Memorandum - DocumentCloud

PRISON
LAw OFFICE
General Delivery, San Quentin CA 94964
Telephone (510) 280-2621 • Fax (510) 280-2704
www.prisonlaw.com
Memorandum
To:
Clark Kelso, Receiver
From: Steven Fama
Date: August 4, 2014
Subject: CHCF site visit, July 15-17, 2014
Director:
Donald Specter
Managing Attorney:
Sara Norman
Staff Attorneys:
Rana Anabtawi
Rebekah Evenson
Steven Fama
Warren George
Penny Godbold
Alison Hardy
Corene Kendrick
Kelly Knapp
Millard Murphy
Lynn Wu
This report follows our visit to California Health Care Facility (CHCF) on July 15-17,
2014. We talked to medical executives including healthcare Chief Executive Officers (CEOs)
Bob Edwards and Jackie Clark, other staff, and prisoner-patients_ We also reviewed documents
including medical records and visited various areas of the prison where medical care is provided
or supported. We were accompanied by attorneys representing your office and defendants.
We continue to have serious concerns about the adequacy of care and medical delivery
practices at CHCF, even though the prison has resolved some previously identified problems and
continues its work to improve systems and processes. Perhaps most significantly- and as
discussed in the sections below regarding patient deaths, E Facility, and medical policies deficient emergency response practices continue, and the prison's ability to identify and selfcorrect these matters also remains deficient.
Our concerns are considerably heightened given that CHCF re-opened to new patient
admissions on July 21st. We understand that the new patients will arrive gradually, with the first
six weeks of transfers staged such that there are week-long pauses between the arrival of the first
100 and the second group of 150 new arrivals. We further understand the pauses will be used by
CHCF, regional, and headquarters medical executives to assess whether the increased number of
patients negatively impacts medical or other services at the prison, and whether the prison has the
staffing, resources, and other processes in place to adequately care for the next group of new
arrivals. We understand that further admissions will be slowed or stopped if necessary.
We appreciate this approach, particularly the plan to repeatedly assess both whether new
admissions have impacted care and how further admissions if permitted will impact care. As you
know, if all planned admissions take place, CHCF's current population will increase by
approximately 70% (an additional approximately 1,100 prisoners, including 7 5 high acuity CTC
patients, more than 330 OHU patients, 400 Speciality Out-Patients (SOPs, so designated because
they are medically high risk with long term care needs and the potential for clinical deterioration),
plus approximately 350 EOPs (very seriously mentally ill, many with high risk medical
conditions).
Board of Directors
Penelope Cooper, President • Michele WalkinHawk, Vice President
Marshall Krause, Treasurer • Christiane Hipps • Margaret Johns
Cesar Lagleva • Laura Magnani • Michael Marcum • Ruth Morgan • Dennis Roberts
Memorandum re CHCF July 2014 Site Visit
Page 2
Given the medical needs of every newly-received patients, the availability of adequate
numbers of Primary Care providers (PCPs) we expect that the availability of staff PCPs will be a
key element when assessing the impact of new admissions. As discussed below, CHCF medical
executives told us that if (or as) patient numbers increase, they will need to add staff PCPs. More
specifically, they stated they will need to not only fill eight currently vacant staff PCP positions
(including some which have been vacant for months), but also add nine more staff PCPs because
that is the number that would be necessary if the patient population reaches full capacity. In other
words, if all planned transfers take place, 17 additional staff PCPs would be needed. Given the
difficulties CHCF has encountered over the last year in recruiting and retaining the 24 staff PCPs
it currently employs, hiring that additional number of PCPs would be an enormous challenge.
Patient Deaths
Three recent deaths raise very serious concerns about the adequacy of medical care,
including emergency response and emergency response review practices. In addition, CHCF's
failure to address headquarters' recommendations following another recent death show that the
prison cannot yet adequately consider or implement corrective actions even when problems are
identified.
May 27, 2014 Death of C-Facility Patient
On May 27, 2014, a patient activated the emergency call light while in a shower in a CFacility (OHU level of care) unit. According to medical records, a registered nurse (RN) and a
correctional officer (CIO) responded immediately and saw the patient unresponsive on the floor.
