Central California Women’s Facility Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General Central California Women’s Facility Medical Inspection Results Cycle 5 May 2018 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General CENTRAL CALIFORNIA WOMEN’S FACILITY Medical Inspection Results Cycle 5 Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General Shaun R. Spillane Public Information Officer May 2018 T C ABLE OF ONTENTS Foreword ........................................................................................................................................ i Executive Summary ...................................................................................................................... iii Overall Rating: Inadequate ........................................................................................................ iii Clinical Case Review and OIG Clinician Inspection Results .............................................. v Compliance Testing Results ............................................................................................. vi Recommendations .......................................................................................................... viii Population-Based Metrics ............................................................................................... viii Introduction ................................................................................................................................... 1 About the Institution ................................................................................................................... 1 Objectives, Scope, and Methodology.............................................................................................. 4 Case Reviews ............................................................................................................................. 5 Patient Selection for Retrospective Case Reviews .............................................................. 6 Benefits and Limitations of Targeted Subpopulation Review ............................................. 7 Case Reviews Sampling Methodology ............................................................................... 7 Breadth of Case Reviews ................................................................................................... 8 Case Review Testing Methodology.................................................................................... 9 Compliance Testing .................................................................................................................. 12 Sampling Methods for Conducting Compliance Testing................................................... 12 Scoring of Compliance Testing Results............................................................................ 12 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ............................. 12 Population-Based Metrics ......................................................................................................... 13 Medical Inspection Results .......................................................................................................... 14 Access to Care ............................................................................................................ 18 Case Review Results ....................................................................................................... 18 Compliance Testing Results ............................................................................................ 21 Diagnostic Services .................................................................................................... 23 Case Review Results ....................................................................................................... 23 Compliance Testing Results ............................................................................................ 24 Emergency Services .................................................................................................... 26 Case Review Results ....................................................................................................... 26 Health Information Management ................................................................................ 30 Case Review Results ....................................................................................................... 30 Compliance Testing Results ............................................................................................ 31 Health Care Environment ........................................................................................... 33 Compliance Testing Results ............................................................................................ 33 Inter- and Intra-System Transfers ............................................................................... 36 Case Review Results ....................................................................................................... 36 Compliance Testing Results ............................................................................................ 39 Pharmacy and Medication Management ..................................................................... 40 Case Review Results ....................................................................................................... 40 Compliance Testing Results ............................................................................................ 42 Central California Women’s Facility, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California Prenatal and Post-Delivery Services ........................................................................... 46 Case Review Results ....................................................................................................... 46 Compliance Testing Results ............................................................................................ 47 Preventive Services ..................................................................................................... 48 Compliance Testing Results ............................................................................................ 48 Quality of Nursing Performance................................................................................ 50 Case Review Results ....................................................................................................... 50 Quality of Provider Performance .............................................................................. 55 Case Review Results ....................................................................................................... 55 Reception Center Arrivals ......................................................................................... 60 Case Review Results ....................................................................................................... 60 Compliance Testing Results ............................................................................................ 61 Specialized Medical Housing .................................................................................... 63 Case Review Results ....................................................................................................... 63 Compliance Testing Results ............................................................................................ 65 Specialty Services ..................................................................................................... 66 Case Review Results ....................................................................................................... 66 Compliance Testing Results ............................................................................................ 68 Administrative Operations (Secondary) ..................................................................... 69 Compliance Testing Results ............................................................................................ 69 Recommendations ........................................................................................................................ 72 Population-Based Metrics ............................................................................................................ 73 Appendix A — Compliance Test Results ..................................................................................... 76 Appendix B — Clinical Data ....................................................................................................... 90 Appendix C — Compliance Sampling Methodology .................................................................... 94 California Correctional Health Care Services’ Response ............................................................ 101 Central California Women’s Facility, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES CCWF Executive Summary Table ................................................................................................. iv CCWF Health Care Staffing Resources as of June 2017 .................................................................. 2 CCWF Master Registry Data as of June 26, 2017............................................................................ 3 CCWF Results Compared to State and National HEDIS Scores .................................................... 75 Table B-1: Sample Sets ................................................................................................................ 90 Table B-2: Chronic Care Diagnoses .............................................................................................. 91 Table B-3: Event — Program ....................................................................................................... 92 Table B-4: Review Sample Summary ........................................................................................... 93 Central California Women’s Facility, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California This page intentionally left blank. Central California Women’s Facility, Cycle 5 Medical Inspection Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. At the time of the Cycle 5 inspection of CCWF, the Receiver had not delegated this institution back to CDCR. