Dixon Correctional Center

(DCC) Report

February 2014

Prepared by the Medical Investigation Team

Ron Shansky, MD
Karen Saylor, MD
Larry Hewitt, RN
Karl Meyer, DDS

Contents
Overview....................................................................................................................................3
Executive Summary ..................................................................................................................3
Findings .....................................................................................................................................4
Le ad e rs hipand Staffing...........................................................................................................4
C linicSpac
e and Sanitation .....................................................................................................7
Intras ys te m T rans fe r................................................................................................................7
M e d ic
alR e c
ord s ......................................................................................................................9
N u rs ingSic
k C all.....................................................................................................................9
C linic
ian Sic
k C all.................................................................................................................13
C hronicD ise as e M anage m e nt................................................................................................15
P harm ac
y/M e d ic
ation A d m inistration....................................................................................21
Laboratory .............................................................................................................................21
U ns c
he d u le d Se rvic
e s /E m e rge nc
y Se rvic
e s ...........................................................................22
Sc
he d u le d O ffs ite Se rvic
e s ....................................................................................................23
Infirm ary C are .......................................................................................................................25
Infe c
tion C ontrol...................................................................................................................32
D e ntalP rogram ......................................................................................................................32
C ontinu ou s Q u ality Im prove m e nt ..........................................................................................40
Recommendations ...................................................................................................................42
Appendix A Patient ID Numbers.........................................................................................46

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xon C orrec ti
onalC enter

P age 2

Overview
O n Fe bru ary 26-28, 2014we visite d the D ixon C orre c
tionalC e nte r(D C C )in D ixon, Illinois. T his
was ou rfirs t s ite visit to D C C and this re port d e s c
ribe s ou rfind ings and re c
om m e nd ations . D u ring
this visit, we :

M e t withle ad e rs hipofc
u s tod y and m e d ic
al
T ou re d the m e d ic
als e rvic
e s are a
T alke d withhe althc
are s taff
R e viewe d he althre c
ord s and othe rd oc
u m e nts
Inte rviewe d inm ate s

W e thank W ard e n C hand le r and he r s tafffor the ir as s istanc

e and c
ooperation in c
ond u c
tingthe
re view.

Executive Summary
D ixon is am u lti-m iss ion prison that hou s e s m ale offe nd e rs withs pe c
ialne e d s inc
lu d ings e riou s ly
m e ntally ill, d e ve lopm e ntally d isable d and ge riatricinm ate s with c
ognitive and /or m obility
im pairm e nts , and ahos pic
e program . T he c
u rre nt popu lation is 2349 inm ate s . T he ins titu tion is
not are c
e ption c
e nte rbu t has a28-be d infirm ary and m e ntalhe althm iss ion. A pproxim ate ly 70%
orm ore are on m e d ic
ations .
T he vac
u u m of le ad e rs hip from the M e d ic
alD ire c
tor pos ition, the D ire c
torofN u rs ingpos ition
and the H e althC are U nit A d m inistratorpos ition have re s u lte d in bre akd owns withalm os t e ve ry
m ajor s e rvic
e that inm ate s re c
e ive . T he non-c
om plianc
e with D O C polic
ies is at le as t in part
attribu table to the s e vac
anc
ies bu t als o pos s ibly to line s taffpos ition vac
anc
ies . T he e nd re s u lt is
liability for boththe inm ate s and the s tate . T his liability be gins withthe abs e nc
e ofafu nc
tional
intras ys te m trans fe r proc
e s s im ple m e nte d to fac
ilitate c
ontinu ity of re qu ire d s e rvic
e s . In othe r
fac
ilities , ne wly trans fe rre d patients are brou ght to the m e d ic
alare ato initiate this c
ontinu ity. T his
is not c
ons iste ntly happe ningat D ixon. In fac
t, som e inm ate s go le ngthy pe riod s oftim e be fore
this proc
e s s is initiate d . A d d itionally, u ns c
he d u le d s e rvic
e s or u rge nt/e m e rge nt s e rvic
e s are not
logge d ortrac
ke d in any way. W e atte m pte d to re view s om e re s pons e s throu ghrand om ly provid e d
inc
id e nt re ports . T he re is no pos s ibility, the re fore , that the re c
an be an organize d proc
e s s to
d e te rm ine tim e line s s and appropriate ne s s ofre s pons e s from bothnu rs ings taffand c
linic
ian s taff.
In ad d ition, we fou nd c
as e s whe re the follow-u p was d e fic
ient bu t ofc
ou rs e the ins titu tion was
u nable to ide ntify this.
E ve n the c
linic
ian s ic
kc
allwas not trac
ke d withthe loggings ys te m and the re fore the page s we
we re provid e d that liste d patients who we re s e e n by s pe c
ificc
linic
ians we re ove rwhe lm ingly not
s e e n at allornot s e e n within awe e k ofthe d ate liste d on the page s provide d .
Sc
he d u le d offs ite s e rvic
e s we re frau ght with le ngthy d e lays , m os t e s pe c
ially afte r the W e xford
phys ic
ian had give n ve rbalapprovalofthe s e rvic
e . T he U ofI c
oord inatorsom e tim e s d id not
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he ar ofthe offic
ialau thorization withanu m be r for u pto two m onths afte r the ve rbalapproval.
T he e nd re s u lt is s ignific
ant d e lays in ac
c
e s s to s e rvic
e s . M any s e rvic
e s , onc
e the au thorization
nu m be ris provide d , d o not oc
c
u rforas m u c
has thre e to five m onths . T he re is no re gu larfollowu p ofthe s e patients in the inte rim and s om e tim e s e ve n afte r the s e rvic
e is provide d the re is not
appropriate follow-u pto ins u re c
ontinu ity ofc
are .
T he re is no s ingle d e s ignate d c
hronicc
are nu rs e . R athe r, e ac
hnu rs e is as s igne d as ingle c
hronic
d ise as e c
linic
. T he re s u lt is afragm e nte d and d isjointe d program withno c
ohe s ive ove rs ight. It
was not s u rprising, the re fore , that we fou nd that the program is not be ingu tilize d e ffe c
tive ly;we
c
am e ac
ros s m any patients withc
hronicillne s s e s who we re not e nrolle d in the program and othe rs
who we re e nrolle d bu t not s e e n ac
c
ord ingto polic
y.
M e d ic
alre c
ord s are not ad e qu ate ly m aintaine d . M any are ove rs tu ffe d withou td ate d inform ation
while lac
kingc
u rre nt re ports and M A R s . P roble m lists are ofte n not ke pt u pd ate d .
T he infirm ary had m u ltiple d e fic
ienc
ies . LP N s are workingou ts ide the s c
ope of prac
tic
e , and
patients are not s e e n ac
c
ord ingto polic
y by provid e rs . R are ly is the re e vid e nc
e that patients are
phys ic
ally e xam ine d by the provide r. D oc
u m e ntation was ins u ffic
ient in te rm s ofd ate s /tim e s , vital
s igns , s ignatu re s and the re qu ire d SO A P form at was not always u s e d . C allbu ttons we re pos itione d
whe re it c
ou ld be d iffic
u lt orim pos s ible forthe patient to ac
c
e s s ;the re we re no c
allbu ttons in the
patient room s alongone longhallway and no d ire c
t line -of-s ight to the nu rs ings tation in s ix ofthe
room s . T he re was no s e c
u rity pre s e nc
e in the infirm ary d e s pite the pre s e nc
e of inm ate s of all
sec
u rity c
las s ific
ations . T he re was ins u ffic
ient e qu ipm e nt and s u pplies .
H avingd e s c
ribe d the above d e fic
ienc
ies , it is not su rprisingthat the qu ality im prove m e nt program
is non-fu nc
tional. A lthou ghthe re are m e e tingm inu te s from A u gu s t 2013and D e c
e m be r2013, in
ne ithe rofthos e m e e tings was the re any d isc
u s s ion ofhow to im prove the qu ality ofs e rvic
e s . T he
pe rs on as s igne d to ru n the program has had no trainingand ad m its that s he is not knowle d ge able
abou t how to perform this d u ty. A s allu d e d to e arlier, in this fac
ility the re we re alm os t no fu nc
tional
logbooks u s e d to trac
k and the re fore c
apable of be ing u tilize d for s e lf-m onitoring and
im prove m e nt ac
tivities . T he re fore , it is not s u rprising that virtu ally no s e lf-m onitoring and
c
e rtainly no im prove m e nt ac
tivities are oc
c
u rring.

Findings
Leadership and Staffing
A t the tim e of ou r visit, the H e alth C are U nit A d m inistrator pos ition was vac
ant as we llas the
D ire c
torofN u rs ingpos ition. B othpos itions are s tate pos itions . A d d itionally, the re was an ac
ting
M e d ic
alD ire c
tor, whic
his aW e xford pos ition, be c
au s e that pos ition had be e n vac
ant s inc
e A u gu s t.
T he W e xford phys ic
ian fillingin forthe M e d ic
alD ire c
tor, whe n qu e ried abou t the M e d ic
alD ire c
tor
d u ties s he pe rform e d , d e s c
ribe d prim arily be ingre s pons ible for the s c
he d u le d offs ite s e rvic
es
u tilization m anage m e nt and be ingavailable to c
ons u lt withnu rs e s and othe rc
linic
ians whe n s he
was ons ite . She was not on c
all, s he provide d no training for staff and s he he rs e lf was not
knowle d ge able withre gard to the qu ality im prove m e nt program . She d id no c
linic
alpe rform anc
e
as s e s s m e nts . A t afac
ility withas c
om ple x am e d ic
alm iss ion as the D ixon
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xon C orrec ti
onalC enter

P age 4

C orre c
tionalC e nte r, the le ad e rs hipvac
u u m raise d are d flag, whic
hwas u ltim ate ly s u pporte d by
ou r c
linic
al find ings. T he s e vac
anc
ies m u s t be fille d as qu ic
kly as pos s ible . T he re we re two
s u pe rvisory nu rs ingpos itions , one as tate nu rs e and one aW e xford nu rs e .
O the rs taffingis liste d in the following
table :Table 1. Health Care Staffin
Position
M e d ic
alD ire c
tor
StaffP hys ic
ian
N u rs e P rac
titione r
H e althC are U nit A d m .
D ire c
torofN u rs ing
N u rs ingSu pe rvisor
N u rs ingSu pe rvisor
C orre c
tions N u rs e I
C orre c
tions N u rs e II
R e giste re d N u rs e
Lic
e ns e d P rac
tic
alN u rs e s
C e rtified N u rs ingA id e
H e althInform ation A d m .
H e althInfo. A s s oc
.
P hle botom ist
R ad iology T e c
hnic
ian
P harm ac
y Tec
hnic
ian
P harm ac
y Tec
hnic
ian
StaffA s s istant I
StaffA s s istant II
C hiefD e ntist
D e ntist
D e ntalA s s istant
D e ntalA s s istant
O ptom e try
P hys ic
alT he rapist
P hys ic
alT he rapy A s s t.
Total

Current FTE
1.0
1.0
2.0
1.0
1.0
1.0
1.0
16.0
2.0
8.0
10.0
6.0
1.0
1.0
0.5
1.0
3.0
1.0
1.0
3.0
1.0
0.4
1.0
1.0
0.2
0.2
1.0
66.3

Filled
0
1.0
1.0
0
0
1.0
1.0
9.0
2.0
7.0
9.0
4.0
0
1.0
1.0
1.0
3.0
1.0
0
3.0
1.0
0.4
1.0
1.0
0.2
0.2
0
48.8

Vacant State/Cont.
1
C ontrac
t
0
C ontrac
t
1
C ontrac
t
1
State
1
State
0
State
0
C ontrac
t
7
State
0
State
1
C ontrac
t
1
C ontrac
t
2
C ontrac
t
1
State
0
State
0
C ontrac
t
0
C ontrac
t
0
C ontrac
t
0
State
1
C ontrac
t
0
C ontrac
t
0
C ontrac
t
0
C ontrac
t
0
State
0
C ontrac
t
0
C ontrac
t
0
C ontrac
t
1
C ontrac
t
18 (10
state & 8
contract)

Staffing Concerns
O fpartic
u larc
onc
e rn are the vac
ant M e d ic
alD ire c
tor, H e althC are U nit A d m inistratorand D ire c
tor
ofN u rs ingpos itions and the le ngthoftim e the y have be e n vac
ant. T he s e thre e pos itions repre s e nt
the le ad e rs hipte am ofthe m e d ic
ald e partm e nt. To have one ofthe thre e pos itions vac
ant re pre s e nts
as ignific
ant ne gative im pac
t on the m e d ic
alprogram , bu t to have allthre e

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xon C orrec ti
onalC enter

P age 5

vac
ant s pe lls d isas te r. E ve n thou gh ad m inistrative s taff has be e n as s igne d to ove rs e e the
d e partm e nt and has worke d hard to hold the program togethe r, this s trate gy is like plac
ingas m all
band -aid on ve ry large wou nd .
W hile the re are two s u pe rvisingR N s , bothare ne w to the irpos itions , and one R N is e m ploye d by
the s tate and the othe ris e m ploye d by the m e d ic
alve nd orand fu nc
tions prim arily as the ve nd or
s
s ite c
ontrac
t m anage r. A s a re s u lt, the ir m iss ions are not c
om ple te ly aligne d . E ac
h of the
ind ivid u als ne e d s to be m e ntore d , to be tau ght, to be m onitore d and to be e valu ate d . T his c
an only
be ac
c
om plishe d by he alth c
are e d u c
ate d , c
re d e ntiale d and lic
e ns e d m e d ic
al d e partm e nt
ad m inistrative s taff, i.e ., aD ire c
torofN u rs ingand H e althC are U nit A d m inistrator.
N u rs ings c
he d u lingis in s ham ble s as are s u lt ofe ac
hs u pe rvisingnu rs e s c
he d u linghe rown s taff,
i.e ., s tate e m ploye d or ve nd or e m ploye d . A s a re s u lt, c
ou ple d with s ignific
ant s tate nu rs ing
vac
anc
ies , ove rtim e is u s e d d aily to provid e for m inim u m s taffing. M inim u m s taffingre s u lts in
m inim u m ac
c
om plishm e nt as the re is not e nou ghs taffto e ffe c
tive ly c
om ple te re qu ire d tas ks s u ch
as c
om ple te c
harting, intake inte rviews , phys ic
ale xam inations , c
hronicillne s s c
linic
s , E K Gs and
s ic
kc
all. T he D ire c
torofN u rs ingpos ition provid e s fors pe c
ificove rs ight ofthe nu rs ingfu nc
tion
throu ghc
e ntralize d s c
he d u ling, training, m onitoringand e valu atingnu rs ings taffpe rform anc
e.
T he H e althC are U nit A d m inistratorpos ition provid e s am e d ic
alad m inistrative pe rs pe c
tive ofthe
totalm e d ic
alprogram and m iss ion. T he pos ition re qu ire m e nts go be yond ju s t s u pe rvision ofs taff
bu t, m ore im portantly, the c
ons tant m onitoring, e valu atingand e d itingofthe program to as s u re
c
om plianc
e withe s tablishe d polic
y and proc
e d u re and the e nhanc
e m e nt ofbothm e d ic
als e rvic
es
d e live ry and the qu ality ofs e rvic
e s . T his is not aone tim e e ffort, as c
ons tant m onitoring, e valu ating
and e d itingare re qu ire d .
W hile on pape rthe M e d ic
alD ire c
torhou rs are be ingfille d by am e d ic
alve nd orprovid e d trave lling
phys ic
ian, it c
annot be argu e d this arrange m e nt is the e qu ivale nt of havingafu ll-tim e M e d ic
al
D ire c
tor. W ith this arrange m e nt, the re is no owne rs hip of the program , no c
ontinu ity of
ad m inistrative ove rs ight and no c
ontinu ity ofm e d ic
alau thority as re qu ire d by the c
om pre he ns ive
he althc
are c
ontrac
t.
ID O C polic
y re qu ire s pe riod icage and ge nd e rs pe c
ificphys ic
ale xam inations are c
ond u c
te d and
d oc
u m e nte d d u ringthe inm ate
s birthm onth. O f10re c
ord s re viewe d , five we re proble m atic
, with
m u ltiple d e fic
ienc
ies . T he proble m s note d we re :
1.
2.
3.
4.

N
N
N
N

o d oc
u m e nte d e ye e xam ination in two re c
ord s
o d ate and tim e ofe xam ination note d ors ignatu re ofthe nu rs e
o d oc
u m e nte d nu rs ingas s e s s m e nt in two re c
ord s
o d oc
u m e nte d phys ic
ian tre atm e nt plan in one re c
ord

T his c
onfirm s the re m ay be proble m s withbothad m inistrative s u pe rvision and s taffing.

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xon C orrec ti
onalC enter

P age 6

Clinic Space and Sanitation

D ixon C orre c
tionalC e nte r originally ope ne d in 1918 for the c
are of e pile ptic
s bu t soon hou s e d
m e ntally illpatients . T he D e partm e nt ofM e ntalH e althas s u m e d c
ontrolin 1961and c
hange d the
nam e to the D ixon D e ve lopm e ntalC e nte r in 1975. T he d e ve lopm e ntalc
e nte r was later c
los e d ,
pu rc
has e d by the Illinois D e partm e nt ofC orre c
tions and re ope ne d in 1983 as am e d iu m s e c
u rity
ad u lt m ale fac
ility hou s ingalarge m e ntalhe alth, s pe c
ialne e d s and ge riatricpopu lations .
A s are s u lt ofthe originalm e ntalhe althhos pitald e s ign, the c
u rre nt m e d ic
albu ild ingis alarge
thre e -s tory bu ild ings e rvingm u ltiple fu nc
tions . A llthre e floors are he ate d and air-c
ond itione d .
T he firs t floor inc
lu d e s alarge inm ate waitingare a, x-ray s u ite , d e ntalc
linic
, optom e try c
linic
,
m e d ic
ation pre paration and s torage , m e d ic
alre c
ord s , proc
e d u re room , library, two nu rs e s ic
kc
all
e xam ination room s , thre e phys ic
ian/N P e xam ination room s and m u ltiple offic
es.
T he s e c
ond floor, ac
c
e s s e d by e le vatororstairs , is d ivid e d in halfwitha25-be d m obility im paire d
u nit (A D A )and the othe rhalfbe inga28-be d infirm ary. A t the tim e ofthe ins pe c
tion, the re we re
19patients in the A D A u nit, and 22patients in the infirm ary.
T he third floor, als o ac
c
e s s ible by e le vatorors tairs , is an 84-be d ge riatricu nit. T o be e ligible , a
patient m u s t be at le as t age 50and have two orm ore d iagnos e d c
hronicillne s s e s . A t the tim e of
the ins pe c
tion, all84be d s we re fu ll.
T he bu ild ingwas re as onably cle an, we lllighte d and we llm aintaine d . T he re are inm ate porte rs
as s igne d to e ac
hfloorforc
le aningpu rpos e s . Ind ivid u als hou s e d on the third floorare re s pons ible
to ke e pthe irroom s c
le an, and inm ate porte rs provid e the janitorials e rvic
e s forthe c
om m on are as .
M e d ic
al are as are obs e rvingblood -borne pathoge n pre c
au tions , and a lic
e ns e d m e d ic
al was te
d ispos alc
om pany is u s e d .
T he be d s on the third floorappe are d e xtre m e ly old and worn. O fs ignific
ant c
onc
e rn was the s tyle
ofbe d be ingu s e d , whic
hwas as te e lfram e withas ys te m ofinte rc
onne c
te d s prings on whic
hthe
m attre s s is laid . T he s tyle is proble m aticforthe s e re as ons :
1. T he re are s ignific
ant s e c
u rity c
onc
e rns s inc
e m any parts of the be d c
an be e as ily take n
apart and fabric
ate d into awe apon.
2. T his s tyle of s prings u pport s ys te m is proble m aticfor old e r patients d u e to it c
au s ing
c
hronicbac
k pain, s tiffne s s and los s offle xibility and m obility.
3. T he be d is d iffic
u lt to thorou ghly c
le an and s anitize be twe e n patients .

