NON DESIGNATE D SE NTIN EL EVENT REVIEW FORM - 2013
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Date uf E\'cnt 12-Feh- /J
l'alit•nt NanH· Ureen,

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CORIZON003364

Exhibit 65 - Page 1 of 27
Dec'l of JTD

 osto\l?y. 2. 2013o 8:49AMx

.... ~

No. 7532

hn6 oount:y

P.

6~oo21oo.,

CGRIZON"
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THIS i<ORM IS TO

[

B~ US~O ONLY WHEN US!! OP A SI'I5Cif"IC SENTINEL E.VENT REVII!W f'O~M DOES NOT EX~~

Non Designated Senllnel E,Vonls Include events for whlclllt may be alleged th~i Corizon railed to provide appropriate care.
These events may have errors ot omlselonfcommlsslon assoclol11d vlith opportunities for Improvement in systems or
processes·.

Cbeok tho Tyno of Evont:
0 Lost of limb

0 VIsual Ot hearing lnmalrmenl or loss
~-Neurologlcnllmpalrmant I Poralysls 1 Brain Damage
0
0
0
0

Reptoducllve organ lmpall'menl or loss
Pre!lnanoy related compllcaUons: ORuptured ectopia OFetal demise
High Pronto evonlo In the medlfl/news
Other (!S ldenllnod as potenllally high risk - - - - - - - - - -

IJi!Allil;

COMPLeTE

l~la~(leCfeenlng procoat

perfonnell
GutfMf me<llcallons oroercd
ConllnuPllon or clro or~ers lmplo me~le~

INCO':?El~

0
D
0

0
[:J

0

!:!El!.!:Itl M~!!l!SM§IH:
foi&P complerell per policy

Henlth oval~allon verlormall
ConU.1uellon or car~ ordots lmp!emenlcw
~

TlmCJy 1\CCOIO IO tare
RererrOit moae es epvrop~Aie

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QH/!ONIC CAfl!il
noullnely ev~t\141ed por pcl!cy
Treotmeol plan rorowoll
AbiiOIOlOIIesls aeled on~~ epproprloto

Mrull.CAL BllCOROS:
Record 11 carnplele end ordorly
RorutaiJ dooomonJtd per pof(cy
Muter Ptol>!am llsl complote
I!!!'ltHI~Jill PROQ~Sl! ;

TrMsfol eulnm~ry a ccur~le
Conllnu~Uon ol """' lmp!emonlod

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·rypall Norrotlvo Summary (lnotucreruentlllod orou no•drng eorrt<llvtacUon for on Oatooory 3 •>•d 4 ovontt)

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MD/DO
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fr)ltla l
Silo Mo(IIOftl Olrootor
Reglonnl Moll leal Director
Fax Complelell Form to: Brentwood (Jail) 0'77·729·1063
,.,.,J.&::o Ot~!tu lod s "'Ml fl•n t n•vr!u rotn>
Sl. louis (OOC) OOB·016.J11J7G
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CONFIDENTIAL

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CORIZON003365

Exhibit 65 - Page 2 of 27
Dec'l of JTD

 ...... lano oounty

IJo. 7532

To: P<Jtlenf Sa fety Committee
1\e: Kelly Green t1 1524456 date of Event 2/ 12/ 2013
Corrective Act101l Plan: summary of case
Areview or the ca re Iss ues surrounding this case raise a number of concefllS tllil t need to be addressed.
The presenting history w<~s on Inmate who h11d rammed his head against a wa ll wit h sufficient force to
Injure himself with head lacerotlon and other less obvious Injuries. He had significant bleeding and
laccrlltlons on his head that rcrrulred Immediate attention. No te~ Include obserya!laos of no LOC alld •lo ,
~·a lws. He app;Hentlv complained that he was ''paralyzed" but he was moving all four extremities
There was a charted notation of neurological examlnallon being "grossly Intact", The components or
that n~uro eKamlnatlon are missing. The charting does not mention any active testing of strength to
evaluate motor function. Out there was a concern abovt a possible cervitll llnjury as the chart men lions
the c-spfne being held supported during the Initial evaluation. The Inmate was \ransported lo clinic for
further ovnluatlon and treatment of lacerntions requiring sutudng. There are no notes thot Inform the
render that the c-s plo~ wos secured or that the Inmate was placed on a bacl< board durlogtranwortalloQ. As the attached no tes by Or. Montoya and tnyself bear out after the pallont was sutured
durloll that time period the practitioner was Informed that the Inmate's relei!se was Imminent Again
the chint supports conce rns on the pn rt of the pr~ctltloncr of·posslble neurological Issues as part of the
A/P was for the lnrnilte to have neuro checl<s evel)t 1· 2 hottrs. Inherent it) that request seems to he an
und erstanding that his release may have lal<en hours to be completed. As the case lmfolded his release
from custody was protracted and during thot period time the lnmotes' neurological st<ttus had worsened
requiring Immediate tra nsfer to the ED,
necommendatlons for CAPs:

1. Thora must be a mandatory ln-sorvlce scheduled for all clinicians and clinical starr regordinc

the approach as well as lmndllng of tho more common head and neck injvrlos i.o. lnclutl lnll the
Indication and uso of ccrvlcill collars and J.>ack boards. The RMD anu RCSM should be notlflod
of tho scheduled train ins and Its completion by nil required staff.
2. Effective Immediately all chart entries must be signed I llme<l <tnd dated. In this coso tho lacl<
of timed documentation mal<es tho accurate assessment of the fl ow of events speculative ilnd
difficult. To ensure compllonco an <lltdlt of charts which reflects 10% of th t~ lnm<'tes seen In a
pi!rtlcular month should he completed monthly to .ensure that this dowmentatlon Is helng
dono. Audit tools to enhance this proce5!1 can b& obtained from J. Slencak RCSM
3. Rovlew with all dlnlcal staff th at ,
'an orders must be written on standard ordet shee t~

