California State Prison, Los Angeles County Cycle 7 Medical Inspection Report

Electronic copies of reports published by the Office of the Inspector General are available free in portable document format (PDF) on our website. We also offer an online subscription service. For information on how to subscribe, visit www.oig.ca.gov. For questions concerning the contents of this report, please contact Shaun Spillane, Public Information Officer, at 916-288-4233. Connect with us on social media NOTE: The Office of the Inspector General (the OIG) originally issued its Cycle 7 medical inspection report for California State Prison, Los Angeles County (LAC), on December 4, 2023. In that publication, the OIG rated the overall medical care this institution provided to the incarcerated patient population inadequate. Since the beginning of the fourth cycle of inspections in January 2015, the OIG has performed medical inspections using assessment methodologies that include both clinical case review and compliance testing components. Doing so has allowed our clinicians to provide a holistic assessment of each institution’s medical care on both individual and system levels. Our case review clinicians examine whether providers used sound medical judgment in the course of caring for a patient. In addition, our compliance nurse inspectors collect data in response to compliance- and performance-related questions as established in the OIG’s medical inspection tool. This tool is designed to aid our inspectors in analyzing how effectively each institution adheres to the California Department of Corrections and Rehabilitation’s own Health Care Department Operations Manual. Since the start of Cycle 4, the OIG has reported its findings by holistically interpreting results derived from these two sides of the process: case review observations and interviews, and compliance testing. By analyzing these collective results, the OIG’s clinicians would determine a final overall rating for each institution, along with separate overall ratings for, potentially, up to 15 indicators. As communicated to both California Correctional Health Care Services and the department on April 19, 2024, after careful consideration, the OIG has updated the manner in which it reports its medical inspection findings by bifurcating the ratings for case review and compliance testing. Specifically, beginning with Cycle 7, instead of providing a single aggregated overall rating for the institution under review, the OIG will now report two overall ratings: one assessing the clinical quality of care provided at the institution and another assessing the institution’s compliance with the department’s own policies. Moreover, the reports will present separate ratings for each institution’s individual case review assessments and compliance testing results across each of the 15 indicators reviewed during the inspection. While neither the processes nor the factors for consideration in the case review or compliance methodologies will change, separating the ratings from each half of our methodology will provide a clearer understanding of the OIG’s findings for each institution by more transparently highlighting areas in which the institution is succeeding and areas in which the institution could improve. Therefore, the OIG has revised the Cycle 7 medical inspection report for LAC—originally published in December 2023—and reissues it herewith under the bifurcated rating format. In addition, future medical inspection reports will continue to report the OIG’s findings under this bifurcated rating format to best promote transparency, clarity, and greater understanding of the OIG’s findings. Amarik K. Singh Inspector General Cycle 7, California State Prison, Los Angeles County | ii (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | iii Contents Illustrations iv Introduction 1 Summary: Ratings and Scores 3 Medical Inspection Results 5 Deficiencies Identified During Case Review 5 Case Review Results 5 Compliance Testing Results 6 Institution-Specific Metrics 7 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 14 Access to Care 14 Diagnostic Services 20 Emergency Services 25 Health Information Management 31 Health Care Environment 37 Transfers 47 Medication Management 54 Preventive Services 62 Nursing Performance 65 Provider Performance 70 Specialized Medical Housing 74 Specialty Services 79 Administrative Operations 85 Appendix A: Methodology 89 Compliance Testing 93 Indicator Ratings and the Overall Medical Quality Rating 94 Appendix B: Case Review Data 95 Appendix C: Compliance Sampling Methodology 99 California Correctional Health Care Services’ Response 107 Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | iv Illustrations Tables 1. LAC Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. LAC Master Registry Data as of December 2022 7 3. LAC Health Care Staffing Resources as of December 2022 8 4. LAC Results Compared With State HEDIS Scores 10 5. Access to Care 17 6. Other Tests Related to Access to Care 18 7. Diagnostic Services 23 8. Health Information Management 34 9. Other Tests Related to Health Information Management 35 10. Health Care Environment 45 11. Transfers 51 12. Other Tests Related to Transfers 52 13. Medication Management 59 14. Other Tests Related to Medication Management 60 15. Preventive Services 63 16. Specialized Medical Housing 77 17. Specialty Services 82 18. Other Tests Related to Specialty Services 83 19. Administrative Operations 86 A–1. Case Review Definitions 90 B–1. LAC Case Review Sample Sets 95 B–2. LAC Case Review Chronic Care Diagnoses 96 B–3. LAC Case Review Events by Program 97 B–4. LAC Case Review Sample Summary 97 Figures A–1. Inspection Indicator Review Distribution for LAC 89 A–2. Case Review Testing 92 A–3. Compliance Sampling Methodology 93 Photographs 1. Indoor Waiting Area 37 2. The Clinic’s Triage Area Did Not Provide Auditory and Visual Privacy 38 3. Expired Medical Supplies Dated September 2022 39 4. Expired Medical Supplies dated between September 2020 and May 2022 39 5. Staff Members’ Food Stored With Medical Supplies 40 6. Compromised Medical Supply Packaging 40 7. Expired Medical Supplies Dated November 2021 41 8. Medical Supplies Stored Directly on the Floor 42 9. Medical Supplies Stored Underneath a Leaking Roof in the Medical Supply Warehouse 42 Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated people1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 7, the OIG continues to apply the same assessment methodologies used in Cycle 6, including clinical case review and compliance testing. Together, these methods assess the institution’s medical care on both individual and system levels by providing an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk, who tend to access services at the highest rate. Through these methods, the OIG evaluates the performance of the institution in providing sustainable, adequate care. We continue to review institutional care using 15 indicators as in prior cycles.3 Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT). In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. The OIG determines a total compliance score for each applicable indicator and considers the MIT scores in the overall conclusion of the institution’s compliance performance. In conducting in-depth quality-focused reviews of randomized cases, our case review clinicians examine whether health care staff used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient. At the same time, our clinicians consider whether institutional medical processes led to identifying and correcting individual or system errors, and we examine whether the institution’s medical system mitigated the error. The OIG rates each applicable indicator proficient, adequate, or inadequate, and considers each rating in the overall conclusion of the institution’s health care performance. In contrast to Cycle 6, the OIG will provide individual clinical case review ratings and compliance testing scores in Cycle 7, rather than aggregate all findings into a single overall institution rating. This change will clarify the distinctions between these differing quality measures and the results of each assessment. 1 In this report, we use the terms patient and patients to refer to incarcerated people. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care that the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 2 As we did during Cycle 6, our office continues to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. At the time of the Cycle 7 inspection of California State Prison, Los Angeles County, the institution had not been delegated back to the department by the receiver. We completed our seventh inspection of the institution, and this report presents our assessment of the health care provided at this institution during the inspection period from May 2022 to October 2022.4 4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews between January 2022 and November 2022, anticoagulation reviews between January 2022 and October 2022, and transfer reviews between April 2022 and September 2022. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of LAC in March 2023. OIG inspectors monitored the institution’s delivery of medical care that occurred between May 2022 and October 2022. The OIG rated the case review The OIG rated the compliance component of the overall health care component of the overall health care quality at LAC inadequate. quality at LAC inadequate. The OIG clinicians (a team of physicians and nurse consultants) reviewed 63 cases, which contained 1,142 patient-related events. They performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our OIG clinicians acknowledged institutional structures that catch and resolve mistakes that may occur throughout the delivery of care. After examining the medical records, our clinicians completed a follow-up on-site inspection in March 2023 to verify their initial findings. The OIG physicians rated the quality of care for 25 comprehensive case reviews. Of these 25 cases, our physicians rated 21 adequate and four inadequate. Our physicians found one adverse deficiency during this inspection. To test the institution’s policy compliance, our compliance inspectors (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 364 patient records and 1,116 data points, and used the data to answer 89 policy questions. In addition, we observed LAC processes during an on-site inspection in December 2022. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in 13 health care indicators.5 5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to LAC. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. LAC Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 5 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.6 The OIG found one adverse event at LAC during the Cycle 7 inspection. • In case 25, the patient returned from the hospital with the diagnosis of gastrointestinal bleed from inflammatory bowel disease, and the hospitalist recommended monitoring the patient’s hemoglobin weekly for two to three weeks. However, the provider did not address the recommendation, placing the patient at risk of severe anemia. Six weeks later, the provider ordered hemoglobin which showed severely low hemoglobin of 7.7 g/dL; however, the provider did not review the laboratory result until 16 days later. The oversight placed the patient at risk of complications from delayed treatment for severe anemia. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed 10 of the 13 indicators applicable to LAC. Of these 10 indicators, OIG clinicians rated three adequate and seven inadequate. The OIG physicians also rated the overall adequacy of care for each of the 25 detailed case reviews they conducted. Of these 25 cases, 21 were adequate and four were inadequate. In the 1,142 events reviewed, we identified 324 deficiencies, 87 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at LAC: • Staff performed well with access to care as most provider and nursing appointments occurred within required time frames. • Staff performed well with health information management as the institution retrieved and scanned hospital records, diagnostic tests, and pathology reports timely. Our clinicians found the following weaknesses at LAC: • Staff performed poorly in completing laboratory tests, and the provider did not thoroughly communicate test results to patients. 6 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 6 • Nurses did not always provide appropriate emergency care including basic life support and cardiopulmonary resuscitation. • Staff performed poorly in most aspects of medication management including chronic medication continuity. • Staff performed poorly in completing follow-up specialty appointments, and the institution also performed poorly in scanning, retrieving, and reviewing specialty reports. • Staff performed poorly in the transfer process; when patients transferred into the institution, staff did not always complete the initial nursing assessments and did not always reconcile the orders from the sending institution. Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to LAC. Of these 10 indicators, our compliance inspectors rated one proficient, one adequate, and eight inadequate. We tested policy compliance in Health Care Environment, Preventive Services, and Administrative Operations as these indicators do not have a case review component. LAC showed a high rate of policy compliance in the following areas: • Medical staff performed well in scanning community hospital discharge reports and requests for health care services into patients’ electronic medical records within required time frames. • Nursing staff processed sick call request forms, performed face-to-face evaluations, and completed nurse-to-provider referrals within required time frames. In addition, LAC housing units contained adequate supplies of health care request forms. LAC showed a low rate of policy compliance in the following areas: • LAC’s medical warehouse and clinical areas had multiple medical supplies that were expired. • Nursing staff did not regularly inspect emergency response bags and treatment carts. • Health care staff did not follow hand hygiene precautions before or after patient encounters. • LAC often did not ensure specialty service reports were received timely. Furthermore, providers often did not review these reports within required time frames. • LAC did not perform well in ensuring that specialty services were provided within specified time frames. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 7 • Providers did not often communicate results of diagnostic services timely. Most patient letters communicating these results were missing the date of the diagnostic service, the date of the results, and whether the results were within normal limits. • LAC staff frequently failed to maintain medication continuity for chronic care patients, patients discharged from the hospital, and patients admitted to a specialized medical housing unit. In addition, LAC maintained poor medication continuity for patients who transferred into the institution, transferred within the institution, or had a temporary layover at LAC. Institution-Specific Metrics California State Prison, Los Angeles County (LAC), houses more than 2,506 patients and is located in the city of Lancaster. The institution has been designated as an intermediate care prison, which responds to nonurgent requests for medical services and provides an enhanced outpatient program. The institution conducts patient screenings in its receiving and release (R&R) clinical area, treats patients who require urgent or immediate care in its triage and treatment area (TTA), and treats patients who require inpatient care in its correctional treatment center (CTC).7 In December 2022, the Health Care Services Master Registry showed that LAC had a total population of 2,506. A breakdown of the medical risk level of the LAC population as determined by the department is set forth in Table 2 below.8 Table 2. LAC Master Registry Data as of December 2022 7 For more information, see the department’s statistics on its website page titled Population COVID‑19 Tracking. 