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Old 02-16-2003, 09:02 PM
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danielle danielle is offline
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Post Audit of Tutwiler Correctional Facility

Tutwiler Correctional Facility

Roger Childers of Moore and Associates conducted and audit of the Tutwiler Correctional Facility on August 1-2, 2002 on behalf of the Alabama Department of Corrections. The audit consisted of 70 chart reviews regarding chronic care, infectious disease, sick call, emergency transport, and off-site consults. Structured interviews were conducted with the Health Services Administrator (HSA), dental assistant, dietary supervisor, nurse practitioner, 2 death row inmates, 5 segregation inmates, 5 general population inmates, 2 infirmary inmates, the deputy warden, physician, health care providers, and mental health staff.

An exit conference was conducted with Deputy Warden, Health Administrator, and the Department of Corrections’ Director of Treatment.

Facility Information

This facility was constructed between 1943 and 1945 with an original capacity of 300 but during the audit had a census of 1007 female inmates. Renovations have been numerous over the last 57 years. One such up grade included new boilers that provide hot water to the dietary department, which was in process during the audit. There are two satellite facilities, Montgomery work release and Birmingham work release. These facilities have populations of 230 and 300 inmates respectively. Dorms were noted to be very crowded with paint peeling in some areas, but generally clean.

Transition

The medical services have transitioned from Correctional Medical Systems to Naphcare effective March 2001. The new contractor has been providing services for approximately 17 months.

Staffing Vacancies and Hours of Service

Current full time staffing consists of
-a site HSA that is an RN
-one nurse practitioner
-4 LPN’s.
-2 LPN’s part time
-1 RN part time
-1 medical record clerk
-1 lab technician
-1 secretary
-a full time dental assistant
-a dentist (0.4 FTE) and
- MD (0.5 FTE)

It should be noted that in addition to providing dental services to the Tutwiler facility and the work release centers, the dentist also provides dental services to the Kilby facility for 4 to 8 hours a week.

Naphcare reported 6 FTE LPN and 1 FTE RN vacancy.

The HSA has been in her position less than three weeks. This was her first experience in correctional health care.

History and Physical Exams

By policy, inmates are to receive health assessment by a qualified provider no later than 7 days after admission to the DOC with annual TB updates every year and a full physical every three years. Record review indicated compliance with this contract provision and policy. Approximately 40-50 new inmates arrive at this facility each week.

Chronic Care

Chronic care clinics have been consistently conducted and well documented at this facility within the last six months. A review of four diabetic charts selected at random yielded no documentation of current Hemoglobin A1Cs being present in any of these four records reviewed. Eye exams to rule - out diabetic retinopathy were present on all four of the diabetic charts reviewed.

Diabetes more than any condition challenges correctional medical staff in its management. Review of a facility’s capacity to manage diabetes is probably the single best indicator of the level of functioning of the medical unit. This lies in the labor intensive nature of the disease and the involvement of all levels of health providers including the dietary department. Monitoring clinical response to therapy presents its own unique problems. Staff are faced with the issue of non-compliance of the inmate and commissary and diet non-compliance. The only reliable method of monitoring response to therapy is with serial glucose levels, or venous draws. Hemoglobin A1Cs are useful in long term assessment of treatment regimen and should be performed every 3-6 months.

Chart review indicated that one out of the four records of inmates reviewed with a diagnosis of hypertension reviewed did not contain current documentation of BUN and creatinine level. All four hypertensive charts reviewed contained documentation of base line blood pressure monitoring however, periodic EKG’s were evident on two of the four charts reviewed.

Three of the four seizure charts reviewed had documentation of recent Dilantin levels within the last year.

Weight was not part of the assessment of chronic care patients as no weights were recorded on the treatment plans. Weight is an essential component of the management and assessment of diabetic inmates and this parameter should be added to routine monitoring.

Problem lists were present and updated and chronic care progress notes were very well documented. A comprehensive tracking system of chronic care patients was evident.

Sick Call

A review of ten inmate medical records that requested sick call indicated that all requests for sick call were seen in a timely manner by the nursing staff. Chart documentation indicated that a RN or LPN saw inmates within 24-48 hours of the inmate’s request.

Documentation of health education was not apparent from the charts reviewed. Inmate interviews also indicated that inmates indicated that they had not received health educational material or material on the medication they were taking.