CONFIDENTIAL

CORIZON003366

Exhibit 65 - Page 3 of 27
Dec'l of JTD

 ~~~

lane county

No. 7532

P. ~oo3too5

Sentinel [:vent Heport
Prepared by:

Justin Montoya, MD
Site Medical Director, Ulna County Adult Corrections 1190806

Inmate:

Greon, l<elly 111524456

Event Date:

february 12, 2013

Report Date:

April 23, 2013

For tills reports I have reviewed chart notes, log notes from deputies, and verbal report from Kris White,

PA

Approximately 11:00
o Kelly Green (Green) reportedly smashed head Into wall In or around courtroom while
handcuffed. Medical staff Including l<rls White, PA (I<W) responded.
o Chart note· untlmed-lndlcates J")atlent with ll<>rga lacerations to scalp. Green
responding to simple questions but not llllproprlate. Roported being ''paralyzed" but
moving all extremities. Also reported not being able to hear KW because "ears
poralyzed".
o Deputy log Indicates Green cros~ed his own legs while lying on floor.
o KW reports c-splne wos non-tender on exam

•

11:15
After being "cleared" by KW patient transported to segregt~tion by wheelchair
I believe It was at this point that his head wounds were sutured In Medical Clinic
Order for neuro check q 1-2 hour
l'er KW yorb ~ l report sbe all!l temporary HSA (VIcki) indfcilted Green needed to be
trilnsported t o bosp lto ~ They were told by deputy he would be relea5ed shortly and
would get a courtesy drop-off at t1ospital. I<W states she was not nwMe \he patient had
been housed
Approximately 11:47
o Depmy log Indicates patient had not moved, reported to medical. Medical (nurse? not
documented) aslced If Green was breathing. When told he was breathing nursing
Informed they would checl< on Green later in day.
o
o
o
o

13:45
o

•

Deputy log Indicated depuly agnin informed medical patient had not moved positions.
Deputy indicates he had spoken to Green prior to that call

15:30
o
o
o

CONFIDENTIAL

Medical contacted by deputy checlced on Green. Green reported ''I tllink I'm paralywd.''
Per deputy unoble to move upper or lower extremllles.
Deputy personally talked with nurses who evaluated Green.
KW and nurse evaluated patient and determined he needed transport to hospital. Per
KW tiote (not timed) plltlenr unable to squeeze fingers with hands or plantarllex ankles.

CORIZON003367

Exhibit 65 - Page 4 of 27
Dec'l of JTD

 ~~~

•
•

•

•

lone cou nty

llo. 7532

Groon hypotensive and IHadycardlc. Green reportedly movinc hend and necl< VJlthout
apparent discomfort
15:50 Nurse Leah took patient vitflls
16:15 Medical personnel cleaned patients tool 'llld place adull undergarment
16:50 Medics arrive to tnmsport pa11e1H lo hospital

Problem 111 Incomplete documentation
o

Recommendation: All charc notes ana ordcr.s need to be signed/ tllllod/ and dated

o

Implementation: Immediate

Pro!JIQm !a Patient with concern for possible spinal Injury cleared without Imaging
o

Recommendallon; All patients VJilh possible spinal Injury receive Imagine he fore being
clearecl

o

lmplementallon: Immediate

Problem 113 Pa~lent with possible splnnllnjury not placed In C·collar or on spine board.
o

Hocommendatlon: All P11tlent wlth,posslble spinal Injury not placed in c-collaror on
spine board until cleared

o

lm lementotlon: Immediate

o

flecommendatlon: Obtain C-collar and spine board for clinic

~Uli_Orqel' for Nc:uro check not written In orders, only on progress nol e

•

o

llccommendatlon: All nursing orders to be written in order sheet

o

Implementation: lm

Problem 116 Neuro checks not done
o

Recommendation: All nursing orders to be written In order sheet

o

lmplemantatlon: lmmP.dlate

,Problem !17 MediCi! I follow-up not done because staff believed the patient was l)elng releasocl
o

Recomrnendatloll: Institute process to ensure all medical follow-up Is dona unLII
confirmed release. HSA shoulcl be involved In this planning

o

CONFIDENTIAL

lmptP.mcntotlon: lmmCldlate

CORIZON003368

Exhibit 65 - Page 5 of 27
Dec'l of JTD

 SENTINEL EVENT REVIEW COMMITIEE FEEDBACK
The Corizon Sentinel Event Review Committee hns reviewed the Sentinel Event submitted by
your facility regnrding patient Kelly Green.
X

The committee agrees with the SMD/RMD ilssessrnent that thi s event is a Category

4.
_ _ We commend your efforts to rnilnage this pi!tient's healthcare appropriiltely.
_ _ There are preventable errors of omission/commission associilted with
opportunities for improvement in systems/processes, please submit those areas
identified with a Corrective Action Plan.
_X__Corrective Action Plan regarding preventable errors of omission/commission
associated with opportunities for improvement in systems/process was received,
no further action necessary at this time.
The committee disagrees with the _ _ assessment of Category __
instead assigns this event as a Category _ _ .

_L.__

_

and

_ _ The Committee commends your effort s to milnage this patient's healthcare
appropriately.
_ _ Since there are preventable errors of omission/commission associated with
opportunities for improvement in systems/processes, please submit those areas
identified with a Corrective Action Plan.
_ _ Corrective Action Plan regarding preventable errors of omission/commission
associated with opportunities for improvement in systems/process was received,
no further action necessary at this time.

Com ments/Explanntion:
Al so noted incomplete intake from 12/20/12. It does not appear intake w<Js ever completed .

I l11~ Uuo ftt t tmpro'Jr·n lC'nCdocv•11 ent 1S con,lldt'fi(IUI ant1 prou:-c tc d o y /ego/ pfiOJ tlegt' 111 <Jl lOrdance 'lll t h St at e PCt!l ReviC' W Lo ws

© Corizon, Inc. 2013 All rights reserved

CONFIDENTIAL

CORIZON003369

Exhibit 65 - Page 6 of 27
Dec'l of JTD

 SENTINEL EVENT NOTIFICATION FORM

C®RIZON.

Form musl be Complete and Legible.

CONFIDENTIAL · DO NOT FILE IN PATIENT'S RECORDS
TO BE SUBMITTED TO CORIZON CLINICAL SERVICES DEPARTMENT ONLY

Site Name (Do Not Abbrovlato)

Cfo~ o t:,

LAN~ C.OUIVIY 'JI~ I L

·-

Dato of Event

Silo Number

//2_/ / 3

;).._

Patient Name

Custody Dato

Gre e. AI JJ:

Last
Inmate Number

I

First

Sox

/):t'f l.J5&.

~Male

0

k~tt.Ly

I

Birth Date

Female

~ I

:J./

I

'2 ~-

/If

;)..

Ml (.,

1/ j

Dato

Lf

//J

1/J

Please check the type of event which occurred:

Type of Event
Non-Designated

Designated
o Mortality

o Loss of Limb

o Completed Suicide

o Vision Impairment I Loss

o DKA

o Hearing Impairment I Loss

o Medication Errorj

If @}Elf 'io/N 1JfF Unexpected Neurological Impairment

o MRSA Infection

1

11

JJ.~' .r!l'

R: Suicide Attempt
o Status Asthmaticus
o Ruptured Viscus

Paralysis

o Brain Damage
0

Unexpected Reproductive Organ
Impairment I Loss (Child-bearing age)

o Pregnancy Related Complications
o Ruptured Ectopic
o Fetal Demise
o Any On-Site Delivery (Precipitous Birth)

o High Profile (Media, Client Attention)
o Other _ _ _ __ _ __ _ __

Completed by:

- -:-:-'-t:. : .~. .:.c'lc:. . '--''IV /?..L!J=S/I"-(..=&!{2
'--'-"---'-£-/V_-'//-''--·5'-::1::::--/ -Name (Pieoso Prlnt Leglo!y)

Tltlo

Fax Completed Form to 877·729-7063
roonJ... SM'.htt ewnl t~:.hc.J~on FoilJt
R$\l~l J..\.ay