In these circumstances, CCHCS and CDCR policy has long and plainly required staff to
immediately begin Basic Life Support (BLS) I Cardio-Pulmonary Resuscitation (CPR). However,
BLSICPR was not started here for six and one-half minutes, only because a physician arrived on
the scene. The medical records indicate that other medical and custody staff in the unit also saw
or were aware of the unresponsive patient, and also did not start BLSICPR. I was also told that
the delay and staff inaction was recorded by CHCF's video surveillance system.
It is shocking that a trained nurse and officer, assigned to a medical unit in a prison
hospital, would delay providing BLSICPR to an unresponsive patient for more than six minutes.
The extreme departure from basic duties, including when other staff in the unit also apparently
failed to promptly act, suggests profound incompetence or an unwillingness to provide care to
prisoners and is deeply concerning.
On June 2, 2014, CHCF medical and custody managers reviewing the incident formally
determined that the delay in providing BLSICPR was a problem I policy violation. However, the
minutes of the Emergency Response Review Committee (ERRC) meeting which made that
finding are extremely conclusory regarding what happened, stating only that "BLS was not
initiated in a timely manner" without providing a time frame, the type of staff involved (including
=
Memorandum re CHCF July 2014 Site Visit
Page 3
that both a registered nurse and a correctional officer failed to act), or any other narrative about
what happened. In fact, the minutes focus almost entirely on what happened after the prison's
Standby Emergency Medical Services (SEMS) staff arrived at the scene, more than 10 minutes
after the nurse and officer discovered the unresponsive patient. The ERRC 's failure to provide
any detail about the egregious BLS/CPR delay is inadequate.
The ERRC also failed to take appropriate action regarding the failure to timely initiate
BLS/CPR. The only corrective action it directed was staff training. While training is appropriate,
that alone is inadequate in these circumstances, particularly with regar:d to nurse and officer who
failed to act, because unless they somehow missed the standard training provided to all nurses and
officers, had already received as is true of all nurses and officers had already received BLS/CPR
training, and such life-saving action is a widely recognized core duty of CDCR medical and
custody staff.
When I asked CHCF medical executives about this incident and the ERRC's actions, I was
told that the acting Healthcare CEO had also requested formal personnel action regarding the RN
who failed to timely provide BLS/CPR to the patient. I also learned that custody executives were
still, at the time of my visit, considering whether to request or conduct an investigation regarding
the C/O's failure to provide timely BLS/CPR. When I asked why these matters were not
referenced in the ERRC minutes, CHCF executives said such minutes would "never" mention
actual or potential personnel actions or investigations, even in a case like this.
CHCF's view that ERRC minutes cannot and should never refer a matter investigation or
potential personnel action is wrong. CCHCS policy explicitly provides for ERRCs to refer
matters for investigation. See Inmate Medical Service Policy and Procedures at Vol. 4, Chapter
4.12.8 at Part IV.A.l.a. In appropriate cases, ERRC must also document that a matter has been
referred to appropriate supervisors or hiring authorities (i.e., the CEO and Warden) to consider
conducting or requesting an investigation or taking personnel action.
Finally, it is inadequate that CHCF's custody managers and executives (and/or CDCR's
internal affairs unit) were still considering- approximately two months after the incident and
approximately six weeks after the ERRC identified a problem- whether to request or authorize
an investigation into the correctional officer's failure to initiate BLS/CPR. It is not clear whether
the delay is due to medical staff not telling the warden, or the warden not knowing, but the ERRC
which considered the matter on June 2nd included a custody associate warden and captain. This
delay demonstrates either a failure to recognize the seriousness of the problem identified or an
unwillingness to promptly address custody staff's violation of basic patient safety requirements.
Aprill8, 2014 D-Facility Death
On June 25, 2014, CCHCS's Death Review Committee (DRC) determined that this death
was "possibly preventable" due to a delay in providing the patient access to care (a renal
ultrasound recommended by a specialist, which did not happen during the last part of December
Memorandum re CHCF July 2014 Site Visit
Page4
2013 and first months of 2014) and untimely review and a lack of recognition of abnormal labs
(which happened during the week before death.)