8 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, LAC had two vacant executive leadership positions, one primary care provider vacancy, 1.2 nursing supervisor vacancies, and 31.6 nursing staff vacancies. Table 3. LAC Health Care Staffing Resources as of December 2022 Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 9 Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 7. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores. However, through the California Department of Health Care Services’ Medi‑Cal Managed Care Technical Report, the OIG obtained California Medi-Cal and Kaiser Medi-Cal HEDIS scores to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered LAC’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. Currently, only one HEDIS measure is available for review: poor HbA1c control, which measures the percentage of diabetic patients who have poor blood sugar control. LAC’s results compared favorably with those found in State health plans for this measure. We list the applicable HEDIS measures in Table 4. Comprehensive Diabetes Care When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—LAC’s percentage of patients with poor HbA1c control was significantly lower, indicating very good performance on this measure. Immunizations Statewide comparative data were not available for immunization measures; however, we include these data for informational purposes. LAC had a 36 percent influenza immunization rate for adults 18 to 64 years old and a 61 percent influenza immunization rate for adults 65 years of age and older.9 The pneumococcal vaccination rate was 82 percent.10 Cancer Screening Statewide comparative data were not available for colorectal cancer screening; however, we include these data for informational purposes. LAC had an 88 percent colorectal cancer screening rate. 9 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. 10 The pneumococcal vaccines administered are the 13, 15, and 20 valent pneumococcal vaccines (PCV13, PCV15, and PCV20), or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at a different institution other than where the patient was currently housed during the inspection period. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 10 Table 4. LAC Results Compared With State HEDIS Scores Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 11 Recommendations As a result of our assessment of LAC’s performance, we offer the following recommendations to the department: Diagnostic Services • The department should consider developing strategies to ensure that providers generate letters communicating results to their patients and that the letters include all elements as required by policy. • Medical leadership should ascertain causative factors related to the untimely provisions of laboratory services and implement remedial measures as appropriate. Emergency Services • Nursing leadership should ensure nursing supervisors are trained on accurately completing the emergency medical response review checklist. In addition, nursing and medical leadership should audit LAC’s emergency events to ensure nursing supervisors and providers are identifying opportunities for improvement. • The institution should consider replacing current automated external defibrillators (AED) with models that include reporting features or the electronic health record system (EHRS) synchronization.11 • The institution should consider replacing vital signs equipment with models capable of synchronizing data with the EHRS. Health Care Environment • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Executive leadership should consider performing random spot checks to ensure that staff properly store medical supplies in medical supply storage areas. • Nursing leadership should consider performing random spot checks to ensure staff follow equipment and medical supply management protocols. • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) and treatment cart logs to ensure that the EMRBs and treatment carts are regularly inventoried and sealed. 11 The department’s electronic health record system is used for storing the patient’s medical history. The clinicians also use the system to communicate with one another. This record stays with the patient during the patient’s time in the prison system. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 12 Transfers • Nursing leadership should develop and implement internal auditing of staff to ensure complete and thorough assessments of patients transferring into the institution or patients returning from hospitalizations. • Nursing leadership should educate R&R nurses to completely answer and address required initial health screening questions. Medication Management • The institution should consider developing and implementing measures to ensure that staff timely make available and administer medications to patients and that staff document accordingly in the EHRS as described in CCHCS policy and procedures. Preventive Services • Nursing leadership should consider developing and implementing measures to ensure that nursing staff monitor patients receiving TB medications according to CCHCS guidelines. • Medical leadership should analyze the challenges related to the untimely provision of preventive vaccines and implement remedial measures as appropriate. Nursing Performance • Nursing leadership should work toward improving patient care coordination with medical providers in communications about medication orders, patient refusals, and incomplete specialists’ reports. • The department and nursing leadership should consider resuming random audits to ensure that nursing staff properly perform and document complete assessments including vital signs and appropriate assessments. Leadership should implement remedial measures as appropriate including training of staff. • The department and nursing leadership should consider a medication management audit that ensures nurses are safely administering medications. Specialized Medical Housing • Nursing leadership should ensure that CTC nurses properly document the results of their care plan assessments. • Nursing leadership should ensure CTC medications are safely administered. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 13 Specialty Services • Medical leadership should develop a tracking system for retrieving, scanning, and reviewing specialty reports. • Nursing leadership should remind staff of the expected assessments and documentation required when patients return from specialty appointments. • Medical leadership should ascertain causative factors related to the untimely provisioning or scheduling of patients’ specialty service appointments and follow-up appointments, and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 14 Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (81.5%) LAC performed well in this indicator. OIG clinicians found LAC staff completed most provider appointments in a timely manner including chronic care, nurse-to-provider, clinic provider after hospitalization, and specialized medical housing provider appointments. LAC also performed well with access for nurse sick calls and provider-to- nurse referrals. OIG rated the case review component of this indicator adequate. Compliance testing found LAC performed exceptionally in reviewing patient sick call requests, completing face-to-face encounters, and referring patients to their primary care providers. In addition, LAC performed satisfactorily in timely provider follow-ups for patients transferring into the institution and returning from hospitalization. However, compliance testing resulted in low scores for provider follow-up appointments in patients with chronic care conditions and returning from specialty service. Factoring all the information, the OIG rated the compliance testing component of this indicator adequate. Case Review and Compliance Testing Results Our clinicians reviewed 532 provider, nursing, urgent or emergent care, specialty, and hospital events that required the institution to generate appointments. We found 13 deficiencies related to access to care; nine of which were considered significant.12 Access to Care Providers Compliance testing found poor completion of chronic care follow-up (MIT 1.001, 48.0%); however, the institution performed well in nurse-to-provider and provider-ordered sick call follow-up appointments (MIT 1.005, 85.7% and MIT 1.006, 100%). The OIG clinicians reviewed 117 clinic provider appointments and identified three deficiencies.13 The following is an example: 12 Deficiencies occurred twice in cases 2, 10, 21, and 24, and once in cases 20, 26, 53, 61, and 62. Significant deficiencies occurred in cases 10, 21, 24, 26, 61, and 62. 13 Deficiencies occurred in cases 21, 24, and 53. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 15 • In case 21, a sick call nurse evaluated the patient for hand cramps and initiated a provider appointment to occur within 14 days; however, the appointment did not occur. Access to Specialized Medical Housing Providers LAC performed excellently with access to specialized medical housing providers. The OIG reviewed 19 provider encounters and did not identify any missed or delayed appointments. Access to Clinic Nurses LAC performed well with access for nurse sick calls and provider-to-nurse referrals. Compliance testing found that all nurse sick call requests were reviewed on the same day they were received (MIT 1.003, 100%). Moreover, nurses evaluated 93.3 percent of their patients within the required one business day time frame (MIT 1.004). OIG clinicians identified three deficiencies related to clinic nurse access.14 The following are examples: • In case 2, a nurse triaged the patient who complained he had difficulty eating due to his false teeth and requested a nursing appointment to occur within one day. However, the appointment occurred in eight days. • In case 20, the sick call nurse requested a nursing follow-up appointment to occur in three days for ear irrigation; however, the appointment occurred in eight days. Access to Specialty Services Compliance testing found that 93.3 percent of the initial high-priority specialty appointments (MIT 14.001), 66.7 percent of the initial medium-priority specialty appointments (MIT 14.004), and 80.0 percent of the initial routine-priority specialty appointments (MIT 14.007) occurred within required time frames. However, the institution performed inconsistently with follow-up specialty appointments (MIT 14.003, 30.8%, MIT 14.006, 50.0%, and MIT 14.009, 71.4%). OIG clinicians reviewed 110 specialty 15 events and identified four deficiencies. These deficiencies are discussed in the Specialty Services indicator. Follow-Up After Specialty Services LAC showed room for improvement in ensuring patients saw their providers after specialty appointments. Compliance testing revealed that 55.8 percent of provider appointments after specialty services occurred within required time frames (MIT 1.008). OIG clinicians identified one delayed appointment and one missed provider appointment, both of which are discussed below: 14 Deficiencies occurred in cases 2, 10 and 20. 15 Deficiencies occurred in cases 24, 26, 61, and 62. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 16 • In case 2, the patient returned from a colonoscopy and an upper endoscopy. The nurse ordered a provider appointment to occur in 14 days; however, the appointment occurred 17 days later. • In case 21, the patient returned from an endocrinology appointment, and the nurse ordered a provider appointment to occur in 14 days; however, the appointment did not occur. Follow-Up After Hospitalization LAC performed sufficiently with ensuring that patients saw their providers within required time frames after hospitalizations. Compliance testing found that 76.0 percent of provider appointments occurred within required time frames (MIT 1.007). OIG clinicians reviewed 14 hospital returns and did not identify any missed or delayed provider appointments. Follow-Up After Urgent or Emergent Care Providers generally saw their patients following a TTA event as requested. OIG clinicians reviewed 36 TTA events and identified one deficiency as follows: • In case 10, the TTA nurse initiated a five-day provider follow-up to address the patient’s dizziness; however, the appointment did not occur until 22 days later. Follow-Up After Transferring Into LAC Compliance testing found that 75.0 percent of provider appointments for newly arrived patients occurred within required time frames (MIT 1.002). Our clinicians evaluated four transfer-in events and did not identify any missed or delayed provider appointments. Clinician On-Site Inspection LAC has four main clinics: A, B, C, and D. Each clinic had two assigned providers and an office technician who attended the morning huddles and ensured that provider appointments were met. Each provider saw about 12 patients per day. At the time of the clinician on-site inspection, there was no backlog of provider appointments for any of the four clinics. Our clinicians discussed missed or delayed appointments with the office technician supervisor, and the supervisor acknowledged that most of the missed or delayed appointments were due to human errors, such as when the medical staff did not order the appointments or did not appropriately order the appointments. For the two missed provider appointments, the supervisor stated that the medical assistant obtained vital signs as the patient was checked in for the appointment; however, there was no provider progress note documenting the encounter. Compliance Testing Results Patients had excellent access to health care services request forms in all five housing units inspected (MIT 1.101, 100%). Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 17 Compliance Testing Results Table 5. Access to Care Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 18 Table 6. Other Tests Related to Access to Care Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 19 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 20 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely completing radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. In addition, in Cycle 7, we examined the institution’s performance in timely completing and reviewing immediate (STAT) laboratory tests. Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Inadequate (62.2%) LAC performed poorly in this indicator. Case reviewers found the institution completed most radiology tests within the required time frames; however, the institution performed poorly in completing laboratory tests. Providers performed well in endorsing both radiology and laboratory tests, but intermittently sent complete patient test result notification letters. Factoring all the findings, OIG rated the case review component of this indicator inadequate. Compliance testing found the institution needs improvement in completing laboratory tests and generating patient test result notification letters with all required key elements. The institution performed well in providing radiology services and endorsing radiology and laboratory results. However, on balance, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results Our clinicians reviewed 286 diagnostic events and identified 38 deficiencies, three of which were significant.16 Of these 38 deficiencies, 32 of them were related to health information management, and six pertained to completing diagnostic tests. Test Completion LAC performed well when completing radiology tests. Compliance testing showed the institution completed 100 percent of radiology tests within required time frames (MIT 2.001). OIG clinicians reviewed 27 radiology tests and identified one X-ray test that was completed late.17 On the other hand, LAC performed poorly when completing laboratory tests. Compliance testing revealed that only 50.0 percent of laboratory tests were completed as requested 16 Deficiencies occurred as follows: eight in case 12, four in cases 26 and 29, three in case 22, twice in cases 3, 23, 25, and 27, and once in cases 2, 9, 10, 11, 13, 14, 17, 20, 21, 28, and 30. Significant deficiencies occurred in cases 14, 27, and 28. 17 A deficiency occurred in case 27. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 21 18 (MIT 2.004). Our clinicians identified five deficiencies related to laboratory completion. The following are examples: • In case 14, a provider ordered an international normalized ratio (INR) blood test as a timed study test, and the test was completed one day late.19 • In case 29, a urine toxicology was not completed. OIG clinicians reviewed one STAT laboratory order. The test was completed timely, and the TTA nurse appropriately communicated the result to the provider. LAC performed well with regard to completing electrocardiograms (EKGs). Our clinicians reviewed 18 EKGs and found all were completed within the requested time frame. Health Information Management LAC staff retrieved laboratory and diagnostic results promptly, and sent them to the providers for review, who then endorsed both radiology and laboratory results within required time frames (MIT 2.002, 80.0% and MIT 2.005, 100%). Our clinicians identified 20 seven deficiencies related to missed or late endorsement of diagnostic tests. Examples include the following: • In case 17, the result of a chest CT scan was not endorsed by a provider. • In case 25, the patient had a low hemoglobin level,21 and the result was not endorsed by a provider until 16 days later. LAC performed poorly in relaying results to patients. Compliance scores for communicating radiology results and laboratory results were poor (MIT 2.003, 30.0% and MIT 2.006, 20.0%). Our clinicians also identified this as an area of underperformance, as 24 deficiencies were identified. In addition, 10 patient letters were found to be missing at least one of the required elements, and on 14 occasions, the providers did not generate patient letters. Examples are listed below: • In case 9, a provider endorsed a hemoglobin A1c test result, but did not generate a patient letter informing that this indicated poorly controlled diabetes.22 • In case 23, a provider sent a patient letter informing of laboratory results, but did not include all required elements such as the test date. 18 Deficiencies occurred in cases 10, 11, 14, 29, and 30. 19 The INR is a laboratory test that measures the body’s ability to clot blood and is used to monitor the effectiveness of blood thinning medications such as warfarin. 20 Deficiencies occurred in twice in case 26, and once in cases 17, 22, 25, 27, and 29. 21 A low hemoglobin level indicates anemia or low blood count. 22 Hemoglobin A1c is a blood test that measures the average plasma glucose over the previous 12 weeks. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 22 • In case 26, a provider endorsed an X-ray result of a left finger, but did not send the patient letter. Compliance testing showed that while LAC staff retrieved pathology reports timely (MIT 2.010, 90.0%) and providers endorsed pathology reports promptly (MIT 2.011, 90.0%), providers did not notify patients of their pathology results within the required time frame (MIT 2.012, zero). Our clinicians reviewed two pathology events and found one pathology report was never retrieved, and the other pathology report did not have the results letter.23 Clinician On-Site Inspection LAC has a phlebotomist assigned to each of the four main clinics, and samples are collected in the clinic hallway. The clinics have a room for processing and storing laboratory tests prior to sending them out to the laboratory processing vendor. TTA nurses collect urgent and STAT laboratory tests, and inform providers of the results. CTC nurses collect laboratory tests for all CTC patients. The radiology supervisor informed OIG clinicians that in-house X-ray services were not available for the month of June 2022 as the institution was replacing the X-ray equipment. The supervisor reported that this delayed completion of some routine X-ray orders. A specialty nurse was responsible for retrieving both pathology reports and numerous off-site specialty reports. Unfortunately, the institution’s medical staff does not have a specific tracking system to ensure all pathology reports were retrieved. The chief physician and surgeon acknowledged the missed or incomplete providers’ letters informing patients of their diagnostic results, and providers have taken steps to address these issues. 23 Deficiencies occurred in cases 2 and 28. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 23 Compliance Testing Results Table 7. Diagnostic Services Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 24 Recommendations • The department should consider developing strategies to ensure that providers generate letters communicating results to their patients and that the letters include all elements as required by policy. • Medical leadership should ascertain causative factors related to the untimely provisions of laboratory services and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 25 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the timeliness and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining the emergency medical response, cardio-pulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing performance. Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) performance in identifying problems with its emergency services. The OIG assessed the institution’s emergency services mainly through case review. Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Not Applicable LAC performed poorly in emergency services. In Cycle 7, OIG clinicians identified more deficiencies than were identified in Cycle 6. Previously identified patterns continued, and we found additional notable concerns. Nurses did not always perform appropriate emergency care related to basic life support (BLS) CPR. Nurses also did not prioritize AED placement when their patients required CPR. As found in Cycle 6, LAC’s quality review process did not identify its nurses’ deficiencies. Subsequently, opportunities to provide staff with training and education were also missed. Considering all the above issues, the OIG rated this indicator inadequate. Case Review Results We reviewed 36 urgent emergent events and found 50 emergency-related deficiencies. Of these 50 deficiencies, 22 were significant.24 Emergency Medical Response Health care staff promptly responded to most medical emergencies. Custody staff frequently initiated CPR and administered naloxone when an overdose was suspected.25 Of the 21 medical responses we reviewed, 13 events occurred as the result of a medical alarm activation. In the other eight events, nursing or custody staff requested a TTA registered nurse’s (RN) assistance by phone. Of the 21 events reviewed, delays were identified in two cases, which are discussed below: • In case 1, this patient had chest pains, and the psychiatric technician (PT) notified the TTA RN. However, the RN did not respond to the patient immediately and inappropriately advised custody staff to escort the patient to 24 Deficiencies occurred in cases 1–11, 19, 20, 23–26, 28, and 62. Significant deficiencies occurred in cases 1–8, 10, 19, 20, and 25. 25 Naloxone is a medication used for the emergency treatment of known or suspected opioid overdose. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 26 a medical clinic. Twelve minutes later, custody staff escorted the patient to the medical clinic, which was locked. Eventually, the patient was transferred to the TTA. • In case 10, a medical alarm was activated for an unresponsive person, and custody staff was performing CPR. The TTA RN did not arrive on scene, to attend to the patient, until nine minutes later. Cardiopulmonary Resuscitation Quality BLS is a set of emergency procedures that are performed to help sustain life in a person experiencing cardiac or respiratory arrests. The BLS sequence is important because it provides the first line of resuscitation for a person with life-threatening illnesses or injuries. The BLS sequence includes steps such as performing CPR timely, early use of an AED, and providing rescue breathing to a person who is not sufficiently breathing or does not have a pulse. The timely and correct performance of these procedures can increase the chances of survival, and reduce the risk of permanent damage to the heart and lungs. Time is of the essence, as the chance of survival decreases significantly with every minute that passes. Consequently, administering naloxone should not delay initiating CPR in a suspected opioid overdose, as staff should start CPR immediately, regardless of the suspected cause. We reviewed eight cases in which cardiopulmonary resuscitation was initiated. Custody staff began CPR in four of the eight cases and administered naloxone to three patients. In addition, staff activated the 9-1-1 system from the scene. We identified several deficiencies related to patients who were not responsive and required CPR. In 50 percent of the events in which staff performed CPR, the medical staff did not follow the BLS sequence of events. Instead, they prioritized administering multiple doses of nasal naloxone, prior to placement of the AED.26 In addition, when patients had a return of spontaneous circulation, nurses did not always promptly assess their patients. The following are examples: • In case 5, health care staff did not promptly attach an AED during CPR. Instead, three doses of nasal naloxone were administered. An AED was not applied to the patient for eight minutes. • In case 7, health care staff performed CPR and administered nasal naloxone for a suspected opioid overdose. However, nurses did not assess the patient’s vital signs, including respiratory rate for 11 minutes. Fortunately, the patient had a return of spontaneous circulation. • In case 8, custody staff had administered two doses of nasal naloxone and initiated CPR. However, when the first medical responder arrived on the scene, the responder administered two additional doses of naloxone prior to attaching an AED. In cases 4 and 7, we found similar delays. 26 According to the manufacturer, nasal naloxone doses can be safely administered every two to three minutes. CCHCS emergency medical training allows nurses to administer five nasal naloxone doses when an opioid overdose is suspected. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 27 Provider Performance Providers performed adequately in urgent and emergent events. They were available for consultation from TTA staff. The providers made appropriate decisions, transferred patients to a community hospital when necessary, and generally documented these events thoroughly. Our clinicians identified two deficiencies related to providers not documenting a progress note for an emergency event.27 Nursing Performance Nurses had opportunities for improvement in the areas of BLS, CPR-related care and assessment, interventions, and planning. The following cases offer examples: • In case 1, the patient arrived in the TTA with abdominal pain. The nurse did not subjectively assess the location of the abdominal pain and did not palpate the abdomen for tenderness. • In case 25, the patient with a history of ulcerative colitis arrived in the TTA with complaints of dizziness, rectal bleeding, and a headache.28 The patient’s heart rate was elevated, which led to concern over dehydration. However, the nurse did not perform thorough subjective and objective assessments, and reassess the patient’s elevated heart rate prior to discharge. • In cases 3, 7, and 10, nurses did not check the patients’ blood sugar levels when their conditions warranted. Nursing Documentation Nurses generally documented their urgent and emergent events. However, we identified areas in which documentation was less than adequate.29 Examples of documentation deficiencies included naloxone administration discrepancies, inaccurate time-line occurrences, and inconsistent activities. The following cases offer examples: • In case 8, the nurse responded to a medical emergency for a patient with a suspected overdose. Multiple time-line discrepancies were identified. The nurse documented that five doses of nasal naloxone were administered; however, the nurse documented administering the first dose before the nurse’s arrival to the patient. The first responder nurse also did not document providing positive pressure ventilations, but instead documented respiratory interventions that occurred later, and by a different nurse. • In case 9, nursing staff performed CPR, and emergency medical services personnel (EMS) pronounced the patient’s death. However, the nurse incorrectly documented CPR efforts were discontinued before EMS had arrived. 27 Deficiencies occurred in cases 10 and 25. 28 Ulcerative colitis is a chronic inflammatory bowel disease that causes inflammation and ulcers in the intestines. 29 Deficiencies in TTA nursing documentation occurred in cases 3–5, 7–10, 19, 23, 25, and 28. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 28 Emergency Medical Response Review Committee Compliance testing showed that events were either not reviewed timely, were not reviewed at all, or the incident package was incomplete (MIT 15.003, zero). Our clinicians found that supervising RNs (SRNs) frequently completed the Emergency Response and Unscheduled Transport Event Checklist form, and designated nursing and physician staff members also conducted clinical reviews. Even so, OIG clinicians found in four of the 18 events a clinical review was not completed. Also, on four of the completed event checklists, the SRN did not accurately record the time line of events. Finally, none of the clinical reviews conducted by LAC captured any of the multiple opportunities for improvement identified by our clinicians. The following two cases provide examples: • In case 5, the nursing staff did not prioritize placement of the AED during CPR. Three doses of nasal naloxone were administered prior to placement of the AED. Clinical reviews conducted by the health care staff did not identify this significant opportunity for improvement. • In case 7, an SRN completing the Emergency Response and Unscheduled Transport Event Checklist did not identify the responding licensed vocational nurse (LVN) as the health care first responder. This subsequently resulted in an inaccurate time line of events. In addition, none of LAC’s health care staff who performed clinical reviews identified the SRN’s time- line inaccuracies or the clinical opportunities for improvement. Time-line inaccuracies were also identified in cases 5, 8, and 10. Clinician On-Site Inspection OIG clinicians toured the TTA and interviewed an RN. They learned that the TTA was staffed with two RNs on each shift. In the TTA, there were four separate areas to provide patient care. Two of these were designated for emergencies; the other two were designated for observation and urgent care. There was an assigned provider during regular business hours; otherwise, an on-call provider was available by telephone. The TTA nurses had two institutional radios, one for each of the RNs. A custody officer was assigned to the TTA and also served as an escort for the TTA RN. According to the nurse our clinicians interviewed, the TTA-assigned custody officer had keys to every gate, and there were no challenges when having to respond and move past multiple gates. Nursing supervisors indicated that LAC’s AEDs and vital signs machines were not capable of directly synchronizing with and transmitting data into the patients’ electronic health records. During our interview with the SRN III, we learned that she had also identified challenges in the emergency responses: the inaccuracy of the data recorded on emergency clinical review checklists and supervisors’ failures to identify deviations from the required standards of care. The SRN III reported providing ongoing education to the nursing supervisors on this process. The SRN III also shared the intent to improve emergencies by implementing “code teams,” whereupon when assuming a shift, nursing staff would be assigned a specific role in the event of an emergency to reduce confusion and expedite care delivery. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 29 While on-site, our clinicians reviewed emergency medical response program (EMRP) training records that indicated LVN first medical responders had been trained in the placement of an airway adjunct.30 Yet during our discussions with nursing supervisors, they indicated that, during the EMRP training, instructors advised that LVNs should not perform this intervention pending further clarification. However, during our inspection, nursing supervisors reported receiving direction which indicated an LVN first responder could initiate an airway adjunct. Subsequently, nursing leadership planned to conduct training with their LVNs. 30 An airway adjunct is a device that is inserted in the nose or mouth to assist with providing adequate oxygenation and ventilation as part of resuscitation efforts. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 30 Recommendations • Nursing leadership should ensure nursing supervisors are trained on accurately completing the emergency medical response review checklist. In addition, nursing and medical leadership should audit LAC’s emergency events to ensure nursing supervisors and providers are identifying opportunities for improvement. • The institution should consider replacing current AEDs with models that include reporting features or EHRS synchronization. • The institution should consider replacing vital signs equipment with models capable of synchronizing data with the EHRS. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 31 Health Information Management In this indicator, OIG inspectors evaluated the flow of health information, a crucial link in high-quality medical care delivery. Our inspectors examined whether the institution retrieved and scanned critical health information (progress notes, diagnostic reports, specialist reports, and hospital discharge reports) into the medical record in a timely manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors checked whether staff labeled and organized documents in the medical record correctly. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Proficient (85.0%) LAC staff managed health information well. Case reviewers found staff retrieved and scanned hospital records, diagnostic tests, and pathology reports within the required time frames. However, LAC did not always retrieve or scan specialty reports timely. Nurses and providers recorded urgent and emergent events sufficiently. Taking all factors into consideration, the OIG rated the case review component of this indicator adequate. Compliance testing found LAC performed excellently in scanning patient sick call requests. The institution also performed well in retrieving and scanning hospital records, labeling, and scanning medical records in the correct patient files. Conversely, the institution needs to improve in scanning specialty documents. Taking all results into consideration, the OIG rated the compliance testing component of this indicator proficient. Case Review and Compliance Results During the period of review, our clinicians found 56 deficiencies related to health information management, three of which were significant.31 Hospital Discharge Reports LAC performed well in retrieving and scanning hospital records. Compliance testing found that LAC staff scanned most hospital discharge records within required time frames (MIT 4.003, 90.0%). Most discharge records included the important physician discharge summary, and providers endorsed reports within five days (MIT 4.005, 84.0%). Our clinicians reviewed 14 hospital events and identified one deficiency related to late endorsement, which is described in the following example: 31 Deficiencies occurred in cases 1–3, 9, 12, 13, 17, 18, 20–23, 25- 29, 40, 42, 45–48, 57, 58, 62, and 63. Significant deficiencies occurred in cases 1, 28, and 63. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 32 • In case 62, a provider did not endorse a hospital record until eight days after the record was scanned into the medical record. Specialty Reports LAC performed poorly in receiving or reviewing the high-priority, medium-priority, and routine-priority specialty reports within required time frames (MIT 14.002, 21.4%, MIT 14.005, 7.1%, and MIT 14.008, 46.7%). LAC also needs improvement in scanning specialty reports as compliance testing showed that 63.3 percent of specialty reports were scanned within the required time frame (MIT 4.002). Our clinicians reviewed 110 specialty reports and identified two reports that were not retrieved, one report that was retrieved late, and one report that was endorsed late. These deficiencies are discussed in the Specialty Services indicator. Diagnostic Reports Compliance testing showed providers endorsed most radiology and laboratory reports timely (MIT 2.002, 80.0% and MIT 2.005, 100%). Our clinicians identified a lack of endorsement of one radiology report, and late endorsements of two radiology reports, two laboratory reports, and two EKGs. Providers performed poorly in thoroughly communicating the results of radiology studies or laboratory tests to their patients (MIT 2.003, 30.0% and MIT 2.006, 20.0%). Our clinicians also identified 23 deficiencies related to insufficient communication of radiology or laboratory tests to patients. These deficiencies are discussed in the Diagnostic Services indicator. LAC performed proficiently in retrieving pathology reports (MIT 2.010, 90.0%). The providers endorsed most pathology reports within required time frames (MIT 2.011, 90.0%), but did not send pathology result letters to their patients within required time frames (MIT 2.012, zero). Our clinicians reviewed two events associated with pathology reports and found one pathology report not retrieved and one pathology report in which a letter was not sent. Urgent and Emergent Records Our clinicians reviewed 36 emergency care events and found that nurses and providers recorded these events sufficiently. However, we identified one deficiency in which staff did not document the AED analysis during an emergent event. Scanning Performance LAC performed very well with the scanning process. Compliance testing showed that the institution scanned, labeled, and named medical files accurately (MIT 4.004, 87.5%). Our clinicians identified one incorrectly labeled specialty report.32 32 A deficiency occurred in case 23. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 33 Clinician On-Site Inspection LAC medical record staff scanned records as they received them. Staff stated that most patients returning from community hospitals had their hospital records with them. TTA nurses were instructed to contact the hospital directly for any missing hospital records. For on-site specialty reports, on-site specialty nurses scanned the reports on the same day the specialty appointment occurred. For off-site specialty reports, medical record staff scanned handwritten reports on the day the specialty appointment occurred and the formal specialty reports as they received them. Specialty nurses also contacted the specialists directly for any missing specialty reports. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 34 Compliance Testing Results Table 8. Health Information Management Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 35 Table 9. Other Tests Related to Health Information Management Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 36 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 37 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ performance in maintaining auditory and visual privacy for clinical encounters. Compliance inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely on the compliance score. Our case review clinicians do not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (37.9%) In this cycle, multiple aspects of LAC’s health care environment needed improvement: medical supply storage areas in and outside the clinics contained expired medical supplies; EMRB logs were missing staff verification or inventory was not performed; several clinics did not meet the requirements for essential core medical equipment and supplies; and staff did not regularly sanitize their hands before and after examining, or performing invasive procedures on, patients. These factors resulted in an inadequate rating for this indicator. Compliance Testing Results Outdoor Waiting Areas The institution had no waiting areas that required patients to be outdoors. Indoor Waiting Areas We inspected indoor waiting areas. Health care and custody staff reported existing waiting areas contained sufficient seating capacity (see Photo 1). During our inspection, we did not observe overcrowding in any of the clinics’ indoor waiting areas. Photo 1. Indoor waiting area (photographed on 1-10-23). Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 38 Clinic Environment All clinic environments were sufficiently conducive to providing medical care; they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Of the nine clinics we observed, five contained appropriate space, configuration, supplies, and equipment to allow their clinicians to perform proper clinical examinations (MIT 5.110, 55.6%). The remaining four clinics had one or more of the following deficiencies: the examination room lacked auditory and visual privacy for conducting clinical examinations; nurses in the clinic’s triage area conducted examinations on two patients at the same time and did not provide auditory and visual privacy for the patients during their clinical encounters (see Photo 2); examination room chairs and tables had torn covers; and clinics had unsecured confidential medical records. Photo 2. The clinic’s triage area did not provide auditory and visual privacy (photographed on 1-9- 23). Clinic Supplies Only one of the nine clinics followed adequate medical supply storage and management protocols (MIT 5.107, 11.1%). We found one or more of the following deficiencies in eight clinics: expired medical supplies (see Photo 3 and Photo 4, next page); unidentified or inaccurately labeled medical supplies; cleaning materials stored with medical supplies; staff members’ food stored with medical supplies (see Photo 5, page 40); medical supplies stored directly on the floor; and compromised medical supply packaging (see Photo 6, page 40). Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 39 Photo 3. Expired medical supplies dated September 2022 (photographed 1-11-23). Photo 4. Expired medical supplies dated between September 2020 and May 2022 (photographed on 1-11-23). Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 40 Photo 5. Staff members’ food stored with medical supplies (photographed on 1-11-23). Photo 6. Compromised medical supply packaging (photographed on 1-9-23). Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 41 None of the nine clinics met the requirements for essential core medical equipment and supplies (MIT 5.108, zero). We found one or more of the following deficiencies in all nine clinics: examination-table paper was missing; staff either did not perform daily performance checks of the AED or did not complete the defibrillator performance test log documentations within the last 30 days; clinic daily glucometer quality control logs were incomplete; and oto-ophthalmoscopes were not functioning. We examined EMRBs to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Only one of the seven EMRBs passed our test (MIT 5.111, 14.3%). We found one or more of the following deficiencies with six of the EMRBs: staff failed to ensure the EMRBs’ compartments were sealed and intact; staff had not thoroughly inventoried the EMRBs in the previous 30 days; staff failed to log EMRB daily glucometer quality control results; and the treatment cart in the CTC had a nonfunctional laryngoscope resulting from no available batteries at the time of the OIG’s inspection. Medical Supply Management None of the medical supply storage areas located outside the medical clinics stored medical supplies adequately (MIT 5.106, zero). We found expired medical supplies (see Photo 7, right); medical supplies stored directly on the floor (see Photo 8, next page); and medical supplies stored under the leaking roof of the medical warehouse (see Photo 9, next page). According to the chief executive officer (CEO), the institution did not have any concerns about the medical supply process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process with the existing system. Photo 7. Expired medical supplies dated November 2021 (photographed on 1-9-23). Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 42 Photo 8. Medical supplies stored directly on the floor (photographed on 1-9-23). Photo 9. Medical supplies stored underneath a leaking roof in the medical supply warehouse (photographed on 1-9-23). Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 43 Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected seven of nine clinics (MIT 5.101, 77.8%). In one clinic, a patient restroom was unsanitary. In another clinic, the gurney was unsanitary and rusty. Staff in one of nine clinics properly sterilized or disinfected medical equipment (MIT 5.102, 11.1%). In eight clinics, we found one or more of the following deficiencies: staff did not mention disinfecting the examination table as part of their daily start-up protocol; examination table disposable paper was not removed and replaced in between patient encounters; staff did not routinely log previously sterilized reusable invasive medical equipment; staff did not date stamp and initial the packaging of sterilized medical equipment; and staff did not clean and disinfect reusable noninvasive medical equipment after each patient use. We found operating sinks and hand hygiene supplies in the examination rooms in three of nine clinics (MIT 5.103, 33.3%). In five clinics, patient restrooms lacked either antiseptic soap or disposable hand towels. The remaining clinic had a nonfunctional examination room sink. We observed patient encounters in eight clinics. In six clinics, clinicians did not wash their hands before or after examining their patients, before applying gloves, or before performing blood draws (MIT 5.104, 25.0%). Health care staff in eight of nine clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105, 88.9%). In one clinic, staff did not mention following an adequate disinfecting process when medical equipment came into contact with biohazardous waste. Physical Infrastructure We gathered information to determine whether the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely and adequate health care. When we interviewed health care managers, they did not have concerns about the facility’s infrastructure or its effect on the staff’s ability to provide adequate health care. At the time of inspection, the institution had three infrastructure projects underway that management staff believed would improve the delivery of care at LAC: • Project D3: Construction of a new medication distribution room at D Yard Housing Unit 3 that began in December 2022 and was expected to be completed by October 2023. • Projects D4 and D5: Construction of new medication distribution Rooms at D Yard Housing Units 4 and 5 that will begin in February 2023 and July 2023, respectively. The projects are expected to be completed by January 2024 and June 2024 . The health care managers reported a delay of project completions due to the COVID-19 pandemic. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 44 • Upcoming Project: At the time of inspection, the CEO reported that construction of a new pharmacy was still awaiting a construction start date. Despite the delay of Projects D4 and D5 described above, the CEO did not believe this negatively impacted the institution’s current ability to provide good patient care (MIT 5.999). Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 45 Compliance Testing Results Table 10. Health Care Environment Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 46 Recommendations • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Executive leadership should consider performing random spot checks to ensure that staff properly store medical supplies in medical supply storage areas. • Nursing leadership should consider performing random spot checks to ensure staff follow equipment and medical supply management protocols. • Nursing leadership should direct each clinic nurse supervisor to review the monthly EMRB and treatment cart logs to ensure that the EMRBs and treatment carts are regularly inventoried and sealed. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 47 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of health care screenings and the continuity of provider appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed whether staff transferred patients with their medical equipment and gave correct medications before patients left. In addition, our inspectors evaluated the performance of staff in communicating vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals; and inspectors confirmed whether staff sent complete medication transfer packages to receiving institutions. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Inadequate (42.7%) Case review found LAC performed poorly in the transfer process. For patients transferring into the institution, LAC nurses performed initial nursing assessments but often missed reconciliation of orders from the sending institution. For patients transferring out of the institution, nurses often did not thoroughly evaluate their patients, and ensure completeness of the transfer documentation. For patients returning from the hospital, the receiving nurses did not consistently perform thorough assessments. The OIG rated case review component of this indicator inadequate. Compliance testing found the institution satisfactory in ensuring transfer packets for patients departing include the required documents and medications. However, nurses performed poorly in completing initial health screening forms and ensuring medication continuity for newly transferred patients. Consequently, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 48 events in 21 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified 21 deficiencies, six of which were significant.33 33 Deficiencies occurred in cases 2, 3, 20, 23–26, 28, 31, 33, 36, and 61–63. Significant deficiencies occurred in cases 20, 23, 25, 31, and 62. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 48 Transfers In The transfer-in process had a mixed performance. OIG clinicians reviewed 11 events in four cases in which patients transferred into the facility from other institutions. We identified five deficiencies, one which was significant.34 Most of the deficiencies were related to poor reconciliation of orders from the sending institutions. Examples of transfer deficiencies are listed below: • In case 31, the patient refused COVID-19 testing prior to transfer. When the patient arrived at LAC, the R&R nurse did not initiate a COVID-19 quarantine; instead, the patient was released to general housing. • In case 33, the sending institution placed an order for a time-study laboratory test. However, LAC staff did not timely reconcile the order, and the test was completed eight days late. The compliance team found that nurses who performed an initial intake assessment were not thorough (MIT 6.001, zero). Frequently, the patient responses warranted additional nursing inquiry, but this did not occur. Also, staff did not always obtain complete vital signs assessments. In addition, nurses did not always complete all sections of the assessment and disposition portion of the initial health screening form (MIT 6.002, 72.0%). The compliance team found poor medication transfer continuity (MIT 6.003, 21.1%). Compliance testing also showed room for improvement in ensuring newly arrived patients were seen by a provider within required time frames (MIT 1.002, 75.0%). In contrast, our clinicians did not identify any medication continuity concerns or delayed provider appointments. Compliance testing also showed patient layovers frequently did not receive their medications (MIT 7.006, 33.3%). Transfers Out LAC’s transfer-out process had a varied performance. OIG clinicians reviewed seven transfer-out cases and found four deficiencies, one of which was significant.35 Compliance testing found that patients who transferred out of the institution often had their medications and required documents (MIT 6.101, 77.8%). However, OIG clinicians determined the required documents did not always include pertinent details for transfer. Examples are seen in the following cases: • In cases 2 and 36, prior to the patients’ transfers, nurses did not obtain a complete set of vital signs. • In cases 36 and 62, the patients were transferred to another institution; however, a nurse did not accurately complete interfacility documentation to include all pending specialist appointments. 34 Deficiencies occurred in cases 31, 33, 63. A significant deficiency occurred in case 31. 35 Deficiencies occurred in cases 2, 36, and 62. A significant deficiency occurred in case 62. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 49 Hospitalizations Patients returning from an off-site hospitalization or emergency room are at a high risk for lapses in care quality. These patients typically experienced severe illness or injury. They require more care and place a strain on the institution’s resources. In addition, because these patients have complex medical issues, successful health information transfer is necessary for good quality care. Any transfer lapse can result in serious consequences for these patients. LAC’s hospitalization transfer process was unsatisfactory. The OIG clinicians reviewed 27 events that occurred in 13 cases for patients who were treated at a community hospital. We identified 13 deficiencies, four of which were significant.36 LAC generally provided follow-up appointments within required time frames to patients returning from hospitalizations and emergency room encounter (MIT 1.007, 76.0%). Compliance testing found that, frequently, discharge documents were scanned into the electronic health record within the required time frame (MIT 4.003, 90.0%); however, at times, the discharge documentation was not timely reviewed by the providers, and in one sample, was not reviewed at all. Case reviewers’ findings were similar to compliance testing results, and in addition, we found, at times, hospital recommendations were not addressed. Case reviewers also found nurses who evaluated patients did not consistently provide thorough assessments. Examples are seen in the follow cases: • In case 20, the patient returned to LAC after a community hospital emergency room (ER) encounter and had a low heart rate. The nurse did not recheck the heart rate and did not perform a thorough assessment. Moreover, the nurse did not order a provider appointment within one day as recommended by the ER physician. • In cases 20, 25, 28, and 61, nurses did not provide thorough assessments in relation to the discharge diagnoses upon the patients’ return from the hospital. Compliance testing showed significant lapses in the continuity of medication upon patients’ return to the institution (MIT 7.003, 40.0%). However, case reviewers found medication continuity satisfactory. Clinician On-Site Inspection During the tour of the R&R area, OIG clinicians interviewed the assigned R&R nurse who reported being in the position for three weeks. Although the nurse was newly assigned to the role, this individual was knowledgeable concerning the processes, and described what a typical day and week looked like in relation to transfers. The R&R nurse stated there was one RN staffed on each shift, and all were responsible for transfer in and out processes. The nurse reported receiving a list of patients who were scheduled for transfer from custody, with revisions made throughout the week. The nurse also reported the 36 Deficiencies occurred in cases 2, 3, 20, 23–26, 28, 61, and 62. Significant deficiencies occurred in cases 20, 23, and 25. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 50 average number of patients transferring varied, with a weekly average of 30 to 50 patients transferring in and an average of 20 to 30 patients transferring out. The R&R nurse detailed the transfer-out process, which included interviewing the patient prior to the day of transfer to review durable medical equipment, medical holds, and specialty appointments; to schedule COVID-19 testing; and to contact the provider for any unmet needs. In addition, on the day of transfer, the nurse reported validating all previous information and reviewing for any changes, as well as medicating patients prior to their departure. The nurse communicated there was a team effort with delineated shift duties, and staffing support from leadership when indicated. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 51 Compliance Testing Results Table 11. Transfers Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 52 Table 12. Other Tests Related to Transfers Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 53 Recommendations • Nursing leadership should develop and implement internal auditing of staff to ensure complete and thorough assessments of patients transferring into the institution or patients returning from hospitalizations. • Nursing leadership should educate R&R nurses to completely answer and address required initial health screening questions. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 54 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to the patient. When rating this indicator, the OIG strongly considered the compliance test results, which tested medication processes to a much greater degree than case review testing. In addition to examining medication administration, our compliance inspectors also tested many other processes, including medication handling, storage, error reporting, and other pharmacy processes. Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Inadequate (55.4%) Case review found LAC generally performed poorly in this indicator. Case reviewers found concerns with medication processes. Patterns included incorrectly ordered medications and not identifying medication order errors. Additionally, we identified problems with medication continuity. Taking all factors into consideration, the OIG rated the case review component of the indicator inadequate. Compared with Cycle 6, LAC’s overall compliance score improved. However, staff continue to need improvement with the medication continuity for patients transferring within the institution and providing patients with newly prescribed medication orders as ordered. Additionally, LAC had lapses in timely providing chronic care medications, hospital discharge medications, and patients temporarily housed in LAC. Considering all testing results, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 148 events related to medications and found 29 medication deficiencies, nine of which were significant.37 New Medication Prescriptions LAC compliance testing showed insufficient performance in ensuring newly prescribed medications were issued to patients (MIT 7.002, 68.0%). Case review found three cases in which there was a lack of continuity of a newly prescribed medication.38 The following case provides an example: 37 Deficiencies occurred in cases 1–3, 9–11, 16, 18, 22, 25, 26, 28, 36, and 61. Significant deficiencies occurred in cases 1, 3, 9, 18, 26, and 61. 38 Lapses in newly prescribed medication continuity occurred in cases 16, 18, and 26. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 55 • In case 26, a newly prescribed antidepressant was not immediately available for administration. Chronic Medication Continuity Compliance testing found that chronic care medications were either not made available within the required timeframes, or the institution did not follow policy for refusals (MIT 7.001, 11.8%). Our clinicians found 11 cases with a lapse in chronic care medication continuity.39 The following cases provide examples: • In cases 3 and 9, diabetic patients were prescribed insulin. However, the patients frequently did not receive insulin due to ordering errors. • Also in case 9, the patient did not receive his chronic care cholesterol medication. Although the medication was prescribed as being an automatic refill, a nurse documented that the patient had not requested a refill, with the result being the medication was not issued to the patient for a month. • In case 10, nurses documented the patient did not show for administration of a chronic care medication; however, nurses administered other medications that were scheduled at the same time. • In case 18, the patient was prescribed a medication to improve neuromuscular function; however, the pharmacy was only issuing a 30-day medication supply every 45 days. This pharmacy error occurred before, during, and after the review period. • In case 25, the patient was prescribed an injectable immuno-suppressive medication every two weeks for the treatment of an inflammatory bowel disease. However, the provider did not ensure timely renewal. In addition, when it was renewed, the nurses did not administer the medication or obtain a refusal. The patient did not receive the medication for 32 days. Hospital Discharge Medications Compliance testing revealed a variety of concerns with continuity of hospital medications. On several occasions, patients missed doses, or the pharmacy did not make the medication available for administration (MIT 7.003, 40.0%). Our clinicians found one deficiency related to missed doses of medications upon the patient’s return from the hospital.40 Specialized Medical Housing Medications LAC performed poorly in assuring medications were available and administered timely (MIT 13.003, 50.0%). Our clinicians also found similar findings in two cases.41 In addition, clinicians found that nurses frequently administered cardiac medications without first 39 Lapses in chronic care medication continuity occurred in cases 1–3, 9, 10, 11, 18, 22, 25, 26, and 61. 40 A deficiency occurred in case 3. 41 Deficiencies occurred in cases 26 and 61. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 56 obtaining their patients’ blood pressure and pulse readings. This situation is further discussed in the Specialized Medical Housing and Nursing Performance indicators. Transfer Medications Compliance testing showed that patients who arrived at LAC had poor medication continuity (MIT 6.003, 21.1%). In contrast, our clinicians did not identify concerns with medication continuity of transfer patients. Compliance testing also showed there were opportunities for improvement when patients transferred within LAC (MIT 7.005, 60.0%) and had layovers (MIT 7.006, 33.3%). Medication Administration LAC performed poorly in ensuring TB medication continuity and did not ensure that its patients were sufficiently monitored (MIT 9.001, 54.6% and MIT 9.002, 10.0%). Our clinicians also identified one case in which medications were not monitored sufficiently as described below: • In case 1, the patient was prescribed nitroglycerin to self-administer as needed for chest pains. During our six-month period of review, the patient requested and received 375 pills (25 pills, on 15 occasions). Frequent use of this medication could indicate a worsening cardiac issue. The high usage was not addressed by health care staff. Clinician On-Site Inspection OIG clinicians interviewed medication nurses and found they were knowledgeable about the medication administration process. We learned that in Facility D, for Units One and Two, medication administration areas were located within the housing units; whereas for Units Three and Four, patients went to a separate location to receive their medications. Although medication administration nurses did not always attend huddles, the care teams discussed medication compliance, including medication nonadherence, and medication continuity for patients transferring into the institution, arriving from another yard, or returning from the hospital. In addition, nursing supervisors indicated that nurses provided education to patients who missed or refused two doses of medications. Our clinicians also met with the pharmacist in charge (PIC), who thoroughly answered our questions and seemed knowledgeable about medication-related processes. During the clinician on-site inspection, we discussed cases involving incorrectly ordered regular insulin sliding-scale orders with directions to administer “as needed.”42 This error resulted in patients not receiving insulin as intended. The PIC and the nursing supervisor indicated they had identified additional patients whose records showed similar errors, and they were actively addressing these orders. In addition, they indicated providers and pharmacy staff had received training. Our clinicians also discussed the refill process for nitroglycerin orders that were prescribed “as needed.” The PIC indicated that there was not an alert to either pharmacy staff or the ordering provider when patients made frequent requests for nitroglycerin. The PIC recognized the concern and indicated he 42 An insulin sliding-scale order is a set of instructions for administering a specific amount of insulin based on the patient’s blood glucose reading or test result. