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Union CI CAP Assessment, CMA-FDC Monitoring, 2015

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Union CI CAP Assessment

November 2015 Focused Review of Mental Health Services
FINDINGS:
On 4/20/16 an on-site CAP assessment at UCI was conducted jointly by CMA staff and surveyors and FDC
staff. Based on the CAP assessment, of the 76 corrective action plans, 49 remained deficient. These
items identified with an “F” indicate failure to meet compliance closure criteria, while the items with a
“P” indicate the corrective action plan closure criteria was met. The status of each CAP was based on the
institutional monitoring reports and/or the review by the CMA/FDC Monitoring Team.
ACTION PLAN:
FDC Mental Health will consult with Centurion Regional Mental Health Director and provide guidance on
oversight of institutional monitoring methodology and interdisciplinary collaboration to improve
compliance closure of corrective action plans for deficient items.

Psychiatric Medication Practices - Inpatient
MH-1
MH-2
MH-3
MH-4
MH-5
MH-6
MH-7
MH-8
MH-9
MH-10
MH-11
MH-12
MH-13
MH-14
MH-15
MH-16
MH-17

F
F
P
F
F
F
F
P
F
P
P
F
P
F
F
P
F

Inmate received medication as prescribed
Psychiatric follow-ups conducted at appropriate intervals
Nurse met with inmate after 2 days of consecutive medication refusals
Physical exam completed within 3 working days of admission
Follow-up laboratory tests ordered and conducted
Physician’s note completed w/in 24 hours of admission to inpatient unit
Appropriate initial laboratory tests were ordered
Abnormal labs for psychotropic meds treated or referred appropriately
Appropriate informed consent signed for each psychotropic medication
ETO accompanied by a physician’s order specifying the medication as an ETO
Psychiatric evaluation completed in required timeframe
AIMS was administered within appropriate timeframes
Psychiatric follow-up notes were detailed and clinically appropriate
Refusal signed after 3 consecutive or 5 in a month medication refusals
Orders include the physician’s signature and are dated & timed
Med(s) ordered are appropriate for the symptoms and diagnosis
ETO rationale documented and it was clinically appropriate

Inpatient Mental Health Services
MH-18
MH-19
MH-20
MH-21
MH-22

F
F
F
F
F

Vital signs taken daily for 5 days for all new admissions
Follow-up vital signs recorded within required timeframes for CSU and TCU
Weight recorded by nursing staff upon admission and once weekly
Required nursing evaluations completed & documented in full
Required hours of planned structured therapeutic services provided & documented
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MH-23
MH-24
MH-25
MH-26
MH-27
MH-28
MH-29
MH-30
MH-31
MH-32
MH-33

F
F
F
P
P
F
P
P
P
F
F

MHP notes completed timely and address progress toward ISP goals
Weekly group/activity summary note completed by MHP
Overall, treatment provided was appropriate
MDST met to review/document Behavioral Levels w/in required timeframes
Initial nursing assessment fully completed within 4 hours of admission
ISP was initiated and reviewed within the appropriate timeframe
Entries dated, timed, signed & stamped
Nursing provided explanation for admission and orientation to the unit w/in 4 hours
Vital signs were obtained within one hour of admission
For CM inmates the BRA was completed accurately and is signed by MDST
Discharge or transfer summary completed before CSU discharge

Outpatient Mental Health Services
MH-34
MH-35
MH-36
MH-37
MH-38
MH-39
MH-40
MH-41
MH-42
MH-43
MH-44
MH-45
MH-46
MH-47
MH-48
MH-49
MH-50
MH-51
MH-52
MH-53
MH-54
MH-55