This case also came to our attention via our review of CHCF's official determinations
regarding its medical emergency response to the patient the day died. This case raises serious
concerns about the adequacy of both CHCF's emergency response practices and its
processes/practices when reviewing those responses. More specifically, in this case there was:
(1)
(2)
(3)
(4)
delay in calling the community ambulance for the patient;
delay in SEMS staff responding to the patient after being notified by housing
unit staff (or medical records that falsely state that was first notified far
earlier than what actually happened);
confusing medical documentation regarding when certain events took place;
and
a review of the incident by CHCF's Emergency Response Review
Committee (ERRC) that:
(a)
failed to identify or address key issues regarding
the emergency response, and
(b)
concluded the community ambulance was
delayed at the prison's sallyport for 21 minutes
while the patient died in the SEMS, seconds
away from the sallyport - and then failed to
further address that egregious problem for more
than two months until we asked about it during
our site visit, after which CHCF re-examined its
conclusion and determined that the ERRC "misinterpreted" information and that the ambulance
was not in fact delayed, with this subsequent
determination itself including information raising
questions about what happened, and when,
regarding calling an ambulance for the patient.
The information below about these matters is very detailed, but such is necessary given how this
matter unfolded and the sometimes inconsistent or confusing documentation of relevant events by
CHCF staff.
This case came to our attention when as part of our site visit we reviewed the minutes of
CHCF's May 12, 2014 Emergency Response Review Committee (ERRC). The ERRC evaluated
the medical staff's response to the emergency both in the housing unit and then in SEMS in the
time just before the patient died. The ERRC on that date, as reflected both in the time-line
included in its official minutes and as it explicitly stated there, determined that the community
ambulance that had been summoned by prison staff spent 21 minutes in the CHCF sallyport
before it reached the patient.
Memorandum re CHCF July 2014 Site Visit
Page 5
A 21 minute delay for an ambulance at a prison sallyport would be extraordinary and
egregious. Such a delay would be especially concerning here given that the patient was at the
SEMS just seconds away and- according to the ERRC time-line- died while the ambulance was
delayed at the sallyport. The ERRC's May 12, 2014 minutes state that the "inadequate"
ambulance response was "[r]eferred to custody." During our site visit, CHCF executives
explained that such action was intended to result in custody staff reviewing and reporting on what
happened, since it is correctional officers who are assigned to the sallyport.
However, the minutes for the subsequent ERRC meetings I was provided (held in early and
late June, respectively), included no information regarding what custody (or anyone else)
determined regarding the ambulance sallyport delay, or even any indication that the issue was still
pending. During the afternoon of the last day (July l71h) of our site visit, I asked what had
happened. No one present, including medical executives, the acting Chief Deputy Warden, and
Associate Warden for Healthcare, knew what had happened, even though no one disputed that the
delay had occurred. CHCF executives and managers indicated that they would look into the
matter. That a question of this magnitude remained unresolved more than two months after it had
been formally identified clearly shows the inadequacy of CHCF's current emergency response
review process.
On July 18,2014, we informed the Receiver's office of this matter. Later that day, that
office forwarded us the community ambulance company's Patient Care Report for the April18,
2014 incident. That report sets forth times for certain matters far different than those reported by
the ERRC. Most notably, while the ERRC reported that the ambulance was notified at 0642, the
ambulance company said it occurred (time-rounded to nearest minute) at 0709- a difference of
more than 25 minutes. In the ambulance company's time-line, there was no sallyport delay.
We then asked how the EERC got its times (and ultimate conclusion of a 21 minutes delay)
so wrong. We subsequently received a copy of a July 21, 2014 e-mail from CHCF's CEO to
headquarters executives that addressed that question. The e-mail states that the ERRC reached a
wrong conclusion because it "mis-interpreted" data provided to it via CHCF's own documents,
and further suggests that certain smaller variations in time might possibly be attributable to a lack
of calibration between clocks. The CEO stated that in the future the efforts would be made so that
the ERRC had accurate information for the ERRC, and to calibrate clocks in the prison. Even if
this were the end of the matter, the ERRC's botched conclusion that there was an egregious delay
of the ambulance at the sallyport further shows the inadequacy of CHCF's current emergency
response review process.
However, the information provided by the CEO raises further questions about what
happened, and when, regarding calling an ambulance for the patient. In particular, the email
states that a "Code 2 ambulance [was}called in," seemingly between 0642 and 0655- which
would be consistent with the ERRC meeting minute's entry for when the ambulance was called.
There is also a reference to a "Code 4" called at 0642, which in emergency response parlance
generally means a request for emergency services is cancelled or withdrawn. It is troubling that
Memorandum re CHCF July 2014 Site Visit
Page 6
these details, which raise further questions about when an ambulance was called, were not
addressed, and we ask for an explanation.