1, 2013

CONFIDENTIAL

CORI ZON003370

Exhibit 65 - Page 7 of 27
Dec'l of JTD

 Sentinel Event Committee

C~RIZO

Review Form

--- - - -

r--

-Revicw~::r:
-

-

Ocm~1ics

-

- ---- -

Tonya Mooningham
Facility: l.ane Count ' J ai I
Patient Name (1 1~1. Firsl lnillnl) Green, Kelly
Inmate /1: 1524456
Date of Incarceration:
Day of Week: Tuesday
I DateofEvent: 02/12/2013
Patient 0013: 2/11 /2013
I Patient Age: 27
I Gender: 0 Male l J Female
Type of Sentinel Event: L J Mortality l J 13chavioral Health l J Non i'vlortality ~ Non Designated ·Past Medical Histo1y (List Pertinent Diagnoses): llx of paranoid schizophrenia
Note pertinent medications:

Succinct, Chronological Summary of "WHAT" llappcncd
-

13riefly sumnwrizc care prior to event: Thi s SE was captured through our PLI team via the inmate's attorney
and not repo11ed fi·om the site.

Primary circumstances leading up to and resulting in the event: PLJ reported the following event: Mr. Green
who hands were handcuffed behind his back at the time, became upset durign his court appearance and ran as
fast he could with his head down before striking his head ngainst the wall. This resulted in him splitting his
head open with much blood on the floor of the courtroom. Following this incident, the patient was treated on
the medical unit at the jnil tor the evaluation and treatment. Later that snrne day, the patient was sent to the ER
for care. He apparently was found to have a frnetured neck.
Describe event :

(

·f,

Post-event pet1inent information (0 N/A) : Event analysis by the site Patient Sn fety Committee: see r~::porl.
Most conccming pnrts olllle review: No documentation that the c-spine wus secm·e<l or ''"" the inmate"'"'
placed on a back board during transport.
·.

--

,
1

CAP includes obtained (C-collnr and spine bonrd becnuse these arc not ;,_,ailablcanhc-siJe. Order for neu ro
checks not written in the physician orders, onl y written in the progress notes. Neuro che~ks not done.
recommendation is that nil nursing orders nrc to be written in the order sheet. Imaging must be performed on all
pntient1s with suspected spinal injury before being released from medical

· -Summary nf"IIOW" It
List Errors of Omission/Commi ssion: See report

r-

~-

- - -- - - - - - - - -

- -------

ll~cncd

- ---

- --

List System Defects (Consider environment/Htcility, tools lsupplieslcquipmcntl , tasks, people. work llow.
policy): see report

I

I

j

1

CONFIDENTIAL

COR IZO N003371

Exhibit 65 - Page 8 of 27
Dec'l of JTD

 nest Judgment of I\ WHY"

1--- - - - - - - - - -

Check possible contributing factors:

0
0

- - - . . = = ; ; : - - - - - --

~ Documentation:

[g) Human error
Mistake
At risk behavior/choice

~ Reckless behavior/choice
0 l3reakdown in communication
Lack of standard processes
0 Corizon policies and procedures
not implemented/ followed
0 Lack of fail safes
0 Motivational issue
0 Engagement
0 Accountability

0

-

0
0
0
0
0
0

0
0
0
0

Desensitization
No use of NETS

Inappropriate Usc or NETS
Poor Documentation
Failure to work as a team
Training issue
Knowledge issue
Decision making issue
Information/data lacking

~ System Detects

0
0
0
0

I

----1

I

Labs
Medications

Tasks
Policies & Procedures
0 Work Flow
1:8] Supplies/Equipment
Facility
0 Other:

0

Other:

---·- - -- - - - - -- -----,....,-- - - - - - - - - - - - - - - - - 1---.=....--c-:-:---~-----,---------"-'
R is!< Man a gem cut Analysis
------Failure to triage properly
12) Training & Education
Delay/failure in diagnosis
Desensitization
~ Delay/failure in treatment
Repeat visits
!3] Failure to follow-up
~ T iming
1:8] Documentation
Patient refusals
NETs
__ __ _
_D_O
=--=t~
he:..:..r.:...._
: _ __ _ _ _ _ _
_ _ _ __
C ase Ana lysis
_ _ _ -:--- --:-:--- What corrective actions need to occur? CAP includes obtained a C-collar and spine board because these
are not available at the s ite. Order for neuro checks not written in the phys ician orders, only written in
the progress notes. Neuro checks not done, recommendation is that all nursing orders are to be written
in the order sheet. Imaging must be performed on all patient's with suspected spinal injury before being
released from medical. See list for the entire CAP

0
0

0
0
0

0

SMD Cat4

IUviD Cat 4

SEC Cat 4

[g) A

0

B

0

I

I

C

2

CONFIDENTIAL

CORIZON003372

Exhibit 65 - Page 9 of 27
Dec'l of JTD

 1:::-:pl!dit~~d

Page 1 of I

Rcvkw-KG(?)NDSE
'

I'

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.
' J J '• I)
Expedited Review-KG(?)NDSEt:/1.[!;?, ..."' )}
Sentinel Event Committee
Monday, April 08, 2013 12:'19 Pt-1
t~l shlcr, Kevin
Cc:
Slcncak, Jennifer; Orr, lfarold; Legg, Jeremy; Garcia, Joanna
Attachments: A Nolification.pdf (30 KB); I Non Dcsignatcd.pdf (31 KB)
Sent:

To:

Sentinel Event Review Request (PLE/\SE EXPEDITE)
The following sentinel event has been identified through Professional Liability. Please forward
attached documents according to Corizon's sentinel event review policy and procedure to
Clinical Services.
Facility:
Patient Name:
Inmate#:
Evont Date:
Type of Event:

Lane County Jail
Kelly Green
Unknown

2/12/13
NOSE

Sentinel Event Committee

COHIZON
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•·: ~ l f))d, 1\ ,vu

I Sll il C'

~ · 'I fu r•t tt•:mo.l ,

-r,;J 1702/

l~t;!../ /_W'/Jw.cor izonheallh .co•n/

This e-mDII correspondence and any al/achments a1e c.C?nftdential and protected by legal pnvtlege tn accordance
with tllo Fedora/ Patient Safety & Quality Improvement Act of 2005 and applicable Stale Peer Review Laws.

If you are not the intended e-mail recipient. be aware that any disclosure. copying, distribution or use of this e-mail
or any attachment is pro/1ibited.

If you lwve received t11is email in error. pleDse notify t11e sender by replying to this e-mail and deleting
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https :. •" l'i111Hlil.corit.onhl!ultlu:omluwa/'!ae- ltl!m& 1'"'1Plvi.Nole&id -Rg;\/\AAClvl:-:dC%2b.. .
CONFIDENTIAL

it. and tile

4/ll/20 I J

CORIZON003373

Exhibit 65 - Page 10 of 27
Dec'l of JTD

 1'\V: Pati~;:nt/lnmatc- Kelly Green, Site - Lane Co. Jail, DOl - 2/12/20 13

FW:

Patient/Inmate~

Kelly Green,

Site ~

Lane Co. Jail,

Page I uf4

DOl ~

2/12/2013

Andersen, Briana
Sent:
Monday, /\pril 08, 2013 7:51 M1
To:
Sentinel Event Committee
Importance: High

Plcilsc request an expedited sentinel event review of the beiO\'i case from Lane County.