P
P
F
F
P
F
P
P
P
F
F
P
P
F
P
F
F
F
F
P
F
P

1 hour group or individual counseling offered per week and documented (CM only)
Inmate received medication as prescribed
ISP lists type and frequency of intervention, and staff responsible
The BRA was completed within required timeframes (CM inmates only)
Interventions and services described by ISP are documented
CM referral assessment completed w/in 5 days (CM inmates only)
Upon arrival current psychotropic meds continued until seen by psychiatry
Frequency of clinical contacts is sufficient and clinically appropriate
Counseling offered every 30 days for inmates with psychotic disorders
ISP is updated w/in 14 days of placement, and is current (CM only)
Appropriate informed consent signed for each psychotropic medication
Psychiatric follow-up conducted at appropriate intervals
After start of MH services, initial ISP completed within 30 days
Identified problems are on the problem list
Inmate seen by psychiatry prior to expiration of psychotropic meds
MSE completed, active MH problems assessed & ISP updated w/in 14 days of arrival
Nurse met with inmate after 2 days of consecutive medication refusals
ISP goals are time limited and written in objective measurable behavioral terms
The BRA is completed accurately and is signed by MDST members (CM only)
All entries were dated, timed, signed, and stamped
ISP signed by all MDST members and inmate or refusal is documented
Progress notes have sufficient detail to follow course of treatment

Special Housing
MH-56

P

Outpatient treatment is continued as indicated on the ISP
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MH-57
MH-58
MH-59
MH-60
MH-61
MH-62

F
P
F
F
P
P

A Special Housing Health Appraisal was completed by nursing staff
Psychotropic medication continued while in special housing
Initial mental status exam was completed in the required timeframe & documented
Follow-up mental status exams are completed in the required timeframes
All entries were dated, timed, signed, and stamped
Mental status exams are sufficient to identify any possible adjustment problems

Discharge Planning
MH-63

F

Consent or refusal signed w/in 30 days after the initiation of aftercare

Inmate Requests
MH-64

F

Interview or referral took place as responded to on inmate request

SHOS
MH-65
MH-66
MH-67
MH-68
MH-69

F
F
P
F
F

Observations recorded on checklist every 15 minutes
Nurse evaluated inmate within 2 hours of admission
Daily counseling by MH staff was conducted and documented
Inpatient Mental Health Daily Nursing Evaluation completed each shift
All entries were dated, timed, signed, and stamped

Psychiatric Restraints
MH-70
MH-71
MH-72
MH-73
MH-74
MH-75
MH-76

F
F
F
F
F
F
F

Patient’s behavior observed every 15 minutes and documented on DC4-650A
Respiration & circulation checks completed and documented on DC4-650A
4-point restraints: limbs exercised every 2 hours and documented on DC4-650A
Restraints removed after 30 minutes of calm behavior
Less restrictive means of behavioral control attempted and documented
Offered food, fluids and bedpan/urinal as required and documented on DC4-650A
Vital signs taken and recorded upon release from restraints

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Overview of Union CI Audit
conducted 11/9/15 - 11/10/15
This was a targeted review conducted jointly by CMA staff and surveyors and FDC staff. The review
consisted of items selected from CMA audit tools and focused on the delivery of mental health services
in the inpatient units (U, V, and T) and special housing dorms (O & P), with an emphasis on inpatient
psychiatric medication practices and the administration of medication.
There were a total of 67 items reviewed that were applicable to inpatient mental health services. Of
these 67 items, 47 fell at or below 80% compliance, resulting in an overall non-compliance rate of 70%.
For outpatient mental health services there were a total of 54 items reviewed. Of these 54 items, 29 fell
at or below 80% compliance resulting in an overall non-compliance rate of 54%
Below is a brief summary of each item with the corresponding percentage of records that were
compliant. Only items that were at 80% compliance or below are included. Please note that while the
total records reviewed is included for each area, each record reviewed was not necessarily applicable for
all of the items.

Psychiatric Medication Practices - Inpatient
MH-1
5%
Inmate received medication as prescribed
MH-2
26%
Psychiatric follow-ups conducted at appropriate intervals
MH-3
33%
Nurse met with inmate after 2 days of consecutive medication refusals
MH-4
36%
Physical exam completed within 3 working days of admission
MH-5
40%
Follow-up laboratory tests ordered and conducted
MH-6
42%
Physician’s note completed w/in 24 hours of admission to inpatient unit
MH-7
50%
Appropriate initial laboratory tests were ordered
MH-8
50%
Abnormal labs for psychotropic meds treated or referred appropriately
MH-9
53%
Appropriate informed consent signed for each psychotropic medication
MH-10
56%
ETO accompanied by a physician’s order specifying the medication as an ETO
MH-11
56%
Psychiatric evaluation completed in required timeframe
MH-12
58%
AIMS was administered within appropriate timeframes
MH-13
61%
Psychiatric follow-up notes were detailed and clinically appropriate
MH-14
67%
Refusal signed after 3 consecutive or 5 in a month medication refusals
MH-15
72%
Orders include the physician’s signature and are dated & timed
MH-16
78%
Med(s) ordered are appropriate for the symptoms and diagnosis
MH-17
78%
ETO rationale documented and it was clinically appropriate
Total Records Reviewed:
19

