ARIZONA DEPARTMENT OF CORRECTIONS
HEALTH SERVICES CONTRACT MONITORING BUREAU
MEMORANDUM

TO:

Arthur Gross

THROUGH: Richard Pratt
FROM: Vanessa Headstream
DATE: March 2013
SUBJECT:

ASPC-Lewis status update

March 5, 2013 –
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Reviewed charts @ ASPC Lewis L11 unit
o Medical Records –
 Care plans are not utilized in patient treatment
 #inmate seen 02/26/13 by a provider, dx of possible LLL pneumonia; chest xray ordered
and completed 02/26/13, no results in chart. Xray report located in xray dept. filing
o Staffing –
 A nurse is not posted in the unit, a PCT is onsite for patient monitoring and the nurse is
posted at the Hub area if needed
o Medications –
 Open bottle of Insulin in refrigerator dated 11/2012

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Reviewed ASPC Lewis Medical Hub –
o HNRs –
 94 HNRs found in a stack on the counter dated from 02/21/13 to current, no triage
date/time stamp
 1 HNR found with a triage date/time stamp of 02/26/13, no medical visit documented or
response to I/M
 In a separate room the following was found:
• 1 HNR for SDU dated 02/10/13, no triage date/time stamp noted
• 42 HNRs for Rast dated 02/28/13 to current, no triage date/time stamp noted
• 19 HNRs for Eagle Point dated 02/21/13 to current, no triage date/time stamp
noted
• 10 HNRs for Bachman dated 03/03/13 to current, 2 had triage dates of 03/05/13
with no response to I/M
 Pharmacy HNRs were found as follows:
• 43 dating from 02/20/13 triage stamped 03/05/13, no responses to I/M
• 3 dating from 02/17/13 triage stamped 03/01/13, no responses to I/M
• 35 dating from 02/28/13 no triage date/time stamp, no responses to I/M

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hospital SOAPE note
#inmate – unresponsive I/M, found face down on the floor; no c-spine precautions
initiated, no NAP/ERO utilized, sent out 911. I/M left hospital AMA 03/17/13, no
provider f/u documented
 #inmate – I/M sent out 03/09/13 with head injuries s/p “a fight”; no NAP/ERO utilized,
no c-spine precautions initiated, return from hospital 03/09/13, no provider f/u
documented; evaluated by nursing 03/10/13, provider contacted and orders received,
orders not noted by nursing
 #inmate – hospital return SOAPE not noted by nursing, not signed by provider
o Consults/Reports  5 outside consult requests returned for more information were found on a cart at medical
–
• #inmate – original c/s 02/19/13, returned 03/07/13
• #inmate – original c/s 02/06/13, returned 03/05/13
• #inmate – original c/s 03/06/13, returned 03/07/13
• #inmate – original c/s 03/05/13, returned 03/07/13
• #inmate – original NFDR 02/11/13, returned 03/08/13
 Multiple consult reports and lab/xray results were found with the c/s returns –
• #inmate – xray report received 02/26/13 indicating “displaced oblique mid shaft
fracture”, not signed by a provider, no f/u evaluation documented in medical file
• #inmate – renal c/s received 02/19/13 indicating 4 wk f/u needed, new treatment
plan recommended including change in medications, labs and facility monitoring;
not signed by a provider
o Chronic care review –
 8 medical files reviewed, 3 non-compliant with f/u appt. (#inmate , #inmate , #inmate )
• #inmate – problem list indicates HTN, medical file labeled with HTN sticker, no
cc appt. history found in SOAPE notes