13ri;m<t Andersen, J.D.
Associate Pilti ent Safety Officer
Co rizo ot Corp or;,t c Office

From: Haggard, Rebekah
Sent: Monday, April 08, 2013 7:'19 AM
To: Andersen, Briana
Cc: Herron, Britt
Subject: RE: Patient/Inmate - Kelly Green, Site - Lane Co. Jail, DOl - 2/12/2013

YES! Please get an expedited SE review .. ..and I will likely add a PLI with it....

Rebekah Haggard, MD, CHCQM, CCHP
Vice President, Patient Safety Officer
Corizon Corporate Headquarters
Office: 615·376·1317
Fax: 615·309·9421
105 Wcstpark Drive

I Suite 200 I Brentwood, TN 37027

l'ltis t•nwil unJ u twchmcnts arc conjidential. /{you orl! nor tht.· illl~nclccl It dJIH' 'H, tillY clll d O>IIrt.', cc'pymg, Uil tfll~tiiWn ot
thh t•mml ;,, error, ph'tHt! nCJtijy thr semh•r by 1!. plyiny tn tid" t'NHIII, tlu·n Jcletino it and th ~ rt•ply frum your muilhvA

UH" IS Jil v lolntt-tl IJ yt;u

hllve ' '-''"<''\'<. il

1

From: Andersen, Briana
Sent: Monday, April 08, 2013 6:'1 1 AM
To: Hilggard, Rebekah
Subject: FW: Patient/Inmate - Kelly Green, Site - Lane Co. Jai l, DOl - 2/12/2013
P l e.1 ~"

sec Brill's e111Jil below. Should v;c request that the si te report this a ~ a Non Designil ted event ?

13ria n.J Andersen, J.D.
A ~s oci ;o te

l'atient S<J f ety Officer
Corizon Corpo rate Offi ce

From: Herron, Britt
Sent: Friday, April OS, 2013 4:13 PM
To: Andersen, Bri<Jna
Sul>ject: Patient/Inmate- Kelly Green, Site - Lane Co. Jail, DO! · 2/12/2013

I urlier this week, we r eceived a letter from iln attorn ey reJ.lresenting this inmate. I he attorney stiltes in his
lett er 1ha t his client '\ truck his head while 111aking an in-custody court appearance" and that he is now
pernt cll lently p <Ht~lyzed. Th e attorney further indica tes that he int ends to pursue a cl <tim ilgil inst Corizon and it s

https: //\\ l'lmwil.~.:urizo nht!altlu:om/owa/'?ae= ltc m &t= l P,\ •l .Notc&id- RgAAAAC;-vlxdC%2b.. .
CONFIDENTIAL

4/8/20 l l

CORIZON003374

Exhibit 65 - Page 11 of 27
Dec'l of JTD

 F\\': Palicnl/lnmalc - Kelly Green, Site - !.am: C'o . .Jail, DOl - 2/12/2013

Page 2 ol'4

!.taft in connection with the injuri P.S sus tain ed by M r . Green
From v/hil t I understilnd right now, rvl r. Green, whose hands w ere hand cuffed behind his hilck at the time,
bPc.rn rc upse t clurine his court appeara nce and r<111 a\ !r~ st as he cou ld with his head rlow n before striking his
lw.Hl .• garn st the V~tlll This re~ ultNI in hin1 spl it tine his hea d open, and there was much blood on the floo r of thE'

<our It •10m. ro llowing the inciden t in the co urtroom, Mr. GrE>en was brought to the nrr dir.alu nit at the jai l for
cvalrro~tron and trea tment. Later o n !I rat sam e d<~y , he was se nt to th e emergency room for care. He appnre ntly
w il~ fPtrnd to havr a fract ured neck.

Per SLi rwontla, this w,1s not report ed as a se ntinel event by the site . Would this be an eve nt the S[ Committee
should review? Or sh ould we instead pro ceed with requesting n PLI review given the apparen t severity of the
injury ~ u sta ined by Mr. Gr een?

Britt W. Herron
Sr. litigation Manager I PL Claims Department

Office: 1115-660-6826
Cell: GIS-519·0186
rax: GI S-309-9402
Em~ll:

hfJ\l her r ot~CO IIWtl h,dlth. com

105 Westpar k D11vc

I Suite 200 I Brentwood, TN 37027

~~-~"'' · ·<~· · i 7 rl!.!l_rt-. 11th

··om

u1 ul r . .• , •:trt,nn 1e ' t I •n1 ,,• . ,.,e tl w
C 0\ 1 II) I \ 1'1.\LI'I \''lOTI : : 'I hi\ curail aud all) ulladtrn<' lll~ llHI) h<·nonfitl~utial anti pmtt·ch-tl h~ ln:al pril'ik~~ ··· II
.' 1111 :r r •· no t I he inii' IHil'll r,•ri pil·nl. h e allan: th:rl ;ur~ tli ~ l'l oM II'l', copying. dislrihutiun ur u~c nf lh•· •·- mail or au~
al lad ofill' Ill " pi u hibilt·tl. I r )'1111 h:t\ (' n·n·il l'U thi' l'lllail in (' 1'1'111', pkil\1' IIOtify "' inHIIl'tlialt.:l)' h~- n· pl~ iu g to thl·
' l' lltlco· anti tlcll-linl! I hi ~ cop)' and l h•· r<'pl) lm111 ~our ~)'\ ll' lll . Thank yon fur ~o11r conp..ratiun.

From: Herron, Britt
Sent: Wednesday, April 03, 2013 3:57 PM
To: Hodge, Schuronda
Subject: RE: Patient/Inmate - Kelly Green, Site - Lane Co. Jail, DOl- 2/12/2013
01<,1y i lra11i<~. I will chPck with the· HSA to see whil t In• cnn tell me.