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. Central California Women’s Facility, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California This page intentionally left blank. Central California Women’s Facility, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California E S XECUTIVE UMMARY The OIG performed its Cycle 5 medical inspection at CCWF from July to September 2017. The inspection included in-depth reviews of 53 patient files conducted by clinicians, as well as reviews of OVERALL RATING: documents from 445 patient files, covering 103 objectively scored tests of compliance with policies and procedures applicable to the Inadequate delivery of medical care. The OIG assessed the case review and compliance results at CCWF using 15 health care quality indicators. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while a team of registered nurses trained in monitoring medical policy compliance conducts compliance testing. Of the applicable indicators, nine were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and three were rated by compliance inspectors only. The CCWF Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. The OIG experts made a considered and measured overall opinion that the quality of health care at CCWF was inadequate. Central California Women’s Facility, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California CCWF Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Score Rating Rating 1—Access to Care Inadequate Adequate Inadequate Inadequate 2—Diagnostic Services Proficient Adequate Adequate Inadequate 3—Emergency Services Inadequate Not Applicable Inadequate Adequate 4—Health Information Adequate Proficient Proficient Inadequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Adequate 6—Inter- and Intra-System Inadequate Adequate Inadequate Inadequate Transfers 7—Pharmacy and Medication I Inadequate Inadequate Inadequate n Inadequate Management a 8—Prenatal and Post-Delivery Adequate Adequate Adequate Adequate Services 9—Preventive Services Not Applicable Proficient Proficient Inadequate 10—Quality of Nursing Inadequate Not Applicable Inadequate Inadequate Performance 11—Quality of Provider Inadequate Not Applicable Inadequate Inadequate Performance 12—Reception Center Arrivals Adequate Inadequate Inadequate Inadequate 13—Specialized Medical Housing Adequate Proficient Adequate Adequate 14—Specialty Services Inadequate Proficient Inadequate Inadequate 15—Administrative Operations Not Applicable Adequate Adequate Inadequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. Central California Women’s Facility, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 600 patient care events.1 Case review clinicians evaluated 12 of the indicators applicable to CCWF. One of the indicator’s case review rating was proficient, four were adequate, and seven were inadequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical • CCWF increased its provider staffing since the OIG’s Cycle 4 inspection. In this cycle, two medical providers staffed each medical clinic, which allowed for continued yard clinic coverage when one of the two providers was unavailable. • As in Cycle 4, the provider and nursing staff in the skilled nursing facility continued to provide good quality care to patients. • Compared to Cycle 4, CCWF demonstrated an improvement in one aspect of the RN sick call process. In most cases in which the patient could safely wait for an RN appointment, the nurse saw the patient within one business day. Program Weaknesses — Clinical • There continued to be an access to care problem at CCWF. The backlog of pending appointments was 550 appointments at the time of the onsite inspection. Of those backlogs, 103 appointments were already overdue. • Although there were no provider vacancies, two of the providers were on extended leave. There were no other providers available to cover for the providers that were gone, which left CCWF short-staffed. • CCWF providers were ineffective, demonstrating insufficient assessment and poor decision-making. They often failed to examine patients when necessary and did not follow up with their patients appropriately. They neglected to review the medical records and often did not make appropriate specialty referrals. 1 Each OIG clinician team consists of a board-certified physician and a registered nurse consultant with experience in correctional and community medical settings. Central California Women’s Facility, Cycle 5 Medical Inspection Page v Office of the Inspector General State of California • CCWF nurses also performed poorly. In the nursing sick call process, nurses often failed to recognize the severity of patients’ conditions and to notify or consult with providers. In emergency services, nurses often failed to recognize dangerous medical conditions and did not intervene or notify the provider. Compliance Testing Results Of the 15 health care indicators, compliance inspectors evaluated 12.2 Four were proficient, five were adequate, and three were inadequate. There were 103 individual compliance questions within those 12 indicators, generating 1,321 data points that tested CCWF’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 103 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance The following are some of CCWF’s strengths based on its compliance scores on individual questions in all the health care indicators: • CCWF nursing staff received and reviewed patients’ Health Care Service Request forms within CCHCS policy guidelines, and housing units at the institution had Health Care Service Request forms available for patients. • Patients at CCWF received their radiology and pathology services timely. • The Health Information Management (HIM) team at CCWF did an excellent job of supporting overall patient health by timely and accurately scanning and maintaining medical records in patients’ files. Notably, the HIM indicator rating improved from inadequate in Cycle 4 to proficient in Cycle 5. • CCWF provided pregnant patients timely provider visits, and nursing staff documented vital information, such as the patients’ blood pressure and weight. The institution also offered lower-tier housing and lower-bunk accommodations to these patients and provided them with prenatal screening tests. • The institution did a good job providing preventive services, such as influenza immunizations, annual testing for tuberculosis, and cancer screenings. The Preventive Services indicator rating improved from inadequate in Cycle 4 to proficient in Cycle 5. 2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. Central California Women’s Facility, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California • CCWF did an excellent job of providing specialty services timely, and providers reviewed specialty service reports within CCHCS policy guidelines. • The institution’s pharmacy followed proper security, organization, and cleanliness management protocols; monitored non-narcotic medications; and properly controlled narcotic medications. Program Weaknesses — Compliance The following are some of the weaknesses identified by CCWF’s compliance scores on individual questions in all the health care indicators: • At CCWF, some clinics were missing equipment and supplies, and clinic common areas did not always provide visual and auditory privacy for patients at waiting areas and blood draw stations. Staff failed at some clinics to properly inventory emergency response bags, and a crash cart had expired medications. • OIG inspectors found that medication storage for non-narcotic medication that required refrigeration was poor; specifically, topical and oral medications were stored together, and staff did not properly label multi-use medications with the date the medication was opened. Also, nursing staff did not always demonstrate appropriate administrative controls during medication administration. • CCWF providers did not always complete history and physical examinations for patients who arrived through the institution’s reception center. In addition, when patients received their required screening tests, CCWF providers did not always communicate the results to patients within required time frames. • Several medication lines at CCWF did not follow proper security controls over narcotic medications and did not properly store non-narcotic medications that did not require refrigeration. • Medical clinics at CCWF did not meet requirements for essential core medical equipment and supplies. Several clinic locations were missing properly calibrated medical equipment and medical supplies necessary to provide standard medical care. • The nursing education department did not timely provide health care orientation to nursing staff who were recently hired. These nurses received orientation from one to six months late. Central California Women’s Facility, Cycle 5 Medical Inspection Page vii Office of the Inspector General State of California Recommendations • CCWF should implement strategies to evaluate, improve, and monitor the TTA nurses’ clinical performance during urgent/emergent encounters to ensure that they make appropriate and timely nursing assessments and interventions. • CCWF medical leadership, including the pharmacist in charge and staff, should implement a quality improvement process to ensure that staff properly closes encounters within the EHRS when patients transfer between CCWF units, and that staff administers medications ordered in the skilled nursing facility (SNF) timely. • CCWF medical leadership should arrange additional EHRS training for providers and nurses. The training should explain the barriers and challenges to the medication management process and should demonstrate the correct procedures to overcome those barriers within the EHRS. • Nursing and physician managers need to improve the consultation process between clinic nurses and providers; CCWF managers must ensure timely notification and communication processes are in place to handle patient situations requiring urgent medical consultation. • CCWF should provide certain specialty services, such as physical therapy. California regulations require Skilled Nursing Facilities, including CCWF to provide these services; if the service cannot be provided at the facility, then CCWF should arrange for transportation to and from the physical therapy service location. Population-Based Metrics In general, CCWF performed very well as measured by population-based metrics. In comprehensive diabetes care, CCWF outperformed other state and national organizations in nearly all of the selected areas measured. With regard to immunization measures, CCWF’s rates were on par with other state and national health care organizations as well. CCWF’s rates for colorectal cancer, cervical