March 20, 2013 –
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Reviewed ASPC-Lewis Medical Hub –
o MARs –
 Eagle Point unit – 64 MARs were incomplete in documentation, i.e. missing dates of
administration, no diagnosis information, nursing initials do not have corresponding
signature, medication not given as ordered per MAR entry (#inmate Carbamazepine
order 03/06/13, not administered until 03/19/13), no allergy information, no start/stop
date shown (#inmate ), notation made on MAR “chg’d to 2” instead of d/c old order and
writing new dose order on MAR (#inmate )
o Consults/Reports –
 Barchey/Buckley – 41 charts pending provider review, i.e. lab results, xray results,
consult reports, consult requests returned for more information (dated 03/05/13, 03/08/13,
03/07/13)
 Stiner – 19 charts pending provider review, i.e. same as above information
 Eagle Point/Sunrise – 20 charts pending provider review, i.e. same as above information
o
Medical Records –
 67 transfer/intake charts are on a cart for processing into the facility, transfer dates are
from 02/2013 to current

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Unsecured transfer medications are on the bottom shelf of the cart not in any type of
packaging
 Barchey unit has 11 pairs of I/M eyeglasses to be delivered in a cabinet (paperwork dated
03/08/13)
 Stiner unit has +/- 25 pairs of I/M eyeglasses to be delivered in a cabinet (paperwork
dated 03/08/13)
 Morey unit has 7 pairs of I/M eyeglasses to be delivered in a cabinet (paperwork dated
03/08/13)
 #inmate – orders written by provider on 03/14/13 were not noted by nursing until
03/19/13
 #inmate – xray order written by provider on 02/15/13 still in the chart, not noted or sent
to xray for processing
 #inmate – chart remains in provider review after hospital return, I/M sustained injury
during transport, injury not addressed by nursing during return assessment
 #inmate – provider orders written 03/07/13 not noted by nursing
o Medication Room –
 62 DOT medication cards past their stop date were found on one rack of the currently
used medication bins. The medication nurses were unsure of the process for pulling
outdated meds, i.e. who is responsible, where to dispose of the meds, etc.
 #inmate – follow up from Monday, March 18, 2013 – medication is KOP, unable to
obtain records for KOP distribution – med nurses indicated security delivers KOP
medications but did not know where to find the signed forms used by the I/M to
acknowledge receipt of meds.
o Tools/Sharps Inventory –
 Mandown bag log documentation indicates noncompliance with daily monitoring of
usage/access into mandown bag contents
March 25, 2013 –
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Reviewed ASPC-Lewis Medical Hub –
o MARs –
 Stiner unit – 88 MARs reviewed (only a portion of the inmates on DOT medications)
were incomplete in documentation, i.e. missing dates of administration, no diagnosis
information, nursing initials do not have corresponding signature, medication not given as
ordered per MAR entry (#inmate Prazosin order 02/07/13, administered 2 doses
(03/01/13 & 03/02/13, then documented “N/A” through 03/24/13; #inmate Buspirone
ordered 03/20/13, first dose documented 03/23/13; #inmate Fluoxetine order 02/12/13,
administered 03/01/13 to 03/05/13, then documented “N/A” through 03/25/13), no allergy
information, no start/stop date shown (#inmate , #inmate )
o
Medical Records –
 Unsecured transfer medications are on the bottom shelf of the intake chart cart not in any
type of packaging, transfer charts remain not completed by nursing
 #inmate – orders written by provider on 03/22/13 were not noted by nursing until
03/25/13, no time of notation documented
 #inmate – I/M seen by nursing for c/o R flank pain 03/21/13, no NAP/ERO utilized, BP
139/100, nurse documented “No acute distress. Palpation elicits pain”; I/M seen again
03/23/13 for extreme abd pain, no NAP/ERO utilized, BP 163/103; sent to hospital; no