In the hope of better understanding what actually happened, we then requested and
reviewed the patient's medical records. With regard to when the ambulance was called, an entry
in the TTA Flow Sheet states it was done at 0704, by a person the CEO's email says is a Certified
Nurse Assistant. Unfortunately however, the records contain no information about Code 2 or
Code 4 calls mentioned in the CEO's email. As indicated above, the meaning of those referenced
calls remains unknown.
The medical records also includes inconsistent or confusing information about when SEMS
staff was notified about the patient emergency by housing unit staff, and what SEMS staff did in
response, including the time at which that staff got to the patient in the housing unit. With regard
to when SEMS was notified, a 0625 note by the housing unit nurse states that s/he "called SEMS
at once." That same nurse also documents that at 0639- 14 minutes after SEMS had first been
notified-- a correctional officer in the housing unit activated an alarm to again alert SEMS.
Similarly the document called "First Medical Responder Data Collection Tool (CDCR
Form 7463)" states that SEMS (referred to as "TTA") was notified at 0625, which is consistent
with the housing unit nurse's note. However, it also documents that "clinical staff' (an apparent
reference to SEMS staff) was notified at 0640, which appears consistent with the housing unit
nurse's note regarding the time the correctional office notified SEMS. It is not clear whether
there were two notifications, or whether the First Responder wrote down every time reference that
appeared on records s/he reviewed. To further confuse matters, the TT A Flow Sheet completed
by SEMS staff indicates- via check boxes and time entries- that it was first notified at 0700, a
time wildly different, and much later than the others reported. This inconsistent and confusing
information shows a serious problem with CHCF's emergency response documentation.
As to what happened after SEMS was notified, the First Medical Responder Form 7463
states that "clinical staff' (again, an apparent reference to SEMS staff) arrived at the housing unit
at 0645, and documents that CPR and AED efforts undertaken at that time. However, there is no
documentation in the record by the housing unit nurse regarding when SEMS arrived. If as it
appears SEMS staff arrived at 0645 after being notified at 0625 (as the housing unit nurse states)
then the response time - 20 minutes - was delayed and inadequate.
The ERRC when reviewing this incident did not address the questions about the multiple
notifications to SEMS, the confusing or conflicting documentation of when that notification
occurred (the ERRC only that one particular form was "incomplete"), or the fact that it took
SEMS staff 20 minutes to reach the patient (in fact, the committee did not even appear to
understand the time line of what happened, as it focused entirely on the community ambulance
response time). The failure of ERRC to identify or address these issues further shows the
inadequacy of CHCF's current emergency response review process.
Memorandum re CHCF July 2014 Site Visit
Page 7
Perhaps the most fundamental question raised by the medical records is why the
community ambulance was not called until 0704 (if in fact it was not called until then). This
patient was known to have, in the words of the physician's post-mortem note, "multiple risk
factors for [an] Acute Cardiac Event." Approximately 90 minutes before the 0704 call for an
ambulance, the patient complained of trouble breathing and left side pain. Approximately 40
minutes before the ambulance was called, the patient again complained of problems breathing; a
nurse documented a drop in oxygen saturation and called for emergency help. Approximately 25
minutes before the ambulance was called, a correctional officer sounded an emergency alarm.
Should the ambulance have been called after any of these points, or at. any point before 0704,
when a Certified Nurse Assistant, apparently acting on his or her own, did so?
CHCF's emergency response review makes no assessment whatsoever regarding whether
the ambulance was timely called. CCHCS policy and procedure requires an ambulance to be
called "as necessary to ensure the most appropriate level of emergency medical care is available
in the shortest time interval" (emphasis added). Inmate Medical Services Policies and
Procedures, Volume 4, Chapter 4.12.2. That this issue was not addressed shows yet again the
inadequacies of CHCF's current emergency response review process.
More generally, this case shows again that confusion regarding medical emergencies in
CHCF's medical units. As discussed below, CHCF has no clear policy, procedure or protocol
regarding what nurses in medical bed housing units should or should not do in a medical
emergency, what SEMS staff that responds can additionally do, when patients should be
transported to SEMS, or when and why a community ambulance (911) should be called. More
than that, as also discussed below, it appears that there is confusion or disagreement among top
medical managers regarding what policies and protocols should be established.