Summary Comments: The review of these records confirmed grave concerns about the
administration of medications in the inpatient units at Union CI. Out of 19 inpatient records reviewed,
only 1 inmate received his medication as prescribed over the past 3-4 months. While there did appear
Page 1 of 6

to be some recent improvement, a review of 50 current MARs for the first 9 days of November
revealed that 54% of this sample did not receive medication as prescribed. The vast majority of the
deficiencies were due to inmates not receiving one or more doses of medication, but there were a few
instances where inmates received the wrong dose of medication. For example, in one case the
physician’s order indicated that the inmate was prescribed 2 mg of Risperdal every evening. However,
according to the October MAR the inmate was administered 2 mg of this medication twice a day.
Compliance with required psychiatric follow-up visits was only at 26%. It was not unusual for inmates
receiving Transitional Care to see a psychiatric provider every 2 months instead of the required
monthly or biweekly visit. As reflected by the above percentages there were also significant
compliance issues in the areas of laboratory tests, medication consents, and Emergency Treatment
Orders (ETOs). Overall, in the area of Psychiatric Medication Practices only 3 of 20 items reviewed
were above 80% compliance.

Inpatient Mental Health Services
MH-18
0%
Vital signs taken daily for 5 days for all new admissions
MH-19
0%
Follow-up vital signs recorded within required timeframes
MH-20
0%
Weight recorded within required timeframes
MH-21
5%
Required nursing evaluations completed & documented
MH-22 10%
Required hours of planned structured therapeutic services provided & documented
MH-23 14%
Mental Health Professional notes were completed timely and clinically appropriate
MH-24 24%
Weekly group note was completed
MH-25 30%
Overall, treatment provided was appropriate
MH-26 57%
MDST met to review/document Behavioral Levels w/in required timeframes
MH-27 64%
Initial nursing assessment fully completed within 4 hours of admission
MH-28 67%
ISP was initiated and reviewed within the appropriate timeframe
MH-29 71%
Entries dated, timed, signed & stamped
MH-30 75%
Nursing provided explanation for admission and orientation to the unit w/in 4 hours
MH-31 75%
Vital signs were obtained within one hour of admission
MH-32 75%
For CM inmates the BRA was completed accurately and is signed by MDST
MH-33 78%
Discharge summary completed before CSU discharge
Total Records Reviewed:
22

Summary Comments: These record reviews revealed additional serious deficiencies in inpatient
nursing care, in addition to the medication administration issues described earlier. In all 22 records
reviewed, weights and vital signs were not recorded per policy and in many instances the most recent
graphic charts were from July or August. Additionally, there were no refusal forms found in the record
to indicate that vitals were offered, but refused by the inmate. There were also many monthly TCU
nursing evaluations missing, resulting in an overall compliance rate of 5%. In V dorm the most recent
monthly nursing evaluations in the records were typically from July.
Only 10% of the sample consistently received the required number of structured therapeutic services
and overall these services primarily consisted of activity therapy and therapeutic community. There is
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minimal individual and/or group counseling provided. For example, most records in U dorm reflected a
total of 15 minutes of individual therapy and 30 minutes of group therapy per week. The provision of
counseling services was even more limited in V dorm. Compliance with weekly group notes and case
management notes was extremely poor and the most recent Mental Health Attendance Records found
in the V dorm charts were typically from the week of September 21. Many of the progress notes in the
TCU records, including the refusal notes, were “cookie-cutter” making it impossible to follow the
course of treatment, including whether the inmate was making progress on the goals listed on his ISP.
Progress notes in the CSU records were better, but did not always contain all of the required
information. Additionally, many of the inpatient individualized services plans only listed the titles (e.g.,
mental health professional, psychiatrist), but did not specify the names of mental health providers.