Intrasystem Transfer
A n ad e qu ate intras ys te m trans fe rprogram be gins withpatients be ingpre s e nte d to the m e d ic
alu nit
at the tim e ofarrivalwiththe ir re c
ord s and the healthtrans fe r s u m m ary form . A nu rs e s hou ld be
re viewingthe form , ide ntifyingproble m s , m e d ic
ations , alle rgies and any appointm e nts that ne e d to
be s c
he d u le d bas e d on what is d oc
u m e nte d in the m e d ic
alre c
ord . T his s hou ld be

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Di
xon C orrec ti
onalC enter

P age 7

ac
c
om plishe d on the s am e d ay the patients arrive , bu t c
e rtainly no late r than the followingd ay
s hift. T he c
u rre nt s ys te m ind ic
ate s that the nu rs e s are not fam iliarwiththe re qu ire m e nts and are
not appropriate ly traine d ;in ad d ition, the proc
e s s is not only not m onitore d bu t nu rs ings taffare
not be ingprovide d with fe e d bac
k s o that the ir pe rform anc
e im prove s . Give n the abs e nc
e of
loggingand trac
kingby the m e d ic
alprogram , it is not at alls u rprisingthat the s e d e fic
its e xist and
u ltim ate ly, liability is c
re ate d both for the inm ate s and for the s tate. It is pos s ible that nu rs ing
pos ition d e fic
its c
ontribu te to this proble m .
W e looke d at 12re c
ord s ofpatients who e nte re d as re c
e ntly as Fe bru ary 2014and as farbac
k as
D ec
e m be rof2013. O fthe 12re c
ord s we re viewe d , the re we re proble m s withvirtu ally allofthe m .
In fac
t, we le arne d that it is u nu s u alfor the norm alintras ys te m trans fe r polic
y to be followe d .
W he n patients are brou ght in, the y are not brou ght to the m e d ic
alare a;ins te ad , anu rs e s e e s the m
and atte m pts to le arn ifthe re are any c
ritic
alm e d ic
ation ne e d s . T he re is an e ffort to re s pond to
thos e ne e d s , bu t that is the only thingthat happe ns withre gard to intras ys te m trans fe rs . W e le arne d
that d u e to staffings hortage s , the y are u nable to ac
qu it this c
ritic
alobligation. W e fou nd five
re c
ord s whic
hwe re d e laye d s ignific
antly and s e ve n whe re the y we re e ithe rnot d one at allord one
inc
orre c
tly. W e willprovide s om e e xam ple s .
Patient #1
T his is a36-ye ar-old who arrive d at D ixon on 2/4/14withm e ntalhe althproble m s and no c
hronic
m e d ic
alproble m s . H is he althtrans fe rs u m m ary has s tillnot be e n c
om ple te d .
Patient #2
T his is apatient from P inc
kne yville withm e ntalhe althproble m s and this was d one inc
orre c
tly.
T he toppart ofthe intras ys te m trans fe rorhe althtrans fe rs u m m ary is to be fille d ou t by the s e nd ing
ins titu tion bas e d on are c
ord re view. T he bottom halfis to be fille d ou t at the re c
e ivingins titu tion
and inc
lu d e s afac
e -to-fac
e d isc
u s s ion withthe inm ate ofthe s u m m arize d proble m s , m e d ic
ations ,
appointm e nts , e tc
. T he nu rs e at D ixon pu lle d ane w he althtrans fe rs u m m ary form and again fille d
ou t the top, whic
hd id not e nable vitals igns to be pe rform e d be c
au s e the nu rs e d id not e ve n s e e
the patient.
Patient #3
A lthou ghthis patient arrive d on 2/4/14, his m e d ic
alre c
ord has not arrive d . T his is anothe rc
as e in
whic
hat Shawne e the tophalfofthe form was c
om ple te d and the D ixon s taffpe rs on pu lle d anothe r
ne w form and re pe ate d that inform ation withou t talkingto the patient orpe rform ingany vitals igns .
Patient #4
T his is a37-ye ar-old as thm aticwithps yc
hproble m s . T his patient arrive d on 2/4/14, the he alth
trans fe r s u m m ary was c
om ple te d on 2/13, e ight d ays late r, bu t it lac
ke d are fe rralto the as thm a
c
linic
.
Patient #5
T his is a27-ye ar-old withm u ltiple s c
le ros is. T he he althtrans fe rs u m m ary was d one on 2/26/14,
approxim ate ly thre e we e ks afte rhe arrive d , bu t the re is no re fe rralto the c
hronicc
are c
linicforhis
m u ltiple s c
le ros is.

Patient #6
Febru ary 2014

Di
xon C orrec ti
onalC enter

P age 9
8

T his is a30-ye ar-old who arrive d 1/29/14, withm e ntalhe althiss u e s and hypothyroid ism , along
withhype rtriglyc
e ride m ia. T he trans fe rs u m m ary was c
om ple te d on 2/9, alittle m ore than awe e k
afte rhis arrival, bu t the re is no re fe rralto the c
hronicc
are program forhis hypothyroid ism and his
hype rtriglyc
e ride m ia.

Medical Records
M any he althre c
ord s we re ove rs tu ffe d and in d ire ne e d ofthinning. T his not only ham pe re d ou r
re view bu t als o m ore im portantly is an obs tac
le to the e ffic
ient d e live ry of c
are by the ons ite
provide rs . N ot only d o the c
harts ofte n c
ontain e xc
e s s ive am ou nts ofou td ate d inform ation, bu t
als o c
u rre nt re ports and M A R s are ofte n m iss ing. A s d e s c
ribe d in the C hronicD ise as e s e c
tion of
this re port, we fou nd pile s ofM A R s d atingbac
k for m onths in the m e d ic
alre c
ord s d e partm e nt.
T his of c
ou rs e re nd e rs it ne arly im pos s ible for provide rs to obje c
tive ly m onitor patients
m e d ic
ation c
om plianc
e.
T he infirm ary c
harts are e s s e ntially s m allpile s ofloos e filingc
lippe d into anc
ient m e talc
lipboard s .
T he pe rm ane nt file s are als o ke pt in the infirm ary, bu t the s e are not u s e d forc
hartinge ve n whe n
patients are pe rm ane ntly hou s e d in the infirm ary. Las tly, we note d that proble m lists we re ofte n
not ke pt u pto d ate .

Nursing Sick Call

N u rs ings ic
kc
allis c
ond u c
te d d aily, M ond ay throu ghFrid ay.
N u rs ings ic
kc
all, at this tim e , is d iffic
u lt to as s e s s d u e to the followingfou rre as ons :
1.
2.
3.
4.

T he fac
ility is u s ingtwo d iffe re nt proc
e d u re s forinm ate s to ac
c
e s s s ic
kc
all.
W he n s ic
kc
allre qu e s t s lips are u s e d , the y are not be ingtriage d by an R N .
T he re is no m ainte nanc
e ofs ic
kc
allre qu e s t s lips oras ic
kc
alllog.
N on-R N s are c
ond u c
tings ic
kc
all.

T he firs t proc
e d u re be ingu se d fors ic
kc
allis the s ic
kc
allrequ e st s lipm e thod . C u rre ntly, an inm ate
c
om ple te s arequ e st s lip and give s it to ac
orre c
tionaloffic
e r, who plac
e s the requ e st in aloc
ked
ins titu tionalge neralm aild rop box loc
ated in the hou s ingarea. Institu tionalm ails taffc
olle c
ts all
m ail, inc
lu d ingthe s ic
k c
all requ e st s lips , from e ac
h d rop box d aily and c
arries the m to the
ins titu tionalm ailroom , whe re allpiec
e s ofm ailare sorte d and d e live re d to e ac
hd e partm e nt. O nc
e
d e live re d to the m e d ic
ald e partm e nt, the s lips are forward e d to nu rs ing, and anu rs ings taffm e m be r,
whic
hc
ou ld be an R N su pervisor, staff R N or LP N , re views e ac
h requ e st s lip and write s the
ind ividu al
s nam e , nu m be r, c
om plaint and d ate to be e valu ated on as ic
kc
alls c
he d u le . A t this point
in the proc
e s s, the originals ic
kc
allre qu e st s lip is thrown away. E ither the inm ate is e s c
orte d or
re ports to the m e d ic
ald e partm e nt fors ic
kc
allbas e d on the d ate the nu rs ings taffm e m be rre c
ord s
on the s ic
kc
alls c
he d u le . W iththis m e thod , m e d ic
als taffretains the m ost c
ontroloverthe s ic
kc
all
sc
he d u le , s inc
e the y are d oingthe sc
he d u ling. B y ID O C polic
y, onc
e

re c
e ive d , re qu e s t s lips are to be triage d within 24 hou rs and c
ate gorize d as to u rge nt or rou tine ,
withind ivid u als in the u rge nt c
ate gory be inge valu ate d the s am e d ay orno late rthan the ne xt, and
ind ivid u als in the rou tine c
ate gory be inge valu ate d within 72hou rs .
Sinc
e the originalre qu e s t is be ingd e s troye d , the re is no way to d ete rm ine if the re qu e s t was
initially triage d , c
ate gorize d and the inm ate e valu ate d within the appropriate tim e fram e . Sim ilarly,
s inc
e as ic
kc
alllogis not m aintaine d , the re is no way to m e as u re c
om plianc
e withthe s e s am e
polic
y re qu ire m e nts .
A d d itionally, withthis proc
e s s the re are m any m e d ic
alc
onfid e ntiality bre ac
he s . Firs t, the inm ate
is re qu ire d to give his c
om ple te d re qu e s t s lipto non-m e d ic
alpe rs onne l. T he s lipis the n plac
e d in
age ne ral m ail d rop box. A s are s u lt, m ore non-m e d ic
al pe rs onne l are c
olle c
tingall the m ail,
inc
lu d ingthe s ic
kc
allre qu e s t s lips . A llthe m ailis the n trans porte d to the ins titu tionalm ailroom
fors orting, whe re m ore non-m e d ic
alpe rs onne lare hand lingc
onfid e ntials ic
kc
allre qu e s ts . Finally,
the m ailis d e live re d to e ac
hd e partm e nt by non-m e d ic
alpe rs onne l.
Sic
kc
allproc
e d u re nu m be r2be ingu s e d is an arm y-type s ic
kc
allproc
e s s . Inm ate s are inform e d
that ifthe y s ign-u pfors ic
kc
allpriorto 4p.m ., the y willbe e valu ate d the ne xt d ay. W iththis type
of s ic
kc
allproc
e s s , the m e d ic
ald e partm e nt has no c
ontrolove r s c
he d u ling. D e pe nd ingon the
nu m be rofinm ate s who s ign-u p, the m e d ic
ald e partm e nt c
ou ld have to e valu ate one or100inm ate s
withno re gard fors taffingre qu ire m e nts orothe rrequ ire d he althc
are ac
tivities . A d d itionally, while
the re are no bre ac
he s ofm e d ic
alc
onfid e ntiality withthis type ofproc
e s s , this m e thod take s away
from any as s e s s m e nt as to whe the rthe ind ivid u al
sc
om plaint is ofan u rge nt orrou tine natu re , and
ind ivid u als withbe nign re qu e s ts c
ou ld be e valu ate d priorto ind ivid u als withm ore u rge nt iss u e s .
Las tly, the are as be ingu s e d in the m e d ic
al d e partm e nt to c
ond u c
t s ic
kc
all are u nac
c
e ptable
be c
au s e :
1. T he y are poorly e qu ippe d .
2. T he re are no e xam table s on whic
hto c
ond u c
t aprope re xam ination.
3. A t tim e s , ahallway is u s e d whe re again the re are no e xam ination table s and no privacy
is available orc
onfid e ntiality m aintaine d .
O u ts id e the m e d ic
ald e partm e nt, an u nac
c
e ptable form ofs ic
kc
allis be ingc
ond u c
te d in the X H ou s e . In this hou s ingare a, nu rs ings taff, ge ne rally, Lic
e ns e d P rac
tic
alN u rs e s (LP N s )go d oorto-d oor inqu iringas to whe the r the re are any he althc
are c
om plaints . Ifthe ans we r is ye s , the
LP N talks withthe patient/inm ate throu ghthe c
e lld oor. B as e d on the c
onve rs ation, the LP N e ithe r
tre ats the patient from e s tablishe d tre atm e nt protoc
ols or re fe rs the patient to a prim ary c
are
provide r.
T his is not s ic
kc
allbu t only afac
e -to-fac
e triage . T he re is no as s e s s m e nt by qu alified m e d ic
al
s taff and no appropriate hand s -on e xam ination. A s a re s u lt, it c
annot be c
ons ide re d an
appropriate s ic
kc
allc
ontac
t, and the patient m u s t be re fe rre d to aprim ary c
are provid e r.

Febru ary 2014

Di
xon C orrec ti
onalC enter

P age 10

In ord e rforthe above proc

e s s to work c
orre c
tly, the c
om plaint m u s t be triage d by an R N and , if
ne c
e s s ary, the patient/inm ate re m ove d from his c
e llto an e xam ination are awhe re the R N c
an
c
ond u c
t an appropriate e xam ination while afford ingthe patient privac
y and c
onfid e ntiality.
P e r ID O C polic
y, inm ate s are c
harge d ac
o-pay for non-e m e rge nc
y s e lf-ge ne rate d he alth c
are
re qu e s ts . In inve s tigatingthe s ic
kc
allproc
e s s , it was le arne d that bothphys ic
ian and nu rs ings taff
are lim itinginm ate s to one c
om plaint pe rs ic
kc
allc
ontac
t and only ad d re s s ingone c
om plaint pe r
c
ontac
t. T his prac
tic
e was c
onfirm e d by both staff and inm ate s . O ne c
om plaint pe r visit is
inappropriate and u nac
c
e ptable . A llofapatient
s proble m s m u s t be ad d re s s e d at an e nc
ou nte ror
aplan d e ve lope d to ad d re s s the proble m in the ne arfu tu re . A s s e s s ingonly one proble m d u ringa
s ic
kc
allvisit c
re ate s the im pre s s ion the s ic
kc
allproc
e s s has be e n d e ve lope d to ge ne rate m ore
re ve nu e .
D aily we llne s s c
he c
ks are c
ond u c
te d by nu rs ings taffon the 3p.m . to 11p.m . s hift forallinm ate s
in c
onfine m e nt or loc
k-d own s tatu s . W e e kly rou nd s are c
ond u c
te d by the nu rs e prac
titione r.
T he s e rou nd s are d oc
u m e nte d in as e gre gation logloc
ate d in the s e gre gation u nit. In the e ve nt of
ahe alth c
are c
om plaint, the nu rs ings taff m e m be r, R N or LP N , d oc
u m e nts the c
om plaint on a
m e d ic
alu nitprogre s s note whic
his file d in the s e gre gation log. A gain, the as s e s s m e nt is pe rform e d
throu ghthe d ooru nle s s the inm ate is trans porte d to the m e d ic
alu nit foram ore d etaile d as s e s s m e nt
and e xam ination. O nc
e the inm ate is re le as e d from s e gre gation, the progre s s note d etailingthe
c
om plaint is file d in the pe rm ane nt m e d ic
alre c
ord .
A gain, the re are m u ltiple iss u e s as follows :
1. T he as s e s s m e nt c
ou ld be c
ond u c
te d by non-qu alified m e d ic
als taff.
2. A c
e ll-s id e e nc
ou nte roc
c
u rs rathe rthan ale gitim ate s ic
kc
alle nc
ou nte r.
3. T he inm ate /patient is afford e d no privac
y/c
onfid e ntiality in e xpre s s inghis c
om plaint
to the nu rs e .
4. T he re is no appropriate as s e s s m e nt of the c
om plaint and c
orre s pond ingappropriate
e xam ination.
5. T he re is ahu ge bre ac
h of patient c
onfid e ntiality by filingthe progre s s note which
d e tails the m e d ic
alc
om plaint in the s e gre gation log.
T he followingm e d ic
alre c
ord s we re s e le c
te d forreview at rand om from s ic
kc
alls c
he d u le s .
Patient #1
T his patient arrive d at D ixon 12/31/2013and s igne d are fu s alto be s e e n in s ic
kc
all.
Patient #2
T his patient arrive d at D ixon 10/2/2013 and was e valu ate d by R N 11/27/2013 for c
om plaint of
right e arpain. T he e nc
ou nte rwas in SO A P form at withR N N ote he ad ing, d ate and tim e , vital
s igns , d oc
u m e nte d e are xam , no d u ration note d and tre atm e nt pe rprotoc
ol. Sic
kc
all2/6/2014by
R N . C om plaint of right foot pain for 12 hou rs . E nc
ou nte r in SO A P form at with R N N ote
he ad ing, d ate and tim e , vitals igns and ad oc
u m e nte d e xam ination ofthe foot. P atient was re fe rre d
to the M .D . and e valu ate d the s am e d ay.
Patient #3

Febru ary 2014

Di
xon C orrec ti
onalC enter

P age 11

T his patient arrive d at D ixon (no d ate ) and was e valu ate d by R N 2/4/2014 for c
om plaint of
e xc
ru c
iatingpain ofthe right hand . T he e nc
ou nte rwas in SO A P form at withR N N ote he ad ing,
d ate and tim e , no d u ration note d , no vitals igns note d , d oc
u m e nte d hand e xam ination. P atient
re fe rre d to m id -le ve lprovid e rand e valu ate d the s am e d ay. Sic
kc
all2/6 by LP N . T he e nc
ou nte r
was in SO A P form at withLP N N ote he ad ing, d ate , no tim e and no vitals igns . C om plaint ofras h
on right s ide ofne c
k, fe e t and groin are a. N o d u ration note d . D oc
u m e nte d e xam ination ofne c
k,
fe e t and groin. A s s e s s m e nt ofT ine ape d is. Tre ate d pe rtre atm e nt protoc
ols bu t pre -printe d protoc
ol
s he e t not u s e d ;give n e d u c
ation. Sic
kc
all2/21 by R N . T he e nc
ou nte rwas in SO A P form at with
R N N ote he ad ing. C om plaint ofpain in the right kne e and right wrist. D ate bu t not tim e , vital
s igns , no d u ration of pain note d . N o d oc
u m e nte d e xam ination bu t as s e s s m e nt of d e ge ne rative
arthritis whic
his not c
ove re d in nu rs ingprotoc
ols . P atient give n wrist brac
e , s oft kne e brac
e and
M otrin inc
re as e d from 400m g. B ID to 600m g. B ID bu t no d u ration note d . P atient was ins tru c
te d
to retu rn as ne e d e d .
Patient #4
T his patient arrive d at D ixon 4/9/2003 and was e valu ate d in s ic
kc
all 1/20/2014 by LP N for
c
om plaint ofd and ru ff. P re -printe d protoc
olform in SO A P form at u s e d . D ate and tim e , no vital
s igns e xc
e pt for te m pe ratu re . N o e xam ination ofs c
alp note d . Give n anti-d and ru ff s ham poo pe r
protoc
ol.
Patient #5
T his patient arrive d at D ixon 1/18/2012. R N s ic
kc
all2/25/2014 for c
om plaint he los t atooth
filling. SO A P form at, d ate and tim e , vitals igns , d u ration note d and re fe rre d to d e ntaland s e e the
s am e d ay.
Patient #6
T his patient arrive d at D ixon 6/5/2012. R N s ic
kc
all5/15/2013forc
om plaint ofc
u ttingthe tipof
his right thu m bon his be d . SO A P form at, d ate /tim e , vitals igns , tim e ofac
c
id e nt;d oc
u m e nte d
d esc
ription of inju ry, e xam ination and as s e s s m e nt. T re atm e nt provid e d with no re fe re nc
e to a
protoc
ol. D oc
u m e nte d tre atm e nt was to was h wou nd with s oap and wate r, apply antibiotic
ointm e nt, band age ;gave T D A P and e d u c
ation. R N s ic
kc
all2/18/2014forc
om plaint ofhe artbu rn
and c
onge s te d e ars . N o SO A P form at and no note d vitals igns . D ate /tim e and e ar e xam ination
note d . H istory ofhe artbu rn note d and M ylantaworke d we llin the pas t. T he re was no re fe re nc
e
to the u s e ofaprotoc
olbu t M ylantatable ts we re give n. T he e ar c
onge s tion was not ad d re s s e d .
R N s ic
k c
all 2/25 for c
om plaint that the M ylanta table ts we re not he lping. SO A P form at,
d ate /tim e , vitals igns and history d oc
u m e nte d ;re fe rre d to M .D . bu t not ye t e valu ate d as of2/28.
Patient #7
T his patient arrive d at D ixon 9/2/2009. R N s ic
kc
all12/24/2013as afollow-u pto right le gm u s c
le
pain on 11/25/2013. C om plainingright le gc
ontinu e s to hu rt as we llas s hou ld e r. SO A P form at,
d ate /tim e and vitals igns note d . N o notation as to whic
hs hou ld e rwas hu rtingorthe d u ration. N o
e xam ination note d . T he as s e s s m e nt was pain.P atient re fe rre d to the phys ic
ian and told it wou ld
be 10-14d ays be fore he wou ld be s e e n. P atient e valu ate d by the phys ic
ian on 1/8and 2/21/2014.