There is a co-payment for sick call services in effect. Awareness of co-pay program was evident among the inmates interviewed and 90% of the inmates interviewed reported that they understood that if they did not have sufficient funds, health care would still be provided.

A review of the segregation logs, and interviews with five inmates in segregation indicated segregation rounds were completed daily. Documentation confirmed this practice.

Consultations

Off site consults were approved in a timely manner by the contractor. Ten of the most recent consults, requiring physician referrals for specialists were approved by Naphcare’s utilization review process within 24 to 48 hours of the facility’s request.

Infection Control

There was no active TB reported in this facility during the audit. A review of 10 medical records indicated that 2 or 20% did not have current annual TB documentation. A representative, Kyle Boyett, of Alabama Containment Labs/University of Alabama, had formerly evaluated all of the “TB” rooms in this facility and found that they had no negative air flow capability. There is no anti-room. The possibility of other inmates contracting TB infection is very high if this housing is utilized in the future. During the interview with the site physician he reported that the was not familiar with the “negative pressure” rooms in the effort to contain communicable disease.

*****Unfortunately the part of the report on HIV positive inmates at Tutwiler was illegible. *****

Dental Services

The facility has a 2 chair dental unit. Sharps and spore counts were current and documented. There was a backlog of 180 inmates waiting for dental services. Five of the twelve inmates interviewed complained of delays in dental care. Many of the inmates interviewed were listed on the backlog list. Medical records were reviewed for dental treatment plans from inmates requesting dental care in the last ninety days. Treatment plans were evident. Naphcare staff reported no routine dental cleanings are provided to inmates. There was a paucity of evidence in the medical record documentation indicating dental hygient instruction. It is policy to include dental hygiene instructions on admission. A copy of this sheet was reviewed and it included the importance of brushing and flossing instructions, however dental floss is not provided to inmates. Flouride s available in toothpaste. Naphcare provided statistices to the DOC’s Director of Treatment indicated a waiting list for dental service to be about 130 inmates. The Naphcare dental assistant reported a backlog of 180 inmates on the second day of the audit. The wait for inmate dental service at this facility is over three to six weeks as reported by the dental staff.

Mental Health Services

On the request of the DOC’s Director of Treatment, the psychiatrist and psychiatric nurse practitioner were interviewed. The mental health housing area in the health care unit is painted pink. While this color was used in the early 60’s and 70’s for isolation units, it is no longer thought to be effective in calming behavior. In reviewing the mental health unit, there was concern regarding the timely filing of medical record documents. There were several inches of mental health forms waiting to be filed. The delay in filing of these records could hamper timely evaluation and prompt treatment and/or compromise Naphcare’s efforts in continuity of inmate care. There has been a great deal of turnover in the medical record staff. Approximately three (3) clerks have been hired and resigned in the last 6-9 months.

Infirmary

There is a total capacity of 4 beds in the health care area termed as an “infirmary.” The 4-bed unit is at 100% capacity and very crowded. During the audit, one inmate was sleeping in the hallway due to “lack of space.” A review of infirmary admissions included diagnosis of cancer, COPD, and hypertension. The inmates housed in these four rooms are over 50 feet away from the nursing station and are not within sight and sound of the health care providers. There is no call system that exists for inmates to notify nurses of emergencies. It is recommended that the DOC correct this area as patients should be within sight or sound of a health provider.

A review of medical records for the infirmary indicated that an admission sheet is completed when inmates are admitted to the infirmary and required nurses and physician notes are present. Separate infirmary medical records are well maintained. Chart review indicated that the physician makes rounds in this unit 3-5 days a week.

There was no documentation that the inmate “infirmary” runners had training on blood borne pathogens, however, it was reported by an inmate “runner” that they processed all of the dirty “infirmary” linen, meal trays, and soiled clothing.

Environmental Conditions

During the tour, box cutters containing a razor, scissors, and a 6 to 8 inch metallic object were found in the medication room which were not regularly counted with other sharps. It was reported that these items were only used for “opening boxes.” All other sharps were accounted for each shift. Due to the potential use of this object as a weapon, it is recommended that this item be added to the sharp count list.