Outpatient Mental Health Services
MH-34
0%
1 hour group or individual counseling offered per week and documented (CM only)
MH-35
8%
Inmate received medication as prescribed
MH-36 15%
ISP lists type and frequency of intervention, and staff responsible
MH-37 20%
The BRA was completed within required timeframes (CM inmates only)
MH-38 29%
Interventions and services described by ISP are documented
MH-39 33%
CM referral assessment completed w/in 5 days (CM inmates only)
MH-40 44%
Upon arrival current psychotropic meds continued until seen by psychiatry
MH-41 46%
Frequency of clinical contacts is sufficient and clinically appropriate
MH-42 50%
Counseling offered every 30 days for inmates with psychotic disorders
MH-43 50%
ISP is updated w/in 14 days of placement, and is current (CM only)
MH-44 53%
Appropriate informed consent signed for each psychotropic medication
MH-45 58%
Psychiatric follow-up conducted at appropriate intervals
MH-46 63%
After start of MH services, initial ISP completed within 30 days
MH-47 64%
Identified problems are on the problem list
MH-48 67%
Inmate seen by psychiatry prior to expiration of psychotropic meds
MH-49 67%
MSE completed, active MH problems assessed & ISP updated w/in 14 days of arrival
MH-50 67%
Nurse met with inmate after 2 days of consecutive medication refusals
MH-51 69%
ISP goals are time limited and written in objective measurable behavioral terms
MH-52 71%
The BRA is completed accurately and is signed by MDST members (CM only)
MH-53 73%
All entries were dated, timed, signed, and stamped
MH-54 75%
ISP signed by all MDST members and inmate or refusal is documented
MH-55 78%
Progress notes have sufficient detail to follow course of treatment
Total Records Reviewed:
18

Summary Comments: The outpatient records reviewed consisted of Close Management or
Death Row S-3 inmates. This review indicated that a total of 22 out of 36 items fell below 80%
compliance. Similar to inpatient records, the review of outpatient MARs indicated that only 8% of the
sample received their medication as prescribed over the past 3-4 months. Additionally, compliance
with items pertinent to the Osterback case was poor. For example, in the applicable records reviewed
Page 3 of 6

none contained documentation to confirm that 1 hour of counseling was consistently offered per week
and only 20% of these records were compliant with the required timeframes for the completion of
Behavioral Risk Assessments. Only 58% of the sample received psychiatric follow-up services in
accordance with the timeframes specified in policy.

Special Housing
MH-56
27%
Outpatient treatment is continued as indicated on the ISP
MH-57
50%
A Special Housing Health Appraisal was completed by nursing staff
MH-58
50%
Psychotropic medication continued while in special housing
MH-59
62%
Initial mental status exam was completed in the required timeframe & documented
MH-60
64%
Follow-up mental status exams are completed in the required timeframes
MH-61
73%
All entries were dated, timed, signed, and stamped
MH-62
80%
Mental status exams are sufficient to identify any possible adjustment problems
Total Records Reviewed:
16

Summary Comments: This area consisted of a review of the delivery of mental health services in
O and P dorms which revealed significant compliance issues as well. Only 1 out of the 8 items in Special
Housing was above 80% compliance.

Discharge Planning
MH-63 25%
Consent or refusal signed w/in 30 days after the initiation of aftercare
Total Records Reviewed:
7

Summary Comments: Records reviewed for Aftercare Planning compliance revealed poor
compliance with the documentation of signed consent or refusal.

Inmate Requests
MH-64
10%
Interview or referral took place as responded to on inmate request
Total Records Reviewed:
15

Summary Comments: A review of documentation in outpatient records revealed when an
interview or referral was indicated in the response to the inmate request, in 9 out of 10 instances it did
not occur as intended, raising significant concerns with access to care.

SHOS
MH-65
MH-66
MH-67
MH-68

40%
60%
67%
71%

Observations recorded on checklist every 15 minutes
Nurse evaluated inmate within 2 hours of admission
Daily counseling by MH staff was conducted and documented
Inpatient Mental Health Daily Nursing Evaluation completed each shift
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MH-69
80%
All entries were dated, timed, signed, and stamped
Total Records Reviewed:
7

Summary Comments: The review of these records indicated less than 80% compliance in
several areas of nursing services for inmates admitted to self harm observation status. In addition,
daily counseling by mental health staff was not consistently conducted and documented.