April 8, 2014 Death of C-Facility Patient
On June 25, 2014, CCHCS's Death Review Committee (DRC) determined that this death
was "possibly preventable due to the failure to properly diagnose and treat the patient for [Acute
Respiratory Distress Syndrome]," which was identified as the cause of death. The death review's
narrative regarding this failure is very troubling:
[The CHCF PCP] neither obtained [nor] documented minimum information to
determine the patient's status nor did he bring the patient to the SEMS for his
personal evaluation, though he was at the facility that night, working in the SEMS,
for the explicit purpose of seeing such patients. Additionally, he did not arrange for
any follow-up for the patient.
These extreme departures from the standard of care (and basic decency) are shocking in a prison
hospital. The DRC referred the PCP to a peer review committee. Because the DRC review was
received here approximately two weeks after our visit, we do not know the present status of this
matter, and ask that we be told if the provider is still providing care at the CHCF.
Memorandum re CHCF July 2014 Site Visit
Page 8
CHCF Response to Headquarters' May 14, 2014 Review of February 8, 2014 Death
On May 14, 2014, the headquarter's Death Review Committee (DRC) determined that a
February 8, 2014 patient death was possibly preventable. Among other things, the DRC recommended
that CHCF establish a roving coumadin clinic. This recommendation had not been formally reviewed
and considered, per the minutes of the CHCF Patient Safety, Medical, and Quality Management
Committees that were provided. The Chief Physician, who indicated he was responsible for local
death review activities, said he had not seen the DRC review and recommendation.
Primary Care Provider Vacancies
CHCF currently has 32 allocated/established staff PCP positions, but its executives
report that if and when CHCF is fully occupied it will need another 9 staff PCP positions, for a
total of 41. At the time of our visit, six of the 32 existing staff PCP positions were vacant, two
others were functionally vacant (one because the physician was on extended medical leave, the
other because the physician was acting in another position), and two others were going to
become vacant within ten days of our visit because physicians had given notice they were
leaving their positions. Thus, as of the date of this report, there are 8 actual and two additional
functional vacancies among the 32 current staff PCP positions. This computes to a current
vacancy rate of 25% or 31%, depending on what figure is used. Either way, CHCF's staff PCP
vacancy rate is among the highest in California's prisons.
Registry providers do not and are not expected to substantially help with CHCF's staff
PCP vacancies. Considerable time and effort is required to train registry staff, and there is a
relatively high turn-over rate, and many work very limited numbers of hours. In accord with
this, the CME reported that only two registry PCPs at CHCF work full-time hours, with four
others working so sporadically that reliable patient scheduling was not possible with them.
Moreover, the two registry PCPs who do work full time have each told the CME of plans to be
away for substantial time starting in August. One of these registry doctors is the only physician
assigned to the building (D-2) that houses CHCF's high acuity total-care patients; replacing his
work and expertise will be a considerable challenge.
CHCF and headquarters executives say the 24 current staff PCPs (minus the two on leave
or redirected, respectively) are enough to provide timely and adequate care for the current and
expected numbers of CTC and OHU patients in Facilities C and D. However, if or as patient
numbers increase in the prison's other facilities (including in particular Facility E), additional
PCPs will be needed. CHCF medical executives say that if the prison is fully occupied with
patients, it would need 17 additional PCPs would be needed.
We appreciate that CHCF, CCMCS, and the Receiver's office in the coming weeks and
months will regularly assess whether CHCF can care for its patients, including those there at
any given point and those expected with each new set of transfers. Unless necessary PCPs are
hired, CHCF patient admissions should be restricted or stopped.
Memorandum re CHCF July 2014 Site Visit
Page 9
Medical Staffing in General- Heavy Reliance on Registry Staff
Currently, between 400 and 500 CHCF medical positions -registered nurse, licensed
vocational nurse, certified nurse assistant, medical assistant, and others - are filled by registry
staff because such staff are not officially budgeted or established at the prison.
This very large registry staff has a relatively high turn-over rate, according to CHCF
managers. This results in substantial numbers of persons working at the prison who are not
readily familiar with policies, practices, and the complex needs of, for. example, CHCF's high
acuity patients. It also results in new staff having to be trained almost constantly. Relying on
hundreds of registry staff who can leave when they want, many of whom are not there for the
long term and who leave far more frequently than permanent staff, is not an adequate staffing
approach at any prison, and especially at a prison hospital that houses what will soon
approximately 2,000 of the sickest and most complicated patients.