cancer, and breast cancer were also very strong. Overall, CCWF’s performance demonstrated by the population-based metrics indicated that the chronic care program and preventative services were well functioning compared to the other state and national health care plans reviewed. Central California Women’s Facility, Cycle 5 Medical Inspection Page viii Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducts a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. Central California Women’s Facility (CCWF) was the 19th medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is secondary because it does not reflect the actual clinical care provided. ABOUT THE INSTITUTION Located in Chowchilla, Madera County, CCWF is the state’s largest female institution and the only female prison designated as a reception center. In addition, the institution houses the state’s only death row for women. The institution runs four medical clinics that provide routine health care services. Patients also receive care at an onsite specialty clinic, and there is a separate clinic for patients in administrative segregation. At the receiving and release clinic (R&R), medical staff screen arriving and departing patients. Medical staff members also treat patients requiring urgent or emergent care at the treatment and triage area (TTA). California Correctional Health Care Services (CCHCS) has designated CCWF as a “basic” health care institution, a designation for institutions that are located in rural areas away from tertiary care centers and specialty care providers. On August 17, 2015, the institution received national accreditation from the Commission on Accreditation for Corrections. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. Based on staffing data the OIG obtained from the institution, CCWF’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was 7 percent in June 2017, with the highest vacancy percentages among primary care providers and nursing supervisors, both at 17 percent. Of note, 20 percent of the medical staff members, including all the management staff, were recent hires, having come on board at CCWF in the last 12 months. There were also six medical staff members on extended leave at CCWF. The CEO reported that in June 2017, there were four medical staff members under disciplinary review. Central California Women’s Facility, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California CCWF Health Care Staffing Resources as of June 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 4% 11.5 9% 10.8 8% 100.7 79% 128 100% Positions Filled Positions 5 100% 9.5 83% 9 83% 95 94% 118.5 93% Vacancies 0 0% 2 17% 1.8 17% 5.7 6% 9.5 7% Recent Hires (within 12 5 100% 3 32% 3 33% 13 14% 24 20% months) Staff Utilized 0 0% 1 11% 0 0% 0 0% 1 1% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 0 0% 0 0% Care Areas) Staff on 1 20% 0 0% 0 % 5 5% 6 5% Extended Leave Note: CCWF Health Care Staffing Resources data was not validated by the OIG. As of June 26, 2017, the Master Registry for CCWF showed that the institution had a total population of 2,922. Within that total population, 4.4 percent were designated as high medical risk, Priority 1 (High 1), and 6.8 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal labs and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. Central California Women’s Facility, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California CCWF Master Registry Data as of June, 2017 Medical Risk Level Number of Patients Percentage High 1 130 4.4% High 2 199 6.8% Medium 1,047 35.8% Low 1,546 52.9% Total 2,922 100% Central California Women’s Facility, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG 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, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery 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. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each state prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator addresses the administrative functions that support a health care delivery system. The CCWF Executive Summary Table on page iv of this report identifies these 15 indicators. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The case review results alone, the compliance test results alone, or a combination of both of these information sources may influence an indicator’s overall rating. For example, the OIG derives the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance entirely from the case review done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. The OIG does not inspect for efficiency or cost-effectiveness of medical operations. Consistent with the OIG’s agreement with the Receiver, this report only addresses the quality of CDCR’s medical operations and its compliance with quality-related policies. Moreover, if the OIG learns of a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by state and federal privacy laws, the OIG does not include specific identifying details related to any such cases in the public report. Central California Women’s Facility, Cycle 5 Medical Inspection Page 4 Office of the Inspector General State of California In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement are not necessarily indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 5 medical inspections. The following exhibit provides definitions that describe this process. Exhibit 1. Case Review Definitions Case = Sample = Patient An appraisal of the medical care provided to one patient over a specific period, which can comprise detailed or focused case reviews. Detailed Case Review A review that includes all aspects of one patient’s medical care assessed over a six-month period. This review allows the OIG clinicians to examine many areas of health care delivery, such as access to care, diagnostic services, health information management, and specialty services. Focused Case Review A review that focuses on one specific aspect of medical care. This review tends to concentrate on a singular facet of patient care, such as the sick call process or the institution’s emergency medical response. Case Review Event A direct or indirect interaction between the patient and the health care system. Examples of direct interactions include provider encounters and nurse encounters. An example of an indirect interaction includes a provider reviewing a diagnostic test and placing additional orders. Case Review Deficiency A medical error in procedure or in clinical judgment. Both procedural and clinical judgment errors can result in policy non-compliance, elevated risk of patient harm, or both. Adverse Deficiency A medical error that increases the risk of, or results in, serious patient harm. Most health care organizations refer to these errors as adverse events. Central California Women’s Facility, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California The OIG’s clinicians perform a retrospective case review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective case review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective case review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective case review when performing appraisals of individual primary care providers. Patient Selection for Retrospective Case Reviews Because retrospective case review is time consuming and requires qualified health care professionals to perform it, the OIG must carefully select a sample of patient records for clinician review. Accordingly, the group of patients the OIG targeted for case review carried the highest clinical risk and utilized the majority of medical services. The majority of patients selected for retrospective case review were high-utilizing patients with chronic care illnesses who were classified as high or medium risk. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective case review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population is high-risk and accounts for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for case review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it is more likely to provide adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient cases generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are more likely to comprise high-risk patients. Central California Women’s Facility, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California Benefits and Limitations of Targeted Subpopulation Review Because the patients selected utilize the broadest range of services offered by the health care system, the OIG’s retrospective case review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective case review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the institution’s ability to respond with adequate medical care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not respond adequately for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of medical conditions or outcomes from the retrospective case reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly controlled diabetes, one cannot conclude that all the diabetics’ conditions are poorly controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes, one cannot conclude that the entire diabetic population is having similarly poor outcomes. The OIG does not extrapolate conditions or outcomes, but instead extrapolates the institution’s response for those patients needing the most care because the response yields valuable system information. In the above example, if the institution responds by providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it is reasonable to infer that the institution is also responding appropriately to all the diabetics in the prison. However, if these same high-risk patients needing monitoring, medications, and referrals are not getting those needed services, it is likely that the institution is not providing appropriate diabetic services. Case Reviews Sampling Methodology Using a pre-defined case review sampling algorithm, OIG analysts apply various filters to each institution’s patient population. The various filters include medical risk status, number of prescriptions, number of specialty appointments, number of clinic appointments, and other health-related data. The OIG uses these filters to narrow down the population to those patients with the highest utilization of medical resources (see Chart 1, next page). To prevent selection bias, the OIG ensures that the same clinicians who perform the case reviews do not participate in the sample selection process. Central California Women’s