Britt W. Herron
Sr. Liticatlon Manager I PL Claims Department

1-'rom: Hodge, Schuronda
Sent: Wednesday, April 03, 2013 3:56 PM
To: Herron, Britt
Subject: RE: Patient/Inmate - Kelly Green, Site- Lane Co. Jail, 001- 2/12/2013

https:·1\\'L'hmai l.corizonhcalth.com/o\\'a/?a{:-= ltcm&t= IPM.Notc&iu= Rgt\t\t\1\C 'MxdC%2b. ..
CONFIDENTIAL

4/8/20 13

CORIZON003375

Exhibit 65 - Page 12 of 27
Dec'l of JTD

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CORIZON003376

Exhibit 65 - Page 13 of 27
Dec'l of JTD

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C~RIZON

LASTilAI.IE

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SOCIAL SECUAIT!' NUMBER

Wllero?
If yes, v.heo?
DYes

0 lnlorprelor Used
Name:

ONo

.I Prlvale Insurance:

Namo:

l~c

OOB

E>IJ-t/65

UMALE
0 FEMALE

SEX

KD

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ALIAS

riSITID

JC'J-4lf50
!\JAM
OPM

lnleko Refused? l.losl Recenllnearcoratlon: 0 t;ono
Woon?
DYes~ II avo you ov~r beon locarccraled here? DYes ONo
lnmale Tr~nsfer? OVos ONo
II yes, re(Ords r~fled?
Primary Care Provider:

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INTAKE
RECEIVING AND SCREENING
LANE COUNTY JAIL
DATE

~

uJ~-~t-ek

1'0.-r

d-vc: !--- ptlj

0 Nona

Namo:

CRITICAL OBSERVATION
UrgenVEmorgoot Medical Referral
0 Yes
-~o Indica!!on
0 S6vera rn;vry 0 ure Throalenngllnoss 0 U~nlrollad Bklooing
0 Sa1·ere Pain 0 Head lrauma wtMeolal Slai\Js Change
OO!her
RosponsivontJSS
Orion!ed To
DYes
ONo
OAJ!/1
Person
o Vo!bal SUmuJus
Placo
DYes
ONO
o PalniJI SUmutus
o Yes
Time
ONo
0 Unrospons~;e
Ooscriba
Oesct.be flosponslveness
Llobllity Restrictions
OVes
0 Oetormity
o Arr.pur.aron
~0
0 Other

OCast
OSp'"nl

UrgenVEmergent Security Referral
OYes~o
0 Uncooperative 0 Threaten'ng
0 Other
UrgenVEmergenl Menlall!eaflh Referral
OYosONo
Reason
o AClive ttaruclnaC~ns o Activa Da'lJS!ons
0 Activef1 Sulddat
OOiher

Physical Alds
0 Parap!<g'c
DYes
OWneelchair
0 Quadripleg!o ~0
0 Cru!chesiCanes
OOiller

Weight

Temperature

Blood Pressure

Pulse

'IR<v«-'.:IIOO<O:Id)

--~ ills

OAciDAp:d

-_ _ _

OActOApld

Initial
Rechec~

OAOP

m~er

Dear
0 Yes 'l!l;t~o
DRi9hl Oleft
DOther

DCPAP

VITAL SIGNS
llolghl

Communlcablo Diseases: Possible
MRSA
DYes ONo
IJa~:•a (Ch'tl<en Pox) avos DNo
Hetpes Zoster (Shlng:es) 0 Yes ONo
LlceiPed'cu'<lsis
DYes 01'\o
DYes ONo
Jaund~a
DYes ONo
Need:emat<S

· [J One

Respirations

Blind •
0 Yes.-hNo
0 Right 0 Left
0 Other

DBoth

0 0o111

or more vital siQns relusod
Pulse Ox

_ _ fn>jat

- --

lf'li1lal

• _ _ Reclleck'

_ _

Recheck' _ _

--

Jn:tial

finger SUck

Peak Flow

--

_ _

Rfchocl<' -

-

lr.il'al

lll'1'al

Rechecil • _ _

Hoc~~·

IDSTORY
Recent Medlcallfospl!allzatlons (wilhln go d.sys)
aves
ONo
Uyes, do!cribe

Recent Mafor Surgical tustory (within 90 days)
o Yes
ONo
0 Bro'n Surgal'f 0 Heart Surgery
0 Abdominal Surgsl'f 0 Olher
Forna!e Hlslory
,fj(_NJA
Date ol lasl Menslrwl Period?
Aro you eutrenL'y pregnant?
OY ON
PrCjjMncy Test Rosull
Cl Pos 0 Neg
Fingers~ck Rew!t (U pregnancy lest Positive)
Have )OU de!ivorcd, had a miscarriage,
or abortion In ~.a pasll2 l'll!o~s?
OY ON

Presoandos
Funerm
Last Pregnancy?

0 Ma)bO I Don't Know
0 Schedu:ed 0/i!A

Promaruro
Aborfuns
last abortion?
LMng

!'RE-ADMISSION MEDICATIONS
NAI.IE

DOSE

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0

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SIG

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Ct.
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Gvor ~.ad a lransp!ant?
DYes
ONo
Ol<idtley
0 OLier
Current mea.cation lor organ trrmsp!ant? 0 Yes 0 No

- -

----- - - - - --

Pap Smear
Dale OfllSI
Rewa

0 Unknc11n
0 1-:ormal

o Abnormal

Mammog•Jm 0 UnknO'.'.n
Oala offal!
Res~ I

ONono
0 Don't Xno~1

ONone

0 Normal o Abnormal o Den' I Krw11

No no Cl Unknown 0 Sco Allached Form
LAST DOSE

REASON

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ALLERGIES - oo you havo •nv allergies (food, medfcallon, envlronmonlatj? o V~s o :-:o

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CONFIDENTIAL

!>20!0 • Prkcn Hea~h ~f\·fces, rr.c. · .All R'ghls Reser~ed.

€0 112.3-908C6

CORIZON003377

Exhibit 65 - Page 14 of 27
Dec'l of JTD

 r-

1\LCOHOL USE
Oo )'OU drink olcohcl?

TOBACCO USE

aves

SUBSTANCE/DRUG USE
Oo ~u usa drugs?

0 Yes Ot.'o
a CUrren! a F01mer 0 Never Do )'OU useiojet!ab'o drugs? OYes Ut.'o Lasl uso ol V~;ecteb:e drugs?
Ho.·1onen?
How much?
lasl uso?
Amo~nl? _ _ packs/day
_ _ _ 0 Hx olvO:\Ildra.nl
0 Hero!n
llrmloog?
0 Hx of wilhdrawal
0 NarcotX:s
Oo you smol<o?

at."o

V/1131?
Las\Usa?
~IOWmiKh?

Howoheo?
Excessive Dookcr?
a Yes (CIWA) 0 No
Ever had alcohol wilhdlawals, tremors, seizures, or DT's
ossoclaled wilh slopplr.g alcohol? o Yes (CIWA) 0 No
II yu, 11hen?

--- - - 0

a Beozodlazepilos
0 Molhampher..,.;nes
o Cocaine
OOiher

Hx ot wirhdrawal

COI\·IMUNI.CADLE DISEASES
Hepalllls
Hove ycu over had hepa•ills?
llopA?
HepB?
HcpC?