CHCF and CCHCS executives agree that the reliance on registry staff described above is
not adequate. The plan is to submit a Fiscal Year 15-16 Budget Change Proposal (BCP) for
these necessary but unestablished (and thus unfunded) positions. If approved by the
Department of Finance, included in the Governor's Budget, then funded by the Legislature,
these positions will be established in July 2015 with hiring of permanent staff to follow.
However, it is not known whether approval and funding for the will be received for any
additional positions. Until it is- and permanent staff then hired- CHCF medical staffing will
remain highly dependent on registries, and thus inadequate.
E Facility- Untimeliness of Emergency Response
Both CHCF patients and executives indicated that emergency response times were a
concern atE-Facility, particularly during first watch (1000 to 0600 hours) when no registered
nurses are posted at that facility. During first watch, the first medical responder must come
from the Standby Emergency Medical Services (SEMS). Unfortunately, CHCF managers could
not tell me the time that it typically takes for SEMS staff to reach a patient in Facility E,
particularly to an outlying dorm in that facility. Nor does the SEMS computer-based log track
such times. However, it is highly doubtful, given the distance between SEMS and Facility E,
and the various custody-operated gates that must be passed through, that medical staff during
first watch can respond to a patient emergency within eight minutes as required by CHCF
policy. At the time of our visit, CHCF executives had not determined what they were going to
do about this problem, even though approximately 300 prisoners were housed there, with
approximately 200 others expected within the next approximately one month and hundreds of
others scheduled after that.
Memorandum re CHCF July 2014 Site Visit
Page 10
Medical Leadership
All medical executives are new to CHCF, or in one case simply acting in the position
while a permanent employee is chosen. The Healthcare Chief Executive Officer, in place
approximately two months, is the most experienced in terms of time at the prison, but he is in
some ways, as he stated, still learning in that he came from outside CDCR. The Chief Medical
Executive (CME) position at the time of our visit was filled by a physician acting in that
capacity, and we were told that a permanent CME will start in a few weeks and could come
from outside the prison. The Chief Nursing Executive started at the week of our visit, and she
came from another prison and thus is new to CHCF. All the same is true for the Chief Support
Executive. Thus, while the executive team is or soon will be in place, they are new to CHCF.
Given the unique mission and size of the prison, and the scope of medical services provided, it
will take considerable time for the executives to become adequately familiar with operations.
Incomplete and Unavailable Medical Policies and Procedures
Key CHCF medical policies remain incomplete, and in at least one key area- emergency
response- there appears to be confusion or uncertainty among even top executives regarding
what is supposed to be done.
When I asked about emergency response policy and protocols at the entrance meeting,
one ofCHCF's two Chief Physicians explained at some length that a tiered emergency response
protocol had been developed via the prison's Patient Safety committee. The Chief Physician
also said a prison-wide e-mail had been sent mandating chest compressions as key part of
certain emergency responses. Not only had these protocols and mandates not been
memorialized in any written policy, I was subsequently told in a meeting with the current and
former interim CEO that despite what the Chief Physician had stated, CHCF would not
implement a tiered emergency response protocol. It is not clear whether the e-mail regarding
chest compressions is still to be followed.
The confusion or uncertainty regarding what emergency response policy or protocol to
establish is obviously troubling. In addition, the most recent Medical I Nursing Subcommittee
meeting minutes I received indicated that 16 SEMS policies were still in the review stage.
Similarly, while CHCF has implemented a new primary care model as part of the April
to July "re-boot," the written policy underlying this model was as of my visit still in draft form
and still under review. CHCF's corrective action log provides no completion date for adoption
of this essential policy.
Other medical policies also remain pending, according to Medical I Nursing
Subcommittee meeting minutes, including some that need review by the Local Governing Body.
Moreover, those minutes also stated that policies that have been updated are not so reflected "in
Wiki making it difficult for staff to reference the latest version."
Memorandum re CHCF July 2014 Site Visit
Page 11
Similarly, CHCF's Quality Management Committee and sub-committees are still in their
infancy. Many of the key subcommittees, including patient safety and medical/nursing care,
have held their first meetings only in last approximately three months, and their agendas are
relatively sparse. CHCF executives said they wanted to re-tool the responsibilities of these
committees.