Facility, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California Chart 1. Case Review Sample Selection Sample Selection Analysts apply filters to the population to obtain samples (S) with high utilization. Six permutations, Population or arrangements, of case review types are possible for each sample. S S MD RN MD RN MD RN S S S S D F D D F D Case = Sample = Patient MD RN RN D D F MD = Provider RN = Registered Nurse D = Detailed F = Focused The OIG’s case sample size matched those of other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 cases had undergone comprehensive, or detailed, clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG found the Cycle 4 medical inspection sample size of 30 for detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the OIG re-analyzed the case review results using half the number of cases; there were no significant differences in the ratings. To improve inspection efficiency while preserving the quality of the inspection, the OIG reduced the number of the samples for Cycle 5 medical inspections to the current levels. For most basic institutions, the OIG samples 20 cases for detailed physician review. For intermediate institutions and several basic institutions with larger high-risk populations, the OIG samples 25 cases. For California Health Care Facility, the OIG samples 30 cases for detailed physician review. Breadth of Case Reviews As indicated in Appendix B, Table B–1: CCWF Sample Sets, the OIG clinicians evaluated medical cases for 53 unique patients. Appendix B, Table B–4: CCWF Case Review Sample Summary clarifies that both nurses and physicians reviewed medical records for 21 of those cases, for 74 reviews in total. Physicians performed detailed reviews of 23 cases, and nurses Central California Women’s Facility, Cycle 5 Medical Inspection Page 8 Office of the Inspector General State of California performed detailed reviews of 18 cases, totaling 41 detailed reviews. Physicians and nurses also performed a limited or focused review of medical records for an additional 33 cases. These generated 1,306 clinical events for review (Appendix B, Table B–3: CCWF Event—Program). While the sample method specifically pulled only 4 chronic care patient records, i.e., 3 diabetes patients and one anticoagulation patient (Appendix B, Table B–1: CCWF Sample Sets), the 53 unique patients sampled included patients with 265 chronic care diagnoses, including 16 additional patients with diabetes (for a total of 19) and one additional anticoagulation patient (for a total of two) (Appendix B, Table B–2: CCWF Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the OIG did assess for adequacy the overall operation of the institution’s system and staff. Case Review Testing Methodology A physician, a nurse consultant, or both clinician inspectors review each case. The OIG clinician inspector can perform one of two different types of case review: detailed or focused (see Exhibit 1, p. 5, and Chart 1, p. 8). As the OIG clinician inspector reviews the medical record for each sample, the inspector records pertinent interactions between the patient and the health care system. These interactions are also known as case review events. When an OIG clinician inspector identifies a medical error, the inspector also records these errors as case review deficiencies. If a deficiency is of such magnitude that it caused, or had the potential to cause, serious patient harm, then the OIG clinician records it as an adverse deficiency (see Chart 2, next page). Central California Women’s Facility, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California Chart 2. Case Review Testing and Deficiencies Case Review Testing The OIG clinicians examine the chosen samples, performing a detailed case review or a focused case review, to determine the events that occurred. Sample = Patient = Case No Deficiency Sample Events Deficiency A sample leading to events Deficiencies Not all events lead to deficiencies (medical errors); however, if there are errors, then the OIG clinicians determine whether any are adverse. Sample Events Deficiency* A sample leading to events with deficiencies observed Adverse * If a deficiency is serious Deficiency enough, the OIG clinician labels it adverse. When the OIG clinician inspectors have reviewed all cases, they analyze the deficiencies. OIG inspectors search for similar types of deficiencies to determine if a repeating pattern of errors existed. When the same type of error occurs multiple times, the OIG inspectors identify those errors as findings. When the error is frequent, the likelihood is high that the error is regularly recurring at the institution. The OIG categorizes and summarizes these deficiencies in one or more health care quality indicators in this report to help the institution focus on areas for improvement. Central California Women’s Facility, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California Additionally, the OIG physicians also rate each of the detailed physician cases for adequacy based on whether the institution met the patient’s medical needs and if it placed the patient at significant risk of harm. The cumulative analysis of these cases gives the OIG clinicians additional perspective to help determine whether the institution is providing adequate medical services or not.4 Based on the collective results of clinicians’ case reviews, the OIG clinicians rated each quality indicator proficient (excellent), adequate (passing), or inadequate (failing). A separate confidential CCWF Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews the OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B-1; Table B-2; Table B-3; and Table B-4. 4 Regarding individual provider performance, the OIG did not design the medical inspection to be a focused search for poorly performing providers; rather, the inspection assesses each institution’s systemic health care processes. Nonetheless, while the OIG does not purposefully sample cases to review each provider at the institution, the cases usually involve most of the institutions’ providers. Providers should only escape OIG case review if institutional managers assigned poorly performing providers the care of low-utilizing and low-risk patients, or if the institution had a relatively high number of providers. Central California Women’s Facility, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California COMPLIANCE TESTING Sampling Methods for Conducting Compliance Testing From July to September 2017, registered nurse inspectors obtained answers to 103 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 445 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of July 17, 2017, registered nurse field inspectors conducted a detailed onsite inspection of CCWF’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,321 scored data points to assess care. In addition to the scored questions, the OIG obtained information from the institution that it did not score. This included, for example, information about CCWF’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. Scoring of Compliance Testing Results After compiling the answers to the 103 questions for the 12 applicable indicators for which compliance testing was applicable, the OIG compliance team derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the Central California Women’s Facility, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for CCWF, the OIG reviewed some of the compliance testing results, randomly sampled additional patients’ records, and obtained CCWF data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. Central California Women’s Facility, Cycle 5 Medical Inspection Page 13 Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The OIG’s case review and clinician teams use quality indicators to assess the clinical aspects of health care. The CCWF Executive Summary Table on page iv of this report identifies the 15 indicators applicable to this institution. The following chart depicts their union and intersection: Chart 3. Inspection Indicator Review Distribution Case Review Compliance 1 — Access to Care 2 — Diagnostic Services 4 — Health Information Management 3 — Emergency 5 — Health Care Services 6 — Inter- and Intra-System Environment Transfers 10 — Quality of 9 — Preventive Nursing 7 — Pharmacy and Medication Performance Management Services 11 — Quality of 15 — Administrative 8 — Prenatal and Post-Delivery Provider Operations Services Performance 12 — Reception Center Arrivals 13 — Specialized Medical Housing 14 — Specialty Services The Administrative Operations indicator is a secondary indicator; therefore, the OIG did not rely upon this indicator when determining the institution’s overall score. Based on the analysis and results of all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at CCWF was inadequate. Summary of Case Review Results: The clinical case review component assessed 12 primary (clinical) indicators applicable to CCWF. Of these 12 indicators, OIG clinicians rated one proficient, four adequate, and seven inadequate. The OIG physicians rated the overall adequacy of care for each of the 23 detailed case reviews they conducted. Of these 23 cases, 16 were adequate, and 7 were inadequate. In the 1,306 events reviewed, there were 341 deficiencies, 103 of which were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Central California Women’s Facility, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California Adverse Deficiencies Identified During Case Review: Adverse deficiencies are medical errors that markedly increased the risk of, or resulted in, serious patient harm. Medical care is a complex and dynamic process with many moving parts, subject to human error even within the best health care organizations. All major health care organizations typically identify and track adverse deficiencies for the purpose of quality improvement. Adverse deficiencies are not typically representative of medical care delivered by the organization. However, the unusually high number and severity of adverse deficiencies at CCWF correlated with the overall Cycle 5 rating for the institution. The OIG normally identifies adverse deficiencies for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal nature of these deficiencies, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse deficiencies. There were ten adverse deficiencies at CCWF: • In case 1, the patient had severe abdominal pain and vomiting. The nurse did not inquire about other related symptoms, such as nausea, or if the patient had a bowel movement. The