Response to:

Enhancement of Medical and Psychological Services April
2012 Audit David L. Moss Criminal Justice Center
6/4/12
To augment this audit, a separate internal review was done on inmates with booking
date 4/16/12. Although every effort was made to assure complete inclusion of all
significant information, we acknowledge possibility that significant items may have not
been located in the EMR.

1. Sick Call Requests –
Although there were no urgent sick call requests found on CHC audit, several cases
were identified where significant potential existed for negative outcomes. These
included:
Booking # 1316340
Booking # 1316398
Booking # 1316425
Booking # 1316434
JMS # 1130451 - although this was not kiosk delay, it was significant delay between
nurse visit and physician visit for what turned out to be pneumonia.
The overall number of inmates with > 4 hr response to kiosk request was quite
substantial. For all the reasons discussed at the March meeting, the primary concern
was avoiding delays in addressing high risk situations. Even without serious outcomes
in this patient set, the key for proper CQI is to eliminate system flaws that allow for
these outcomes.
Related to the above, there appears to be a major gap in meeting NCCHC guideline
under Correctional Nursing Practice Series – 4. Screening, Sick Call and Triage: If
the request describes a clinical symptom, the inmate must be seen in a face-to-face
sick-call encounter within the next work day. The majority of sick call requests,
reviewed in 4/16 audit, did not meet this guideline.

2. Admissions to the Special Housing Unit/Infirmary
15 inmates on CHC audit did not have a record of compliance with policy for medical
clearance.
Although no apparent effect on outcome, policy non-compliance should be eliminated.

3. Criteria for Immediate Referral to a Hospital

 Booking # 1316434 failed to comply with blood pressure parameter for referral as well
as failing to follow the Chest Pan protocol. Menses protocol B 07 not used.
JMS # 0063094 abnormal vital signs
JMS # 0068731 blood pressure criteria
Booking # 1318034 – appears to meet delirium criteria
4/16 audit could not identify actual occurrence where staff complied with policy. The
above episodes are of major concern for potential of the system to allow serious
adverse outcomes.. This should be cause to generate immediate systems’
improvement.

4. Daily Review of Infirmary Patients Clinical Status
JMS # 0063094 no documentation CMO not contacted for > 48 hr admission.

5. Review of all Emergency Department send outs occurring within 48
hours of a sick call visit or within 48 hours of booking in to the facility
JMS # 0063094 Complex chest pain, dyspnea

7. Review of Intake Prescriptions
On 4/16 audit:, the following showed medication delays:
B # 1316296 - also missed indication of ETOH Withdrawal Protocol L03.
B # 1316307 - also missed indication of Seizure Protocol K03.
B # 1318217
B # 1317908
B # 1316340 - missed indication of Asthma Protocol P01.
B # 1316374 B # 1316389 Based on the above cases and the CHC audit, it appears that this policy has
deficiencies for a large enough number that it warrants further system revisions.

8. Chest Pain Protocol
On 4/16 audit:, the following inmates demonstrated issues with protocol:
1207559 – needed protocol
0063094 needed protocol
1316434 protocol not followed
1316324 needed protocol
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 Based on the above, it appears that this policy has deficiencies in protocols being
initiated and complied with. Because of serious risk potential, the system flaws need to
be addressed immediately.

Summary
Assuming above date is accurate, overall the audits demonstrated deficiencies in
meeting majority of action plans as agreed upon in March and documented in 3/23/12
letter from Dr. Herr. Several [#3,8] are of major concern as they involve high risk
issues.
A key concept we are hoping to actualize is CQI that captures deficiencies real time
rather than on after the fact audits. We would like to have a detailed time-specific plan
for accomplishing this. Plan should include methods to identify policy deviation
immediately for high risk areas, and strong consideration for system identification of
others within 24 hrs rather than on delayed retrospective reviews.

Howard Roemer MD
Consultant for Tulsa Co. Sheriff’s Office
e-mail: moehowie@aol.com
Phone: 918-298-2377

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