Febru ary 2014

Di
xon C orrec ti
onalC enter

P age 12

Patient #8
T his patient arrive d at D ixon 12/15/2013. LP N s ic
kc
all2/25/2014forc
om plaint ofd and ru ff. T he
d and ru ff pre -printe d protoc
ol form was u s e d . T he d ate /tim e , vital s igns , d u ration and pas t
su c
c
e s s fu ltre atm e nt was note d . D oc
u m e nte d e xam ination of s c
alp whic
h re fe re nc
e d e xte ns ive
flakine s s ofs c
alp. A ntidand ru ffs ham poo provide d pe rprotoc
ol.
Patient #9
T his patient arrive d at D ixon 2/18/2010. LP N s ic
kc
allfor c
om plaint ofright s ide d pain. SO A P
form at, d ate /tim e , vitals igns and history ofan old inju ry d oc
u m e nte d . N o d oc
u m e nte d phys ic
al
e xam ination oras s e s s m e nt and re fe rre d to the phys ic
ian. N o d oc
u m e ntation in the m e d ic
alre c
ord
as havingbe e n e valu ate d by the phys ic
ian.
Patient #10
T his patient arrive d at D ixon 4/4/2001. R N s ic
k c
all 11/28/2013 for c
om plaint of a s e ve re
toothac
he . N o SO A P form at bu t ad e taile d narrative note. D ate /tim e , vitals igns and d u ration note d .
E valu ation ofm ou thand pote ntialtoothc
au s ingthe pain note d . T he phys ic
ian was c
ontac
te d by
te le phone and pain m e d ic
ation ord e rs re c
e ive d . T he re was no d oc
u m e ntation ofad e ntalre fe rral.
T he toothac
he protoc
olwas not re fe re nc
e d in the re c
ord . R N s ic
kc
all1/22/2014forc
om plaint of
le ft s hou ld e rpain fore ight m onths . A pre printe d protoc
olform was u s e d . D ate /tim e and ve ry brief
e xam ination and as s e s s m e nt note d . T he re no vitals igns note d . T he patient was provide d ove r-the c
ou nte rpain m e d ic
ation thre e tim e s ad ay forthre e d ays .

Significant Issues with Nursing Sick Call

1. V iolation of the Illinois N u rs e P rac
tic
e A c
t for Lic
e ns e d P rac
tic
al N u rs e s (LP N s ) to
c
ond u c
t s ic
kc
alld u e to aphys ic
ale xam ination and as s e s s m e nt be ingre qu ire d whic
h is
be yond the s c
ope ofprac
tic
e foran LP N .
2. ID O C polic
y re qu ire s s ic
k c
all e nc
ou nte rs are d oc
u m e nte d in the Su bje c
t-O bje c
tive A s s e s s m e nt-P lan (SO A P )form at, whic
his not c
ons iste ntly u s e d .
3. D oc
u m e ntation is inc
ons iste nt and inc
om ple te , in that fre qu e ntly d ate s , tim e s , vitals igns ,
d u ration ofc
om plaint, e xam ination and as s e s s m e nt are not d oc
u m e nte d .
4. ID O C polic
y re qu ire s the u s e ofapprove d tre atm e nt protoc
ols in ord e rforaR N to c
ond u c
t
s ic
kc
all. Sic
kc
alle nc
ou nte rs are fre qu e ntly d oc
u m e nte d withno re fe re nc
e to aprotoc
ol.
5. P atients are only pe rm itte d one c
om plaint pe rs ic
kc
alle nc
ou nte r.
6. T he R N inad ve rte ntly pre s c
ribe d am e d ic
ine by inc
re as ingthe ove r-the -c
ou nte rd os age to
apre s c
ription d os age , whic
his pre s c
ribingand be yond the nu rs ings c
ope ofprac
tic
e.
7. P roble m s , like e arc
onge s tion, we re ne ve rad d re s s e d forone patient.
8. Som e patients are s e e n withou t e ithe ran ad e qu ate history orphys ic
alas s e s s m e nt.
9. D iffic
u lt to d ete rm ine if ac
c
e s s to s ic
kc
all is im pe d e d d u e to abroke n s ys te m or the
s ignific
ant nu m be rofhe althc
are u nit le ad e rs hipand nu rs ingpos ition vac
anc
ies .

Clinician Sick Call

B as e d on s e ve ral appointm e nt books give n to u s by the nu rs ings u pe rvisors , we s e le c
te d 12
appointm e nts d oc
u m e nte d as havingoc
c
u rre d . In 10ofthe 12re c
ord s , we c
ou ld ne ithe rfind anote
on the d ay the appointm e nt was writte n in the book norwithin awe e k be fore orafte rthat

Febru ary 2014

Di
xon C orrec ti
onalC enter

P age 13

d ate . It s e e m e d c
le arto u s that the re c
ord ke e ping, vis avis the appointm e nt books, was not ac
c
u rate
in the s e ns e that the patients who we re d oc
u m e nte d as havingbe e n s e e n by ac
linic
ian had no note s
in the irre c
ord s . T he re we re afe w e xc
e ptions .
Patient #1
T his is a37-ye ar-old who was s e e n on 12/10/13forrhe u m atoid arthritis follow u p. T he re we re no
note s in the re c
ord forthat. H owe ve r, on 12/11, the patient was s e e n forac
ys t withpu s c
om ing
ou t ofit. T he N P wrote an appropriate note and re fe rre d the patient to the phys ic
ian, who s aw the
patient on 12/17.
Patient #2
T his is a53-ye ar-old withno c
hronicproble m s . H e was to be s e e n foran as s e s s m e nt ofhis pain
m e d s on 12/19/13, bu t the re is no note forthat d ate.
Patient #3
T his is a22-ye ar-old s u ppos e d ly s e e n on 12/19/13 for bac
k pain, bu t the re we re no note s in his
re c
ord forthe m onthofD e c
e m be r.
Patient #4
T his is a47-ye ar-old m an withm u ltiple c
hronicd ise as e s . O n 6/21/13, the P A s aw the patient for
as e bac
e ou s c
ys t. H e d raine d and pac
ke d the c
ys t and re qu e s te d d aily d re s s ingc
hange s and follow
u pin two we e ks . T he re we re no d re s s ingc
hange s d oc
u m e nte d in the c
hart and the re was no followu pvisit d oc
u m e nte d at the two-we e k m ark. H e was ne xt s e e n on 7/31by aphys ic
ian, bu t the re is
no m e ntion ofthe wou nd s .
A t nu rs e s ic
kc
allon 9/24, the patient re qu e ste d to s e e aprovide rre gard inghis C O P D m e d ic
ations .
M D line was ord e re d for9/25, bu t the re is no note in the c
hart c
orre s pond ingto that d ate.
Patient #5
T his is a45-ye ar-old withm u ltiple iss u e s , inc
lu d ings e ve re re frac
tory tre m ors for whic
hhe has
s e e n in the ne u rology d e partm e nt at U IC . T he ir re c
om m e nd ation was for inc
re as ingd os e s of
K lonopin.
O n 12/12/13, he re qu e s te d to have his K lonopin inc
re as e d as re c
om m e nd e d by ne u rology and was
re fe rre d to the M e d ic
alD ire c
tor. She re ne we d the m e d ic
ation that d ay, bu t ne ithe r c
hange d the
d os e nors aw the patient. H e was s c
he d u le d fore valu ation on 12/26, bu t the re is no note from that
d ay.
O n 1/7/14, the R N d oc
u m e nte d that s he s poke to the ward e n abou t gettingthe patient in to s e e D r.
B , and was prom ise d that the patient wou ld be able to s e e the d oc
torthat M ond ay, bu t he was not
s e e n. H e finally d id s e e the phys ic
ian am onth late r on 2/13, and his m e d ic
ation was inc
re as e d .
T he re was no follow-u pnote as ofthe d ate ofou rvisit.

Febru ary 2014

Di
xon C orrec ti
onalC enter

P age 14

Opinion:T his patient has not be e n s e e n tim e ly (orat all)in re s pons e to his re qu e s ts . T his patient
is hou s e d in the H e althC are U nit, m akinghim re ad ily ac
c
e s s ible to the provide rs . E ve n the nu rs e
s
atte m pt at inte rve ntion throu ghthe ward e n d id not re s u lt in the patient be ings e e n.
Patient #6
T his is an 86-ye ar-old m an withhype rte ns ion and history ofprostate c
anc
e rwho s aw his rad iation
onc
ologist on 7/23/13 in follow-u p of his prostate c
anc
e r. T he c
ons u ltant note d that the patient
re porte d ne w ons et re c
talble e d ingand re c
om m e nd e d c
olonos c
opy. W he n the patient s aw the ons ite
provide ron retu rn from this trip, the re c
om m e nd ation forc
olonos c
opy was bru s he d as ide withthe
e xplanation that the patient has e xternalhe m orrhoid s and anorm alhe m oglobin.
O n 10/22, the M D visits tam pwas c
ros s e d ou t and M D c
hart re viewwas writte n in. T he plan
was to s c
he d u le afollow-u pappointm e nt to e valu ate his he m orrhoids .
O n 11/6, the appointm e nt was c
anc
e lle d pe r M D re qu e stand re s c
he d u le d for11/18. O n 11/18,
the patient was s e e n forc
hronicc
are c
linic
. T he he m orrhoids and ble e d ingwe re not ad d re s s e d .
O n 12/4, the patient was s e e n on M D line fore valu ate throm bos is.T he patient re porte d ongoing
re c
talble e d ing. T he e xam s howe d only s m all e xte rnalhe m orrhoid and s toolwas ne gative for
blood . A nothe rC B C was ord ere d and was s table at 13.3.
Opinion:T his patient was not s e e n tim e ly for his c
om plaint of re c
tal ble e d ingnor has this
c
om plaint be e n thorou ghly e valu ate d . C onc
lu d ingthe he m orrhoid is the c
u lprit withou t e xc
lu d ing
m ore s e riou s pathology is not appropriate .

Chronic Disease Management

T he re was no way to d ete rm ine how m any inm ate s are e nrolle d in the c
hronicd ise as e c
linicat this
fac
ility, northe ind ivid u alc
linice nrollm e nts , as the s e are not trac
ke d in ac
om pre he ns ive , u pd ate d
and re liable way at this fac
ility.
T he re is no s ingle d e s ignate d c
hronicc
are nu rs e ;we we re told this is d u e to s taffings hortage s .
R athe r, e ac
h nu rs e is as s igne d as ingle c
hronicd ise as e c
linic
. T he re s u lt is afragm e nte d and
d isjointe d program withno c
ohe s ive ove rs ight. T he program is not be ingu tilize d e ffe c
tive ly;we
c
am e ac
ros s m any patients withc
hronicillne s s e s who we re not e nrolle d in the program and othe rs
who we re e nrolle d bu t not s e e n ac
c
ord ingto polic
y.
P atients withm u ltiple c
hronicillne s s e s are e nrolle d in the M IC or m u ltiple illne s s c
linic
. T he
c
linicnu rs e s c
oord inate the tim ingofthe c
hronicc
are c
linic
s withthe provid e rs . O nc
e d ate s for
c
linic
s are c
hos e n by the provide rs , the nu rs e s provid e that inform ation to the phle botom ist who
c
oord inate s the blood work withthe visits . Labs are to be d rawn within 30d ays priorto the visit
by polic
y.

Febru ary 2014

Di
xon C orrec ti
onalC enter

P age 15

Cardiac/Hypertension
W e re viewe d five rand om re c
ord s ofpatients withhype rte ns ion and had c
onc
e rns withtim e line s s
and c
linic
ald e c
ision m akingin the thre e c
as e s d e s c
ribe d be low. In afou rthc
hart, the proble m list
had not be e n u pd ate d in ove r10ye ars .
Patient #1
T his is a74-ye ar-old withm u ltiple c
hronicillne s s e s , inc
lu d inghype rte ns ion, whos e c
are has be e n
c
om plic
ate d by his nonc
om plianc
e . T he only re c
e nt labin the c
hart is an e le c
trolyte pane lfrom a
ye arago. T he las t labte s t priorto that was in 2009.
O n 2/11/13, the patient was s e e n at M D s ic
kc
allforac
ou gh. H is blood pre s s u re was 156/90. T he
phys ic
ian wrote, State s he d oe s n
t ne e d to s e e m e . P roble m re s olve d . T he blood pre s s u re was
not ad d re s s e d .
D u ringan offs ite visit to U IC onc
ology on 2/23, the patient
s blood pre s s u re was 194/108. H e was
give n ad os e ofC lonid ine by the onc
ology re s id e nt. T he re was no follow-u pofthe blood pre s s u re
afte rhis re tu rn to the ins titu tion.
O n 7/8, he was s e e n in c
hronicc
are c
linicfor hype rte ns ion, d iabe te s and as thm a. T he phys ic
ian
note d nonc
om plianc
e with tre atm e nt and re fu s als to have labs d rawn. E d u c
ation was provide d .
T he re we re no fu rthe rc
hronicc
linicnote s as ofthe d ate ofou rvisit.
Opinion:T his patient is ove rd u e forc
hronicc
are c
linic
. H is e le vate d blood pre s s u re has not be e n
ad e qu ate ly ad d re s s e d . Fu rthe ratte m pts s hou ld be m ad e to e nhanc
e this patient
sc
om plianc
e.
Patient #2
T his is a69-ye ar-old m an withoxyge n d e pe nd e nt C O P D , c
oronary arte ry d ise as e withhistory of
M I, hype rte ns ion and he aringim pairm e nt who arrive d at D ixon on 6/11/13. H is m e d ic
ations
inc
lu d e an A C E inhibitorand as pirin.
H is c
hronicd ise as e bas e line c
linicwas on 7/19. Labs we re d rawn tim e ly priorto the visit and his
blood pre s s u re was we llc
ontrolle d .
T he ne xt c
hronicc
are c
linicwas on 10/11. T he re we re no ne w labs . T he patient
s blood pre s s u re
was 160/80 and blood pre s s u re c
he c
ks we re ord e re d . T he s e we re not in the c
hart, nor we re
s u bs e qu e nt c
hange s m ad e to his m e d ic
ation. Follow-u pwiththe nu rs e prac
titione rwas ord e re d for
thre e we e ks late rbu t d id not oc
c
u r.
A t the ne xt c
hronicc
are c
linicon 2/6/14, the provid e r note d that nitroglyc
e rin he lps with his
angina.T he re we re no othe rd etails abou t the natu re ofhis c
he s t pain and no fu rthe rinve s tigation
was ord e re d . H is blood pre s s u re was 158/80and the A C E inhibitorwas inc
re as e d .
Opinion:T his high-risk patient
s re port of angina ne e d s to be inve s tigate d thorou ghly. H is
c
oronary arte ry d ise as e has not be e n m anage d ac
c
ord ingto c
u rre nt gu ide line s , whic
h wou ld
inc
lu d e a be ta-bloc
ke r and s tatin. H is blood pres s u re s hou ld be m onitore d and tre ate d m ore
d ilige ntly.

Febru ary 2014

Di
xon C orrec ti
onalC enter

P age 16

Patient #3
T his is an 86-ye ar-old m an with hype rte ns ion and history of prostate c
anc
e r. H is m e d ic
ations
inc
lu d e d as pirin, potas s iu m , hyd roc
hlorothiaz id e and m e toprolol. A t his 3/11/13 c
hronicc
are
c
linic
, his c
ard iace xam was d e s c
ribe d as irre gu larly irre gu lar, bu t no E C G was obtaine d . H is
blood pre s s u re was e le vate d and m e d ic
ation was pre s c
ribe d . Labs we re d one tim e ly priorto this
visit.
H is ne xt c
hronicc
are c
linicoc
c
u rre d s ix m onths late ron 9/23. N o ne w labs we re obtaine d . H is
c
ard iace xam was d e s c
ribe d as R SR [re gu lars inu s rhythm ]withfe w irre gbe ats .A gain, no E C G
was obtaine d . B lood pre s s u re was we llc
ontrolle d .
T he ne xt c
hronicc
are visit was on 11/18. T his tim e his c
ard iace xam was , rs rwithrare e c
topic
be at.T he re we re no re c
e nt labs .
Opinion:T his patient has not be e n s e e n tim e ly in c
hronicc
are c
linicand his e le c
trolyte s have not
be e n c
he c
ke d in ove raye ar. Irre gu larhe art rhythm s s hou ld be inve s tigate d withan E C G.

HIV Infection/AIDS
R e view ofthe H IV c
linicre ve ale d that the ID te le m e d ic
ine visits d o not always oc
c
u rtim e ly and
the re ports we re not c
ons iste ntly file d in the he althre c
ord . T he ons ite provide rs d o not partic
ipate
in m onitoringpatients H IV d ise as e at this fac
ility. W hile we wou ld not e xpe c
t the m to be fac
ile
in pre s c
ribingH IV m e d ic
ations , we wou ld e xpe c
t that the y wou ld partic
ipate in m onitoring
patients m e d ic
ation c
om plianc
e , s ide e ffe c
ts and ge ne rald e gre e ofd ise as e c
ontrol.
T he c
as e be low e xe m plifies the type s ofiss u e s we obs e rve d at this fac
ility:
Patient #4
T his is a47-ye ar-old m an with m u ltiple c
hronicillne s s e s , inc
lu d ingad vanc
e d H IV d ise as e on
s alvage the rapy. W he n he was s e e n by ID te le m e d ic
ine in Janu ary 2013, the e le c
tronics tethos c
ope
was broke n. H is re gim e n was c
hange d d u e to c
onc
erns ove rpote ntiald ru ginte rac
tions and athre em onthfollow-u pwas re qu e ste d withblood work prior. T he re we re no on-s ite provide rnote s afte r
this to m onitorthe patient fors ide e ffe c
ts , c
om plianc
e ortole rability.
W he n he s aw ID again in A pril, the e le c
tronics te thos c
ope was stillbroke n. T he patient re porte d
havingm iss e d 2-3d os e s ofm e d ic
ation. Labs we re not d one priorto this visit;this ove rs ight was
partic
u larly c
ru c
ialgive n the re c
e nt c
hange in the rapy. It d oe s not appe arthat the labs we re d rawn
afte rthe visit e ithe r, as the ne xt s et oflabs was d ate d 7/8/13. A 3-m onthfollow u pwas re qu e ste d
bu t he was not s e e n again u ntilSe pte m be rac
c
ord ingto the nu rs e
s note ;the re was no re port in the
he althre c
ord .
A t his ne xt ID te le m e d ic
ine visit on 11/15/13 he was d oing we ll and no c
hange s we re
re c
om m e nd e d . H e was ne xt s e e n on 2/20/14bu t the re was no re port in the c
hart.
T he re are no c
hronicc
are form s in the c
hart. T he only provid e rs m anagingthis patient
s c
hronic
illne s s e s are the offs ite s pe c
ialists .

Febru ary 2014

Di
xon C orrec ti
onalC enter

P age 17

Opinion:T his patient has had no on s ite m onitoringofhis H IV d ise as e , m e d ic

ation c
om plianc
e or
s id e e ffe c
ts . H is ID c
linicvisits have not always be e n tim e ly and re ports from the c
ons u ltant have
not be e n c
ons iste ntly obtaine d .