nurse did not listen for the patient’s bowel sounds. Instead, the nurse released the patient back to her housing unit with unresolved abdominal pain without notifying the provider on call. The patient needed further evaluation and possible treatment for the patient’s severe abdominal pain. The Emergency Services indicator also discusses this case. • In case 2, the patient had a history of chronic anemia (low levels of red blood cells) and a recent diagnosis of rectal cancer. She had severe abdominal pain and activated the medical alarm due to unrelenting pain. In the TTA, the nurse did not evaluate her abdominal pain, recognize the significance of the patient’s elevated blood pressure, recognize the patient’s need for pain relief, or notify the provider on call. After the nurse told the patient to stop activating the medical alarm to request pain medication, the patient refused further care in the TTA, and the nurse released the patient back to her housing unit with unresolved, severe abdominal pain. The nurse failed to properly arrange for evaluation or seek pain relief for the cancer patient. The next day, the patient was unresponsive in her housing unit. She died despite emergency CPR measures. The Quality of Nursing Performance, Quality of Provider Performance, Emergency Services, and Inter and Intra-System Transfers indicators also discuss this case. • In case 8, the patient developed worsening back pain, associated with loss of feeling in her legs. The patient placed five separate sick call requests, and a nurse saw the patient each time. The nurses failed to recognize the urgency of the patient’s condition and did not notify the provider, even after the patient developed unsteady gait and began to fall repeatedly. The nurse did not consider the possibility of acute spinal cord compression, which can potentially lead to more falls and injury from the weakening of the lower Central California Women’s Facility, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California extremities. The patient needed an emergent evaluation for possible surgery. The Quality of Nursing Performance indicator also discusses this case. • In case 9, the nurse failed to implement the chest pain protocol immediately for a patient with chest pain, nausea, and elevated blood pressure. The delay in the emergent intervention placed the patient at risk of cardiac complications. The Emergency Services indicator also discusses this case. • In case 19, the patient developed weakness, fever, and chills. The TTA RN did not recognize the need to evaluate the patient urgently, and inappropriately canceled the patient’s TTA evaluation without consulting a provider. This decision placed the patient at risk of worsening infection. The patient was hospitalized a week later with pneumonia. The Emergency Services indicator also discusses this case. • In case 21, the nurse did not consider the possibility of a leg blood clot for the patient’s complaint of an acute swollen right leg and did not refer this complaint to the provider that same day for urgent intervention. There was a four-day delay in care, during which the patient could have suffered severe complications or even death. Fortunately, the patient did not have a blood clot. The Quality of Nursing Performance indicator also discusses this case. • In case 23, the diabetic patient developed chest pain. The nurse did not implement the chest pain protocol or notify the provider on call. The Emergency Services indicator also discusses this case. • In case 36, the nurse did not implement the chest pain protocol, did not perform an EKG, and did not notify the provider on call about this patient’s complaints of chest pain and body pain. The failure to implement the chest pain protocol placed this patient at increased risk of cardiac complication. • In case 49, after the RN referred the patient for symptoms of her significant anemia, the provider failed to examine the patient for causes of anemia or the need for a possible urgent blood transfusion. When the provider saw the patient in the clinic the following week, the provider did not address or evaluate the potential causes of anemia and did not review the recent laboratory test results of this patient. The Quality of Provider Performance indicator also discusses this case. • In case 55, the provider prescribed a medication with a maximum dose of 10 tablets per month. Instead, CCWF administered 50 tabs in the first month, and 80 tablets in each of the following two months. In another month, CCWF administered 20 tablets. The Pharmacy and Medication Management indicator also discusses this case. Central California Women’s Facility, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California Summary of Compliance Results: The compliance component assessed 12 of the 15 indicators. Of these 12 indicators, OIG inspectors rated four proficient, five adequate, and three inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. Central California Women’s Facility, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: patients with timely clinical appointments. Inspectors review Inadequate areas specific to patients’ access to care, such as initial Compliance Score: assessments of newly arriving patients, acute and chronic care Adequate follow-ups, face-to-face nurse appointments when patients (83.2%) request to be seen, provider referrals from nursing lines, and Overall Rating: follow-ups after hospitalizations or specialty care. Compliance Inadequate testing for this indicator also evaluates whether patients have Health Care Services Request forms available in their housing units. For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning an inadequate rating and the compliance review resulting in an adequate score. The OIG’s internal review process considered those factors that led to both scores. Poor provider access for patients referred from nurses and for those who had just arrived to the institution placed patients at increased risk of harm. The OIG ultimately rated this indicator inadequate. Case Review Results The OIG clinicians reviewed 341 provider, nurse, specialty, and hospital events that required follow-up appointments and identified 52 deficiencies relating to access to care, 28 of which were significant. The rating for the Access to Care indicator was inadequate. Provider-to-Provider Follow-up Appointments CCWF performed acceptably with provider-ordered follow-ups. There were 60 provider ordered follow-ups reviewed, and the OIG clinicians identified eight deficiencies. RN Sick Call Access CCWF performed well with nursing sick call access. There were 87 sick call face-to-face requests events reviewed. There were only five deficiencies in this area, which was an improvement compared to Cycle 4. RN-to-Provider Referrals CCWF performed poorly with RN-to-provider referrals. Of the 37 referrals reviewed, there were 11 deficiencies, of which three were significant. In the following examples, the appointments should have occurred within two weeks: • In case 47, the nurse referred the patient to the provider for a new breast lump, which may have been breast cancer. The appointment did not occur for more than four weeks. Central California Women’s Facility, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California • In case 51, the nurse referred the patient to the provider for complaints of leg and finger pain. The appointment did not occur for nearly five weeks. • In case 54, the nurse referred the patient to the provider for shoulder problems. The appointment did not occur as scheduled for more than five weeks. RN Follow-up Appointments CCWF performed appropriately with RN follow-ups. There was only one significant deficiency out of 18 ordered RN follow-up appointments: • In case 43, the patient had a worsening rash despite using several different ointments and creams. The provider ordered antibiotics and a nurse follow-up appointment in seven days, but the nurse appointment did not occur. Provider Follow-up after Specialty Services CCWF performed sufficiently by providing follow-up appointments after specialty services. Of the 137 specialty events that needed provider follow-up, the OIG clinicians identified seven deficiencies, including the following two examples: • In case 21, the patient saw an endocrine specialist regarding the patient’s thyroid condition, but the provider follow-up did not occur not until 14 weeks later. • In case 26, the patient saw a blood specialist regarding iron deficiency anemia, but CCWF delayed the provider follow-up to discuss the recommendations by three months. Inter- and Intra-System Transfers / Reception Center CCWF did not ensure provider appointments for newly arrived patients. The OIG reviewed the cases for 13 newly arrived patients. There were follow-up deficiencies in four of the cases, three of which were significant: • In case 2, the patient arrived from the county jail with a fractured kneecap. The RN referred her for a next-day provider appointment, but the appointment did not occur. The institution also failed to provide the required seven-day provider appointment for an intake examination. • In case 10, the patient transferred from another institution and had a chronic lung condition. The provider appointment occurred beyond the required 30 days. When the provider saw the patient 55 days after her arrival, the provider failed to discuss her lung condition. Central California Women’s Facility, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California • In case 36, the patient arrived at CCWF and should have received an intake examination within seven days. Instead, she received a follow-up appointment for the required intake examination 24 days after arrival. Follow-up After Hospitalization The institution is required to ensure that their providers see patients returning from the hospital or the emergency department within five days. The providers saw the majority of these returning patients within the required time. Among 26 events, the OIG clinicians identified only one minor deficiency. Follow-up After Urgent/Emergent Care CCWF performed acceptably with ensuring that the providers followed patients after they were discharged from the TTA. The OIG clinicians reviewed 52 urgent/emergency care events in which patients required provider follow-ups. There were seven follow-up deficiencies, of which five were significant: • In case 22, the provider appointment to follow up on the patient’s rash and itching occurred ten days late. • In