Inadequate Medical Care Practices
CHCF continues to have problems providing adequate patient care. The acting CME
explained that a review of a sample of progress notes done by each staff PCP showed that
documentation problems persist, including with tracking pending consults and acting on
specialty recommendations.
In one case I reviewed, a neurologist in a report received at CHCF on 6/27/14
recommended a change in a patient's medication, to help improve slurred speech and cramping
in a patient diagnosed with multiple sclerosis, certain lab tests, and a MRI of the brain and
cervical spine. A PCP on 6/28114 failed to address the recommendations, and neither did a
second PCP who saw the patient on 7/1114. On 7/4/14, the first PCP noted the
recommendations but said the matter would be deferred to the second PCP. However, on
7/7114, the second PCP when seeing the patient did not even address the matters, even though
the patient stated he had seen the neurologist. The recommendations were not acted on until
7110/13, when a third provider happened to see the patient and took action, noting that
"unfortunately" the neurologist recommendations had not been carried through by the other
providers. In another recent case, a January 2014 ENT recommendation that a patient get bone
conduction hearing aids was not properly acted on until July, when the patient was finally
referred to a specialty provider that could actually get him the recommended aids.
I also reviewed a substantial number of charts in which neither recently received
specialty consult reports nor the corresponding RFSs (CDC Form 7243) had been signed and
dated by PCPs, as required by policy. CHCF's acting CME and medical records supervisor
subsequently determined this was a systemic problem at CHCF. Apparently, consult reports
and Form 7243s were being scanned into the medical record without the PCP having had a
chance to sign them.
Memorandum re CHCF July 2014 Site Visit
Page 12
Medical records
CHCF continues to be more or less current with its scanning of documents into patients'
medical records (e UHRs ), a salutary development that contrasts sharply with the scanning
backlog crisis that existed earlier this year. Nevertheless, medical records at CHCF remain
inadequate and a risk to patient safety because locating documents and information is difficult
and very time-consuming. Among the problems are: (1) the identical labeling in the eUHR of a
patient's request for healthcare services (Form 7263) and a PCP's Request for (Specialty)
Services (Form 7243); the identical labeling of PCP and nurse progress notes when document
names are viewed in the typical I default eUHR viewing mode (the different labels can be seen
only be waiting for a dialog or name box to open); (3) the failure to label PCP progress notes for
high acuity patients as comprehensive versus interval; (4) the labeling of medication refusal
notifications as "Placement Chronos;" and (5) the filing of off-site specialist reports in one subtab unless that specialist happens to see a patient at a hospital (as is the case for certain
providers frequently used by CHCF), in which case under a different sub-tab. In each case, and
for other medical records snafus, my understanding is that medical records staff is following
directives from Elk Grove headquarters that cannot be altered, or that a fix would require
alterations of the eUHR system that are not practical or too expensive given the plan to move to
a true electronic record in the next approximately one year. The result, currently is a medical
records process that is "dysfunctional," to quote the acting CME.
E-Facility- Coordination of Dialysis Patient Care
Among the first SOPs moved to E were almost three dozen dialysis patients. At the time
of our visit, medical staff were still determining how to coordinate with the contract provider of
on-site dialysis services so as to provide adequate care and information exchange. For example,
a plan to take vital signs of dialysis patients before and after they returned from dialysis did not
work because it required patients on the first run to miss or rush the breakfast meal, and did not
work after dialysis was completed both because of patient fatigue and because their vital signs
had been taken by dialysis staff just before they left that unit. Medical staff were also
identifying what documents and information to obtain from the provider on periodic basis, and
how to coordinate the flow of information between PCPs in E facility and the nephrologist and
others who work for the contract dialysis provider.
Medical Appeals
In May, CHCF executives described their medical appeals as a "disaster," with hundreds
of healthcare appeals pending with responses overdue. As of our July visit, the situation
remains essentially the same. I was told that well over 300 appeals were pending in which
responses were overdue, and saw a log indicating that many of those had been pending since
February and March.
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Memorandum re CHCF July 2014 Site Visit
Page 13
Perhaps most troubling, no one at CHCF had a clear understanding of why so many
appeals were delayed or plan to address the problem. The acting CME was certain that medical
staff had established processes to timely address appeals received from the healthcare appeals
office, and indicated that their responses back to healthcare appeals were up to date. The
healthcare appeals office, however, indicated there were only a total of (at most) 80 to 100
appeals for which it had received information from healthcare staff that they were waiting to
process and return responses to patients. In their view, there would be well over 200 appeals
that are overdue because information has not been received from healthcare staff.
