is is being being met. met. It is feasible for the the objective I, objectiveof ofCAP CAP- -33totobe beimplemented implementedas asof ofApril April 1, 1, 2011. 2011. This ongoing monthly Thiscomponent componentwill wil be be assessed assessed through through ongoing monthly 37 37 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 42 of 65 and quarterly quarterlyreview reviewby byCHS CHSand andby byme meofofrepresentative representative and medical records. records. The The overall overall rate rate of of monthly monthly transfers transfers from from medical the 4th 4 th Avenue will also also be be the Avenue Intake Intake Center Center to to the the LBJ LBJInfirmary Infirmar wil tracked, trended trendedand andreported. reported. tracked, CAP -- 4: Persons in Non-Acute Non-Acute and and CAP 4: Health Assessments for Persons Stable Condition Condition Stable With implementation implementation of of CAP CAP -- 11 and CAP CAP -- 2, be aa With 2, there there will wil be substantial decrease decrease in of persons persons who need substantial in the number of who will wil need to have their Initial Health Assessments (also (also known as Health Health Appraisals) completed between between day day 22 and and day 14 following Receiving Screening their Receiving Screening evaluations. evaluations. The majority of such such persons have no significant significant acute acute or chronic medical medical persons will wil have conditions time of of entry entry to to the the 4th 4 th Avenue Avenue Intake conditions at the time Intake Center. A will exhibit A small small number number of of such such patients patients will exhibit onset onset of acute acute medical their initial initial two two weeks medical problems problems during during their weeks of of incarceration incarceration and need to be promptly promptly seen seen and evaluated with with aa complete complete Initial Initial Health Health Assessment Assessment by by aa physician physician or or PAjNP. PA/NP. PAjNP. For For the the far greater number of newly newly admitted admitted persons persons who who are are in in good good condition, condition, completion completion of ofthe the Initial Initial Health Health Assessment Assessment can can safely safely be be done donewithin within 14 14 days days after after arrival arrival at at th Avenue Jail. the the 44th Avenue JaiL. 38 38 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 43 of 65 At this this time, time,Dr. Dr.Alvarez Alvarez is is reviewing reviewing several several options options with with At respect to to content content and andeffectiveness effectiveness of of the the CHS Initial Health respect CHS Initial Health Assessment form and and process. process. Among Among the the questions questions he he is is Assessment considering are are which whichtypes typesof ofprofessional professionalpersonnel personnel(CMT's, (CMT's, considering RN's, MD's, MD's, PA's, PA's, and NP's) NP's) should be be involved in in completing completing RN's, the Initial Initial Health Health Assessment Assessment including the traditional traditional the Physical Examination for persons of acute or or Physical persons with no history of chronic medical medical problems. problems. Specific Specific NCCHC NCCHC standards standards pertain pertain chronic to these these questions, especially especially with with respect respect to to scope scope of of practice, practice, to training and and oversight. oversight. Another Another important consideration training important consideration concerns what what components components of of the the traditional traditional periodic periodic physical physical concerns examination are are supported examination supported by by evidence-based evidence-based recommendations of of authoritative professional organizations, organizations, recommendations authoritative professional such as the the U.S. u.s. U.S. Preventive Preventive Services During the such as Services Task Task Force. Force. During the next next sixty days, days, I will will be be having having frequent frequent detailed detailed discussions discussions with Dr. Alvarez Alvarez regarding the physical regarding the the content content of ofthe examination CHS appraisal examination within within the the CHS appraisal and and which professional personnel for completion of personnel are appropriate for of this this clinical clinical task. task. By 1,2011, will provide provide aa more more specific specific ByJune June 1, 2011, II wil recommendation recommendation in in this this regard. regard. CAP CAP- -5:5:Nursing NursingCare CareStaffing Staffing Expansion Expansion CHS (FTE) complement CHScurrently currently has has aa full-time full-time equivalent (FTE) complement of of 88 (LPN), 88 Registered Registered Nurses Nurses (RN), (RN),59 59 Licensed Licensed Practical Practical Nurses (LPN), 63 (CHT), and one 63 Correctional Correctional Health Technicians (CHT), one RN RN 39 39 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 44 of 65 Discharge Planner. Planner. For Fortheir theirbudget budgetyear year2010, 2010,CHS CHS Discharge leadership has has proposed proposed adding adding 11 11 FTEs, FTEs, including including66RNs, RNs, 22 leadership LPNs and CHTs. They also also anticipate anticipate aa stand-alone stand-alone LPNs and 33 CRTs. CHTs. They supplemental budget request for for 2012 2012 funding funding wil willbe be budget request supplemental submitted to to address address staffing staffing needs not addressed addressed in in the the submitted proposal. original proposal. original In order order to to achieve achieve compliance compliance with with SAJ SAJ requirements, requirements, II· In believe itit is and supplemental supplemental believe is essential essential that that the the initial initial and requests noted noted above above be be approved approved