DYes
DYes.
OYts
OYes

ONo
ONo
Q t-.'o
ONo

STO's
Oo you currenl.,. havo an STD? Q YesONo
0 Syphilis?
0 Bc'ng Treated
OGonorrhea?
Q Deilg Treated
Q Cll13m)'ll:a?
o llc'ng Trcalcd
o Herpes?
0 ae·ng Treated
00!11817
o Be~ Treated
Oo )'OU currcnL'y havo symp!oms? a Yu 0 No
Oewlbe

0 llx ollreanJenl

a Hx ot.treamenl

HIV/AIOS
Q Yes ONo
oo you have fiiV inlection or AIDS?
Are you cuuenlly ta!dr.g rneoicat'on(s)? a Yes o~·o

I

T6Symploms
TB Sktn Teel
Do )'CU havo?
PriortPPO?
0 Yes 0 No 0 Oon'l Knov1
Welglllk>ss DYes ONo Pers1slent Co~ogh > 21Yeeks 0 Yes ONo Curren ITB medicaLion? OYesONo
OYes ONo Current LTBI merf<:afonf D Yos 0 No
N!Qhl Sweals OYes ONo Coughing Blood
Fover
DYas ONo Weak!Tired
DYos ONo

Plant PPO Novfl

0 Y8S

ONo

II no, Rea Eon
LocaL'on?
OLFA
OAFA
Oalo Plant~ _ _ _ Plantc(s lni"!als _ _

CHRONIC ILLNESSES
Asthma
Do you havo asl~.ma?
DYes
ONo
How long?
LasI episode of shortness of brcalh? _ _ _
f:R m:t in las I90 days?
OYos
D No
lyu, when?
Hospl~li1ation IIIIas Iyear?
DYes
ONo
Wyes, when?
Evor Intubated?
DYes
DNo
H~s. when?
Cuuently on storo.'(fs?
rea%flow

D Yes

DNo

(

Angina?
aves
DYos
S!ents?
lleart AHaclr?
DYes
Bypass Surgerr?
DYes
CHf?
DYes
Heart valve reptaceiN!nt? 0 Yes

ONo
ONo
DNo
ONo
ONo
ONo

Dale of cn;et:

Alrial Fibriilation?
Pacemaker?
lntom2t Dof,bri'tator?
Endocard.'Cs?
Blood clot in1\.ogs or legs?
Arc )OU talclr.g Warfarin,
Coumad·n. or Jantovon?

OYesDNo
OYesONo
OYesDNo
OYesONo
0 Yes D No

0 YesD No

Disease

Have IOU ever had a:
CVA (S~oko)?
DYes
When was last?
Wilh!n past year? DYos
TIA (Milli.S!ro~o)? 0 Yes
l'lhon was la1t?
\'f.th'n pasl year? DYes

ONo
ONo
Ofl:o
DNo

Commants

last episo<le:

C010monls
)

Olabttn
Have you over hed d'.abeles 01 a problem w:th h'gh b~ood sugar?
Howloog?
Are ycu currently lak!og meoicat'on(s)?
Aro you curreoL'y Ia~ lnsurn?
HO!p'!a'izaron in ~sl ~ar?
It yes, when?

-DYes ONo Flr.ger Slid(
II Finger Stkk >300. ask tho to:k;11lng
Nausea?
DYes
DYes Olo.'o
Vonil'llg?
DYes
DYes a No
Excesstle lh'tst?
DYes
DYes DNo
Urlno Ketones 11 t>Cau.J

Epllepsy/Solzure
Havo you ever had a seizure or cc·nVU'.sion?
l as I Solzuro?
Frequency greater than once a month?
T11o or moro antlconwlsanls?

DYes Olio

Oaslrolnteellnal
Have you ever been Ilea led tor problems 11ith slomach cr bowe:S?
Havo you over vomited b!ood?
Ever had dark, b!Jck s!oo!s from b:Oed'ng?
Havo )'OU over been lo!d )'CU have clrrh~~:S?

DYes
DYos
DYos
OYos

Canctt
Have you over had ~ncar?
DYes Olio
Co IW correnL'y have e<~ncer?
OYesONo 0 l111ktlo.m
Aro you currenlly being lrcated lor cancer? 0 Yes 0 No

Olio
ONo
ONo
D/1/o

Frequency?

lasl?
Lasr?

fr~uency'l

Cctm1enls

-

(

)

(

I

Qf(o
UNo
Olio

---

Hyperlenslon
Havo you over had h~h b!ood pressure or hypertens!on? 0 Yes Olio
How long?
Are you wrrenltf laking medlcalion(s)?

Ccreb!ovoscu~t

Cardiovascular Obeaso (ask eoch quesllon)
Have you ever had any ollhe foUOI'I.ro!J prob'cms v.ilh your hca~:

-

Dlalytls
Aro \'tUClllrenl~/ on dlaiys's?
D Yes Di':o
Aro )'CU re~lving )'OUr diatJdS kealmcrJs? 0 Yes D :O.:o
Type?
0 Hemod'a:ys:s 0 Peri:oneal
Number ol ~mes per week? _ _ __

I
I

OYes Olio
DYes ONo
DYes ONo

Ccm.r:enls
Comments
COPO/Emphysoma
Do I'CU have COPO or emph;seml? 0 Yes Olio
02 dependant'!
DYes ONo
{
Peak Flow
i

I
I
I
'

l asI dia ~Jzed?

·--~--~~------------------~~~:=:----~=====-------~--------------------~

• Other Curtent Slgnltlcantl.tedlcal Conditions:

Pa~e

2 ~~ J

CONFIDENTIAL

Referral Needed' 0 Yes

02010 • Priseo ttral:h Serlocos, rnc. ·All R'ghts Aesr

60lt 2J·90eco

DNo

A~''· 121~9

CORIZO N003378

Exhibit 65 - Page 15 of 27
Dec'l of JTD

 MENTAL HEALTH
Do you have a history ol a menial hea~h diwrdet?
Ha'/11 vou been diagnose<! as bipolar?

~es

DNo

Ha\'e you beon diagoosed with schlzoph:onla?

DYes

DNo

Have you been d·agoose<l with ma;or depression?

~OS

DNo

DYes

DNo

History of heamg things?

DYes DNo History ol psycholtop~ rr.edicat:OO(s)? D Yes DNo Hislory ol psych hospilatizd!ion?
~sONo
(I
o Vos ftiNo""' /2..1.-IH
With'n last year?
..
9:3-Yes DNo lliSIOr/ ol seeilg things?
~Yes DNo /vo you Wn'<ing about hutUng youtse:l7 u Yes D No

Fam1ynriends Nsl()()' ol su'(tda?

DYes DNo Recent slgni.'icant !oss?

Do )W leel lrope:m 0{ he:p!ess?

-·

DYes Dl\'0 Hisloty ol suicide a~empt(s)?
Are you lhlnl<:ll1J about suicide no.v?

o

fl{jo

a

Yes No Last attempt? _
DYes ONo

_

Ara )'llU lhlll!Ung about hurting olhots? DYes ONo Evet hospitalized ft(){O head ~<uma? 0 Yes DNo
Histoty ol: Special educa!ioll p'acement? 0 Yes D No
History ol 11olent boha'lior7

D Yes D

No

Leatnlt19 dsabi•ity? 0 Yes D f'.:o

History ol vict.imizaUon't

0 Yes 0 No

Oevc!opmenlal d'sabeity?

0 Yes

~No

Menlaltela•daiO,n? 0 Yes ON?
D Yes ONo

lttistory ol sex ol!enses?