Pulmonary
W e re viewe d s e ve n re c
ord s of patients with pu lm onary d ise as e , bu t only two appe are d to be
e nrolle d in the pu lm onary c
linic
. O fthos e two c
as e s , one was proble m atic(P atient #1be low). O f
the re m ainingc
as e s , only two m e ntione d (bu t d id not ad d re s s )the patients C O P D .
Patient #5
T his is a69-ye ar-old m an withoxyge n d e pe nd e nt C O P D , c
oronary arte ry d ise as e withhistory of
M I, hype rte ns ion and he aringim pairm e nt who arrive d at D ixon on 6/11/13.
A t his bas e line c
linicon 7/19, his pe ak flow was low at 250and his inhale rs we re ad ju s te d . A t his
ne xt c
hronicc
are c
linicon 10/11, he had rhonc
hiin bothlowe rlobe s and his pe ak flow was ve ry
low at 150. A third inhale rwas ad d e d , bu t no othe rworku portre atm e nt was ord ere d forthe C O P D
e xac
e rbation, norwas he d iagnos e d withs u c
h. Follow-u pwiththe nu rs e prac
titione rwas ord e re d
forthre e we e ks bu t d id not oc
c
u r.
O n 1/6/14, he was s e e n at nu rs e s ic
kc
allforac
old .T he patient re porte d s hortne s s ofbre athon
e xe rtion and aprod u c
tive c
ou gh. T he nu rs e note d d e c
re as e d lu ngs ou nd s on e xam . T he re we re no
vitals d oc
u m e nte d and no pe ak flow. T he nu rs e d e c
ide d that he had ac
old and gave him an ove rthe -c
ou nte rre m e d y. T he re was no re fe rralto aprovid e r.
T e n d ays late r, the patient re tu rne d withd iffic
u lty bre athing. H e was s e e n by an R N , who note d
that his bre athings e e m e d u nlabore d . T he re was no lu nge xam d oc
u m e nte d . T he as s e s s m e nt was
ille gible , and the plan was to m anage s ym ptom s . U s e inhale rs as pre s c
ribe d .
O n 1/21, he was s e e n on M D line forfollow u pofhype rte ns ion and C O P D . H e re porte d whe e z ing
d aily in the m orningand c
om plaine d that his s hortne s s ofbre athwas ge ttingwors e . T he re was
no pu ls e oxim e try and no pe ak flow m e as u re m e nt. T he lu ngs we re d e s c
ribe d as c
le ar. T he d oc
tor
ord e re d nitroglyc
e rin as ne e d e d and ne bu lize rtre atm e nts d aily as ne e d e d forone ye ar.
O n 2/6, he was s e e n in c
hronicc
are c
linic
. H is pe ak flow was low at 270. H is C O P D was not
e valu ate d fu rthe rand no m e d ic
ation c
hange s we re m ad e .
Opinion:A lthou ghthis patient has be e n s e e n in c
hronicc
are c
linicac
c
ord ingto polic
y, his d ise as e
has not be e n m onitore d orm anage d ad e qu ate ly. N u rs ingas s e s s m e nts we re inad e qu ate and nu rs ing
s tafffaile d to re fe rthe patient to aprovide rwhe n appropriate .
Patient #6
T his is a47-ye ar-old m an with m u ltiple c
hronicillne s s e s , inc
lu d ingC O P D , ye t the re we re no
c
hronicc
are form s in this patient
sc
hart.

Febru ary 2014

Di
xon C orrec ti
onalC enter

P age 18

T he firs t provid e rvisit s inc

e Janu ary 2013was d ate d 6/2/13and foc
u s e d m ainly on the patient
s
anxiety abou t be ingm ove d to afou rpatient room and his risk forc
atc
hingan illne s s .
A t nu rs e s ic
kc
allon 9/24, the patient re qu e ste d to s e e aprovide rre gard inghis C O P D m e d ic
ations .
M D line was ord e re d for9/25, bu t the re is no note in the c
hart c
orre s pond ingto that d ate.
O n 10/8, he s aw the nu rs e prac
titione r re gard ingd iffic
u lty trans portingwiththe blac
k box. N o
c
hronicc
ond itions we re ad d re s s e d and the re we re no fu rthe rprovide rnote s in the c
hart.
Opinion: T his patient
s C O P D has not be e n ad d re s s e d in m ore than aye ar, d e s pite his re qu e s t.
Patient #7
T his is a55-ye ar-old m an whos e proble m list inc
lu d e s only d e pre s s ion withs u ic
id alid e ation. H e
e vid e ntly als o has anoxicbrain inju ry and m od e rate C O P D ac
c
ord ingto apu lm onary fu nc
tion te s t
d ate d Ju ly 2013. T he re are no c
hronicc
are form s in the c
hart. T he re is only one m e ntion ofC O P D ;
on 8/2/13, the patient was s e e n on M D line for C O P D follow-u p, bu t this was ne ve r ad d re s s e d .
Ins te ad , the visit foc
u s e d on the patient
s bac
k pain. A lthou ghhe was s e e n m u ltiple tim e s ove rthe
ne xt fe w m onths forbac
k pain, his C O P D was ne ve rad d re s s e d .

Seizure Disorder
W e re viewe d five re c
ord s of patients with s e izu re d isord ers . T wo patients d id not appe ar to be
e nrolle d in the s e izu re c
linic
, and anothe rc
as e was s ignific
antly proble m aticas d e s c
ribe d be low.
Patient #8
T his is a70-ye ar-old m an withs e izu re s , as thm a, he patitis C , c
oronary arte ry d ise as e , late nt T B
infe c
tion and s c
hizophre nia.
O n 9/1/13, the R N re s pond e d to the u nit afte rthe patient had as e izu re . T he patient re fu s e d to c
om e
to the he althc
are u nit, so the nu rs e allowe d him to re st in his c
e ll, notingthat the C O willc
he c
k
1
on him in /2 hou r.T hirty m inu te s late r, the re is an R N note statingno e nc
ou nte r. Spoke with
sec
u rity on H R 3. IM O live rs le e pings ou nd ly on his be d . Side lyingpos ition.T he re is no m e ntion
ofc
allingaprovide r. O fnote, the patient had had as u bthe rape u ticT e gretolle ve l(3.4)on 8/7. T he
labre port was s igne d by aprovide ron 8/8, bu t no c
hange s we re m ad e . T he M A R s hows that the
patient had be e n c
om pliant withhis m e d ic
ation.
O n 9/5, anote s tam pe d nu rs e s ic
kc
alls tate s only, alre ad y on M D line .T he M e d ic
alD ire c
tor
s aw the patient this d ay foram e d ic
alwrit follow-u p, bu t the re is no m e ntion ofthe re c
e nt s e izu re .
O n 1/22, the patient was s e e n in c
hronicc
are c
linic
. H e re porte d havingone s e izu re s inc
e the las t
c
linic
. H is T e gre tolle ve lhad las t be e n m e as u re d on 12/3 and was the rape u ticat that tim e . N o
m e d ic
ation c
hange s we re m ad e .
T wo d ays late r, the patient had awitne s s e d s e izu re and was re fe rre d to the d oc
torthat d ay. T he
d oc
tornote d that his m os t re c
e nt priors e izu re was in N ove m be r2013, bu t the re is no

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d oc
u m e ntation in the c
hart to that e ffe c
t. T he phys ic
ian inc
re as e d the T e gre told os e and ord e re d a
le ve lto be d rawn in two we e ks . T he le ve lwas d rawn on 2/7 and was not s ignific
antly d iffe re nt
from the las t valu e .
Opinion:It is not appropriate to e xpe c
t sec
u rity s taffto pe rform m e d ic
alm onitoringofapost-ic
tal
patient. T he nu rs e s hou ld have gone bac
k to the u nitto m onitorthe patient and s hou ld have re fe rre d
the patient to aprovid e rforfollow-u p. E ve n whe n the patient late rd id s e e aprovid e r, the d oc
tor
d id not ad d re s s the re c
e nt bre akthrou ghs e izu re . It appe ars that this patient
s s e izu re d isord e ris not
ad e qu ate ly c
ontrolle d by the m e d ic
ation he is pre s c
ribe d .
Patient #9
T his is a65-ye ar-old m an with s e izu re s , hype rte ns ion and as thm a. A t the 1/23/13 c
hronicc
are
c
linic
, he re porte d that he had ru n ou t of his s e izu re m e d ic
ation. H is las t s e izu re was not
d oc
u m e nte d . T he re was no s u bje c
tive inform ation;this was partly d u e to the s tru c
tu re of the
c
hronicc
are form , whic
hhas not be e n u pd ate d in ove r 10 ye ars (2002). Labs we re d one tim e ly
priorto the visit (1/17).
A t the 7/8/13c
hronicc
are c
linicvisit, the re had be e n no inte rim s e izu re ac
tivity s inc
e the las t visit.
T he m os t re c
e nt labs had be e n d one in M ay.
O n 10/1, it is note d that the patient s igne d offfrom c
hronicc
are c
linic
. Labs d one 9/18s howe d
as u bthe rape u ticD ilantin le ve lat 3.9.
Opinion:It is not c
le arwhat s igne d offfrom c
hronicc
are c
linicm e ans , othe rthan to im ply that
the patient has d ise nrolle d him s e lf. T his d oe s not s e e m appropriate , give n that he c
ontinu e s to
re c
e ive tre atm e nt fors e izu re s . T he re as ons be hind his ru nningou t ofm e d ic
ation are not c
le ar, and
his s u bthe rape u ticm e d ic
ation le ve lhas not be e n pu rs u e d .

TB Infection Clinic
A t the tim e ofou r visit, the re we re fou r patients e nrolle d in this c
linic
. T wo ofthe fou r patients
we re s tarte d on tre atm e nt at D ixon;the othe rtwo arrive d alre ad y on the rapy. In none ofthe fou r
c
harts d id the tre atingprovide rd oc
u m e nt as ym ptom as s e s s m e nt priorto initiatingthe rapy. O ne
patient had no re c
e nt labs in his c
hart d e s pite be ginningthe rapy ove r two m onths prior. T wo of
the fou rre c
ord s had no bas e line c
he s t x-ray in the file .
N one ofthe patients had M A R s file d in the ir c
harts. T he re is no m e c
hanism in plac
e to ale rt the
c
hronicc
are nu rs e (or anyone e ls e )whe n patients m iss d os e s . M iss e d d os e s are only re c
ognize d
d u ringthe m onthly R N visit, thou ghthis is highly d ou btfu l, as the M A R s forallthe patients we re
in giant pile s ofloos e filingd atingbac
k form onths in the m e d ic
alre c
ord s offic
e . W e fou nd five
pile s ofM A R s , e ac
hat le as t one foot high. It was c
le ar from ou r c
hart re views that the c
hronic
d ise as e nu rs e is not we llinform e d abou t the statu s ofpatients m e d ic
ation c
om plianc
e.
O ne patient had m iss e d thre e ofhis las t e ight d os e s ;anothe r inform e d the c
hronicd ise as e nu rs e
that he had s toppe d the rapy e ntire ly two we e ks pre viou s ly afte rs pe akingwithone ofthe provide rs .
N o su c
hc
onve rs ation was d oc
u m e nte d in the he althre c
ord . In anothe rc
as e , the T B

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c
linicnu rs e note d that the patient had afe w m iss e d d os e s , ye t re view ofthe M A R d id not s u pport
this c
laim .

Pharmacy/Medication Administration
B os we llP harm ac
e u tic
als , loc
ate d in P e nns ylvania, provide s allpre s c
ription and ove r-the -c
ou nte r
m e d ic
ations for the fac
ility. T he s e rvic
e is a fax and fill s ys te m , whic
h m e ans patient
pre s c
riptions faxe d to the pharm ac
y tod ay by agive n c
u t-offtim e willarrive at the fac
ility the ne xt
d ay. P atient s pe c
ificpre s c
riptions , s toc
k pre s c
riptions and c
ontrolle d m e d ic
ations arrive pac
kage d
in a31-d ay bu bble pac
k. O ve r-the -c
ou nte r m e d ic
ations are provide d in bu lk by the bottle , tu be ,
e tc
. A loc
albac
k-u ppharm ac
y is u s e d to obtain m e d ic
ation whic
his ne e d e d im m e d iate ly and is
not available in s toc
k.
T he m e d ic
ation pre paration/storage are ais s taffe d withfou rpharm ac
y te c
hnic
ians , thre e c
ontrac
t
and one s tate e m ploye d , and B os we llprovid e s ac
ons u ltingpharm ac
ist to c
om e on-s ite onc
e a
m onthto re view pre s c
ription ac
tivity, to as s e s s pharm ac
y te c
hnic
ian pe rform anc
e and te c
hniqu e
and to d e stroy ou td ate d orno longe rne e d e d c
ontrolle d m e d ic
ations pu rs u ant to the re qu ire m e nts
ofthe Fe d e ralD ru gA d m inistration (FD A )and D ru gE nforc
e m e nt A ge nc
y (D E A ).
Ins pe c
tion ofthe m e d ic
ation pre paration/storage are are ve ale d ave ry large , c
le an, we ll-lighte d and
ge ne rally we ll-m aintaine d are a. A n inte rview withthe c
hiefte c
hnic
ian re ve ale d aknowle d ge able
ind ivid u alwith m any ye ars workingas apharm ac
y te c
hnic
ian. Ins pe c
tion ofthe are aind ic
ate d
tight ac
c
ou nting of c
ontrolle d m e d ic
ations , both s toc
k and re tu rn ite m s , ne e d le s /syringe s ,
s harps /ins tru m e nts and m e d ic
altools . A rand om ins pe c
tion of pe rpetu alinve ntories and c
ou nts
ind ic
ate d allwe re c
orre c
t.
M e d ic
ation ad m inistration c
ons ists oftwo m e thod s . W ithm e thod 1, m e d ic
ation is ad m iniste re d at
c
e ll-s id e . W ith m e thod 2, inm ate s m ove in large line s to the H e alth C are U nit to re c
e ive the ir
m e d ic
ation. T he fac
ility c
ontinu e s to u s e apape rm e d ic
ation ad m inistration re c
ord (M A R ), and
e ac
hd os e ofm e d ic
ation ad m iniste re d orre fu s e d is note d on the patient s pe c
ificM A R .
O bs e rvation ofm e thod 1re ve ale d m e d ic
ation ad m inistration by aLic
e ns e d P rac
tic
alN u rs e (LP N ),
who prope rly id e ntified the patients , ad m iniste re d the m e d ic
ation throu ghafood s lot port in the
s olid c
e ll d oor, obs e rve d the inge s tion, pe rform e d a m ou th c
he c
k and d oc
u m e nte d the
ad m inistration on the M A R . A s e c
u rity offic
e r was obs e rve d e s c
orting the LP N d u ring
ad m inistration.

Laboratory
Laboratory s e rvic
e s are provide d throu ghthe U nive rs ity ofIllinois-C hic
ago H os pital(U IC ). T he
c
om pre he ns ive s e rvic
e s m e d ic
alc
ontrac
torprovid e s one FT E phle botom ist to d raw and pre pare
the s am ple s for trans port to U IC . R e s u lts are ele c
tronic
ally trans m itte d bac
k to the fac
ility,
ge ne rally, within 24 hou rs vias e c
u re fax line loc
ate d in the m e d ic
ald e partm e nt. T he re we re no
re ports ofany proble m s withthis s e rvic
e.

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Unscheduled Services/Emergency Services

In ord e rto re view u ns c
he d u le d s e rvic
e s , we typic
ally atte m pt to re view bothu ns c
he d u le d ons ite
s e rvic
e s and u ns c
he d u le d offs ite s e rvic
e s . D ixon was not able to provid e alogbook that had e ithe r
type ofs e rvic
e trac
ke d ove rtim e . T he re fore , it was c
le ar the y we re u nable to pe rform any s e lfm onitoring. T he y d id not e ve n have available alogofoffs ite or e m e rge nc
y s e nd ou ts . T he only
thingthe y c
ou ld provide u s was inc
id e nt re ports from the las t thre e m onths . H owe ve r, it appe are d
that the inc
id e nt re ports we re inc
om ple te . W e re viewe d s ix ons ite e m e rge nc
ies and fou re m e rge ncy
s e nd ou ts. A llofthe e m e rge nc
y s e rvic
es c
ontaine d proble m s , the m os t c
om m on ofwhic
hwas that
the ins titu tion ne ve rre c
e ive d e ithe re m e rge nc
y room re ports forthos e s e nt ju s t to the e m e rge ncy
room or hos pitald isc
harge s u m m aries for thos e ad m itte d to the hos pital. T his c
om prom ise s the
ability of the c
linic
ians to u nd e rs tand what s e rvic
e s we re provide d and what the bas is for any
re c
om m e nd ations m ight be .
Patient #1
T his is a 69-ye ar-old with hype rte ns ion, hypothyroid ism and s tatu s post trac
he os tom y. O n
11/26/13, ac
od e 3was c
alle d in the x-ray d e partm e nt at the fac
ility. A ppare ntly, the inm ate was
havingd iffic
u lty bre athingd u e to his trac
he os tom y be ingplu gge d . T he trac
he os tom y was c
le ane d
and the patient was s e nt bac
k to the hou s ingu nit. T he re is no as s e s s m e nt ord isc
u s s ion withany
ad vanc
e d le ve lc
linic
ian, only abriefnote by an LP N . T he patient was not s e e n by an ad vanc
ed
le ve lc
linic
ian u ntilm ore than awe e k late r.
Patient #2
T his is a48-ye ar-old withs e izu re d isord e r. O n 1/1/14, anu rs e was c
alle d to the hou s ingu nit fora
c
od e 3. In the re c
ord the re is no d e s c
ription ofthe e ve nt, bu t the patient was brou ght to the c
linic
and u ltim ate ly wante d to retu rn to the hou s ingu nit. T he only note in the re c
ord is anote by an
LP N whe re the as s e s s m e nt re ad s , pos t s e izu re .T he patient was retu rne d to the hou s ingu nit by
the LP N withno c
ontac
t withan ad vanc
e d le ve lc
linic
ian. T he re was an inad e qu ate history and
phys ic
al as s e s s m e nt s inc
e only an LP N s aw the patient, and the re we re s ignific
ant liabilities
e nge nd e re d by this re s pons e .
Patient #3
T his is a57-ye ar-old who has apos itive tu be rc
u los is s kin te s t bu t has be e n tre ate d and als o has a
s e izu re d isord e r, asthm aand bipolard isord e r. O n 10/31/13at abou t 12:15p.m ., ac
od e 3was c
alle d
withthe inm ate c
om plainingofc
he s t pain. T he re is an inad e qu ate as s e s s m e nt pe rform e d by an R N
who ind ic
ate s that the inm ate s tate s , I
m worried abou t goingou t in fou rm onths .T he vitals igns
we re norm al and the inm ate is d e s c
ribe d as hold inghis c
he s t. T he history is inad e qu ate . T he
as s e s s m e nt is c
he s t vs . anxiety. Sinc
e the patient ind ic
ate d he fe lt be tte r, the as s e s s m e nt was
ru le ou t anxiety and the patient was re le as e d to the hou s ingu nit. C he s t pain s hou ld always
re qu ire an as s e s s m e nt by an ad vanc
e d le ve lc
linic
ian.
Patient #4
T his is a27-ye ar-old withm e ntalhe althproble m s . O n 1/6/14, ac
od e 3was c
alle d and the patient
was brou ght to the he althc
are u nit. T he inm ate had be e n fou nd u nre s pons ive in his c
e ll, lyingon the
floor and havingase izu re. W he n the y e nte re d the c
e ll, he was still je rkingor twitc
hingon the
m attre s s. H e state d he inte ntionally hit his he ad on the wall. O n 1/7/14, he is d e s c
ribe d as having

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had as ync
opale pisod e bu t the re is no as s e s s m e nt. The patient was s e e n late rby anu rs e prac
titione r
bu t the re was no d isc
u s s ion ofthe e pisod e oc
c
u rringone d ay e arlier.
Patient #5
T his is a42-ye ar-old withhype rlipid e m ia. A c
od e 3 was c
alle d on 11/25/13 be c
au s e the inm ate
was fou nd lyingon the s id e walk ou ts id e ofhis hou s ingu nit. H e had told anu rs e that he had worke d
ou t in the gym , be c
am e d izz y and s at d own. W he n he s tood u pqu ic
kly he got d izz y again and the n
lay d own on the s id e walk. T he nu rs e pe rform e d vitals igns on the s ide walk and s inc
e the y we re
norm al, re le as e d him to the hou s ingu nit. T he re was no follow u ppe rform e d and he was not s e e n
again u ntilm ore than am onthlate rin his re gu larhype rte ns ion c
linic
;howe ve r, the inc
id e nt with
the e pisod e s ofd izz ine s s was ne ve rd isc
u ssed .
Patient #6
T his is a53-ye ar-old withhype rte ns ion and type 2d iabe te s alongwithhe patitis C . O n 12/7/13, a
c
od e 3was c
alle d in d ietary. W he n the y arrive d the patient ind ic
ate d , M y kne e gave ou t.H e was
plac
e d in the infirm ary forobs e rvation and re le as e d s hortly the re afte r. T he re has be e n no phys ic
ian
as s e s s m e nt re gard ingthis s itu ation.
Patient #7
T his is a68-ye ar-old withm e ntalhe althproble m s and as thm a. O n 10/25/13, at abou t 12:40p.m .,
ac
od e 3was c
alle d and whe n the nu rs e arrive d the patient was walkingto avan ac
c
om panied by
c
orre c
tionaloffic
e rs . H e c
ou ld be he ard whe e z ingand he was obs e rve d to be u s inghis inhale r.
T he nu rs e pe rform e d apu ls e oxim e te rre ad ing, whic
hwas 85% . T he patient was take n to the he alth
c
are u nit and was s e e n by the phys ic
ian, who ord e re d bothorals te roids and inhale d s te roids . T his
patient has ne ve rbe e n followe d u pon.
Patient #8
T his is a35-ye ar-old withm e ntalhe althproble m s . O n 11/3/13, ac
od e 3was c
alle d and the patient
was fou nd withblood on the floor from alac
e ration on his he ad . W hile be ingtrans porte d to the
m e d ic
alu nit, he was note d to have proje c
tile vom itingand the re fore was s e nt to the hos pital. O n
11/5, two d ays late r, he retu rne d withthe hos pitald iagnos is, patient ind u c
e d hyponatre m iac
au s ing
s e izu re s .T he patient was ad m itte d to the infirm ary d ry c
e ll. T he re were no hos pitalre c
ord s in the
m e d ic
alre c
ord and on 11/12he was d isc
harge d to his hou s ingu nit.