by by the the Maricopa Maricopa County requests soon as as possible possible by by Board of Supervisors Supervisors and and implemented as as soon CRS. My most most recent recent reviews reviews of of medical records show that CHS. CHS. My unacceptable frequency gaps in frequency of there continues to be be an unacceptable of gaps continuity of medical medical care care and and medication medication administration, administration, as of RN-generated RN-generated well documentationof well as as lapses lapses in quality and documentation care between between medical assessments and coordination coordination of ofcare patient patient assessments the planned of and nursing personnel. and nursing personneL. With With the planned expansion expansion of th Avenue Infirmary and the practitioner practitioner staffing staffing in in the the 44th Avenue Infirmar and resultant in Day Day 11 Initial Health Assessments, resultant increase in expanded RN and expanded RN and LPN LPN staffing staffingwill wil be be critically needed. CHS has recognized the In In recent recent discussions discussions with me, CHS has also recognized the need need to to have have an an RN RNwho whohas has expertise expertise in in chronic chronic wound wound care care need for some evaluation particular need for some evaluationand and treatment. treatment. This is a particular patients patients served served within within the the LBJ LBJ Infirmary Infirmary but but also also for for referrals referrals from from the the other other eight eight CHS CHSoutpatient outpatienthealth healthfacilities. facilties. 40 40 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 45 of 65 is reasonable reasonable to to expect expect that thatthe theinitially initially proposed proposed nursing nursing ItIt is staffing for forbudget budgetyear year2012 2012 can canbe be phased-in phased-inbetween between April April11 staffing and September September 1,2012, 1,2012, including includingrecruitment recruitmentofofan anRN RN and wound care care specialist. specialist. Between Between April April 11 and and July July1, 1, 2011, 2011, II wound bein incommunication communicationwith withCHS CHS leadership leadership to to identify identify any any willbe wil other additions additions to to nursing nursingstaffing staffing required required after after September September 1, 1, other 2011. 2011. CAP - - 6: CAP 6: Physician Staffing and Chart Documentation at the LBJ LBJ Infirmary the Infirmary CHS has that defines defines the three three levels levels of CHS has aa well-written well-written policy that medical/ nursing services services available available to the LBJ LBJ medical/nursing to patients patients in the Infirmary. Eachofofthese thesethree threeservice servicelevels levels is is linked linked with aa Infirmar. Each specified assigned specified frequency frequencywith withwhich whichthe theInfirmary's Infirmar's assigned physicians are expected expected to to evaluate evaluate and and document document periodic medical medical evaluations evaluations and and updates updates in in each each patient's patient's plan of care. These frequencies However, care. These frequencies are are medically medically appropriate. appropriate. However, my my medical medical record record reviews reviews have have identified identifiedaa serious serious problem problem with with the the legibility legibility of ofmany manyphysician physician generated generated Infirmary Infirmary admission admission and and progress notes. These types of illegible ilegible medical medical record record entries entries truly truly impede effective effectivecommunication communication and and coordination coordination among amongthe the physicians, physicians,nurses nurses and andother other staff staff that advance the that need need to to understand understand and advance the plan plan of care. care. Therefore, Therefore,IIhave haveasked asked Dr. Dr. Alvarez Alvareztotoidentify identifyand andimplement implement 41 41 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 46 of 65 aneffective effective corrective an corrective action action to to ensure ensure legibility legibilty of of Infirmary Infirmar physician entries entries as as well well as any any other other similar similar situations situations he he physician becomes aware aware of of in CHS CHS health is reasonable reasonable to to becomes health facilities. facilities. ItIt is expect that thatthis thisobjective objective be be accomplished accomplished by June June 1, 1, 2011. 2011. 1,2011. expect In concert concert with withthe thechanges changes described described in inCAP-1 CAP-l CAP-1 and and CAP-2, CAP-2, itit In is predictable predictable that that there there wil willbe be aa significant significant increase increase in in the the is number and acuity of patients patients referred referred from fromthe the4th 4 th Avenue Avenue number and acuity of .Intake Intake Center Center to to the the LBJ LBJ Infirmary onweekends weekends and andholidays. holidays. Intake Infirmar on For this this reason reason and and also also on on the the basis basis of of prior priorexperience, experience, there there compelling medical reasons to have have are compellng reasons for for the the LBJ LBJ Infirmary Infirmar to part-time (four (four hours hours per per day) day) practitioner practitioner coverage coverage on on-site part-time weekends and dutyof of the the practitioner practitioner weekends and holidays. holidays. The The primary primar duty providing providing this this coverage coveragewill wil be be to to see see and evaluate any new patients after 55 PM the prior patients admitted admitted to to the the Infirmary Infirmar after PM the prior day day and and also write progress also to to evaluate evaluate and and write progress notes notes for for any any other other patients whose need for whose clinical clinical condition dictates the need for such an evaluation. propose that CHS phase-in expanded evaluation. II propose that CHS phase-in this this expanded physician coverage of physician coverage of the the LBJ LBJ Infirmary lnfirmary between between April April 11 and and August August 1,2011. 