case 23, the patient made multiple visits to the TTA for chest pain, fainting episodes, and chest pain. On four occasions, the provider follow-up appointments were significantly delayed (7, 14, 21, and 24 days late). Specialized Medical Housing The skilled nursing facility (SNF) medical provider saw patients within medically appropriate time intervals. The provider was readily available for consultation. The provider usually performed admitting history and physical exams the day following each patient’s admission. There were no deficiencies in this subcategory. Specialty Access and Follow-up CCWF was typically able to provide patients with access to specialty care. The OIG clinicians reviewed 137 specialty access events. There were eight deficiencies, of which six were significant. The Specialty Services indicator also discusses performance in this area. Clinician Onsite Inspection At the time of the onsite inspection, there was no backlog for RN appointments. The backlog for the providers was approximately 340 appointments, of which 103 were already past due. Most of the backlogged provider appointments were for pap smears and for referrals from the nurses. There were no significant backlogs for chronic care appointments. CCWF leaders explained that recently hired providers should improve patient appointment backlogs in future months. The CME reported Central California Women’s Facility, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California that CCWF had successfully filled all provider positions, but two of the providers were on extended leave. Case Review Conclusion Compared to Cycle 4, the OIG clinicians found access to care improved in several areas, including nursing sick call, provider-ordered follow-up, provider follow-up after specialty consultation, and provider follow-up after a hospitalization. However, CCWF still demonstrated poor performance for RN-to-provider referrals and provider referrals for newly arrived patients. The case review rating for the Access to Care indicator was inadequate. Compliance Testing Results The institution performed in the adequate range in the Access to Care indicator, with a compliance score of 83.2 percent. Five tests earned scores in the proficient range, as follows: • Inspectors sampled 30 Health Care Services Request forms (CDCR Form 7362) submitted by patients across all facility clinics. Nursing staff reviewed all service request forms on the same day they were received (MIT 1.003). • The one patient sampled who was referred to and seen by a provider and for whom the provider subsequently ordered a follow-up appointment was seen for her follow-up appointment timely (MIT 1.006). • Patients had access to health care services request forms at all six housing units the OIG inspected (MIT 1.101). • Among the 25 sampled patients who were discharged from a community hospital, 22 (88 percent) received a timely PCP follow-up appointment upon their return to CCWF. Two patients received their follow-up appointments one and two days late; for one final patient, there was no evidence found that she received a follow-up appointment (MIT 1.007). • For 26 of the 30 patients sampled who submitted health care services requests (87 percent), nursing staff completed a face-to-face encounter within one business day of reviewing the service request form. In the four exceptions, the nurse conducted the visit one or two days late (MIT 1.004). One test scored in the adequate range: • Inspectors sampled 29 patients who received a routine or high-priority specialty service; 24 of them (83 percent) received a timely follow-up appointment with a provider. Two patients’ routine follow-up appointments were six and seven days late; for one other Central California Women’s Facility, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California patient, there was no evidence that the routine follow-up appointment occurred. Two patients’ high-priority follow-up appointments occurred 15 and 17 days late (MIT 1.008). Three tests received scores in the inadequate range: • Among 25 patients sampled who transferred into CCWF from other institutions and were referred to a provider based on nursing staff’s initial health care screenings, only 13 (52 percent) were seen timely. Four patients received their provider appointments from 14 to 42 days late; four patients received their appointments 61 to 114 days late; two patients received their appointments 187 and 188 days late, and for two final patients, no medical record evidence was found to indicate they were ever seen (MIT 1.002). • Inspectors sampled 25 patients who suffered from one or more chronic care conditions; only 17 received their provider ordered follow-up appointments timely (68 percent). Eight other patients received their appointments late or not at all, including three patients whose follow-up appointments occurred between 23 and 33 days late; four patients whose appointments were between 88 and 151 days. One final patient received an appointment for one of her chronic care conditions 45 days late, but she also had two other conditions which were not addressed by a provider in follow-up appointments (MIT 1.001). • For seven health care service requests sampled on which the nursing staff referred the patient for a provider appointment, five of the patients (71 percent) received a timely appointment. For two patients the follow-up appointments occurred 19 and 34 days late (MIT 1.005). Central California Women’s Facility, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether the institution provided timely Proficient radiology and laboratory services to patients, whether the primary Compliance Score: care provider timely reviewed the results, and whether the provider Adequate timely communicated the results to the patients. In addition, for (76.7%) pathology services, the OIG determines whether the institution Overall Rating: received a final pathology report and whether the provider timely Adequate reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning a proficient rating and the compliance review resulting in an adequate score. The OIG’s internal review process considered those factors that led to both scores. The compliance findings of delayed laboratory tests and the delayed provider review of radiology and laboratory tests were important and could result in lapses in care. However, most diagnostic testing was sufficient at CCWF and the OIG ultimately rated this indicator adequate. Case Review Results The OIG clinicians reviewed 201 applicable diagnostic events and found nine deficiencies. Of the nine deficiencies, there was only one where the external laboratory failed to complete an ordered test. The other eight deficiencies involved health information management; four of these were significant. Test Completion CCWF completed diagnostic tests as ordered, and the OIG found only one deficiency: • In case 29, the TTA nurse submitted an urgent blood test for processing by the laboratory service provider, but the offsite laboratory did not pick up the blood sample. Health Information Management Staff correctly retrieved, reviewed, and relayed most laboratory reports to their patients. Among 201 diagnostic tests the OIG clinicians reviewed, there were only four significant deficiencies: • In case 17, a surgeon recommended an X-ray to help locate a bullet before deciding to remove it. The patient’s primary care provider ordered the X-ray but reviewed the result four weeks late. Central California Women’s Facility, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California • In case 19, the provider did not review an abnormal chest X-ray until six days after the test (four days late). This delay placed the patient at risk of worsening pneumonia. • Also in case 19, a computer malfunction prevented the laboratory service provider from transmitting test results to the EHRS. This malfunction resulted in an eight-day delay before the diagnostic staff notified the provider about the result of a urine culture. • In case 20, the esophageal biopsy pathology report was incorrectly scanned with the title “Headaches Protocol—Text.” This important but misfiled report would be difficult to locate during subsequent medical encounters. Case Review Conclusion CCWF staff properly performed, retrieved, reviewed, and communicated most diagnostic tests to patients. Diagnostic errors were rare. The case review rating of the Diagnostic Services indicator at CCWF was proficient. Compliance Testing Results The institution received an adequate compliance score of 76.7 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below: Radiology Services • CCWF timely performed radiology services for all ten patients sampled (MIT 2.001). CCWF providers timely reviewed the corresponding diagnostic services reports for only seven of the ten patients (70 percent); providers reviewed two patients’ reports five and eight days late, and for one patient, no evidence was found that the report was reviewed (MIT 2.002). Providers timely communicated the test results to only six of the ten patients (60 percent); they communicated three patients’ results from 5 to 23 days late. For one final patient, there was no evidence found that the diagnostic service result was communicated to her at all (MIT 2.003). Laboratory Services • Seven of ten sampled patients (70 percent) received their provider-ordered laboratory services timely; three of the ten services were provided 28, 35, and 65 days late (MIT 2.004). The institution’s providers reviewed six of the ten resulting laboratory service reports within the required time frame (60 percent); three reports were reviewed one, two, and 15 days late. For one other report, there was no evidence found to indicate that it had been reviewed (MIT 2.005). Finally, providers timely communicated the report results to only four of the ten patients (40 percent); five patients received results from 2 to Central California Women’s Facility, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California 26 days late. For one final patient, there was no evidence that the report result was ever communicated to her (MIT 2.006). Pathology Services • CCWF timely received the final pathology report for all ten patients sampled (MIT 2.007). Providers also properly evidenced their review of the pathology results for all ten sampled reports (MIT 2.008). Finally, providers timely communicated the final pathology results to nine of the ten patients sampled (90 percent). For one final report sampled, there