Scheduled Offsite Services

W e we re inform e d that the proc
e s s for ac
c
om plishingas c
he d u le d offs ite s e rvic
e inc
lu d e s , onc
e
the phys ic
ian orad vanc
e d le ve lprovid e rord ers the s e rvic
e, su c
has ac
ons u ltation orproc
e d u re ,
the ac
tingM e d ic
alD ire c
torre views the re qu e s t and the n pre s e nts it at awe e kly c
olle gialre view
withW e xford c
e ntraloffic
e phys ic
ian s taffwho work forthe iru tilization m anage m e nt program .
E ac
hc
as e is d isc
u s s e d and the re is e ithe r an approvaloran alte rnate plan is re c
om m e nd e d . T he
alte rnate plan m ay re s u lt in s om e ad d itionalte s ts to be d one be fore the ord e re d s e rvic
e is provide d .
O nc
e the W e xford c
e ntral offic
e phys ic
ian has approve d the s e rvic
e ove r the te le phone , this
u tilization m anage m e nt program is re s pons ible forprovid ingan au thorization nu m be rattac
he d to
the approve d s e rvic
e and the n notifyingthe U nive rs ity ofIllinois at C hic
ago s c
he d u le r, who the n
willprovid e an appointm e nt and notify the D ixon C orre c
tionalC e nte r

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sc
he d u le r. W e fou nd that the re we re le ngthy d e lays in this proc
e s s , s om e tim e s d u e to as u bs tantial
d e lay be twe e n the ve rbalapprovalove rthe phone and the notific
ation to the U nive rs ity ofIllinois
sc
he d u le r and s om e tim e s , ad d e d to that, is ad e lay bas e d on the U nive rs ity ofIllinois not be ing
able to tim e ly provid e an appointm e nt. A bou t 10-15% of s c
he d u le d offs ite s e rvic
e s are finally
obtaine d loc
ally be c
au s e this c
an be ac
c
om plishe d m ore rapid ly. T he c
u rre nt trac
kinglogd oe s not
inc
lu d e d ate oford e rnord ate ofappointm e nt, s o that the le ngthoftim e be twe e n the re qu e s t, the
au thorization and the appointm e nt c
annot be visu ally re viewe d in an e ffic
ient m anne r. A ls o, the re
are oc
c
as ions whe n an approvalis provide d bu t this s c
he d u lingproc
e s s ge ts d e laye d to s u c
han
e xte nt that the n ane w re qu e s t m u s t be c
re ate d . A ny s ys te m that allows e ffic
ient as s e s s m e nt ofa
sc
he d u le d offs ite s e rvic
e program s hou ld have the d ate oford er, the d ate ofau thorization, the d ate
ofthe appointm e nt and the d ate ofthe prim ary c
are c
linic
ian follow u pwiththe patient in atrac
king
log.
W e re viewe d 11re c
ord s ofpatients forwhom ac
linic
ian had ord e re d as c
he d u le d offs ite s e rvic
e.
E ight of11 we re proble m atic
, e ithe r d u e to d e lays or d u e to lac
k ofc
ritic
alfollow u p withthe
patient.
Patient #1
T his is a65-ye ar-old m ale with hype rte ns ion, as thm a, GE R D , and apos itive T B s kin te s t. O n
11/20/13, the c
linic
ian ord e re d aC T s c
an ofthe c
he s t to ru le ou t am as s . T his patient was pre s e nte d
at the c
olle gialre view alittle ove rtwo we e ks late r, on 12/4, and an approvalwas obtaine d . T hre e
we e ks late r the au thorization nu m be r was provid e d . T he re port d one on 2/12/14 ind ic
ate s
s u s pic
iou s forc
anc
e r. A re qu e s t forapu lm onary c
ons u lt was m ad e and approve d ove rtwo we e ks
ago and ye t an au thorization nu m be rforthis has s tillnot be e n provide d .
Patient #2
T his is a47-ye ar-old m ale withno c
hronicproble m s . O n 11/13/13, abone s c
an was ord e re d d u e
to apriorre port d e m ons tratingbilate rald e ns ities in the ile acare as . T he au thorization was provide d
on 12/20 and ye t the U nive rs ity of Illinois s c
he d u le r ind ic
ate s that s he has re c
e ive d no
c
om m u nic
ation from the W e xford c
e ntraloffic
e , s o the re is no appointm e nt d ate provide d .
Patient #3
T his is a62-ye ar-old m ale with hype rte ns ion, d iabe te s type 2, c
onge s tive he art failu re , gou t, a
pac
e m ake r, obs tru c
tive s le e papne aand c
ard iom yopathy. A n appointm e nt forthe c
ard iology c
linic
was ord e re d on 10/2/13. T he patient was finally s e e n on 2/14/14, fou rm onths late r.
Patient #4
T his is a64-ye ar-old withhype rte ns ion, d iabe te s type 2and as oft tiss u e m as s . O n 10/8/13, a30d ay E K G m onitor was ord e re d bas e d on aprior c
ard iology re c
om m e nd ation. T his s e rvic
e was
au thorize d on 10/24. T he patient was s e nt bac
k to c
ard iology on 1/28/14, whic
hre -re c
om m e nd e d
the E K G m onitor, bu t this has not ye t oc
c
u rre d , alm os t halfaye arlate r.
Patient #5
T his is apatient withhype rte ns ion and he patitis C alongwithahistory ofapos itive T B s kin te st.
O n 11/7/13, an ortho c
linicappointm e nt was ord ere d . It was au thorize d within as hort pe riod of
tim e , bu t as ye t it has not be e n s c
he d u le d .

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Patient #6
T his is a46-ye ar-old witham as s in his jaw. H e als o has ablind right e ye and an ortho appointm e nt
was ord ere d on 9/12/13. T he c
olle gial re view oc
c
u rre d two we e ks late r on 9/25, bu t it was
re c
om m e nd e d that an u ltras ou nd be obtaine d priorto the ortho appointm e nt. T he u ltras ou nd was
ord ere d and approve d on 10/16and pe rform e d on 11/13. T he d oc
tord isc
u s s e d the c
as e withthe
patient and the n re ord e re d the orthope d ice valu ation. T his was au thorize d on 11/27, bu t as ofye t
the appointm e nt has not oc
c
u rre d .
Patient #7
T his is a 58-ye ar-old m ale with an e nlarge d pros tate and apos itive T B s kin te s t. A u rology
appointm e nt was ord e re d on 7/30/13 and it was au thorize d on 8/7. T he appointm e nt has be e n
sc
he d u le d now for3/12/14. T his is an e xtre m e ly longd e lay.
Patient #8
T his is a66-ye ar-old m ale withhype rte ns ion forwhom as tre s s te s t was ord e re d on 11/12/13, bas e d
on ac
ard iology re c
om m e nd ation. T he s tre s s te s t was au thorize d on 12/27;howe ve r, the patient
has s tillnot be e n s e e n. T he re has as ofye t be e n no c
om m u nic
ation to the U nive rs ity ofIllinois
from W e xford .
Patient #9
T his is a45-ye ar-old withhype rte ns ion, s e ve re trem ors and as e izu re d isord e r. H e has be e n s e e n
by U IC ne u rology who has re c
om m e nd e d inc
re as ingd os e s ofK lonopin (u pto 4m gtwic
e ad ay)
and othe r m e d ic
ations , bu t nothings e e m s to c
ontrol his tre m ors . N e u rology has not m ad e a
d e finitive d iagnos is;at one visit, his c
ond ition is d e s c
ribe d as non P arkins onian tre m or, at
anothe rtre m orwithP arkins onian fe atu re s .T he patient was s e e n in Fe bru ary and M ay of2013;
re qu e s t for follow-u p visit was d e nied in A u gu s t. T he alte rnate plan was to c
ontinu e to follow
and tre at ons ite . R e pre s e nt in thre e m onths . M e anwhile , the patient c
ontinu e s to fallfre qu e ntly
and m u s t be pe rm ane ntly hou s e d in the he althc
are u nit.
Opinion: T his patient s till d oe s not have a c
le ar d iagnos is and tre atm e nt re s pons e has be e n
s u boptim al. W e inte rviewe d this patient d u ringou r visit. C ons ide ringthe s e ve rity ofhis tre m or,
the d e gre e of his d isability and his you ngage , we wou ld re c
om m e nd e ithe r follow u p with
ne u rology, a s e c
ond ne u rologist
s opinion, or a trial of tre atm e nt for e s s e ntial tre m or be
u nd e rtake n, s u c
has propranololorprim id one ifnot alre ad y tried .

Infirmary Care
T he d e s ignate d infirm ary is loc
ate d on the s e c
ond floorofthe m e d ic
albu ild ing. T he re are 28total
be d s withpatient c
e ns u s of22 d u ringthe ins pe c
tion. O fthe 22 patients , fou r we re c
las s ified as
ac
u te withallothe rs c
las s ified as e ithe rpe rm ane nt hou s ingorc
hronicc
are .
T he are ais staffe d withat le ast one R N pers hift e xc
e pt forone 11-7s hift. D u ringthis s hift, the re is
aR N in the bu ild ingbu t not as s igne d to the infirm ary. A s are s u lt, aLic
e ns e d P rac
tic
alN u rse (LP N )
is d ire c
tingthe c
are in the infirm ary whic
h, ac
c
ord ingto the Illinois N u rs e P rac
tic
e A c
t, is be yond
the s c
ope ofprac
tic
e foraLP N . A d d itionally, the fac
ility is u s ingC ertified N u rs ing

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P age 25

A s s istants (C N A s )on the 7-3and 3-11s hifts and s oon on the 11-7s hift. U s e ofthe C N A s is going
we lland qu ite be ne fic
ialin provid ingc
are .
Ins pe c
tion ofthe are aind ic
ate d alarge , we ll-lighte d , re as onably we llm aintaine d and c
le an u nit.
T he infirm ary is c
onfigu re d in are c
tangle , two longhalls and two s hort halls at e ac
he nd , withthe
patient room s alongthe ou te rpe rim e te rofthe re c
tangle . A s are s u lt, the re are nu m e rou s wind ows
provid ingnatu rallight.
P atient be d s are in re as onably good s hape . R e c
e ntly, u s e d trad itional-s tyle hos pitalbe d s had be e n
pu rc
has e d from the loc
alhos pital, and m ore are goingto be pu rc
has e d whic
h willu pgrad e the
m ajority ofthe be d s . E ac
hofthe be d s has am attre s s withan im pe rviou s c
oatingc
ond u c
ive for
c
le aning/sanitizingwhe n ne e d e d , bu t partic
u larly be twe e n patients .
A longone longand one s hort hallway, e ac
hofthe be d s has ac
allbu tton loc
ate d on the wallabove
the be d . T he c
allbu tton provide s avisu alind ic
atorou ts ide the patient room and on anu m be re d
pane lins id e the nu rs ings tation;howe ve r, the re is no au d ible ind ic
ator. Sinc
e the c
allbu ttons are
m ou nte d on the wall, d e pe nd ingon the patient
s c
ond ition, it c
ou ld be d iffic
u lt to im pos s ible for
the patient to ac
c
e s s the c
allbu tton.
A longthe othe rlonghallway, the re are no patient c
allbu ttons , and s ix ofthe room s have no line of-s ight to the nu rs ings tation. B e lls have be e n provide d for the patient to m anu ally ring. W he n
m e d ic
alpe rs onne lare in the nu rs ings tation are a, d oors to e ac
hhallway are c
los e d . A s are s u lt, if
pe rs onne lwe re in the nu rs ings tation oroc
c
u pied in apatient room , it is d ou btfu lthe be llc
ou ld be
he ard . A d d itionally, ifthe patient be c
am e inc
apac
itate d , he c
ou ld not ringthe be ll.
E ac
hbe d had abe d s id e table bu t the re are no ove r-the -be d table s . A s are s u lt, patients e ithe re at
hold ingthe ir food tray on the ir laps orby plac
ingthe tray on the irbe d . Forpatients who c
annot
ge t ou t ofbe d , plac
e m e nt ofthe food tray c
ond u c
ive to e atingis d iffic
u lt.
T he re is one ne gative -air pre s s u re re s piratory isolation room loc
ate d in the infirm ary. N e gative
airflow is only c
he c
ke d e ve ry 30d ays re gard le s s ifare s piratory isolation patient is oc
c
u pyingthe
room .
R e s pons ibilities ofR N s workingthe infirm ary are :
1. Su pe rvision ofalls taffand patients
2. IV the rapy and m e d ic
ations
3. A s s e s s m e nts
4. P hle botom y
5. D re s s ingc
hange s
6. C harting
R e s pons ibilities ofLP N s workingthe infirm ary are :
1. Su pe rvision ofC N A s
2. A d m inistration oforaland topic
alm e d ic
ations
3. D re s s ingc
hange s
4. C harting

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P age 26

5. A s s e s s m e nts
R e s pons ibilities ofC N A s workingthe infirm ary are :
1. C olle c
tingand re c
ord ingvitals igns
2. B athingpatients
3. Fe e d ingpatients
4. C hangingbe d line ns
5. Fole y c
athe te rc
are
6. M e as u ringand re c
ord ingintake and ou tpu t
Ins pe c
tion ofinfirm ary line ns re ve ale d the following:
1. T hre ad bare s he e ts
2. T orn/fraye d s he e ts
3. T orn/fraye d towe ls and was hc
loths
4. Ins u ffic
ient nu m be rofpillows
5. Ins u ffic
ient nu m be rofblanke ts
6. Staine d s he e ts , towe ls and was hc
loths
In ins pe c
tingthe infirm ary, the re s e e m e d to be an abs e nc
e of ne e d e d patient c
are e qu ipm e nt as
follows :
1. IV pu m ps
2. T u be Fe e d ingpu m ps
3. H oye rlift
4. M axi-Lift B e d s lid e
5. Ge riC hairs (c
u rre nt c
hairs ne e d to be re c
ove re d in ord e rto ad e qu ate ly c
le an/sanitize
6. B e d alarm s
From as afe ty pe rs pe c
tive , the re was no s e c
u rity pre s e nc
e within the infirm ary e ve n thou ghall
sec
u rity c
las s ific
ations , m axim u m -m e d iu m -m inim u m , are hou s e d within this one are a. T he re is a
m anne d s e c
u rity s tation on the s e c
ond floor, bu t the offic
e ris e nc
los e d in aroom whic
his d own a
longhallway and s e parate d by ad oorfrom the nu rs ings tation and patient c
are are as . M e d ic
als taff
is not iss u e d ind ivid u alpanicalarm s orrad ios . Two rad ios are iss u e d to the infirm ary, howe ve r,
on the 7-3and 3-11s hifts ifm ore than two s taffis working. Ifam e d ic
als taffpe rs on was as s au lte d
in one of the bac
k patient c
are room s and had no rad io, it is d ou btfu lthe s e c
u rity s taff pe rs on
s tatione d 50 to 60 fe e t away be yond ac
los e d d oor and within an e nc
los e d room c
ou ld he ar any
c
ries forhe lp. A t the le as t, ad d itionalrad ios s hou ld be provide d and , optim ally, ind ivid u alpanic
alarm s . A d d itionally, while a s e c
u rity e s c
ort is re qu ire d d u ringm e d ic
ation ad m inistration in
d e s ignate d hou s ingu nits , no s u c
hesc
ort is provid e d in the infirm ary d e s pite alls e c
u rity le ve ls
be inghou s e d in this one are a.
N u rs ings taffwe re knowle d ge able c
onc
e rningthe patient popu lation, c
onc
e rningac
u te orc
hronic
c
are s tatu s , c
u rre nt ac
tivities /c
apabilities , he alth c
are /phys ic
al/soc
ial ne e d s and pe rs onalities .
W hile be ingable to e as ily artic
u late the above , nu rs ings taff c
hartingwas ve ry ge ne ricand
u ninform ative . It is u nd e rs tand able withge ne rally long-term , longs tay s kille d nu rs inghom e type s
ofpatients to fallinto the habit that the re is nothingne w to s ay abou t the patient. Ifs taffwou ld pu t
into word s what the y ve rbalize d abou t patients , c
hartingwou ld be

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Di
xon C orrec ti
onalC enter

P age 27

e nhanc
e d and c
ons id e rably m ore d e s c
riptive and inform ative c
onc
e rningthe patient
s c
u rre nt
c
ond ition.
W e fou nd the provide rs d oc
u m e ntation to be s im ilarly lac
king. In m any c
as e s , patients we re not
s e e n tim e ly pe rpolic
y, norwe re e valu ations c
om pre he ns ive . R are ly we re phys ic
ale xam inations
orm e d ic
ald e c
ision m akingd oc
u m e nte d , and m anage m e nt was qu e s tionable in s e ve ralc
as e s .
E xam ple s are d e s c
ribe d be low.
Patient #1
T his patient is a68-ye ar-old m ale who was ad m itte d on 12/27/2013. H e is pe rm ane ntly as s igne d
to the infirm ary followingate rm inald iagnos is of c
anc
e r ofthe brain (glioblas tom a)as we llas
c
hronic lym phoc
ytic le u ke m ia, hype rte ns ion, pu lm onary hype rte ns ion and c
hronic atrial
fibrillation. H e re c
e ive d a s e ries of rad iation tre atm e nts in Ju ne 2013. H e s igne d a D o N ot
R esu sc
itate (D N R )ord e r 12/27. P e r ID O C polic
y, the re c
ord ingof vitals igns and c
hartingis
re qu ire d we e kly forapatient ofthis s tatu s . A re view ofc
hartingind ic
ate d , ge ne rally, d aily nu rs ing
note s , and at le as t we e kly phys ic
ian note s . A phys ic
ian ad m iss ion note c
ou ld not be loc
ate d . T he
ad m iss ion R N note was d ate d 12/27.
Patient #2
T his patient was ad m itte d 10/21/2012. In Janu ary 2012, this patient was d iagnos e d with lu ng
c
anc
e r whic
h had m e tas tas ize d to the brain. H e re c
e ive d both c
he m o and rad iation the rapy. A t
pre s e nt he is be d rid d e n and atotalc
are patient. P hys ic
ian and nu rs ingnote s we re d oc
u m e nte d at a
m inim u m we e kly.
Patient #3
T his patient was ad m itte d 2/12/2009, and has along-term d iagnos is ofP arkins on
s d ise as e . P atient
has afe e d ingtu be , Fole y c
athe te r and a2 c
m x 1c
m d ec
u bitu s on the c
oc
c
yx. T he patient is
c
las s ified as c
hronicc
are and , e ve n thou gh only we e kly phys ic
ian and nu rs ing note s are
re qu ire d , c
hartingis m ore fre qu e nt.
Patient #4
T his patient was ad m itte d 2/25/2014. C las s ified as ac
u te c
are d u e to influ e nz ainfe c
tion. T he re
we re appropriate phys ic
ian and R N ad m iss ion note s and c
olle c
tion and re c
ord ingof vitals igns ,
he ight and we ight. C hartingand the re c
ord ingofvitals igns was pe rform e d at am inim u m d aily.
Patient #5
T his patient is a46-ye ar-old m an with history of as thm a, s e izu re s and m e ntalillne s s who was
ad m itte d ac
u te ly to the infirm ary on 2/19/14withhyponatre m ia(s od iu m 122m g/d L). T he re was
an appropriate R N ad m iss ion note and c
olle c
tion and re c
ord ingofvitals igns , he ight and we ight.
A d d itionalc
harting, inc
lu d ingvitals igns , oc
c
u rre d at am inim u m d aily. T he phys ician
s ad m iss ion
note was fairly thorou ghe xc
e pt the re was no ne u rologice xam , argu ably the m os t im portant s ys te m
to e xam ine in apatient withlow s od iu m .
T he re is anothe rnote by aphys ic
ian on 2/21, bu t it is only are view ofthe labs ;the patient was not
s e e n. A t this tim e , the s od iu m was u p to 128 m g/d L and s alt table ts we re ad d e d . T he re was no
work-u pto d ete rm ine the c
au s e ofthe patient
s low s od iu m .