During a tour of the medical unit, it was noted that the pharmacy, clinic, inmate housing area and dental unit had pain that was peeling on the walls and ceilings. These environmental issues which ultimately affect work place and recruitment issues should be addressed by the DOC.

Medical Records

The medical records area is extremely busy and noisy, small and crowded. Lab results print out in this small area which also serves as the secretary/receptionists office. Personnel issues are handled here and inmate consults/transfers are scheduled out of this small office. Due to the congestion and activity, there is a moderate element of stress and chaos that was present in this area.

Medical records were not well organized and often elements required by the NCCHC standards were not filed in a timely fashion or were hard to locate because they were out of place.

Problem lists were evident on all but one record. Documentation of full compliment of vital signs were not always present, as noted in the chronic care comments. Physician orders were consistently signed, and dated.

The reported high turnover of medical staff and the backlog of filing of mental health documents does not provide up to date information about a patient and decreases the provider’s ability to provide continuity of care.

Pharmacy

Pharmacy inspection reports from August and November 01 and February and June 02 were available for review. The reports were comprehensive and addressed all aspects of medication storage and controlled substances.

Narcotic counts are recorded on each shift and were correct. The pharmacy area was well organized. Two open vials of insulin were found in the medication refrigerator without dates. Open vials are only good for 30 days after opening. Reminders should be provided to the nursing staff on this issue. Tylenol suppositories found in the refrigerator had expired. A container of drinking water was found in the medication refrigerator. Pharmaceutical practices prohibit the storage of food products with medications. Future staff meeting should address these issues.

Professional Regulations

Current licensure was on file for all staff including the optometrist. CPR training for all health providers was current. There was inservice documentation for all health care staff and a planned agenda for training for the next several months.

Staff Administrative and Staff Meetings, CQI

Administrative meetings were held weekly with the warden and minutes available for review. Health care meetings were well documented. Minutes were reviewed from January 2001 to present.

There was no evidence of quality improvement activities conducted at this facility. The HSA submitted monthly CQI meeting minutes, however, non of the staff interviewed indicated that they attended or participated in CQI activities. The deputy warden reported that he had recently received a corporate Naphcare policy and procedure manual only a few days prior to the audit. The manual was not site specific.

There has been no disaster drills conducted at this facility in the last twelve months.

There have been 266 complaints regarding health care that were reported in the last four weeks. Many of the complaints (42-54%) included timeliness of care. There is no formal grievance process or a recording process of inmate complaints. It is recommended that complaints be logged and monitored so that corrective actions can be taken.

Kitchen Inspection and Food Services

The food services area was found to be clean and orderly. A first aid kit was present and stocked, however burn ointment was not available. There were signs in the inmate bathrooms to remind inmates of hand washing. External thermometers for the cooler and freezers were operational and appeared to be accurate. The last inspection report by the Alabama Department of Public Health yielded a rating of 93%. A sample tray of each meal is kept for 24 hours.

Critical Incidents and Mortality Reviews

Death reviews were not provided during this audit. Naphcare reported that deaths in this facility would come under review of the medical advisory committee. Autopsy reports or coroner summaries were not on site for review. It should be noted that the Medical Advisory Committee is a year behind in reviewing mortalities that have occurred at the DOC facilities. Current standards require an on-site mortality review within 30 days of the death.

Summary

Diagnostic laboratory tests such as therapeutic blood levels for Hemoglobin A1C are standard practice for the management of diabetic conditions and should be initiated as part of the Naphcare’s chronic care program. Areas recommended for improvement include the development of policies and procedures that are site specific to this facility. Inmates with airborne illnesses should be transferred to appropriate facilities. Negative pressure rooms for active cases of TB should be provided to inmates for the protection of the staff and to avoid a TB epidemic of other inmates.

Staff participation in mandatory disaster drills, and site physician involvement in autopsy reviews should enhance QI efforts. Provider staffing of physician and dental hours should be reviewed in regard to current backlogs of care. Attention should be given to the medical records department including the filing of mental health reports. Nursing vacancies have hampered the development of this program. Recruitment should focus on this facility.
__________________
Monica Danielle
***********
On September 22, 2003, my better half came home after 657 days in an Alabama prison!!!

And he's now forever free - passing away from this life and into the next - on January 9, 2010.

My Sweet Wayne
January 21, 1954 - January 9, 2010

I'll always love you.
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