EXAMINATION
Oon!ral Appeatanca

DNAO

U Aj:poars Hydrated

Otal Screening
D lkYemarl<ab!o 0 ~Usslng Teeth
Cl AI»<: esse s
a Ca~ ties
0 l es!ons
a Dentures Looso

D Other

Describe

Skin

0 Sy10f ng
tJ Other

Desr.rtbe

Visible skin exam?
0 Umomarl:eblo
Cl Open l es!on(s)
0 SOres
0 Lacotatloos

0 Yes
;i/No
0 Surg'cal Scars 0 Javnd'Q)
o Rash
o Pa~or
D Trac:<S
00Ul6t
D Talloos

DISPOSITION
Placement

oor

q lnf tmary
0 Svtc!do Wa:ch

Referral
DH &P
D Routine D Expedi:ed ~~lentallleallh Roleual ·lt(Rouline a Expedled
0 Nursing S!ck eag
D Routine 0 Exped'~cd 0 Chton'c Care Ctinlc
Q.Rout'nc D fxpedited
D MO,NP,PA Sick Ca'l D Routine D Expedited 0 Dental Referral
D Rou~na D Exped'led

a lsola~oo: ReaS()n
Cl Obsorvatloo _s;;,:c;.,

~Other

•/

Consent lot Tttaltnenl Signed
OYosONo Reasoo

Ia~rlevanca

Access to Care Reviewed
D Yes D No Aoasoo

Nolillca!lon
D lmmeo.ala Supoi'l.sor
D MllJNPrPA On Ca'l
0 ER FcrTtansport

Ptocess Explained
Yos D No Reason

ADDITIONA L COMMENTS

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1My In/ormation Is correct and I accept lho provision ol rnedlcal, dental, and mental health care.

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IPatient's Signature

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CORIZON003379

Exhibit 65 - Page 16 of 27
Dec'l of JTD

 C~RIZON.
.
General Consent to Medical ~ ..:rvices
PA11ENT INFORMATION

I

Patient Nou1e:

Dale of Birth:

I

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CONSENT TO TRBA1'MENT

I do hereby authorize my health care provider to provide me with gener2l clinical and emergency care.
My health care provider, mental health and dental staff wilt use clinical and patient management technique:s that
are reasonable, necessmy and advisable.
Separate informed consent will be required for specific procedures.
In the event that a staff member is exposed to my blood or other bodily fluids, r agree to have my blood dra\'vn
and tested for Hepatitis B Virus (HBV), Hepatitis C vims (HCV), and the human immunodeficiency vilus
(IllY). I understand that this testing would be done in 11 confidential manner, and would be made available Ot\lY
to the person (and physician responsible) who was exposed.

CONSENT FOR USE & D!SG'I.OSTIRE OF HEALTH TNFORJ'r/ATION

I understand that, by signing this consent fonn, I am giving my consent to the use and disclosure of my
protected health information as described on the Notice of Privacy Practices to cany out treatment, payment
activities and health care operations.

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Signature:

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Time

INTER VIEWER

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CONFIDENTIAL

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CORIZON003380

Exhibit 65 - Page 17 of 27
Dec'l of JTD

 TR ANSPORT REPORT
Lane County Sheriff's Office

~~===--------------------+~--1=~--~--~~~~--

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On the above listed date/time I transported Green (VIa Medic 10) to Rlverbend ER for treatment of
self Inflicted Injuries sustained while In custody at LCAC.
Green was released to his father (Kelly Green 971-533-9278) via 3rd party release and provided a
citation to appear In Eugene Munl. Court.
I returned to LCAC wlthou Incident.

29. Ttonsporfing

Robb Ralph #149

41161
Form C77-335 Updol ed 8120 12

CONFIDENTIAL

CORIZON003381

Exhibit 65 - Page 18 of 27
Dec'l of JTD

 PROGRESS NOTES
Date/Time

G

Inmate's Name:

; AC:
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CONFIDENTIAL

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CORIZON003382

Exhibit 65 - Page 19 of 27
Dec'l of JTD

    

 

Date/Tl

 

  

 

  
  
 

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CONFIDENTIAL

    

Inmawa Name:

     
 
  
 

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CORIZON003383

Exhibit 65 - Page 20 of 27
Dec'l of JTD

Date/Time

.31  
gagg 423.5 QM QM. ?P?k



PROGRESS NOTES 

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CONFIDENTIAL

?aws/sf ?gie?rJ?cp? . Vivi/MA. 

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CORIZON003384

Exhibit 65 - Page 21 of 27
Dec'l of JTD

Date/Time

~P/L?J

Inmate's Name:

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CORIZON003385

Exhibit 65 - Page 22 of 27
Dec'l of JTD

 C~RBZON
Mental Health Pro ress Nute
Inmate Number:

Facility Neme:

Dole ofDhth:

/5 2.Ul/~C,
5

2-1

0

Time Seen:

85

Female
• ' ,1;

'Mi.:DJCATIONS .

Cw·fenl Mcdicntions (nil):

--------------------------------------------------------------

Med Complaint: QNo OYes:
Lnb~ Ordered: QNo OYes
_ __

_

Side Effects: 0No OYes:__________
Previous Labs Reviewed: ONo QYes Lab Results: _ _ _ __

1
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ODJEC1'1¥E Mental Stlltus: Orientation: Person: ,. Yes 0No Place:~Yes 0No Time: ' Yes 0No Situntion: p;_Yes 0No
0Fair
~I
0 Calm nnd·Co";ernti~ 0Normal social rhythm

Insight: }Jyoor . 0Fair
0Good
Judgment: ~Poor
AppearAnce Behavior (check all thnt nppl)•):O Adequate grooming and hygiene

0 Angt)'l~) .~Guarded

Sleep:
C)J>O'Or
Jftrnir
Mood/Affect (check all that apply):

0

0 Other: _ ___ __
~-·-QGood
Appetite: OPoor
.,0Ynir
0Good
Stable affect/unremmkable & mood congruent
rtl.J'lnt

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Speech (check all that apply): 0 Unremarkable
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G(J,y~

0

0Expansive

--

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[LJ'Difficult to intcmtpt
.,

0Months
Name{priol

CONFIDENTIAL

CORIZON003386

Exhibit 65 - Page 23 of 27
Dec'l of JTD

 ·

.Cf~RIZON

Mental Health Progress Note
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hunale Name:

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Today's Date:

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Current Medications (all):

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lnm at~ Numbrr:

Date of Birth:

ITime Seen:

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McdComplaint:QNo QYcs:'--- - - -- - - -- -- Side Effects: QNo QYes:_ __ _ _ __ _ _ _ .__
Labs Ordered: QNo ·QYcs
Previous Labs Reviewed: QNo QYes Lab Results: _ __ _ __ __ __ _ ___ _

MENTAL SfA.'J'US EXAM

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"JJIJ... ~o\'1' 1~ .d~,» b MtM. UJ.J8Js &:b 11/~KI)J& .