was no evidence found in the medical record that it was ever communicated to the patient (MIT 2.009). Central California Women’s Facility, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing effective and timely emergency medical response, assessment, Case Review Rating: Inadequate treatment, and transportation, 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG Overall Rating: reviews emergency response services, including first aid, basic life Inadequate support (BLS), and advanced cardiac life support (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 81 urgent/emergent medical response events. There were 47 deficiencies, of which 14 were significant. CCWF provider and nursing staff’s failure to provide appropriate assessments or interventions was the primary cause of the significant deficiencies. CPR Response In the emergency medical response cases reviewed, medical and custody staff responded promptly and initiated CPR when needed. Nursing staff responded quickly and performed resuscitative measures properly. Nursing staff activated 9-1-1 when appropriate and necessary. Provider Performance The CCWF provider performance in emergencies was usually sufficient. In most cases, providers made appropriate triage assessments and decisions. However, there were nine deficiencies, three of which were significant: • In case 2, the patient had a history of chronic anemia (low red blood cell levels) and rectal cancer. On one occasion, the TTA RN attempted to reach the provider on call, but the provider did not respond until 45 minutes later. • Also in case 2, after she had surgery to remove cancer, the patient developed severe abdominal pain. When notified, one provider failed to evaluate the patient. Instead, the provider increased the dose of the patient’s pain medication, which could have potentially worsened an intestinal bowel obstruction. • In case 9, the TTA RN attempted to reach the provider on call, but the provider did not respond for more than one hour. Central California Women’s Facility, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California CCWF on-call providers occasionally did not document their telephone progress notes (cases 1 and 9). They also sometimes failed to order appropriate follow-up appointments for their patients (cases 1 and 23). Nursing Performance CCWF nurses provided poor emergency services. The OIG clinicians identified 38 nursing deficiencies in this area, of which 11 were significant. The TTA nurses repeatedly made errors, which included incomplete nursing assessments, failures to intervene appropriately for chest pain, failures in recognizing dangerous symptoms, and failures to notify providers when patients warranted further evaluation and treatment. The following are some of these significant deficiencies: • In case 1, the patient had severe abdominal pain and vomiting. The nurse did not inquire about other related symptoms, such as nausea, or about whether the patient had a bowel movement. The nurse did not listen for the patient’s bowel sounds. Instead, the nurse released the patient back to her housing unit with unresolved abdominal pain without notifying the physician on call. The patient needed further evaluation and possible treatment for severe abdominal pain. • In case 2, the patient had a history of chronic anemia (low red blood cell levels) and the recent removal of rectal cancer. After her surgery, she developed severe abdominal pain. The nurses repeatedly failed to properly assess the patient or notify a provider despite her ongoing symptoms and requests for help. During one of these encounters, custody staff activated the medical alarm due to the patient’s unrelenting pain. In the TTA, the nurse did not evaluate the patient’s abdominal pain, did not recognize the significance of the patient’s elevated blood pressure, did not recognize the patient’s need for pain relief, and did not notify the provider on call. After the nurse told the patient to stop activating the medical emergency system to request pain medication, the patient refused further care in the TTA, and the nurse released the patient back to her housing unit with unresolved, severe abdominal pain. The nurse failed to properly arrange for evaluation or seek additional pain relief for the cancer patient. The next day, CCWF staff found the patient unresponsive in her housing unit. She died despite emergency medical CPR measures. • In case 8, the TTA nurse evaluated the patient with numbness, stiffness, and pain in both legs. She had fallen several times. The nurse did not evaluate the patient’s lower extremities for sensation or circulation. The nurse did not review the patient’s two-month history of back pain and worsening numbness. The nurse also did not notify the physician on call and instead inappropriately sent the patient back to her housing unit. The nurse failed to recognize the presenting symptoms that could have represented serious spinal cord damage. Furthermore, by sending the patient back to her housing unit when she was at high risk for recurrent falls, the nurse disregarded patient safety issues and the potential risk of physical injury. Central California Women’s Facility, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California • In case 9, the patient had symptoms suggestive of a possible heart attack. The patient informed the TTA nurse that she had already taken pain medication and three doses of nitroglycerin, which did not relieve the pain. The nurse did not notify the physician on call until 30 minutes after the patient’s arrival at the TTA, and the physician did not return the call for an additional 25 minutes. The TTA nurse improperly delayed implementation of the CCHCS nursing chest pain protocol by not administering aspirin or nitroglycerin (medications needed to help potential heart attack victims). Furthermore, even after the physician finally gave the telephone order to implement the chest pain protocol, the nurse still did not administer the proper medications for almost 30 minutes. • In case 19, the patient with a possible infection presented to the medication nurse with complaints of weakness, chills, and fever. The medication nurse called the TTA RN, who instructed the medication nurse to bring the patient to the TTA. The patient never arrived at the TTA because the TTA RN subsequently canceled the TTA evaluation. By refusing to evaluate the patient, the RN placed the patient at risk of harm due to delayed evaluation and treatment of a possible infection. A week later, a CCWF provider diagnosed the patient with pneumonia and the patient required hospitalization for antibiotic treatment. • In case 23, there were three significant deficiencies: o The TTA RN responded to the housing unit for a diabetic patient who was having a seizure. By the time the RN arrived, the patient was no longer seizing. The nurse did not evaluate the patient for injuries, did not review the patient’s current insulin administration or blood sugar levels, and did not notify the provider about the patient’s first-time seizure. The nurse inappropriately released the patient back to the housing unit without investigating the cause of the seizure. o On another occasion, the patient complained of sharp chest pain. The TTA nurse did not follow the CCHCS nursing chest pain protocol. The nurse failed to assess for non-cardiac chest wall pain, did not obtain an EKG, did not place the patient on a cardiac monitor, and did not administer aspirin and nitroglycerin. The nurse checked vital signs only once during the encounter and did not notify the provider about the patient’s chest pain. Lack of appropriate chest pain assessment placed the patient at increased risk of complications due to potential delayed treatment. o The third significant deficiency occurred when the patient lost consciousness while out in the yard. The patient had low blood sugar and became more responsive after a psychiatric technician administered sugar tablets. Upon arrival to the scene, the TTA RN did not evaluate the patient for possible injury or the presence of needle marks. The nurse did not reassess the patient’s vital signs before releasing her back to custody staff. The TTA nurse did not notify the provider of the incident and did not schedule a follow-up appointment with either the primary care provider or the clinic RN. Central California Women’s Facility, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California Nursing Documentation The OIG clinicians identified numerous documentation deficiencies during the review of urgent/emergent encounters. The first medical responders often did not document their initial patient assessment findings upon arrival to the scene of the emergency medical response. For example, the patient in case 23 had several emergency medical response encounters. The first medical responders did not document a description of the seizure activity, whether the patient had fallen, or if the patient had any injuries. During the onsite visit interviews, the first medical responders admitted that they did not always enter the first medical responder information in the electronic medical record. Instead, they inappropriately relied on the TTA RN to document second-hand information from the emergency response scene. Emergency Medical Response Review Committee The OIG clinicians reviewed the EMRRC minutes for several case reviews in which poor nursing care occurred. The EMRRC did not recognize the poor care and did not address delays in the transfer of patients from the yards and housing units to the TTA. • For example, in case 2, it took 30 minutes for the emergency response van to transport the patient with abdominal pain from the yard to the TTA. The EMRRC did not address the reason for the 30-minute transportation delay. Clinician Onsite Inspection The TTA had two clean and orderly rooms with two gurneys in each room and readily available crash cart, oxygen supply, and other emergency equipment. While there were two RNs per shift, the TTA staff identified the need for a third nurse due to multiple medical emergencies that often occurred simultaneously. Additionally, CCWF used the TTA for non-urgent follow-up care, including on weekends and holidays. Examples of non-urgent care included provider follow-up visits, wound care, blood pressure checks, and medication administration. The TTA provider also cared for SNF patients during weekdays, while the provider on call covered patients in the TTA and SNF on weeknights and weekends. The TTA