In May we also raised concerns about aggressive and inappropriate rejection and
cancellation practices in the healthcare appeals office, including the rejection of appeals when a
patient raises more than a single medical care concern. These concerns do not appear to be
addressed.
We also saw other rejections showing that CHCF and its medical appeals staff will go to
great lengths to avoid answering appeals instead of using them to identify and solve problems.
For example, on May 30, 2014, a medical appeal was received from a C-unit patient who said
medically ordered eyeglasses had been received in the optometry clinic at the prison two weeks
before, but that he had not been able to get them because he is a SNY prisoner and needs an
escort to get to the clinic. He indicated he had tried asking doctors and nurses in his unit to
help. On July 3, 2014- more than a month after it was received- medical appeals staff
cancelled the patient's appeal, telling him that his problem was a custody not a healthcare issue.
Other Matters
We heard about problems with certain medical supplies, including a certified nurse
assistant in one high acuity unit imploring supervisors during a morning huddle to solve the
problem of not having correctly sized Chuxs. Executives told us the matter had been resolved,
but we were unable to determine what had happened to cause the problem in the first place.
With regard to special orders for medical supplies, it appears that documents required for such
orders to be initiated are still not being scanned into the relevant patient's medical record.
With regard to medication distribution, we observed one new Omni-Cell unit, but were
unable to determine whether or how they- recently installed in each C and D Facility unithave affected medication distribution.
With regard to pharmacy operations, a recent e-mailed assessment by the out-going
pharmacy consultant- a CCHCS-employed Pharmacist in Charge- raises deep concerns about
CHCF's pharmacy management structure. The consultant explains that when CCHCS opened
its administrative I management model somehow was changed. The result is that CHCF now
has a Pharmacy Service Manager and only one Pharmacist II (Pharm II) instead of two as
originally planned, with that Pharm II provided no administrative assistant or office technician
help. He concludes that CCHCS is "asking the impossible" from the Pharm II and that CHCF
has "created a model of mediocrity .... " The consultant recommends returning to the original
Memorandum re CHCF July 2014 Site Visit
Page 14
management model, creating other Pharm II positions, and providng at least one of the Pharm
Ils with administrative help.
With regard to on-site specialty services, a new scheduler- the third or fourth in the last
several months - is in place for physical therapy (PT), respiratory therapy, and Physical
Medicine & Rehabilitation (PM&R) appointments, and that a process has been established to
make sure that PCPs act on initial PT evaluations. However, there still appears to be no formal
process for referrals to PM&R, or for prioritizing such appointments (RFSs are not used).
With regard to food service, CHCF the week of our visit had just started distributing
meals in one-use paper trays, which the Food Service manager believes will solve at least for
now the problems with the prison being unable to remove the plastic wrap from the previouslyused plastic trays. However, we were also told that the kitchen is not- and apparently cannotlog complaints it receives regarding the meals served, or even those stating that a meal tray was
received that was not in accord with a PCP's order.
We were also unable to assess whether and to what degree CHCF had addressed the
previously identified problems with POLSTs and obtaining court orders for incompetent
prisoners. A recent death review done by CCHCS headquarters staff determined that one
CHCF prisoner's POLST had been completed by a mid-level practitioner instead of a physician
as required by CCHCS policy. The Acting CME indicated that he believed that was an isolated
case, and we intend to check on this matter during our next visit to the prison.
+++++
Thank you and your staff, including at CHCF, for the anticipated consideration and
action regarding the matters discussed above. Please let us know if you have any questions or
concerns.
cc:
Roscoe Barrow, Chief Counsel, Receiver's Office of Legal Affairs
Chris Swanberg, Staff Counsel, Receiver's Office of Legal Affairs
Jared Goldman, Counsel to the Receiver
Tom Gilevich, Assistant Chief Counsel, Health Care- CDCR Office of Legal Affairs
Healthcare Chief Executive Officer, CHCF, via Receiver's Office of Legal Affairs
Acting Chief Medical Executive, CHCF, via Receiver's Office of Legal Affairs
Madie LaMarre, Court Expert
Joe Goldenson, Court Expert
Mike Puisis, Court Expert
Starr Babcock

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