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Di
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P age 28

O n 2/25, the re is aphys ician note d e s c

ribingthe patient as u nru ly and d isru ptive . H e was not
e xam ine d , pre s u m ably d u e to his be havior. It was note d that the patient has be e n hou s e d in aroom
whe re he has fre e ac
c
e s s to wate rd e s pite his ord e rforflu id re s tric
tion.
Opinion:T his patient has not be e n s e e n by the phys ic
ian ac
c
ord ingto polic
y and his low s od iu m
has not be e n prope rly inve s tigate d . Salt table ts are not appropriate tre atm e nt forthe m os t c
om m on
c
au s e oflow s od iu m in ou tpatients (SIA D H ).
Patient #6
T his patient was ad m itte d 2/17/2012 and c
las s ified as c
hronic c
are d u e to e nd -s tage
C O P D /A s thm a. D N R s igne d 5/13/2011. C u rre ntly ad m itte d to ac
om m u nity hos pital. A re view of
the re c
ord ind ic
ate d m ore than we e kly nu rs ingnote s and vitals ign d oc
u m e ntation withphys ic
ian
note s be ing, at am inim u m , we e kly.
Patient #7
T his patient was ad m itte d 12/24/2013. C las s ified as ac
u te c
are d u e to u nc
ontrolle d d iabe te s . T he
patient c
od e d 12/16/2013in his hou s ingu nit. E M S was c
alle d and d u ringtrans port to ac
om m u nity
hos pital, the patient arre s te d in the am bu lanc
e . T he patient was re vive d , s tabilize d and trans porte d
to U IC whe re he re m aine d u ntil12/24, whe n he was re tu rne d to the ins titu tion. T he re is aR N
ad m iss ion note bu t no phys ic
ian ad m iss ion note. V itals igns and nu rs ingnote s are re c
ord e d at a
m inim u m d aily.
Patient #8
T his pate nt is a25-ye ar-old m an ad m itte d to the infirm ary c
hronic
ally on 1/28/14afte rfrac
tu ring
his jaw and havingit wire d s hu t. T he re is nu rs ingad m iss ion note, bu t it was not tim e d . T he re was
abriefnote by the M e d ic
alD ire c
toron 1/31, bu t itwas the nu rs e prac
titione rwho d id the ad m iss ion
note the followingd ay. T he nu rs e prac
titione r s aw him again awe e k late r. O n 2/11, the M e d ic
al
D ire c
tornoted as ix-pou nd we ight los s s inc
e ad m iss ion;this was the las t provide rnote in the c
hart
as of the d ate of ou r visit 10 d ays he nc
e . T he re we re s hift nu rs ingnote s and d aily vitals igns
d oc
u m e nte d . W ire c
u tte rs are im m e d iate ly available in the nu rs ings tation.
Opinion:T his patient has not be e n s e e n tim e ly d u ringhis infirm ary ad m iss ion. H e s hou ld be
e valu ate d forwe ight los s .
Patient #9
T his patient is a52-ye ar-old m an withno known m e d ic
alhistory who was ad m itte d to the infirm ary
on 2/13/14forac
u te c
are followingan e pisod e ofu nre s pons ive ne s s and s e izu re s in Janu ary ofthis
ye ar. H e was fou nd to have s e ps is from s tre ptoc
oc
c
alm e ningitis and ac
ave rnou s s inu s throm bos is.
T he re are appropriate ly d oc
u m e nte d phys ic
ian and nu rs ingad m iss ion note s . T he re are d aily vital
s igns and s hift nu rs ingnote s ;howe ve r, he has not be e n s e e n by the phys ic
ian pe rpolic
y while in
the infirm ary. T he re we re only two phys ic
ian visits d oc
u m e nte d in the c
hart as ofthe tim e ofou r
visit on 2/27.
Opinion:T his patient has not be e n s e e n by aphys ic
ian pe rpolic
y. C ons id e ringthe s e ve rity ofhis
illne s s , this is partic
u larly proble m atic
.

Patient #10
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Di
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onalC enter

P age 30
29

T his patient was ad m itte d 8/30/2012d u e to re pe ate d falling, hallu c

inations and T IA s . T he patient
was pe rm ane ntly as s igne d to the infirm ary. O n 2/22/2014, while goingto the bathroom , he fe ll,
frac
tu ring his le ft d istal fe m u r. H e was trans porte d to a c
om m u nity hos pital whe re an
intram e d u llary fixation was pe rform e d . T he patient was retu rne d to the fac
ility whe re he re m ains
in the infirm ary. T he re was athorou gh, we ll-writte n R N ad m iss ion note ;howe ve r, it was not
s igne d .
Patient #11
T his is a77-ye ar-old m an with c
ognitive im pairm e nt who has be e n c
hronic
ally hou s e d in the
infirm ary s inc
e at le as t Janu ary 2013, whic
h is whe n his progre s s note s be gin. H is proble m list
was las t u pd ate d in M arc
hof2012and lists only B P H and ps orias is.
In A pril2013, he was s e e n in c
ons u ltation by U IC ne u rology forhis m e m ory los s . T he y re qu e s te d
labs , C T ofthe he ad and an E E G, as partialc
om ple x s e izu re s we re in the d iffe re ntiald iagnos is.
T he E E G was not approve d and the C T (d one two m onths late r)s howe d only s m allve s s e lisc
he m ic
c
hange s . In Ju ly 2013, ne u rology follow-u pwas d e nied . T he d e c
ision was that the patient probably
has d e m e ntiaand tre atm e nt withA ric
e pt s hou ld be c
ons ide re d . It was ne ve rs tarte d .
H e is on the m e ntalhe althc
as e load and pre s c
ribe d s e ve ralps yc
hotropicm e d ic
ations , inc
lu d ing
R ispe rd al, whic
h is re lative ly c
ontraind ic
ate d in e ld e rly d e m e ntiapatients and has ablac
k box
warningforthis s e ttingd u e to inc
re as e d risk ofs troke and d e ath. H e is re pe ate d ly d e s c
ribe d as
friend ly, c
alm and c
oope rative in the re c
ord , s o it is not c
le arwhy an antips yc
hoticm e d ic
ation is
ne c
e s s ary;the risks appe ar to ou twe igh the be ne fits . H e is d e s c
ribe d as d e lu s ionalwith s om e
au d itory hallu c
inations , bu t the s e d o not appe arto be d istre s s ingto him and are not abou t harm ing
s e lforothe rs .
H e was s e e n we e kly throu ghM ay;the note s appe are d ad e qu ate . H e was not s e e n by aprovide rat
allin Ju ne . In Ju ly the re we re two note s ;the firs t appe ars to be ac
hart re view, as the re we re no
vitals , no e xam and no s u bje c
tive inform ation. It is not c
le ar that the provide r ac
tu ally s aw the
patient. T he s e c
ond note was foras kin ras h.
H e was s e e n onc
e in A u gu s t by the M e d ic
alD ire c
tor. A gain, the re was no phys ic
ale xam or
s u bje c
tive inform ation. T he re is no c
onvinc
inge vid e nc
e that the re was inte rac
tion be twe e n the
d oc
torand the patient.
T he M e d ic
alD ire c
tors aw him we e kly in Se pte m be r, bu t no note s c
ontain aphys ic
ale xam , only
u pin d ay room ,u pabou t,N A D ,s u gge s tingthat he was m e re ly obs e rve d from afar.
In O c
tobe r, the M e d ic
alD ire c
tor s aw him for bac
k pain with ins piration. T he re was no e xam ,
as s e s s m e nt orplan. She ord e re d ac
he s t x-ray, whic
hwas d one the ne xt d ay and re porte d as norm al.
W he n s he s aw him again five d ays late r, the re was no m e ntion ofthe bac
k pain.

O n 11/17/13, the R N note d ale ft fac

iald roop. T he M e d ic
alD ire c
tors aw the patient the ne xt d ay
and note d , R e porte d u nable to ke e ple ft e ye c
los e d at noc
.T he re was no e xam , no as s e s s m e nt or
d iagnos is. She ord e re d the le ft e ye to be tape d s hu t. T he followingd ay, s he note d ale ft fac
iald roop
and d iagnos e d B e ll
s pals y. She ord ere d artific
ialte ars and c
ontinu e tapingthe e ye s hu t. N o worku porothe rtre atm e nt was initiate d .
H e was s e e n onc
e m ore in N ove m be r, twic
e in D e c
e m be r, we e kly in Janu ary, and onc
e in Fe bru ary
as ofthe d ate ofou rvisit (2/26).
R e view ofhis pe rm ane nt re c
ord (whic
his als o ke pt in the infirm ary)re ve ale d that in Ju ly 2012
the patient had ac
olonos c
opy s howingtwo ad e nom atou s polyps , one ofwhic
hs howe d high-grad e
d ys plas iaon pathology. T he re has be e n no follow-u pc
olonos c
opy as ofthe d ate ofou rvisit.
Opinion:T his patient has not be e n s e e n ac
c
ord ingto polic
y while in the infirm ary. T he note s are
inad e qu ate ;m os t lac
k s u bje c
tive orobje c
tive inform ation and rare ly artic
u late m e d ic
ald e c
isionm aking. T his patient s hou ld have be e n tre ate d withs teroids forhis B e ll
s pals y, in ac
c
ord anc
e with
c
u rre ntly pu blishe d gu ide line s . A s e riou s , pre c
anc
e rou s c
ond ition has be e n ove rlooke d in this c
as e .
T his c
as e was brou ght to the atte ntion ofthe M e d ic
alD ire c
torforfollow-u p.
Patient #12
T his is a45-ye ar-old with hype rte ns ion, s e ve re tre m ors and as e izu re d isord e r who was in the
infirm ary from at le as t A u gu s t u ntilN ove m be rof2013. T he re we re two phys ic
ian note s in A u gu s t,
rou ghly we e kly in Se pte m be r, two visits in O c
tobe rand one in N ove m be r. N one c
ontain aphys ic
al
e xam that re fle c
ts that the provid e r laid ahand on the patient. A lls im ply d e s c
ribe obs e rvations ;
tre m or,u pto e at in d ay room ,in be d ,e tc
.
Opinion:T his patient was not s e e n in ac
c
ord anc
e withpolicy, nord o the note s re fle c
t that he was
e xam ine d in the las t s ix m onths .

Infirmary Care Issues

1. LP N s are workingou ts ide the s c
ope ofprac
tic
e.
2. P atients are not s e e n ac
c
ord ingto polic
y by provid e rs . R are ly is the re e vid e nc
e that patients
are phys ic
ally e xam ine d .
3. O ne 11-7s hift has no R N as s igne d to the infirm ary and aLP N is d ire c
tingthe c
are . A gain,
this plac
e s the LP N in the pos ition ofworkingou ts ide the s c
ope ofprac
tic
e be c
au s e the
LP N m ay ne e d to e valu ate apatient c
om plaint, e xam ine the patient and bas e d on the
find ings ofthe e xam ination and patient s ym ptom s , form an as s e s s m e nt, and bas e d on the
as s e s s m e nt, d e ve lop and im ple m e nt a plan of tre atm e nt. A ll of this is be yond the
ed u c
ationalpre paration and s c
ope ofprac
tic
e foraLP N .
4. Stale , non-d e s c
riptive and u ninform ative c
harting.
5. Inc
om ple te c
hartingwith d ate s /tim e s , vital s igns , s ignatu re s m iss ingand the re qu ire d
SO A P form at not always u s e d .
6. C allbu ttons pos itione d whe re it c
ou ld be d iffic
u lt to im pos s ible forthe patient to ac
c
ess.
7. N o c
allbu ttons in the patient room s alongone longhallway and no d ire c
t line -of-s ight to
the nu rs ings tation in s ix ofthe room s .

8. N o s e c
u rity pre s e nc
e in the infirm ary d e s pite alls e c
u rity c
las s ific
ations be ingpre s e nt.
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31

9. N ot e nou ghrad ios and no panicalarm s available forstaff.

10. Ins u ffic
ient e qu ipm e nt.
11. Ins u ffic
ient am ou nt ofnon-thre ad bare , non-torn/fraye d ornon-s taine d line ns and blanke ts .
12. Ins u ffic
ient nu m be rofpillows .

Infection Control
A t pre s e nt, the re is no nam e d infe c
tion c
ontrolnu rs e . T he two nu rs ings u pe rvisors are re s pons ible
forc
om plianc
e withID O C polic
yc
onc
e rningc
om m u nic
able d ise as e s , blood borne pathoge ns and
c
om plianc
e withIllinois D e partm e nt ofP u blicH e althre portingre qu ire m e nts .
T he fac
ility has ac
ontrac
t withalarge nationwid e m e d ic
alwas te d ispos alc
om pany whic
hc
om e s
on s ite two tim e s pe rm onthto hau laway m e d ic
alwas te . T he re we re no re porte d iss u e s withthis
s e rvic
e.
Ins pe c
tion ofthe infirm ary, s ic
kc
allare as in the m e d ic
ald e partm e nt and X -hou s e and e m e rge ncy
re s pons e bags ve rified the pre s e nc
e ofpe rs onalprote c
tive e qu ipm e nt. P u nc
tu re proofc
ontaine rs
forthe d ispos alofs harps are in u s e in allm e d ic
alare as and are appropriate ly plac
e d in the m e d ic
al
was te c
ontaine rs whe n fu ll.
Inm ate s as s igne d as porters in the infirm ary and who pe rform janitoriald u ties m ay orm ay not
have re c
e ive d any trainingas to appropriate c
le aningand s anitation m e thod s . N u rs ings u pe rvisors
have not ad d re s s e d the iss u e withthe porters .
R e portable ST Is are pic
ke d -u pand re porte d by U IC .

Dental Program
Executive Summary
O n Ju ly 15 and 16, 2014, a c
om pre he ns ive re view of the d e ntal program at D ixon C C was
c
om ple te d . Five are as ofthe program we re ad d re s s e d :1)inm ate s ac
c
e s s to tim e ly d e ntalc
are ;2)
the qu ality ofc
are ;3)the qu ality and qu antity ofthe provide rs ;4)the ad e qu ac
y ofthe fac
ility and
e qu ipm e nt d e vote d to d e ntalc
are ;and 5)the ove ralld e ntalprogram m anage m e nt. T he following
obs e rvations and find ings are provide d .
T he c
linicits e lfis rathe rlarge and s pac
iou s and we lle qu ippe d . It is athre e -c
hairc
linic
, bu t one of
the c
hairs is not fu nc
tioning. N o plans forre pairare in plac
e . A lthou ghthe s taffingle ve lforthe
d e ntists is ad e qu ate , the re is no hygienist on the d entals taff. A s s u c
h, hygiene c
are is ne arly none xiste nt. T his is as e riou s om iss ion and ahygienist s hou ld be hire d as s oon as pos s ible .
A m ajorare aofc
onc
e rn re late s to c
om pre he ns ive c
are . C om pre he ns ive c
are was provide d withou t
ac
om pre he ns ive intra and e xtra-oral e xam ination and we ll d e ve lope d tre atm e nt plan. N o
e xam ination ofs oft tiss u e s norpe riod ontalas s e s s m e nt was part ofthe tre atm e nt proc
ess.

H ygiene c
are and prophylaxis we re ne ve r provid e d and oral hygiene ins tru c
tions we re ne ve r
d oc
u m e nte d . B ite wingorpe riapic
alrad iographs we re ne ve rtake n to d iagnos e c
aries . R e s torations
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we re provide d from the inform ation on apane lips e rad iograph. N one of the re c
ord s re viewe d
d oc
u m e nte d the tim e ofthe appointm e nt.
A s im ilar are a of c
onc
e rn is d e ntal e xtrac
tions . A ll d e ntal tre atm e nt s hou ld proc
e e d from a
d oc
u m e nte d d iagnos is. T he re as on for e xtrac
tions s hou ld be part ofthe re c
ord e ntry. In none of
the re c
ord s re viewe d was ad iagnos is orre as on forthe e xtrac
tion inc
lu d e d . A larm ingly, in none of
the re c
ord s re viewe d was ac
ons e nt fortre atm e nt form available . T his is as e riou s om iss ion and
ne e d s to be c
orre c
te d im m e d iate ly.
P artiald e ntu re s s hou ld be c
ons tru c
te d as afinals te pin the s e qu e nc
e ofc
are d e live ry inc
lu d e d in
the c
om pre he ns ive c
are proc
e s s . A re view of s e ve ralre c
ord s re ve ale d that allpartiald e ntu re s
proc
e e d e d withou t ac
om pre he ns ive e xam ination and tre atm e nt plan. P e riod ontalas s e s s m e nt and
tre atm e nt was s e ld om provide d . O ralhygiene ins tru c
tions we re ne ve r inc
lu d e d . It was alm os t
im pos s ible to d e m ons trate that allfillings and e xtrac
tions we re c
om ple te d prior to im pre s s ions .
P e riod ontalhe althwas ne ve rd oc
u m e nte d .
A t D ixon C C , d e ntals ic
kc
allis ac
c
e s s e d throu ghad aily s ic
kc
alls ign u p throu ghthe m e d ic
al
d e partm e nt and viathe inm ate re qu e s t form . T he re was no s ys te m in plac
e to e valu ate u rge nt c
are
ne e d s (pain and /ors we lling)from the re qu e s t form . Inm ate s withu rge nt c
are c
om plaints from the
re qu e s t form ofte n took fou rorfive d ays to be s e e n by the d e ntist fore valu ation. T he s e inm ate s
s hou ld be s e e n within 24-48hou rs from the d ate ofthe re qu e s t form .
In none ofthe re c
ord s re viewe d was the SO A P form at be ingu s e d . T re atm e nt was provid e d with
little inform ation or d etailpre c
e d ingit. R e c
ord entries d id not inc
lu d e c
linic
alobs e rvations or
d iagnos is to ju s tify tre atm e nt.
A we ll d e ve lope d P olic
y and P roc
e d u ral M anu al ins u re s that a d e ntal program ad d re s s e s all
e s s e ntialare as and is ru n withc
ontinu ity. T he P olic
y and P roc
e d u re s m anu alat D ixon C C only
paraphras e s the A d m inistrative D ire c
tive s . It inc
lu d e d nothings pe c
ificfor D ixon C C and the
ru nningof the d e ntal program . T he d e ntal d ire c
tor kne w little of its e xiste nc
e and had ne ve r
re viewe d it.
T he D ixon C C Inm ate O rientation M anu alonly m e ntions d e ntalin re lation to c
o-pays . N o m e ntion
is m ad e on ac
c
e s s to c
are.
M e d ic
alc
ond itions that re qu ire pre c
au tions and c
ons u ltation with m e d ic
als taff prior to d e ntal
tre atm e nt s hou ld be we lld oc
u m e nte d in the he althhistory s e c
tion ofthe d e ntalre c
ord and re d
flagge d to bringthe m to the im m e d iate atte ntion ofthe provide r. T he d e ntalre c
ord is m aintaine d
in the d e ntalc
linics e parate from the m e d ic
alre c
ord . Id e ntific
ation on the d e ntalre c
ord ofinm ate s
on antic
oagu lant the rapy was ve ry inc
ons iste nt and s e ld om re d flagge d .
B lood pre s s u re s s hou ld , at the le as t, be take n on patients withahistory of hype rte ns ion. W he n
as ke d , the c
linic
ians ind ic
ate d that the y d o not rou tine ly take blood pre s s u re s on the s e patients .