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1 triage date 03/21/13

March 28, 2013 –
- Reviewed ASPC-Lewis medical hub –
o Medical records –
 #inmate – seen for (R) upper arm wound, NAP utilized, not completed by nurse (no plan
or education documented), no inmate identifying information noted on SOAPE note
(name, ADC #, DOB), no signature by nurse evaluating the inmate
 #inmate – ICS 03/27/13 @ 2320 c/o chest pain; no NAP/ERO utilized, I/M c/o numbness
(R) arm & epigastric pain, pain 7/10; nursing documentation states “I/M left at unit for
staff to bring up for ECG due to staffing issues on the unit”; 03/28/13 @ 0001 I/M arrived
to medical hub, pain 9/10; ECGs (performed 3 times) abnormal with possible acute
infarct, medications administered, provider notified and 911 contacted for transport, no
time of transport noted on SOAPE
 #inmate – SOAPE note, ECG report, and emergency transport paperwork dated 01/18/13
found in a red outguide on the counter; inmate was transferred to ASPC-Yuma on
01/22/13 then to Florence West (M55) on 02/21/13 per AIMS
 #inmate – return from hospital note incomplete; no date or time noted at top of SOAPE;
then “I/M returned from TSL @ 2045 hours” documented under “S”, “Returned to unit @
2010 hours” documented under “P”
 #inmate – return from hospital note documents medication orders from sending facility,
no provider notification made by evaluating nurse
- Tools/Sharps Inventory –
o Mandown Bag lock log indicates noncompliance with daily checks  Bag #1 missing check dates of 03/06/13, 03/18/13, 03/19/13, 03/21/13, 03/22/13,
03/23/13
 Bag #2 missing check dates of 03/01/13, 03/02/13, 03/04/13, 03/06/13, 03/07/13,
03/08/13, 03/09/13, 03/10/13, 03/12/13, 03/13/13, 03/14/13, 03/15/13, 03/16/13,
03/17/13, 03/21/13, 03/22/13, 03/23/13, 03/24/13, 03/26/13, 03/27/13
o Tool count book #3 appeared compliant with daily inventory counts
- MARs –
o #inmate – Nortriptyline 75mg not administered as ordered, missing doses on 03/01/13,
03/03/13; circled doses on 03/04-06/13 documented as “patient not in cell”; post it note dated
03/19/13 is attached to the MAR and states “What am I to do with this?”
o #inmate – Diphenhydramine 50mg, Carbamazepine 200mg and Risperidone 2mg are
documented as refused on several dates, no refusals were found in the medical file matching the
dates documented on the MAR; 03/23/13 & 03/24/13 are blank for all medications, no reason
code given
- HNRs –
o Eagle Point/Sunrise units – 6 HNRs not responded to by nursing
 2 dated 03/22/13, no triage date/time
 1 triage date 03/23/13
 1 triage date 03/24/13
 1 triage date 03/25/13
 1 triage date 03/26/13
o Stiner unit – 1 HNR not responded to by nursing
 1 triage date 03/23/13

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o Morey unit – 7 HNRs not responded to by nursing
 1 dated 03/16/13, triage date 03/21/13
 1 dated 03/18/13, triage date 03/21/13
 1 dated 03/19/13, triage date 03/20/13
 2 triage date 03/21/13
 2 dated 03/21/13, no triage date/time
o Barchey unit – 3 HNRs not responded to by nursing
 2 dated 03/26/13, no triage date/time
 1 dated 03/27/13, no triage date/time
 #inmate HNR dated 03/27/13, nurse called the unit in response to the HNR request,
security returned the call and denied a medical need at that time, no response to inmate
o Buckley unit – 1 HNR not responded to by nursing
 1 dated 03/26/13, no triage date/time
o Rast unit – 5 HNRs not responded to by nursing
 5 triage date 03/27/13
o Bachman – 4 HNRs not responded to by nursing
 1 dated 03/03/13, no triage date/time
 3 triage date 03/16/13
L11 unit –
o Medical charts were not available for review, were in supervisor office for scheduling purposes
Concerns regarding the nurse’s application of the molded splint to #inmate without provider supervision
or provider review of xray were relayed to Kathy Campbell, Nurse Coordinator and Dr. Robertson,
Medical Director. Clarification of scope of practice guidelines has been requested.

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