Psychiatric Restraints
MH-70
0%
Patient’s behavior observed every 15 minutes and documented on DC4-650A
MH-71
0%
Respiration & circulation checks completed and documented on DC4-650A
MH-72
0%
4-point restraints: limbs exercised every 2 hours and documented on DC4-650A
MH-73
0%
Restraints removed after 30 minutes of calm behavior
MH-74 50%
Less restrictive means of behavioral control attempted and documented
MH-75 50%
Offered food, fluids and bedpan/urinal as required and documented on DC4-650A
MH-76 50%
Vital signs taken and recorded upon release from restraints
Total Records Reviewed:
1

Summary Comments: This section of the audit was comprised of a single record, with 2 discrete
events. This was the only applicable record documenting use of restraints at the time of the audit. The
areas of significant non-compliance involved nursing staff documentation on DC4-650A of required
monitoring during the restraint process, as well as a lack of documentation that less restrictive
behavioral controls were attempted prior to the application of psychiatric restraints for 1 of the
restraint episodes.

Mental Health Systems Review and Inmate Interviews
A review of staffing indicated 18 current nursing vacancies which included 12.6 LPNs, 4.6 RNs and the
Director of Nursing position. It was reported that approximately 10 of the 18 vacancies are filled with
agency nurses.
A review of mental health logs found that both the Psychiatric Restraint Log and the Emergency
Nursing Log had missing information.
A total of ten inmates were interviewed (5 inpatient and 5 outpatient inmates). Overall, the
information from the inmate interviews was consistent with the findings from the inpatient and
outpatient record reviews.
The primary complaint pertained to medication administration. Inmates reported they do not always
receive their medication(s) and are informed by nursing staff that they ran out, the bottle is empty, etc.
Inmates in V dorm reported that they are receiving little to no individual or group therapy. Overall, the
inmates interviewed in V dorm reported more complaints about their mental health care than the
inmates in U dorm.

Page 5 of 6

In addition to medication complaints, inmates in O dorm reported some difficulties with access to
inmate request forms and also indicated that when inmates declare mental health emergencies they
are sometimes ignored by security staff. Two inmates independently described an incident where an
inmate attempted to declare a mental health emergency, was reportedly ignored for several hours, and
then attempted to hang himself. In an effort to verify these reports, the record of this inmate was
reviewed and he had recently been placed on SHOS after a hanging attempt. A review of this inmate’s
record revealed several concerning issues. He had recently been discharged from TCU level care to O
dorm and per the MARs did not receive any of his medications the first 2 days following TCU discharge
and did not receive one of his medications for 4 days. Additionally, there was no documentation that
the decision to discharge this inmate was by the consensus of the MDST or that discharge was being
contemplated. In fact, the inmate was seen in mid-September by a psychiatrist with a plan to see the
inmate in 2 weeks due to medication changes, including a dosage increase of an anti-psychotic
medication. There was no documentation in the record to indicate that after this appointment he saw
a psychiatric provider or his case manager individually prior to his discharge at the end of October. At
the time of this review he was on self-harm observation status (SHOS) and had been referred to the
CSU.

Overall Summary
This review indicates serious and multiple deficiencies in the delivery of mental health care in both the
inpatient and outpatient settings at Union Correctional Institution. The deficiencies in the
administration of medication were particularly striking, as was the current nursing vacancy rate. The
overall mental health care delivered in the inpatient units is inadequate, as evidenced by poor
compliance with required psychiatric, psychological, and nursing services and sparse or missing
documentation. The delivery and documentation of care in the Special Housing dorms was equally
problematic with respect to the administration of medication and other requirements including those
applicable to the Osterback case. Additionally, in many instances, inmates who submitted requests
were not seen as intended, raising significant questions about access to care. In some cases it is possible
that care was delivered, but was not documented, or the documents had not yet been filed.
Nonetheless, this is unacceptable practice and certainly does not account for the majority of the findings
in this report.

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