T he s te rilization flow from d irty to ste rile was im proper. T he re was no biohaz ard labe lpos te d in
the s terilization are a. Safe ty glas s e s we re not always worn by patients . A rad iation haz ard warning
s ign was not pos te d in the x-ray are a.
T he c
ontinu ingqu ality im prove m e nt proc
e s s was inad e qu ate ly u tilize d . A s tu d y was in proc
ess
bu t s e e m e d rathe rins ignific
ant. C Q I stu d ies s hou ld be d e ve lope d to ad d re s s program d e fic
ienc
ies
note d in the bod y ofthis re port.

Staffing and Credentialing

D ixon C C has ad e ntals taffofone fu ll-tim e d e ntist, one 14-hou rpart-tim e d e ntist and two fu lltim e as s istants . T he re is no hygienist at D ixon C C . T his is as e riou s om iss ion. T o e xpe c
t the
d e ntists to provide hygiene and pe riod ontalc
are to apopu lation the s ize ofD ixon C C is u nre alistic
and u nobtainable . It is als o apooru s e ofad e ntist
s tim e and re s ou rc
e s . A d e ntalhygienist s hou ld
im m e d iate ly be m ad e part ofthe d e ntals taffat D ixon C C .
C P R trainingis c
u rre nt on alls taff, allne c
e s s ary lic
e ns ingis on file , and D E A nu m be rs are on file
forthe d e ntists .
Recommendations:
1. T hat ad e ntalhygienist im m e d iate ly be m ad e part ofthe d e ntals taffat D ixon C C .

Facility and Equipment

T he c
linicc
ons ists ofthre e c
hairs and u nits , one fore ac
hd e ntist and athird fore ithe rofthe two
d e ntists . T wo ofthe d e ntalu nits are two ye ars old and in ve ry good re pair. T he third c
hairis ve ry
old , worn and d oe s not work at all. N o plans to repairthis c
hairare in plac
e . T he re is apanore x
u nit in the he alths e rvic
e s x-ray d e partm e nt in ad e d ic
ate d room . It is old bu t fu nc
tions ad e qu ate ly.
T he x-ray u nit in the c
linicis in good re pairand works we ll. T he au toc
lave is old e rbu t fu nc
tions
we ll. T he c
om pre s s or is in the bas e m e nt and works we ll. T he ins tru m e ntation is ad e qu ate in
qu antity and qu ality. T he d e ntist e xpre s s e d no c
om plaints . T he hand piec
e s are old e r bu t we ll
m aintaine d and re paire d whe n ne c
e s s ary. T he c
abine try is rathe r old and s howingwe ar and
c
orros ion and s tainingon work s u rfac
e s , bu t fu nc
tionally alright. T his d oe s m ake d isinfe c
tion of
s u rfac
e s m ore d iffic
u lt. T he u ltras onicworks we ll.
T he c
linicits e lf c
ons ists of thre e c
hairs in thre e s e parate and ad e qu ate s pac
e s . Fre e m ove m e nt
arou nd e ac
hu nit is ac
c
e ptable . P rovid e rand as s istant have ad e qu ate room to work and none ofthe
c
hairs inte rfe re withe ac
hothe r. T he re was as e parate s terilization are aofad e qu ate s ize and s u rfac
e
works pac
e . T he s taffoffic
e is large withas ingle d e s k. T he d e ntalre c
ord s are m aintaine d in this
room . It als o hou s e s the d e ntallaboratory withits e qu ipm e nt and works pac
e . T he re is ad e qu ate
room forall.
T he c
linicis ad e qu ate in s ize and fu nc
tion to m e e t the ne e d s ofthe inm ate popu lation at D ixon
CC.
Recommendations:

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1. R e pairorre plac
e the c
hairand u nit that is not working.

Sanitation, Safety, and Sterilization

I obs e rve d the s anitation and s te rilization te c
hniqu e s and proc
e d u re s . Su rfac
e d isinfe c
tion was
pe rform e d be twe e n e ac
hpatient and was thorou ghand ad e qu ate . P rope rd isinfe c
tants we re be ing
u s e d . P rote c
tive c
ove rs we re u tilize d on s om e ofthe s u rfac
es.
A n e xam ination of ins tru m e nts in the c
abine ts re ve ale d that the y we re prope rly bagge d and
s te rilize d . A llhand piec
e s we re s te rilize d and in bags.
T he s te rilization proc
e d u re its e lf was flawe d . Flow s hou ld go from d irty to s te rile in a line ar
fas hion. T he u ltras onicwas on the oppos ite s ide ofthe au toc
lave from the s ink. It s hou ld flow from
u ltras onicto s ink to work are ato au toc
lave withou t c
ros s ingits path.
T he re was not abiohaz ard labe lpos te d in the s terilization are a. Safe ty glas s e s we re not always
worn by patients . E ye prote c
tion is always ne c
e s s ary, forpatient and provid e r. I als o obs e rve d that
no warnings ign was pos te d whe re x-rays we re be ingtake n to warn ofrad iation haz ard s , e s pe c
ially
to pre gnant fe m ale s .
T he c
linicwas , allin all, c
le an, ne at and ord e rly.

Review Autoclave Log

I looke d bac
k thre e ye ars and fou nd the s te rilization logs to be in plac
e . T he y s howe d that
au toc
lavingwas ac
c
om plishe d we e kly and d oc
u m e nte d . T he y u tilize the M axite s t s ys te m throu gh
H e nry Sc
he in. A s ingle ne gative re s u lt was d oc
u m e nte d , bu t c
orre c
te d im m e d iate ly withare te st,
whic
hwas ne gative . I d id obs e rve that no biohaz ard warnings ign was pos te d in the s te rilization
are a.
Recommendations:
1. T hat the s te rilization flow to the au toc
lave be c
orre c
te d as s u gge s te d .
2. T hat s afe ty glas s e s be provide d to patients while the y are be ingtre ate d .
3. T hat abiohaz ard warnings ign be pos te d in the s te rilization are a.
4. A warnings ign be poste d in the x-ray are ato warn pre gnant fe m ale s ofrad iation haz ard s .

Comprehensive Care
W e re viewe d 10d e ntalre c
ord s ofinm ate s in ac
tive tre atm e nt c
las s ified as C ate gory 3patients . O ne
ofthe m os t bas icand e s s e ntials tand ard s ofc
are in d e ntistry is that allrou tine c
are proc
e e d from a
thorou gh, we lld oc
u m e nte d intraand e xtra-orale xam ination and awe lld e ve lope d tre atm e nt plan,
to inc
lu d e allne c
e s s ary d iagnos ticx-rays . A re view of10re c
ord s re ve ale d that no c
om pre he ns ive
e xam ination was e ve rperform e d and no tre atm e nt plans d e ve lope d . N o e xam ination ofs oft tiss u e s
or pe riod ontalas s e s s m e nt was part ofthe tre atm e nt proc
e s s . H ygiene c
are and prophylaxis was
ne ve rprovide d and oralhygiene ins tru c
tions we re ne ve rd oc
u m e nte d . B ite wingorperiapic
alx-rays
we re ne ve rtake n to d iagnos e c
aries . R e storations we re provide d

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from the inform ation from the panore x rad iograph. T his rad iographis not d iagnos ticforc
aries . A
pe riod ontalas s e s s m e nt was not d one in any ofthe re c
ord s . N one ofthe re c
ord e ntries we re tim e
d oc
u m e nte d .
Recommendations:
1. C om pre he ns ive rou tine c
are be provid e d only from awe lld e ve lope d and d oc
u m e nte d
tre atm e nt plan.
2. T he tre atm e nt plan be d e ve lope d from athorou gh, we lld oc
u m e nte d intraand e xtra-oral
e xam ination, to inc
lu d e a pe riod ontal as s e s s m e nt and d etaile d e xam ination of all s oft
tiss u e s .
3. In allc
as e s , that appropriate bite wingorpe ri-apic
alx-rays be take n to d iagnos e c
aries .
4. H ygiene c
are be provide d as part ofthe tre atm e nt proc
ess.
5. T hat c
are be provide d s e qu e ntially, be ginning with hygiene s e rvic
e s and d e ntal
prophylaxis.
6. T hat oralhygiene ins tru c
tions be provide d and d oc
u m e nte d .
7. T hat allre c
ord e ntries inc
lu d e d ate and tim e .

Dental Screening
W e re viewe d 10 inm ate d e ntalre c
ord s that we re re c
e ive d from the re c
e ption c
e nte rs within the
pas t 60d ays to d ete rm ine if:1)s c
re e ningwas pe rform e d at the re c
e ption c
e nte rand 2)apanoram ic
x-ray was take n. A lthou ghD ixon C C is not are c
e ption and c
las s ific
ation c
e nte r, I re viewe d the s e
re c
ord s to ins u re the re c
e ption and c
las s ific
ation polic
ies as s tate d in A d m inistrative D ire c
tive
04.03.102, s e c
tion F. 2, are be ingm e t forthe ID O C .
Recommendations: N one . A llre c
ord s re viewe d we re in c
om plianc
e.

Extractions
O ne ofthe prim ary te nets in d e ntistry is that alld e ntaltre atm e nt proc
e ed s from awe lld oc
u m e nte d
d iagnos is. In none ofthe 10re c
ord s e xam ine d was ad iagnos is orre ason fore xtrac
tion inc
lu d e d as
part ofthe d e ntalre c
ord e ntry. In none ofthe re c
ord s re viewe d was ac
ons e nt form available . W he n
as ke d , I was told that it was ju s t not apart ofthe tre atm e nt proc
e s s fors u rgery at D ixon C C . T his
is as eriou s om iss ion and am ajor violation of awe lle s tablishe d s tand ard of c
are. It le ave s the
ins titu tion u nne c
e s s arily e xpos e d to pote ntiallitigation.
Recommendations:
1. A d iagnos is orare as on forthe e xtrac
tion be inc
lu d e d as part ofthe re c
ord e ntry. T his is
be s t ac
c
om plishe d throu ghthe u s e ofthe SO A P note form at, e s pe c
ially fors ic
kc
alle ntries .
It wou ld provide m u c
hd e tailthat is lac
kingin m os t d e ntale ntries obs e rve d . T oo ofte n, the
d e ntal re c
ord inc
lu d e s only the tre atm e nt provid e d with no e vid e nc
e as to why that
tre atm e nt was provide d . N e ithe rthe patient
sc
om plaint northe d e ntist
s find ings.
2. T hat ac
ons e nt form be d e ve lope d and s igne d by the patient and the d e ntist. T hat the
proc
e d u re and any pote ntialc
om plic
ations be we lle xplaine d to the patient.

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Removable Prosthetics
R e m ovable partiald e ntu re pros the tic
s s hou ld proc
e e d only afte r allothe rtre atm e nt re c
ord e d on
the tre atm e nt plan is c
om ple te d . T he pe riod ontal, ope rative and orals u rge ry ne e d s alls hou ld be
ad d re s s e d firs t. W e re viewe d d e ntalre c
ord s of five patients havingre c
e ive d c
om ple te d partial
d e ntu re s . In only two ofthe five re c
ord s re viewe d on patients re c
e ivingre m ovable partiald e ntu re s
we re oralhygiene ins tru c
tions provid e d . P e riod ontalas s e s s m e nt was not provide d in any ofthe
re c
ord s . In two of the five re c
ord s aprophylaxis and /or as c
alingd e brid e m e nt was provide d .
B ec
au s e the re is no c
om pre he ns ive e xam ination orany tre atm e nt plans d e ve lope d and d oc
u m e nte d
in any ofthe re c
ord s , it is alm os t im pos s ible to as c
e rtain ifallne c
e s s ary c
are , inc
lu d ingope rative
and /or orals u rge ry tre atm e nt, is c
om ple te d prior to fabric
ation ofre m ovable partiald e ntu re s . I
u s e d rad iographs and re c
ord e ntries to c
onc
lu d e that e xtrac
tions we re probably c
om ple te d .
Recommendations:
1. A c
om pre he ns ive e xam ination and we ll d e ve lope d and d oc
u m e nte d tre atm e nt plan,
inc
lu d ingbite wingand /or periapic
alrad iographs and pe riod ontalas s e s s m e nt, pre c
e d e all
c
om pre he ns ive d e ntalc
are , inc
lu d ingre m ovable prosthod ontic
s.
2. T hat pe riod ontalas s e s s m e nt and tre atm e nt be part of the tre atm e nt proc
e s s and that the
pe riod ontiu m be s table be fore proc
e e d ingwithim pre s s ions .
3. T hat all ope rative d e ntistry and oral s u rge ry as d oc
u m e nte d in the tre atm e nt plan be
c
om ple te d be fore proc
e e d ingwithim pre s s ions .

Dental Sick Call

W e re viewe d 10 d e ntals ic
kc
allc
harts to d ete rm ine ifthe y are ad e qu ate . Inm ate s ac
c
e s s d e ntal
s ic
kc
allthrou ghe ithe r as ic
kc
alls ign u p proc
e s s or viathe inm ate re qu e s t form . T he s ic
kc
all
s ign u ptake s plac
e in the he alths e rvic
e s u nit e ve ry m orning. T he y s ign u pone d ay and are s e e n
and e valu ate d the ne xt d ay by an R N . T he R N the n re fe rs the c
om plaint to the d e ntalprogram and
the inm ate is s c
he d u le d ford e ntalwithin fou rto five d ays . I am u ns u re why d aily s ic
kc
allis not
s e e n d ire c
tly by the d e ntal program . T he nu m be r is re lative ly s m all and c
ou ld e as ily be
ac
c
om plishe d . It wou ld ins u re that u rge nt c
are c
om plaints are ad d re s s e d in atim e ly m anne r.
R e qu e s t form s are re c
e ive d from the ins titu tion m ailand e valu ate d by the d e ntist and s c
he d u le d
foran e xam ination and e valu ation within fou rto five d ays . N o s ys te m was in plac
e to atte m pt to
s e e inm ate s withu rge nt c
are c
om plaints within 24to 48hou rs from the d ate ofthe re qu e s t form .
A gain, the nu m be ris s m alland the y c
ou ld e as ily be s c
he d u le d forthe ne xt workingd ay.
E m e rge nc
yc
all-ins from s taffare s e e n the s am e d ay.
In none ofthe re c
ord s was the SO A P form at be ingu s e d . A s s u c
h, little in the way ofad iagnos is
was available forany d e live re d c
are .
R ou tine c
are was not be ingprovide d at s ic
kc
allappointm e nts .
T he c
hiefc
om plaint, as we llas c
ou ld be d e te rm ine d , was be ingad d re s s e d at s ic
kc
all.

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Recommendations:
1. Im ple m e nt the u s e ofthe SO A P form at fors ic
kc
alle ntries . It willas s u re that the inm ate
s
c
hief c
om plaint is re c
ord e d and ad d re s s e d and a thorou gh foc
u s e d e xam ination and
d iagnos is pre c
e d e s alltre atm e nt.
2. D aily d e ntals ic
kc
alls hou ld be s e e n and e valu ate d by the d e ntist, rathe rthan throu ghthe
m e d ic
alprogram .
3. R e qu e s ts from inm ate s withu rge nt c
are c
om plaints s hou ld be s c
he d u le d forthe ne xt work
d ay from re c
e ipt ofthe re qu e s t form .

Treatment Provision
A rathe rwe ak triage s ys te m is in plac
e that prioritize s tre atm e nt ne e d s . A llinm ate re qu e s t form s
are e valu ate d from the d ay re c
e ive d by the d e ntalprogram and appointm e nts provid e d from this
e valu ation, u s u ally within fou rto five d ays . D aily s ic
kc
alls ign-u ps are s e e n by the R N
s by the
followingd ay, e valu ate d and provid e d pain m e d s if ne c
e s s ary. T he y are the n re fe rre d to d e ntal
fore valu ation. T he s e re fe rrals from the R N
s from d aily s ic
kc
alls ign-u ps are e valu ate d by the
d e ntalprogram by the followingd ay from re c
e ipt ofthe re fe rral, and s c
he d u lingis prioritize d .
T he y are s c
he d u le d ac
c
ord ingly or plac
e d on the tre atm e nt list. T he R N s have pain m e d ic
ation
protoc
ols available . N on-u rge nt c
are ne e d s are be ings e e n in atim e ly m anne r and the ir iss u e s
ad d re s s e d .
Inm ate s c
an s e e k u rge nt c
are viathe inm ate re qu e s t form , by s igningu pfors ic
kc
allwiththe R N ,
or, ifthe y fe e lthe y ne e d to be s e e n im m e d iate ly, by c
ontac
tingD ixon C C s taff, who willthe n
c
allthe d e ntalc
linicwiththe inm ate
sc
om plaint. R e qu e s t form s are s e nt viathe ins titu tion m ail
and are e valu ate d the d ay the y are re c
e ive d in d e ntal, and s c
he d u le d ac
c
ord ingly, u s u ally thre e to
five d ays . Sic
kc
alls ign-u ps are s e e n by the followingd ay by aR N and e valu ate d and re fe rre d to
d e ntalby the ne xt d ay. T he y have pain m e d ic
ation protoc
ols available . A s s u c
h, it take s thre e to
five d ays ford e ntalto ad d re s s u rge nt c
are ne e d s . T he d e ntalc
linicre c
e ive s abou t thre e re qu e s t
form pe rd ay and only one in thre e orfou ris foru rge nt c
are , i.e ., pain, s we llingand toothac
he s .
T he s e inm ate s c
ou ld e as ily be s c
he d u le d the ne xt workd ay for d ire c
t e valu ation by the d e ntist.
A ls o, d e ntalc
ou ld s c
he d u le the s ic
kc
allpatients d ire c
tly, rathe rthan throu ghthe R N . T his wou ld
ins u re that u rge nt c
are ne e d s are ad d re s s e d in atim e ly m anne r, within one workingd ay.
Inm ate s who s u bm it re qu e s t form s for rou tine c
are are e valu ate d in the d e ntalc
linicwithin one
we e k and plac
e d s e qu e ntially on awaitinglist forthis c
are . T he waitinglist is approxim ate ly two
m onths longat this tim e . T he s ys te m is fairand e qu itable .
Recommendations:
1. T hat e fforts be m ad e to s e e u rge nt c
are c
om plaints viathe re qu e s t form in am ore tim e ly
m anne r. T he y c
ou ld e as ily be s c
he d u le d forthe ne xt d ay. Sic
kc
alls ign-u ps are s e e n the
followingd ay by R N s who have pain m e d ic
ation protoc
ols available . D e ntals ic
kc
alls ignu ps s hou ld be s c
he d u le d d ire c
tly by d e ntalfor the followingd ay, rathe r than by the R N
who the n re fe rs the m to d e ntal.

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Orientation Handbook
T he D ixon C C O rientation M anu alonly m e ntions d e ntalin re lation to c
o-pays . It d e s c
ribe s m e d ic
al
s ic
kc
allproc
e d u re s , bu t no m e ntion is m ad e ofd e ntals ic
kc
all.
Recommendations:
1. A m e nd the orientation m anu alto inc
lu d e d e ntals ic
kc
allproc
e d u re s and ins tru c
tions on how
to ac
c
e s s rou tine , u rge nt and e m e rge nc
yc
are .

Policies and Procedures

T he P olic
y and P roc
e d u re s M anu al and s tate m e nts for D ixon C C only paraphras e the
A d m inistrative D ire c
tive s . It inc
lu d e s nothings pe c
ificforD ixon C C and the ru nningofthe d e ntal
program . W he n as ke d , the d e ntald ire c
torkne w little ofits e xiste nc
e and had ne ve rre viewe d it.
Recommendations:
1. T hat the d e ntalprogram at D ixon C C d e ve lop ac
u rre nt d etaile d , thorou gh and ac
c
u rate
polic
y and proc
e d u re s m anu althat d e fine s how allas pe c
ts ofthe d e ntalprogram are to be
ru n and m anage d , to inc
lu d e ac
c
e s s to c
are , c
are provision, c
linicm anage m e nt, infe c
tion
c
ontrol, e tc
. O nc
e d e ve lope d , it s hou ld be re viewe d and u pd ate d on are gu larbas is and as
ne e d e d forne w polic
ies and proc
e d u re s .