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 57 would train his pharmacist to check for frequent refills, as well as to consult a provider and to consider other possible solutions. Compliance Testing Results Medication Practices and Storage Controls The institution excellently stored and secured narcotic medications in all the nine clinic and medication line locations (MIT 7.101, 100%). LAC appropriately stored and secured nonnarcotic medications in five of 10 clinic and medication line locations (MIT 7.102, 50.0%). In five locations, we observed one or more of the following deficiencies: the medication storage cabinet was disorganized; the medication area lacked a clearly labeled designated area for medications that were to be returned to the pharmacy; and nurses did not maintain unissued medication in its original labeled packaging. Staff kept medications protected from physical, chemical, and temperature contamination in four of the 10 clinic and medication line locations (MIT 7.103, 40.0%). In six locations, we found one or more of the following deficiencies: staff did not consistently record room and refrigerator temperatures; staff did not store oral and topical medications separately; the medication refrigerator was unsanitary; and staff members’ personal food was stored with medications. Staff successfully stored valid, unexpired medications in all nine applicable medication line locations (MIT 7.104, 100%). Nurses did not exercise proper hand hygiene and contamination control protocols in all of six applicable locations (MIT 7.105, zero). In the six locations, some nurses neglected to wash or sanitize their hands before preparing and administering medications, prior to donning gloves, before each subsequent regloving, or after intentionally touching the patient’s skin. Staff in two of six medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 33.3 %). In four locations, medication nurses did not describe the process they followed when reconciling newly received medication and the medication administration record (MAR) against the corresponding physician’s order. Staff in five of six medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 83.3%). In one location, medication nurses did not distribute medications to patients within the time frame of one hour before or one hour after the normal distribution time. Pharmacy Protocols LAC followed general security, organization, and cleanliness management protocols in its pharmacy (MIT 7.108, 100%). Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 58 In its main pharmacy, staff did not properly store nonrefrigerated medication. Staff stored food items within the medication preparation area. As a result, LAC received a score of zero in this test (MIT 7.109). The institution properly stored refrigerated or frozen medications in the pharmacy (MIT 7.110, 100%). The PIC correctly accounted for narcotic medications stored in LAC’s pharmacy (MIT 7.111, 100%). We examined 14 medication error reports. The PIC timely or correctly processed only three of these 14 reports (MIT 7.112, 21.4%), but had no evidence a pharmacy error follow- up review was performed for the other 11 reports. Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors also followed up on any significant medication errors found during compliance testing. We did not score this test; we provide these results for informational purposes only. At LAC, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in restricted housing units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. Of 19 applicable patients interviewed, 12 indicated they had access to their rescue medications. Seven patients reported they did not have their prescribed rescue inhaler. Four patients stated the medication was taken away when they were transferred to the restricted housing unit. One patient stated his medication was not reissued upon returning from the hospital. Another patient stated that, for the past month, he had asked the provider and the medication nurse to provide his medication without success, and a third patient stated his medication was never given to him. We promptly notified the CEO of this concern, and health care management immediately issued replacement rescue medications to the patients (MIT 7.999). Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 59 Compliance Testing Results Table 13. Medication Management Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 60 Table 14. Other Tests Related to Medication Management Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 61 Recommendations • The institution should consider developing and implementing measures to ensure that staff timely make available and administer medications to patients and that staff document accordingly in the EHRS as described in CCHCS policy and procedures. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 62 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution as being at high risk for coccidioidomycosis (Valley Fever), we tested the institution’s performance in transferring out patients quickly. The OIG rated this indicator solely according to the compliance score. Our case review clinicians do not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (58.8%) LAC had a mixed performance in preventive services. LAC performed well in screening patients annually for TB, offering patients an influenza vaccine for the most recent influenza season, and offering colorectal cancer screening for patients from ages 45 through 75. However, the institution faltered in administering TB medications as prescribed, monitoring patients who were taking prescribed TB medications, and offering required immunizations to chronic care patients. These findings are set forth in the table on the next page. Overall, the OIG rated this indicator inadequate. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 63 Compliance Testing Results Table 15. Preventive Services Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 64 Recommendations • Nursing leadership should consider developing and implementing measures to ensure that nursing staff monitor patients receiving TB medications according to CCHCS guidelines. • Medical leadership should analyze the challenges related to the untimely provision of preventive vaccines to chronic care patients and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 65 Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care delivered by the institution’s nurses, including registered nurses (RN), licensed vocational nurses (LVN), psychiatric technicians (PT), certified nursing assistants (CNA), and medical assistants (MA). Our clinicians evaluated nurses’ performance in making timely and appropriate assessments and interventions. We also evaluated the institution’s nurses’ documentation for accuracy and thoroughness. Clinicians reviewed nursing performance across many clinical settings and processes, including sick call, outpatient care, care coordination and management, emergency services, specialized medical housing, hospitalizations, transfers, specialty services, and medication management. The OIG assessed nursing care through case review only and performed no compliance testing for this indicator. When summarizing nursing performance, our clinicians understand that nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Not Applicable LAC’s overall nursing care was insufficient. Compared with Cycle 6, we reviewed fewer nursing encounters, but found more overall and significant nursing deficiencies. In Cycle 6, nursing emergency care, assessments, interventions, and documentation showed opportunities for improvement in multiple areas. In Cycle 7, these patterns continued, revealing a further cause for concern when nurses frequently did not initiate the use of an AED when their patients required CPR. We also found further decline of nursing care in the CTC, R&R, and in medication management practices. After taking all these factors into consideration, the OIG rated this indicator inadequate. Case Review Results We reviewed 254 nursing encounters in 60 cases. Of the nursing encounters we reviewed, 132 occurred in the outpatient setting, and 67 were sick call requests. We identified 170 nursing performance deficiencies, 47 of which were significant.43 Outpatient Nursing Assessment and Interventions A critical component of nursing care is the quality of nursing assessment, which includes both subjective elements (patient interviews) and objective elements (observation and 43 Deficiencies occurred in cases 1–11, 16, 18–20, 22–26, 28, 31, 33, 36, 38–40, 42, 44-48, and 50-63. Significant deficiencies occurred in cases 1–11, 19, 20, 22, 23, 25, 26, 31, 50, and 60–63. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 66 examination). A comprehensive assessment allows nurses to gather essential information about their patients and to develop appropriate interventions. Nurses had opportunities for improvement in their assessments and interventions. Our clinicians identified 92 outpatient nursing deficiencies, 20 of which were considered significant. These deficiencies occurred when nurses in the medical clinics did not always properly identify symptomatic sick call requests, and frequently their assessments were incomplete. Examples of incomplete assessments and interventions are listed in the following cases: • In case 3, the patient submitted a sick call request for lower extremity pain. The nurse incorrectly indicated the request did not include symptoms and initiated an appointment to occur within 14 days, instead of on the next business day. • In case 10, a nurse saw the patient after a TTA evaluation for chest pains. The nurses did not obtain the patient’s vital signs and did not perform a physical assessment. • In case 25, the patient with a history of ulcerative colitis had diarrhea and weakness. The sick call nurse did not obtain the patient’s weight and did not assess for frequency of diarrhea. Further, the nurse did not assess the patient for signs of dehydration and did not perform an abdominal assessment. Outpatient Nursing Documentation Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook changes in patients’ conditions. Nurses did not always document their assessment findings and interventions. Examples are listed in the following cases: • In case 1, a TTA RN documented the patient was referred by a PT for abdominal pain. However, the PT did not document having contact with the patient and did not document a hand-off with the TTA nurse. Furthermore, on another occasion, a PT did not document the administration of nitroglycerin in the patient’s MAR. • In case 51, the nurse documented checking the patient’s vital signs, but did not document the results. Wound Care We reviewed five cases in which patients had wounds and found three deficiencies.44 A deficiency example is given in the following case: • In case 44, this diabetic patient was evaluated by a nurse for a foot laceration. The nurse did not initiate a follow-up to ensure the wound healed. 44 Deficiencies occurred in cases 1, 24, and 44. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 67 Emergency Services We reviewed 36 urgent or emergent events and found 29 nursing deficiencies. Nurses did not always provide sufficient BLS CPR when the placement of an AED was not prioritized. In addition, TTA nurses did not perform thorough assessments and interventions. Please see the Emergency Services indicator for additional information. Hospital Returns We reviewed 13 events that involved returns from off-site hospitals or emergency rooms. We identified eight deficiencies, one of which was considered significant.45 Nonetheless, nurses mostly performed sufficient nursing assessments, which we detailed further in the Transfers indicator. Transfers We reviewed 21 cases involving transfer-in and transfer-out processes. We found that nurses frequently did not thoroughly complete initial assessments, and when patients transferred from LAC, nurses’ documentation was not always complete. Please refer to the Transfers indicator for further details. Specialized Medical Housing We reviewed four cases with a total of 65 events. In the CTC, we found that, often, nurses did not thoroughly evaluate their patients and did not follow safety measures prior to administering medications. Please refer to the Specialized Medical Housing indicator. Specialty Services We reviewed 26 events within 10 cases, in which nurses evaluated patients prior to or after their return from off-site specialist appointments or procedures. We identified 13 nursing deficiencies related to specialty services. We found that when patients returned without recommendations or specialist records, nurses did not attempt to obtain missing records and did not inform a provider. In addition, nurses frequently did not perform thorough assessments. Please refer to the Specialty Services indicator for additional details. The following case provides an example: • In case 26, the patient had a urology procedure and returned without the specialist’s records. The nurse did not attempt to obtain the recommendations and did not inform a provider. Medication Management OIG clinicians reviewed 148 events involving medication management. Our clinicians found that nursing staff did not always follow the prescriber’s orders prior to administering medications and administered medications without an order. In addition, when patients refused several doses of medications, nurses and the primary care team did 45 Deficiencies occurred in cases 2, 20, 23–26, 28, and 61. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 68 not provide education to these patients. Additional information is found above and in the Medication Management indicator. The following three cases provide examples: • In case 1, on multiple occasions, PTs administered medications for chest pain without contacting a provider for an order. • In case 3, the patient refused long-acting insulin numerous times in one month, but nurses did not educate him on the risks associated with the refusals. • In case 22, on multiple occasions, nurses administered heart medication without first checking the patient’s pulse and blood pressure. Legibility Most provider and nursing progress notes were electronically entered into the patient’s electronic health record. Nurses occasionally reviewed patients’ health care services request forms and signed them, with the OIG clinicians identifying eight deficiencies related to an illegible name or signature of a nurse.46 Clinician On-Site Inspection On-site, our clinicians toured the facilities, and interviewed staff and supervisors. We learned that the chief nurse executive (CNE) and SRN III had been serving in acting roles for one month and three months, respectively. Previously, these leadership positions had also been filled with other staff who had also served in an acting capacity. Although neither of those leaders were in their current positions during the OIG review periods, they attempted to answer the OIG clinicians’ questions thoroughly. In addition, the SRN III shared her own quality improvement process, part of which involved the institution’s emergency medical response clinical review. The SRN III acknowledged that she had found some concerns in the accuracy of the reviews and had implemented actions to improve this process. Our clinicians attended huddles and toured LAC’s CTC, TTA, R&R, medical clinics, and selected medication administration areas. During a clinic huddle, nursing supervisors indicated that any patients who missed two doses of medications were scheduled to be evaluated by nurses to receive education to improve compliance. Recommendations • Nursing leadership should work toward improving patient care coordination with medical providers in communications about medication orders, patient refusals, and incomplete specialists’ reports. • The department and nursing leadership should consider resuming random audits to ensure that nursing staff properly perform and document complete assessments including vital signs and appropriate assessments. The 46 Deficiencies occurred in cases 40, 42, 45–48, 57, and 58. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 69 leadership should implement remedial measures as appropriate including training of staff. • The department and nursing leadership should consider a medication management audit that ensures nurses are safely administering medications. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 70 Provider Performance In this indicator, OIG case review clinicians evaluated the quality of care delivered by the institution’s providers: physicians, physician assistants, and nurse practitioners. Our clinicians assessed the institution’s providers’ performance in evaluating, diagnosing, and managing their patients properly. We examined provider performance across several clinical settings and programs, including sick call, emergency services, outpatient care, chronic care, specialty services, intake, transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only and performed no compliance testing for this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable LAC providers delivered generally good care consistent with Cycle 6. They made appropriate assessments and decisions, managed chronic medical conditions effectively, reviewed medical records thoroughly, and addressed the specialists’ recommendations adequately. The OIG rated this indicator adequate. Case Review Results OIG clinicians reviewed 154 medical provider encounters and identified 25 deficiencies, eight of which were significant.47 OIG physicians also rated the overall adequacy of care for each of the 25 comprehensive case reviews. Of these 25 cases, 21 were adequate and four were inadequate. Outpatient Assessment and Decision-Making Providers generally made appropriate assessments and sound medical plans for their patients. They diagnosed medical conditions correctly, ordered appropriate tests, and coordinated effective treatment plans for their patients. However, there was one significant deficiency related to poor decision making. • In case 25, the provider endorsed a laboratory test result showing a severely 48 low hemoglobin level of 7.7 g/dL. However, the provider did not evaluate the patient urgently for signs and symptoms of severe anemia. 47 Deficiencies occurred five times in case 25, four times in case 15, three times in case 9, twice in cases 2 and 12, and once in cases 1, 10, 17, 20, 24, 26, 29, and 33. Significant deficiencies occurred three times in case 15, twice in cases 9 and 25, and once in case 12. 48 The normal hemoglobin range is from 13.2 to 17.1 g/dL. A level of 6 g/dL is a critically low level. A level of 7.7 g/dL is significant and indicates anemia, which is a low blood count. A low blood count can affect normal bodily functions. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 71 Outpatient Review of Records For patients returned from hospitalizations, providers generally performed well in reviewing medical records and addressing hospitalists’ recommendations. However, there was one significant deficiency as described below: • In case 25, the patient returned from the hospital with diagnoses of anemia and gastrointestinal bleed, and the hospitalist recommended to closely monitor the patient’s blood count weekly for two to three weeks. However, the provider did not order the recommended weekly blood count testing. Providers also performed well in reviewing patients’ MARs and in timely renewing patients’ medications. However, there were two deficiencies related to delay in renewing medications.49 The following case provides an example: • In case 15, a nurse messaged a provider that the patient’s regular insulin sliding scale expired. However, there was no response from the provider. Two weeks later, a different provider renewed the insulin. Emergency Care Providers made appropriate triage decisions when the patients arrived at the TTA for emergency treatment. In addition, providers were available for consultation with the TTA nursing staff. We identified two deficiencies related to the lack of a provider progress 50 note for an emergent event. Chronic Care Providers performed well in managing chronic medical conditions such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. For patients with diabetes, the providers regularly monitored patients’ blood glucose levels and adjusted diabetic medications. However, our clinicians identified six deficiencies related to 51 diabetic care. The following cases provide examples: • In case 9, the patient had poorly controlled diabetes; however, the provider did not timely adjust the patient’s insulin or have the patient follow up sooner than 90 days. • In case 15, the patient had poorly controlled diabetes; however, the provider did not review the patient’s glucose log or adjust the patient’s insulin as medically indicated. Specialty Services Providers appropriately referred to specialists and reviewed specialty reports in a timely manner, and the providers also adequately addressed the specialists’ recommendations. 49 Deficiencies occurred in cases 15 and 25. 50 Deficiencies occurred in cases 10 and 25. 51 Deficiencies occurred three times in cases 9 and 15. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 72 52 Our clinicians identified two provider deficiencies related to specialty services. The case below provides an example: • In case 12, the optometrist recommended to have the patient follow up in two weeks for an eye examination; however, the provider did not order the follow-up eye examination. Outpatient Documentation Quality Providers generally documented outpatient encounters on the same day of the encounter. Our clinicians did not identify any deficiencies related to documentation quality. Patient Notification Letter Providers performed poorly in relaying diagnostic results to their patients as the providers did not send patient letters or thoroughly communicate test results with their patients. These deficiencies are discussed in the Diagnostic Services indicator. Clinician On-Site Inspection LAC had eight full-time providers and two and a half vacant provider positions. The providers were enthusiastic about their work and generally satisfied with nursing, diagnostic, and specialty services. The provider morning report occurred every morning of the working days; the providers discussed patients returning from the hospital and significant TTA events. Our clinicians attended morning huddles during which the patient care team discussed the specialty appointments. Nurses informed providers of scheduled clinic appointments, expiring medications, and new arrivals coming from other institutions. Our clinicians attended a population health management meeting for Clinic C. The medical staff discussed delays in chronic care appointments and strategized solutions to eliminate these delays. The medical staff reviewed health care measures such as hemoglobin A1c to identify patients with poorly controlled diabetes and discussed solutions to reach diabetic care goals. Medical staff also discussed preventive health screening guidelines and identified patient-required screening services such as providing colonoscopy screening. The chief medical executive (CME) had been at LAC for one and a half years, and reported achieving success in reducing previous backlogs of provider appointments in the four main clinics. The CME stated that the biggest challenge at LAC in this indicator was the ongoing concern of specialty appointment backlogs as further discussed in the Specialty Services indicator. 52 Deficiencies occurred in cases 12 and 26. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 73 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 74 Specialized Medical Housing In this indicator, OIG inspectors evaluated the quality of care in the specialized medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring close medical supervision. Our inspectors also evaluated the timeliness and quality of provider and nursing intake assessments and care plans. We assessed staff members’ performance in responding promptly when patients’ conditions deteriorated and looked for good communication when staff consulted with one another while providing continuity of care. Our clinicians also interpreted relevant compliance results and incorporated them into this indicator. At the time of our inspection, LAC’s specialized medical housing consisted of a correctional treatment center (CTC). Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Inadequate (62.0%) Compared with Cycle 6, case review found LAC had more overall and significant deficiencies. CTC nurses did not always perform thorough assessments and often administered medications without ensuring that ordered parameters were met. In addition, nurses documented conflicting information and completed a care plan without documenting the result of the task performed. Taking all factors into consideration, the OIG rated the case review component of this indicator inadequate. Compared with Cycle 6, compliance testing showed LAC needs improvement in this indicator. LAC providers did not complete the history and physical examination within the required timeframe. Additionally, records demonstrated poor medication continuity with patients newly admitted to specialized medical housing. In contrast, nursing staff performed excellently in completing initial assessments. Factoring all the information, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed four CTC cases that included 23 provider encounters and 21 nursing encounters. Due to the frequency of nursing and provider contacts in specialized medical housing, we bundled up to two weeks of patient care into a single event for review. We identified 30 deficiencies, 10 of which were significant.53 Provider Performance Compliance testing found that providers did not always perform timely admission history and physical examinations (MIT 13.002, 60.0%). However, in case review, providers generally delivered good care: they completed their rounds at clinically appropriate 53 Deficiencies occurred in cases 26, 61, 62, and 63. Significant deficiencies occurred in cases 26, 61, and 63. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 75 intervals, timely reviewed off-site medical records, and made appropriate medical decisions. Nursing Performance Compliance testing concluded that patients admitted to the CTC received timely initial health assessments (MIT 13.001, 100%). Our clinicians discovered one instance in which the admission assessment was not completed timely and also did not include a fall risk assessment as indicated. While nurses did perform assessments, their assessments did not occur each shift and were frequently incomplete. OIG clinicians concluded that, of the 30 deficiencies identified in this indicator, 21 of them were directly related to the quality of nursing care. Prominent areas of concern were incomplete assessments, lack of documentation of completed care-plan tasks, and failure to implement safety measures resulting in patient harm. Examples are described below: • In case 26, after a recent stroke, the patient with impaired mobility was admitted to the CTC. The nurse did not perform a timely admission assessment and accurately record the patient’s fall risk. Unfortunately, only a few hours after admission, the patient fell, resulting in a finger fracture. Furthermore, nurses subsequently recorded additional patient falls, but did not always perform assessments and interventions. • In case 63, the patient was admitted to the CTC after a jaw fracture and surgical repair. The patient had a limited ability to open his mouth and eat normally, which placed him at risk for aspiration.54 CTC nurses developed a care plan that included assessing the patient’s ability to swallow and listening to the patient’s lungs before and after meals; however, nurses rarely documented the results of their assessments. The compliance team identified that the CTC’s call light system, which works to ensure patients have access to requesting health care, was not operational (MIT 13.101, zero). However, the compliance team did report health care staff were able to perform patient safety checks and access patient cells in urgent or emergent situations within a minute of receiving notice (MIT 13.102, 100%). Medication Administration CTC nursing staff performed poorly in medication administration. Compliance testing showed 50.0 percent of newly admitted patients received their medications within required time frames (MIT 13.003). Our clinicians found in two cases, nurses did not check their patients’ blood pressure and pulse readings prior to administering medication or administered medication despite orders to hold. OIG clinicians identified eight deficiencies related to medication management; five were considered significant.55 The following are examples: 54 Aspiration means to inhale food or liquid into the lungs. 55 Deficiencies occurred three times in case 26 and 61, and once in case 63. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 76 • In case 26, nursing staff administered metoprolol on numerous occasions without first obtaining the patient’s blood pressure and pulse readings.56 • In case 61, on multiple occasions, nurses inappropriately administered medication to lower the patient’s blood pressure. However, nurses frequently did not first check the patient’s blood pressure, or often administered the medication when the patient’s blood pressure was outside the ordered parameter. Clinician On-Site Inspection Our clinicians toured LAC’s CTC, and interviewed a registered nurse and nursing supervisor. They reported there were four medically designated beds, two of which were negative pressure rooms. There were an additional 12 mental health beds located within the CTC. The nursing supervisor reported that the unit was staffed with RNs, LVNs, and PTs each shift. The nursing supervisor indicated that the medical patients were divided among the nurses caring for patients within the mental health area. The CTC nursing supervisor described nursing expectations in the CTC; this included a thorough admission assessment and a fall risk assessment. In addition, the nursing supervisor indicated that nurses were expected to perform complete assessments each shift and to document their assessments at the time the nurses assessed the patients. Nurses also described their workflow, which included morning rounds to collect vital signs, perform nursing assessments, and administer medications. They also indicated that patients were weighed each week unless ordered more frequently. Our clinicians inquired about the “24-hour chart check” that we identified during case reviews. The nursing supervisor stated that, in this chart check, the RN is required to review all events and orders occurring in the previous 24 hours to ensure orders were accurately carried out. However, in our case reviews, we found that these 24-hour chart checks had not captured the lapses that we identified. 56 Metoprolol is a blood pressure medication that can decrease blood pressure and heart rate. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 77 Compliance Testing Results Table 16. Specialized Medical Housing Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 78 Recommendations • Nursing leadership should ensure that CTC nurses properly document the results of their care plan assessments. • Nursing leadership should ensure CTC medications are safely administered. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 79 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG clinicians focused on the institution’s performance in providing needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, and medical staff’s retrieval, review, and implementation of any specialty recommendations. Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Inadequate (49.2%) Case review found LAC needed improvement in this indicator. Although the providers generally addressed all the specialists’ recommendations, we found the institution performed poorly in completing specialty appointments. The institution also performed poorly in retrieving, scanning, and reviewing specialty reports. Factoring all the findings, OIG rated the case review component of this indicator inadequate. Compared with Cycle 6, compliance testing showed LAC overall performed poorly in this indicator. LAC’s performance was satisfactory for providing routine-priority specialty service, and was excellent in providing high-priority specialty service. However, the institution still needs improvement in providing initial medium-priority specialty service, and subsequent follow-up appointments for medium- and routine-priority specialty services. Additionally, LAC performed poorly in receiving and endorsing specialty service reports and providing pre-approved specialty services appointments. Factoring all the information, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results Our clinicians reviewed 136 events related to specialty services, including 110 specialty consultations and procedures, and found 30 deficiencies; six of which were 57 significant. Access to Specialty Services Compliance testing found that 93.3 percent of the initial high-priority specialty appointments (MIT 14.001), 66.7 percent of the initial medium-priority specialty appointments (MIT 14.004), and 80.0 percent of the initial routine-priority specialty appointments (MIT 14.007) occurred within required time frames. However, the institution performed inconsistently with follow-up specialty appointments (MIT 14.003, 57 Deficiencies occurred seven times in case 26, five times in case 62, three times in cases 25 and 26, twice in cases 1, 10, 23, and 29, and once in cases 2, 24, 27, and 61. Significant deficiencies occurred in cases 1, 24, 26, 61, 62, and 63. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 80 30.8%, MIT 14.006, 50.0%, and MIT 14.009, 71.4%). OIG clinicians identified four 58 significant deficiencies, two of which are described below: • In case 61, a provider requested a neurology appointment to occur within 14 days; however, the appointment did not occur. • In case 62, a provider requested a plastic surgery appointment to occur within 14 days; however, the appointment did not occur. Provider Performance Providers generally referred appropriately, reviewed specialty reports within recommended time frames, and addressed specialists’ recommendations. We identified one deficiency when the provider did not address the podiatrist’s recommendation of daily wound dressing. Nursing Performance Specialty nurses reviewed requests for specialty services and arranged for specialty appointments. The nurses performed nursing assessments when patients returned from their specialty appointments, reviewed specialists’ findings and recommendations, and communicated those results to providers. Nurses also requested provider follow-up appointments. We reviewed 26 nursing encounters related to specialty services and 59 identified 13 deficiencies. These deficiencies generally related to inadequate nursing assessments after patients returned from their specialty appointments. The following case offers an example: • In case 62, the patient returned from an off-site neurology appointment; the nurse could not determine the specialist’s recommendations and did not attempt to contact the specialist for clarification or to notify the provider. Health Information Management Compliance testing showed that LAC needed to improve its performance in scanning specialty reports within required time frames (MIT 4.002, 63.3%). The institution also performed poorly in receiving or reviewing the high-priority, medium-priority, and routine-priority specialty reports within required time frames (MIT 14.002, 21.4%, MIT 14.005, 7.1%, and MIT 14.008, 46.7%). Our clinicians identified 12 deficiencies related to 60 scanning, retrieving, or reviewing specialty reports. The examples are discussed below: • In case 1, the patient had a cardiac stress test; however, the report was not retrieved or scanned into the EHRS. • In case 25, the gastroenterologist evaluated the patient; however, the report was not reviewed by a provider. 58 Deficiencies occurred in cases 24, 26, 61, and 62. 59 Deficiencies occurred in cases 2, 10, 23, 25, 26, 62, and 63. 60 Deficiencies occurred in cases 1, 23, 25, 26, 27, 29, 62, and 63. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 81 • In case 63, the patient had a surgical repair of the jaw, but the procedure report was not retrieved or scanned into the EHRS. Patient Care Environment The telemedicine staff appeared to have appropriately maintained the video, audio, and remote medical equipment such as stethoscope and otoscope, so the telemedicine specialists could effectively assess their patients. We did not identify any deficiencies related to the medical equipment. Clinician On-Site Inspection LAC specialty staff processed about 20 to 40 specialty requests per day and arranged for about 25 off-site specialty appointments per day. At the time of the OIG inspection, specialty staff reported a backlog of around 40 specialty appointments. The CME observed that the biggest medical challenge at LAC is the specialty appointment backlogs. Certain specialty appointments such as those for neurology, orthopedic surgery, and plastic surgery are still difficult to obtain, as some of these specialists do not treat inmate-patients; thus, the CME had reached out to specialists who were located as far away as the city of Los Angeles. Specialty staff often informed providers when delays might occur or appointments were not available. Specialty staff often used the department’s email system to communicate with providers; however, these communications were not captured in the EHRS. LAC had a nurse who was responsible for retrieving specialty off-site reports. Specialty staff acknowledged the missed off-site specialty reports, and it appeared that LAC did not have a dedicated tracking process to ensure all off-site specialty reports were retrieved. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 82 Compliance Testing Results Table 17. Specialty Services Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 83 Table 18. Other Tests Related to Specialty Services Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 84 Recommendations • Medical leadership should develop a tracking system for retrieving, scanning, and reviewing specialty reports. • Nursing leadership should remind staff of the expected assessments and documentation required when patients return from specialty appointments. • Medical leadership should ascertain causative factors related to the untimely provisioning or scheduling of patients’ specialty service appointments and follow-up appointments, and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 85 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the medical grievance process and checked whether the institution followed reporting requirements for adverse or sentinel events and patient deaths. Inspectors checked whether the Emergency Medical Response Review Committee (EMRRC) met and reviewed incident packages. We investigated and determined whether the institution conducted required emergency response drills. Inspectors also assessed whether the Quality Management Committee (QMC) met regularly and addressed program performance adequately. In addition, our inspectors determined whether the institution provided training and job performance reviews for its employees. We checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score. Our case review clinicians do not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (70.4%) LAC’s performance was mixed in this indicator. While the institution scored well in some applicable tests, it showed room for improvement in several areas. The EMRRC did not complete the event checklist or the review was not completed timely. The institution conducted medical emergency response drills, yet documentation was incomplete. Nurse managers did not complete documentation of the annual training of nurses who administer medications, and nurse educators did not ensure newly hired nurses received required onboarding training. These findings are set forth in the table below. The OIG rated this indicator inadequate. Compliance Testing Results Nonscored Results At LAC, the OIG did not have any applicable adverse sentinel events requiring root cause analysis during our inspection period (MIT 15.001). In our review period, we examined mortality reports that occurred before the newly revised CCHCS mortality review policy requirements. Prior to May 2022, we obtained CCHCS Death Review Committee (DRC) reporting data. Four unexpected (Level 1) deaths occurred during our review period. In our inspection, we found that the DRC did not timely complete three death review reports; the DRC finished three reports five to 69 days late and submitted the reports to the institution’s CEO three to 62 days late. The remaining death report was completed in the appropriate time frame. Effective May 2022, we obtained CCHCS Mortality Case Review reporting data. At the time of the OIG’s inspection, for four patients, we found no evidence in the submitted documentation that the preliminary mortality report had been completed. These reports were overdue at the time of OIG’s inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 86 Compliance Testing Results Table 19. Administrative Operations Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 87 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 88 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 89 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the receiver’s office, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A–1. Inspection Indicator Review Distribution for LAC Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 90 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 7 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 91 The OIG eliminates case review selection bias by sampling using a rigid methodology. No case reviewer selects the samples he or she reviews. Because the case reviewers are excluded from sample selection, there is no possibility of selection bias. Instead, nonclinical analysts use a standardized sampling methodology to select most of the case review samples. A randomizer is used when applicable. For most basic institutions, the OIG samples 20 comprehensive physician review cases. For institutions with larger high-risk populations, 25 cases are sampled. For the California Health Care Facility, 30 cases are sampled. Case Review Sampling Methodology We obtain a substantial amount of health care data from the inspected institution and from CCHCS. Our analysts then apply filters to identify clinically complex patients with the highest need for medical services. These filters include patients classified by CCHCS with high medical risk, patients requiring hospitalization or emergency medical services, patients arriving from a county jail, patients transferring to and from other departmental institutions, patients with uncontrolled diabetes or uncontrolled anticoagulation levels, patients requiring specialty services or who died or experienced a sentinel event (unexpected occurrences resulting in high risk of, or actual, death or serious injury), patients requiring specialized medical housing placement, patients requesting medical care through the sick call process, and patients requiring prenatal or postpartum care. After applying filters, analysts follow a predetermined protocol and select samples for clinicians to review. Our physician and nurse reviewers test the samples by performing comprehensive or focused case reviews. Case Review Testing Methodology An OIG physician, a nurse consultant, or both review each case. As the clinicians review medical records, they record pertinent interactions between the patient and the health care system. We refer to these interactions as case review events. Our clinicians also record medical errors, which we refer to as case review deficiencies. Deficiencies can be minor or significant, depending on the severity of the deficiency. If a deficiency caused serious patient harm, we classify the error as an adverse event. On the next page, Figure A–2 depicts the possibilities that can lead to these different events. After the clinician inspectors review all the cases, they analyze the deficiencies, then summarize their findings in one or more of the health care indicators in this report. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 92 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 93 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and compliance inspectors. Analysts follow a detailed selection methodology. For most compliance questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the relationships and activities of this process. Figure A–3. Compliance Sampling Methodology Compliance Testing Methodology Our inspectors answer a set of predefined medical inspection tool (MIT) questions to determine the institution’s compliance with CCHCS policies and procedures. Our nurse inspectors assign a Yes or a No answer to each scored question. OIG headquarters nurse inspectors review medical records to obtain information, allowing them to answer most of the MIT questions. Our regional nurses visit and inspect each institution. They interview health care staff, observe medical processes, test the facilities and clinics, review employee records, logs, medical grievances, death reports, and other documents, and obtain information regarding plant infrastructure and local operating procedures. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 94 Scoring Methodology Our compliance team calculates the percentage of all Yes answers for each of the questions applicable to a particular indicator, then averages the scores. The OIG continues to rate these indicators based on the average compliance score using the following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent and 75.0 percent), or inadequate (less than 75.0 percent). Indicator Ratings and the Overall Medical Quality Rating The OIG medical inspection unit individually examines all the case review and compliance inspection findings under each specific methodology. We analyze the case review and compliance testing results for each indicator and determine separate overall indicator ratings. After considering all the findings of each of the relevant indicators, our medical inspectors individually determine the institution’s overall case review and compliance ratings. Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 95 Appendix B: Case Review Data Table B–1. LAC Case Review Sample Sets Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 96 Table B–2. LAC Case Review Chronic Care Diagnoses Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 97 Table B–3. LAC Case Review Events by Program Table B–4. LAC Case Review Sample Summary Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 98 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 99 Appendix C: Compliance Sampling Methodology California State Prison, Los Angeles County Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 100 Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 101 Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 102 Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 103 Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 104 Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 105 Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 106 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7, California State Prison, Los Angeles County | 107 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: May 2022 – October 2022 Report Issued: June 2024 Cycle 7 Medical Inspection Report for California State Prison Los Angeles County OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Neil Robertson Chief Deputy Inspector General STATE of CALIFORNIA June 2024 OIG