SilllJECTIVE Inmate Comments/ChiefComplaint:

IJ~

(b)

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ODJECTlYE Mental Status: Orientation: Person: .¢Yes ONo Placc~_ycs 0No Time: ~.).'es 0No Situationi) Yes 0No
Insight: koor
OFair
0Good
Judgment: ·@'.Joor
0Pnir
QGood
Appcruauce Behavior (check all that apply):O Adequate grooming and hygiene ,ID_calm and Cooperative 0 Nom1al social rhythm

0 Angty/Agitnted
Guarded
C\ 0 Otbcr: __..:..(?-bb=r-./.
= .~'-'.::: f';t."'-- @1(
'--'-----~.''+';- - - - - - -------- - - Sleep:
QPoor
QFair
~Good
Appetite: QPoor
_.<QFair,
QGood
Mood/Affect (check all that apply): 0 Stable affectlunrcmarkablc & mood congruent
[(J Flat
0 Expansive
_. _ ....._ __
0 Eutbymic Mood 0Dysphoric Mooli OOther:
Speech (check aU that apply):
Unremarkable
0 Pressured
0Loud
0 son spoken
-ODifficult to interrupt
OOtber:
---------e--~--------------------------------Abnormal Movements:.S.No QYes:
•
----~----~~----------~-------Thought Form (check all that apply): 0 Goal directed
0 Logical
0 Coherent @ .Circumstantial D Persevcrativc

JQ

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0 Obsessional
0 Loosely associated
0 Tangential
dQJragmented
0 Other: - --:=--- - - -- - Thought Content (check all that apply): 0 No evident psychosis
0 Delusional content
0 Flight of ideas
0 Ideas of reference
0 Allditory hallucinations
0 Visual hallucinations
0 Paranoia
0 Other: J>~rrs PS'tctlo1iC F&ffvMS, .!!:t.rr t5 /l.tSlovC4ikY f?<;JJT~'I JIL ·
Current Suicidal Ideation: ~o 0Yes: Plan of Action: _ _ _ _ _ _ __ __ __ _ __ _ _ __ _ _ __
Current Homicidal Ideation: _92No QYes: Plan of Action: _ _ _ _ __ _ _ _ _ _____ _ _ __ _ _ _ _ _
0Additional notes on reverse.
Cognitive FIUlctioning: 0 No gross cognitive deficits apparent ,g,Diminished ability to concentrate nearly everyday (cite objectil·e
information to support, i.e. decline in work or school performance):....:----'0-'-N-'-IWJ
-:.=..:...
Wc...JJ_ _ _ _ _ _ _ _ _ __ _ _ _ _ _ __
Oother Findings: _ _ __ _ _ __ _ __ _ __ _ _ __ _ __ _ _ __ _ __ _ _ __ _ _ ___
6SSESSMENT QStable
QMininlallmprovement
QModeratelmprovement
OUnchanged from last FlU
()Ofuer:_________________________ _ ______ _ ___________________ ___
Diagnosis:

P/o

Ps<fcijo1tc .bJS01b6ll, JJo5

Diagnosis Changed: 9)JI!o 0Yes:'--- - - ' - - - -- - - - - -- - - - - - - - - - -- - _. _ ___
~ QReferroll{oOther MH Services or MH Clinician: (Specify)_ _ __ _ _ __ _ _ _ _ _ _ _ _ _ _ .. _ _
Ongorng Patient Educahon about medtcattons and tllncss QNo QYes:'--- - - -- - - - -- -- -- - - -- Plrul for continued mental health trcahncut:
Nt~.fb

/JS

--~~~--------------------------

Name (p1int)

CONFIDENTIAL

CORIZON003387

Exhibit 65 - Page 24 of 27
Dec'l of JTD

 Appearance I Behavior.
Mood I Affect:

0 Normal social rhythm
0 Calm & cooperative
Adequate grooming & hygiene
~Other: .blS..YI.r SfOI~ ~ ((11A1aJJJ( /(r?:XtorJIJ§S
Angry & agitated
J
0 Stable 1ttect
J21Pysphoric mood
Euthyrnlc mood
OOther:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _-..-_ _ __ _ __
0
0
0

Speech:

0

Thought Form:

0
0
0
0
0

Goal directed
Obsessional
Illogical
Delusional content
Vtsual hallucinations

0

No gross cognitive deficits apparent 0 Other findings: _ _clt-'n"-{e><-''-''t,.,_:;-""!>'------Observed
Offender Reported

Thought Content:
Cognitive Functioning:

Normal
0 Pressured
ri1l Difficult to Interrupt
~~~
OOther: _ _ __ _ _ _ _ _ _ _ _ _ _ _ __ _ __
_ __ _ __ _

c:J

0 Perseverative
Circumstantial
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,@::Fragmented
~Flight of ideas
0 Auditory hallucinations
0 Other: lJJ\'I<J,~>WI'j 011J6)'v '7( .
Y

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Current suicide ideation, threats, behavior, or plan
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Current self-Injurious ideation, threats, behavior, or plan
Delusional ideation
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Psychotic symptoms
ftJ~
Agitation, anxiety, or tension
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Deterioration in appearance, self-care or hygiene•
Disoriented to person, place, time, and situation
Uncooperative with assessment
Other. _ _ _ _ __ _ __ _ _ __ __ __ 0

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CONFIDENTIAL

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Check all that apply:
on suicide watch status
Remove from suicide watch status & initiate step down procedures
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0 No current lntervention/recommendalion Indicated
0

Other.

CORIZON003388

Exhibit 65 - Page 25 of 27
Dec'l of JTD

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DESCRIBE CURRENT CONDmON:

Al-J'Y VERBAL HEALTH CO'Ml'Lr\INTS

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AS STATED BY INMATE

PHYS!CAL FD!D0:GS

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•l~;thl~ re"S.t:rvcxJ

Exhibit 65 - Page 26 of 27
Dec'l of JTD

 FOR OFFICE USE ONLY

SY

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Insurance - - - -- - -

Emergency Room Referral

PHS PRE·CERT

#
Onto:
From:
(Rofouing Pllys'clartllnstilul!on)

snell

SUe Nome:
To:

CCon•ultlnn Phvslcl&n/Addrossl

lnmato's Name:

CORlZON
105 Weslpar:{ Dr . Suite 2CG
Brentwood, TN 37027
Min:

Clal111s Depl.

DO NOT inform pusoners ci datetlime of re•,isits
or impending hospitalizalion.

Inmate's 1.0. II
ER PHYSICIANS: If llospltal admiss•on is recom·
mended. please nol i~/ PHS beforehand .

Dolo of Birth:
Social Security #
Wrillen by:
U R Authll

T

Financial Responsibility

Slgnlncant Findings, Including Tests Done:

Diagnosis:

Ordors/Recommendallons:

M.D. Signature
CORIZON70062

CONFIDE NTIAL

Date
(While · lloallh Record Copy, Yellow - Physician Copy)

CORIZO N003390

Exhibit 65 - Page 27 of 27
Dec'l of JTD