Failed Appointments
A re view of m onthly re ports and d aily work s he e ts re ve ale d afaile d appointm e nt rate ofabou t
10.4% . A llfaile d appointm e nt inm ate s are re qu ire d to s ign are fu s alform . T he y are allloc
ate d and
brou ght to the d e ntalc
linicto d o so. T he s e pe rc
e ntage s are s lightly highand s hou ld be watc
he d .
Recommendations: N one

Medically Compromised Patients

B ec
au s e the d e ntalre c
ord is m aintaine d in the d e ntalc
linics e parate from the m e d ic
alre c
ord ,
id e ntific
ation ofm e d ic
ally c
om prom ise d patients re lies on as s e s s m e nt by the c
linic
ian and on the
history s e c
tion on the c
ove rofthe d e ntalre c
ord . O fthe 10re c
ord s re viewe d ofinm ate s on antic
oagu lant the rapy, only one was ad e qu ate ly re d flagge d to c
atc
hthe im m e d iate atte ntion ofthe
provide r. Fou rofthe re c
ord s d id not ind ic
ate that the inm ate was on antic
oagu lant the rapy. Five
ofthe re c
ord s ind ic
ate d antic
oagu lant the rapy, bu t the y we re not s u ffic
iently re d flagge d . O n one
re c
ord , tre atm e nt was provide d and was m anage d properly.
W he n as ke d , the c
linic
ians ind ic
ate d that the y d o not rou tine ly take blood pre s s u re s on patients
withahistory ofhype rte ns ion.
Recommendations:
1. T hat the m e d ic
alhistory s e c
tion ofthe d e ntalre c
ord be kept u p to d ate and that m e d ic
al
c
ond itions that re qu ire s pe c
ialpre c
au tions be re d flagge d to c
atc
hthe im m e d iate atte ntion
ofthe provide r. T he s e wou ld inc
lu d e m e d ic
ation alle rgies , antic
oagu lants , inte rfe ron

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the rapy, pre -m e d ic

ate d c
ard iacc
ond itions and any othe r he alth c
ond ition that wou ld
re qu ire m e d ic
alinte rve ntion priorto d e ntaltre atm e nt.
2.
T hat blood pre s s u re re ad ings be rou tine ly take n of patients with a history of
hype rte ns ion,
e s pe c
ially priorto any s u rgic
alproc
e d u re .

Specialists
T he d e ntalprogram at D ixon C C u tilize s the Joliet O raland M axillo-fac
ialSu rge ry c
linicin Joliet,
Illinois. T his c
as e was the only one s e nt ou t in the pas t nine m onths . It was alarge c
ys t ofthe bod y
and ram u s ofthe m and ible , ave ry e xte ns ive s u rge ry. A llothe rs u rge ries , inc
lu d ingim pac
tions that
re qu ire re m oval, s u rgic
ale xtrac
tions and le s ion re m ovals , are d one in-hou s e by the d e ntists at
D ixon C C .
Recommendation: N one . Spe c
ialists are available and u tilize d .

Dental CQI
A re view ofm onthly m inu te s from the M e d ic
alC Q I C om m itte e re ve als that the d e ntalprogram
c
ontribu te s m onthly d e ntals tatistic
s to the C Q I c
om m itte e . W aitinglists are am ain c
onc
e rn. T he
waitinglist for e xtrac
tions and ope rative is e ight we e ks and for d e ntu re s is 12 we e ks . T he s e are
ve ry re as onable le ngths of tim e . N o c
onc
e rn was e xpre s s e d . T he d e ntal program re c
e ntly
c
om ple te d aC Q I stu d y that e valu ate d pe rc
e ntage ofre qu ire d d e ntu re ad ju s tm e nts at the tim e of
ins e rtion. Ins e rtions we re e valu ate d for Janu ary, Fe bru ary and M arc
h 2014. T hirty-s e ve n and a
halfpe rc
e nt ne e d e d s u c
had ju s tm e nts . T he s tu d y is s tillbe inge valu ate d to s e e ifany c
hange s c
an
be m ad e in the c
ons tru c
tion ord e live ry proc
e s s to im prove this pe rc
e ntage . N o othe rstu d ies are
ongoingat the tim e ofthis re port.
Recommendations:
1. T hat the C Q I proc
e s s be u s e d e xte ns ive ly to ad d re s s the program d e fic
ienc
ies ou tline d in
the bod y ofthis re port. P olic
ies and proc
e d u re s s hou ld be d e ve lope d from this proc
e s s to
ins u re that m e as u re s are in plac
e to m aintain program c
ontinu ity and im prove m e nt.

Continuous Quality Improvement

T he re have be e n no m e e tings s inc
e the re was am e e tingin D e c
e m be r of 2013, for whic
h we
re viewe d the m inu te s . T he m e e tingd e tails s u c
h things as the nu m be r of patients be ings e e n in
phys ic
ian or N P or nu rs e s ic
kc
allas we llas nu m be rs of s taff vac
anc
ies , nu m be rs of inc
id e nt
re ports , infe c
tion c
ontrold ataand othe rre ports ofs e rvic
e s provide d . T he re is no d oc
u m e ntation
ofany e fforts to inve s tigate e ithe rproc
e s s e s orprofe s s ionalpe rform anc
e noris the re any e ffort to
im prove e ithe rare a. T he ac
tingQ I c
oord inatoris am e m be rofthe nu rs ings taffwho has had no
trainingin C Q I m e thod ology and philos ophy. T he pre viou s m inu te s from be fore D e c
e m be r2013
we re in A u gu s t 2013 and s im ilarly c
ontaine d no e fforts inve s te d in im provingthe qu ality of
s e rvic
e s . T his c
an only be d e s c
ribe d as an inac
tive qu ality im prove m e nt program . Give n the
abs e nc
e oflogs to trac
k u ns c
he d u le d ons ite and offs ite s e rvic
e s orad e qu ate logs to re view s u c
h
things as the tim e line s s of s c
he d u le d offs ite s e rvic
e s , s inc
e the d ate of ord e r is not available ,
atte m ptingto m onitorproc
e s s e s willbe qu ite ine ffic
ient. In ord e rto as s e s s intras ys te m trans fe rs
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we had to obtain c
u s tod y re c
ord s ofpatients trans fe rre d in on agive n d ay. T he re is no intras ys te m
trans fe r logals o. T he C Q I program ne e d s to be c
om ple te ly re bu ilt afte r ke y s taff are provide d
trainingand the le ad e rs hippos itions are fille d .

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Recommendations
Leadership and Staffing:
1. M ake apriority of fillingthe vac
ant M e d ic
alD ire c
tor, H e alth C are U nit A d m inistrator,
D ire c
torofN u rs ing, N u rs e P rac
titione rand s e ve n, C orre c
tionalN u rs e I (R N )pos itions .
2. D u e to c
onc
e rns re gard ingnon-re giste re d nu rs e s c
ond u c
tings ic
kc
alland workingou ts id e
of the ir e d u c
ational pre paration and lic
e ns e d s c
ope of prac
tic
e and whe n all the
C orre c
tional N u rs e I pos itions are fille d , total re giste re d nu rs ingpos itions s hou ld be
e valu ate d as to the ne e d forad d itionalpos itions orare c
onfigu ringofc
u rre nt pos itions in
ord erto provide an allR N c
ond u c
te d s ic
kc
allproc
ess.
Clinic Space and Sanitation:
1. D e ve lopand im ple m e nt aplan to re plac
e the s tyle ofbe d s be ingu s e d forgeriatricpatients
on the third floorofthe m e d ic
albu ild ing.
2. P rope rly e qu ipd e s ignate d s ic
kc
allroom s in the he althc
are u nit and X -hou s e .
Intrasystem Transfer:
1. T he intras ys te m trans fe r proc
e d u re m u s t be gin with all ne wly trans fe rre d inm ate s be ing
pre s e nte d to the m e d ic
alu nit, whe re an appropriate re view ofthe trans fe r s u m m ary and
m e d ic
alre c
ord are d isc
u s s e d withthe patient, alongwithvitals igns be ingtake n, and whe re
ind ic
ate d , aplan be ingim ple m e nte d to ins u re c
ontinu ity ofs e rvic
e.
Medical Records:
1. M e d ic
alre c
ord s s taff s hou ld trac
k re c
e ipt ofallou ts ide re ports and e ns u re that the y are
file d tim e ly in the he althre c
ord .
2. C harts s hou ld be thinne d re gu larly and M A R s file d tim e ly.
3. P roble m lists s hou ld be ke pt u pto d ate .
Nursing Sick Call:
1. D e ve lopand im ple m e nt aproc
e d u re forone s tyle ofs ic
kc
all.
2. D e ve lopand im ple m e nt aplan foran allR N s ic
kc
allproc
ess.
3. D e ve lop and im ple m e nt aplan to as s u re non-m e d ic
al pe rs onne ld o not have ac
c
e s s to
inm ate s ic
kc
allre qu e s ts .
4. D e ve lopand im ple m e nt aplan to m aintain inm ate s ic
kc
allre qu e s ts on file .
5. D e ve lopand im ple m e nt aplan to initiate and m aintain as ic
kc
alllog.
6. In the X -hou s e , d e ve lopand im ple m e nt aplan to c
ond u c
t ale gitim ate s ic
kc
alle nc
ou nte r,
inc
lu d ing liste ning to the patient c
om plaint, c
olle c
ting a history and obje c
tive d ata,
pe rform ingaphys ic
ale xam ination whe n re qu ire d , m akingan as s e s s m e nt and form u lating
aplan oftre atm e nt rathe rthan the c
u rre nt prac
tic
e oftalkingto the patient throu ghas olid
s te e ld oorand bas ingany tre atm e nt on the c
onve rs ation only.
7. P e rO ffic
e ofH e althSe rvic
e s polic
y, as s u re alls ic
kc
alle nc
ou nte rs are d oc
u m e nte d in the
m e d ic
alre c
ord in the Su bje c
tive -O bje c
tive -A s s e s s m e nt-P lan (SO A P )s tyle .
8. D e ve lopand im ple m e nt aplan to as s u re the O ffic
e ofH e althSe rvic
e s approve d , preprinte d
tre atm e nt protoc
olform s are u s e d at e ac
hs ic
kc
alle nc
ou nte r.

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9. D e ve lop and im ple m e nt aplan to as s u re e ac

h of apatient
s c
om plaints are ad d re s s e d
d u ringas ic
kc
alle nc
ou nte roraprioritization ofne e d s to ad d re s s d u ringfu tu re e nc
ou nte rs
is d e ve lope d rathe rthan the c
u rre nt prac
tic
e ofallowingonly one c
om plaint pe rvisit.
10. D e ve lopand im ple m e nt aplan ofe d u c
ation forallnu rs ings taffwhic
hwillbe c
ond u c
te d
by the M e d ic
alD ire c
torand ad d re s s e s the followingiss u e s :
a. A s s u re the patient
sc
om plaint is ad d re s s e d at the tim e ofthe s ic
kc
alle nc
ou nte r.
b. A s s u re d oc
u m e ntation is c
om ple te and , at am inim u m , ad d re s s e s the c
om plaint,
d u ration, history, pain le ve lifapplic
able , loc
ation ofpain, loc
ation ofinju ry, e tc
.,
c
olle c
tion ofc
om ple te vitals igns inc
lu d ingwe ight, an e xam ination if applic
able
and an as s e s s m e nt and plan.
c
. U s e ofthe O ffic
e ofH e althSe rvic
e s approve d tre atm e nt protoc
ols at e ac
hs ic
kc
all
e nc
ou nte r.
d . W he n u s ingthe protoc
ol, s taffm u s t c
om ply withthe O T C d os age s , as inc
re as ing
the s tre ngth or fre qu e nc
y m ake take the O TC d os age to an u nau thorize d
pre s c
ription d os age .
Clinician Sick Call:
1. T he nu rs ingd e partm e nt m u s t im ple m e nt as ic
kc
all logbook with field s inc
lu d ingd ate ,
patient nam e , patient nu m be r, re as on for visit, d ate of c
linician appointm e nt and if
c
anc
e lle d , re as on forc
anc
e llation and d ate forthe re s c
he d u le d appointm e nt.
Chronic Disease Program:
1. T he re s hou ld be as ingle nu rs e as s igne d to the c
hronicc
are program to ide ntify, e nroll,
m onitorand trac
k patients in an organize d and c
om pre he ns ive way.
2. P atients withH IV s hou ld be e nrolle d and m onitored in the c
hronicd ise as e program . T he re
s hou ld be as ys te m in plac
e to ide ntify m e d ic
ation nonc
om plianc
e (orothe rm iss e d d os e s )
and re fe rthos e patients to aprovide rtim e ly.
Urgent/Emergent Care:
1. U ns c
he d u le d s e rvic
e s re qu ire alogbook that c
ontains field s for d ate , tim e , patient nam e ,
patient nu m be r, pre s e nting s ym ptom , whe re the as s e s s m e nt was pe rform e d , and the
d ispos ition, inc
lu d ingif the patient was re tu rne d to the c
e llhou s e or s e nt offs ite . W he n
patients are s e nt offs ite , astaff pe rs on m u s t be as s igne d the re s pons ibility of obtaining
e ithe r the e m e rge nc
y room re port or, if the patient was ad m itte d to the hos pital, the
d isc
harge s u m m ary. A llpatients s e nt offs ite s hou ld be brou ght to the c
linicforanu rs e to
re view the re le vant d oc
u m e nts and ins u re the re qu ire d d oc
u m e nts , if not available , are
obtaine d and the patient is s c
he d u le d forafollow-u pvisit withaprim ary c
are c
linic
ian. A t
the prim ary c
are c
linic
ian visit, the c
linic
ian m u s t d oc
u m e nt ad isc
u s s ion ofthe find ings
and plan.
Scheduled Offsite Services:
1. T he d e lays in obtainings c
he d u le d offs ite s e rvic
e s m u s t be e lim inate d . W e xford m u s t be
re qu ire d within s e ve n d ays afte rve rbalapprovalto have provide d au thorization to the U of
Ic
oord inator. If the U of I is as s igningan appointm e nt d ate gre ater than 30 d ays in the
fu tu re, an e ffort m u s t be m ad e to obtain the s ervic
e loc
ally. A fte rthe s ervic
e has be e n

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provide d the patient s hou ld be re tu rne d throu gh the m e d ic

al c
linicand anu rs e s hou ld
re view the pape rwork ortake s te ps to obtain it. A fte rthe pape rwork is obtaine d , the patient
m u s t be s c
he d u le d forafollow-u pvisitwiththe prim ary c
are c
linic
ian, who m u s t d oc
u m e nt
the d isc
u s s ion ofthe find ings and plan.
Infirmary Care:
1. Staffthe infirm ary withare giste re d nu rs e 24hou rs ad ay, s e ve n d ays awe e k.
2. E d u c
ation ofnu rs ings taffon the ne e d forc
om ple te c
harting, whic
hinc
lu d e s provid inga
thorou ghd e s c
ription ofthe patient
s m e d ic
alc
ond ition.
3. D e ve lopand im ple m e nt aplan to provide an ac
c
e s s ible nu rs e c
alls ys te m forpatients who
are phys ic
ally u nable to ac
c
e s s the c
u rre nt c
alls ys te m and provide for ac
re d ible s ys te m
forthos e patient room s withno nu rs e c
alls ys te m .
4. E s tablishm inim u m inve ntory le ve ls forbe d d ing, line ns and pillows and provid e ac
c
e ptable
ite m s whic
hare not torn, thre ad bare orfraye d .
5. P rovid e ape rm ane nt m anne d s e c
u rity pos t within the infirm ary.
6. D e ve lopand im ple m e nt aplan to obtain ne e d e d ad d itionale qu ipm e nt as d e te rm ine d by the
M e d ic
alD ire c
tor, H e althC are U nit A d m inistrator, D ire c
torofN u rs ingand anu rs ings taff
re pre s e ntative who is rou tine ly as s igne d to the infirm ary.
7. D e ve lop and im ple m e nt a plan to provid e ad d itional ins titu tional rad ios to infirm ary
nu rs ings taff.
Infection Control:
1. D e ve lopapos ition d e s c
ription and nam e an Infe c
tion C ontrolR e giste re d N u rs e (IC -R N ).
2. D e ve lopand im ple m e nt aplan forthe IC -R N to c
ond u c
t m onthly d oc
u m e nte d s afe ty and
s anitation ins pe c
tions foc
u s ingat a m inim u m on the he alth c
are u nit, infirm ary and
d ietary d e partm e nt with m onthly re porting to the Q u ality Im prove m e nt C om m itte e
(Q IC ).
3. D e ve lop and im ple m e nt aplan forthe IC -R N to m onitor food hand le r e xam inations and
c
le aranc
e forstaffand inm ate s .
4. D e ve lopand im ple m e nt aplan forthe IC -R N to m onitorc
om plianc
e withinitialand annu al
tu be rc
u los is s c
re e ning, with m onthly re portingto the Q IC and fac
ility ad m inistration as
ne e d e d .
5. D e ve lopand im ple m e nt aplan to aggre s s ive ly m onitors kin infe c
tions and boils and work
jointly with s e c
u rity and m ainte nanc
e s taff re gard ingc
e llhou s e c
le aningprac
tic
e s with
m onthly re portingto the Q IC and fac
ility ad m inistration as ne e d e d .
6. D e ve lop and im ple m e nt a plan to d aily m onitor and d oc
u m e nt ne gative air pre s s u re
re ad ings whe n the room (s ) are oc
c
u pied for re s piratory isolation and we e kly whe n not
oc
c
u pied .
7. D e ve lop and im ple m e nt atrainingprogram for he alth c
are u nit porte rs whic
h inc
lu d e s
trainingon blood -borne pathoge ns , infe c
tiou s and c
om m u nic
able d ise as e s , bod ily flu id
c
le an-u p, prope r c
le aningand s anitizingof infirm ary room s , be d s , fu rnitu re , toile ts and
s howe rs .
8. M onitoralls ic
kc
allare as to as s u re appropriate infe c
tion c
ontrolm e as u re s are be ingu s e d
be twe e n patients i.e ., u s e ofpape ron e xam ination table s whic
his c
hange d be twe e n patients
oras pray d isinfe c
tant is u s e d be twe e n patients , e xam ination glove s are available to staff
and hand was hing/sanitizingis oc
c
u rringbe twe e n patients .
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9. D e ve lop and im ple m e nt aplan to m onthly m onitor allpatient c

are as s oc
iate d fu rnitu re ,
inc
lu d inginfirm ary m attre s s e s , to as s u re the inte grity ofthe prote c
tive ou te rs u rfac
e with
the ability to take ou t ofs e rvic
e and have re paire d orre plac
e d as ne e d e d .
10. Inte rfac
e with the C ou nty D e partm e nt of H e alth and Illinois D e partm e nt of H e alth and
provide re portingas re qu ire d by e ac
h.
Continuous Quality Improvement:
1. T his program m u s t be re c
re ate d and provide d the le ad e rs hipthat has had trainingin qu ality
im prove m e nt philos ophy and m e thod ology. T he program s hou ld foc
u s on both proc
ess
im prove m e nt and profe s s ionalpe rform anc
e im prove m e nt as we llas grievanc
e re s pons e s .
T he program m u s t be u s e d to im prove intras ys te m trans fe rs , bothnu rs e and provid e rs ic
k
c
all, the c
hronicc
are program , infirm ary c
are , u ns c
he d u le d s e rvic
es c
are , s c
he d u le d offs ite
s e rvic
es c
are , m e d ic
alad m inistration, grievanc
e s , infe c
tion c
ontrol, d e ntals e rvic
e s and
m e ntalhe alths e rvic
e s . T his program re qu ire s the u s e oflogbooks fortrac
kingc
apabilities
forbothintras ys te m trans fe rs , s ic
kc
all, infirm ary c
are , c
hronicc
are , u ns c
he d u le d s e rvic
es
c
are , s c
he d u le d offs ite s e rvic
e s and grievanc
es.
2. T he le ad e rs hipofthe c
ontinu ou s qu ality im prove m e nt program m u s t be re traine d re gard ing
qu ality im prove m e nt philos ophy and m e thod ology, alongwith s tu d y d e s ign and d ata
c
olle c
tion.
3. T his trainings hou ld inc
lu d e how to s tu d y ou tliers in ord e rto d e ve loptargete d im prove m e nt
s trate gies .

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Appendix A Patient ID Numbers

Intrasystem Transfer:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6

Name

Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Nursing Sick Call:

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10

Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Clinician Sick Call:

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6

Name

[redacted]
[redacted]
[redacted]

Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Chronic Disease:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9

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Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Di
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Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

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Unscheduled Offsite Service:

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8

Name

Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Scheduled Offsite Service:

Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9

Name

Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

[redact

Infirmary:
Patient Number
P atient #1
P atient #2
P atient #3
P atient #4
P atient #5
P atient #6
P atient #7
P atient #8
P atient #9
P atient #10
P atient #11
P atient #12

Febru ary 2014

Name
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

Di
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Inmate ID
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]
[redacted]

P age 47