1, 2011. CAP CAP- -7:7:Evaluation Evaluationand andTreatment Treatmentof ofPatients Patientsat at Risk Risk for for Alcohol Alcoholand and Opiate Opiate Withdrawal Withdrawal Syndromes Syndromes CHS CHSalready alreadyhas hasin in place place use use of of the the CIWA CIWA Scale Scale(Clinical (Clinical Institute for CIW CIWAAscale Institute for scaleWithdrawal Withdrawal Scale Scale for Alcohol) Alcohol) for for 42 42 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 47 of 65 evaluation of of patients patients at at risk riskfor foralcohol alcoholwithdrawal withdrawalsyndrome. syndrome. evaluation CHS also has in place place a a treatment protocol for usc use of of Librium, Librium, CHS benzodiazepine benwdiazepine medication) medication) that that is is consistent consistentwith with aa benzodiszepine authoritative professional professional recommendations recommendations including including authoritative Pharmacological Management Management of ofAlcohol MetaPharmacological Alcohol Withdrawal Withdrawal-- AA Metaanalysis and andEvidence Evidence Based Based Guideline Guideline by M.F. Mayo-Smith, Mayo-Smith, analysis JAMA 1997; 1997; 278(2): 278(2): 144-152: 144-152: From Fromthe theAmerican American Society Society of of JAMA Addiction Medicine Medicine Committee on Practice Practice Guidelines. Guidelines. Addiction Committee on With respect respect to evaluation evaluation of of persons at risk risk for for opiate opiate With CBS CHS is withdrawal syndromes, CHS is not not now now using using aa separate, separate, distinct scale and validated evaluation evaluation scale scale such such as as the Clinical Opiate Opiate Withdrawal Withdrawal Scale Scale (COWS) (COWS) or Clinical Clinical or the the Clinical Institute Narcotic Assessment Assessment (CINA) I, 2011 Institute Narcotic (CINA)Scale. Scale.By ByJuly July 1, i, 2011 CBS COWS to CHS will wil utilize utilize the the COWS to evaluate evaluate incoming incoming patients patients with with aa prior prior history history of of use of opiates of any use of opiates of any type type including including heroin, heroin, methadone, methadone, and and analgesic analgesic such such as as oxycodone, oxvcodone,dilaudid dilaudid and codeine. of both alcoholism codeine. For patients patients with with aa prior history of and I addiction, both CIWA-Ar and and opiate opiate dependence dependence/addiction, both the ClWA-Ar COWS COWSwill wilbe beutilized. utilzed. CHS CHScurrently currently relies relies on on use use of of c1onidine, clonidine, hydroxyzine, hydroxyzine, and and loperamide loperamidefor fortreatment treatment of ofpatients patients at at risk risk for for opiate opiate withdrawal withdrawal syndrome, syndrome,including including those those who whoare are being beingtreated treated in in community-based community-basedmethadone methadone treatment treatment programs programs prior prior th Avenue Intake Center. As has been stated entry entry into into the 44th Avenue Intake Center. As has been stated 43 43 Case 2:77-cv-00479-NVW Document 1966 Filed 04/06/11 Page 48 of 65 repeatedly in in my my prior prior reports, reports, patients patientsparticipating participatingin inlegal legal repeatedly methadone treatment treatmentprograms programs should shouldcontinue continuetotoreceive receive methadone methadone maintenance maintenance after after during duringtheir theirpre-trial pre-trialdetention. detention. methadone In addition, addition, since since methadone methadoneisismedically medically preferable preferable to to In clonidine in in most most respects, respects, methadone methadone needs needsto tobe beavailable available clonidine within the the MCJ MCJ for for use in an an opiate opiate withdrawal withdrawal treatment treatment within use in protocol for patients patients who who are are heroin dependent. dependent. Two Two other other protocol drugs -- Suboxone Suboxone and and Subutex Subutex -- are are also also acceptable acceptable drugs alternatives. alternatives. Alvarez and I are having ongoing discussions about his Dr. Alvarez approvals and diligent efforts to secure the approvals and community necessarytotoprovide providemethadone methadone maintenance maintenance partnerships necessar after use of of methadone or other other drugs drugs for for after jail jail entry entry and and use methadone or treatment of opiate Multiple regulatory, regulatory, legal, legal, opiate withdrawal. withdrawal. Multiple licensure remain to to be be resolved. resolved. There There licensure and and training training issues issues remain appear be three main options, options, which which are appear to to be three main are not not necessarily necessarily lllutuallyexclusive. nlutuallyexclusive. These options are are the following: exclusive. These following: mutually licensed and drug addiction addiction treatment •. AA licensed and community-base community-base drug treatment network COlne into MCJ facilities network might might be be engaged to come facilities to to evaluate, evaluate, counsel counsel and and treat treat patients patients receiving methadone methadone maintenance maintenanceor orat atrisk risk for for opiate opiate withdrawal withdrawal and and addiction addiction counseling eounselingand andfollow-up follow-up addiction addiction treatment. treatment. •. CHS CHS may may be be able able to obtain Opiate Opiate Treatment Program Program (OTP) (OTP)certification certificationby bythe the Substance SubstanceAbuse Abuseand andMental Mental 44 44