provider admitted during interviews that the patient load became very difficult to handle at times. Case Review Conclusion Providers on call often failed to timely respond. The TTA nurses often made critical errors in judgment and decision making for patients with potentially high-risk conditions. CCWF performed poorly regarding emergency services, and the case review rating was thus inadequate. Central California Women’s Facility, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information to Adequate make sound judgments and decisions. This indicator examines Compliance Score: whether the institution adequately manages its health care Proficient information. This includes determining whether the information is (93.0%) correctly labeled and organized and available in the electronic Overall Rating: medical record; whether the various medical records (internal and Proficient external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic medical record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores. The OIG clinicians found very few provider and nursing deficiencies related to health information management. The few deficiencies identified did not affect the delivery of patient care. As a result, the OIG’s medical inspection team concluded that the appropriate overall rating for this indicator was proficient. Case Review Results Among 1,306 reviewed events, 39 deficiencies occurred related to health information management, 14 of which were significant. The low frequency of errors represented good performance in this indicator. Hospital Records CCWF performed well with hospital records. Staff properly retrieved and scanned hospital and emergency department summaries. Staff also forwarded copies of these records to providers for their review and signature. The providers reviewed and signed nearly all the summaries appropriately. The Quality of Provider Performance indicator addresses the deficiencies associated with failure to review these records. Specialty Services CCWF had significant problems with specialty records. Staff failed to retrieve or to retrieve timely numerous specialty reports. The Specialty Services indicator further discusses performance in this area. Central California Women’s Facility, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California Diagnostic Reports The institution performed well with diagnostic reports. The Diagnostic Services indicator further discusses performance in this area. Urgent/Emergent Records CCWF performed well with emergency documentation. There were only four minor deficiencies in the form of missing documents in the TTA. Incomplete Documentation The OIG clinicians identified a strong pattern of minor deficiencies whereby nursing documentation was incomplete or lacking. Cases 4, 8, 9, 17, 18, 19, 23, 52, and 53 had missing documentation. Most of these deficiencies occurred when nurses did not properly document the care they provided. The Quality of Nursing Performance indicator further discusses these problems. Legibility For most records, legibility was not a problem because the records were dictated or typewritten directly into the EHRS. However, the specialty consultation notes were sometimes difficult to decipher because the institution often failed to retrieve the dictated specialty reports. Scanning Performance When CCWF medical records staff properly retrieved reports, they usually scanned them promptly. Case Review Conclusion CCWF performed well in most areas in Health Information Management, except regarding missing nursing documentation and specialty reports. The case review rating was adequate. Compliance Testing Results With a compliance score of 93.0 percent, CCWF performed very well in the Health Information Management indicator. The following four tests earned proficient scores: • Health Information Services staff timely scanned all five sampled non-dictated progress notes into the patients’ electronic medical records (MIT 4.001). • CCWF scored 100 percent in its labeling and filing of documents scanned into patients’ electronic medical records. For this test, the OIG bases its score on a maximum allowance of 24 mislabeled or misfiled documents; OIG inspectors found no mislabeled or misfiled documents (MIT 4.006). Central California Women’s Facility, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California • The OIG tested 20 patients’ discharge records to determine if staff timely scanned the records into the patients’ electronic medical records. Nineteen of the 20 samples (95 percent) were compliant. One record was scanned four days late (MIT 4.004). • Institution staff timely scanned 18 of 20 specialty reports sampled into patients’ electronic medical records (90 percent). The other two specialty reports were both scanned three days late (MIT 4.003). One test earned an adequate score: • The OIG reviewed discharge reports for 25 sampled patients sent to an outside community hospital. For 20 of the 25 patients (80 percent), the discharge reports were complete and timely reviewed by CCWF providers. For four patients, providers reviewed the hospital discharge summary reports two to four days late. For one other patient, there was no evidence found that a provider reviewed the discharge report at all (MIT 4.007). Central California Women’s Facility, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for patient visits, Inadequate (61.7%) and the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is Overall Rating: based entirely on the compliance testing results from the visual Inadequate observations inspectors make at the institution during their onsite visit. The OIG’s compliance team alone evaluates this indicator. There is no case review portion. Compliance Testing Results The institution received an inadequate compliance score of 61.7 percent in the Health Care Environment indicator, and needs to improve in 6 of 11 test areas, as described below: • The non-clinic bulk medical supply storage areas did not meet the supply management process and support needs of the medical health care program, earning CCCWF a score of zero on this test. CCWF stored medical supplies directly on the floor (MIT 5.106) (Figure 1). • Only two of ten clinic locations (20 percent) met compliance requirements for essential core medical equipment and supplies. The remaining eight Figure 1: Medical supplies stored directly on floor. clinics were missing one or more functional pieces of properly calibrated core equipment or other medical supplies necessary to conduct a comprehensive exam. The missing items included a nebulization unit, hemoccult cards and developers, and an emergency delivery kit. In addition, the AED, oto-ophthalmoscope, and nebulization units had expired calibration stickers (MIT 5.108). • Only four of the ten clinics inspected followed adequate medical supply storage and management protocols (40 percent). Medical supplies at six clinics had one or more of the following deficiencies identified: medical supplies were not clearly identifiable; Central California Women’s Facility, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California germicidal disposable cloths were stored together with medical supplies; and multiple medical supplies were stored beyond manufacturers’ guidelines (MIT 5.107). • Clinic common areas at four of nine clinics (44 percent) had an environment conducive to providing medical services. The vital sign stations in three clinics compromised patients’ auditory privacy. In five clinics, the following deficiencies occurred: vital signs stations were too close to the patient waiting areas, which prevented auditory privacy; patient waiting areas did not have sufficient seating; blood draw stations did not provide reasonable auditory privacy; and medication areas lacked adequate space for medication nurses to perform their preparation and medication administration duties (MIT 5.109) (Figure 2). • Inspectors examined emergency response bags (EMRB) to determine if CCWF staff inspected them daily, inventoried them Figure 2: Vital signs station too close to patient waiting areas; no auditory privacy. monthly, and if they contained all essential items. Emergency response bags were compliant in only four of the nine clinical locations where they were stored (44 percent). One or more of the following deficiencies occurred in these locations: an inventory of the EMRB had been not completed in the previous 30 days; the EMRB log showed that staff did not inspect or verify that the EMRB’s compartments were sealed and intact; the crash cart had multiple medical supplies that were stored beyond manufacturers’ guidelines (MIT 5.111). • OIG inspectors observed clinician encounters with patients in ten clinics. Clinicians followed good hand hygiene practices in six clinics (60 percent). At four clinic locations, clinicians failed to wash their hands before or after patient contact; or before applying gloves (MIT 5.104). Five tests earned scores in the proficient range: • Inspectors examined CCWF’s ten clinics to verify that adequate hygiene supplies were available and sinks were operable; all clinics were compliant (MIT 5.103). • Health care staff at all ten clinics followed proper protocols to mitigate exposure to blood borne pathogens and contaminated waste (MIT 5.105). Central California Women’s Facility, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California • CCWF appropriately disinfected, cleaned, and sanitized nine of ten clinic locations inspected (90 percent). Staff did not appropriately maintain the cleaning log in one clinic (MIT 5.101). • Clinical health care staff at nine of ten applicable clinics (90 percent) correctly sterilized or disinfected reusable invasive and non-invasive medical equipment. In one clinic, staff maintained a sterilization log for reusable invasive medical equipment only (MIT 5.102). • Nine of ten clinic exam rooms observed (90 percent) had appropriate space, configuration, supplies, and equipment to allow clinicians to perform a proper clinical examination. One clinic had furniture in disrepair; there was an exam table with a torn vinyl cover (MIT 5.110). Non-Scored Results • The OIG gathered information to determine if the CCWF maintained the institution’s physical infrastructure in a manner that supported health care management’s ability to provide timely or adequate health care. The OIG does not score this question. When OIG inspectors interviewed health care managers, they did not identify any significant concerns. At the time of the OIG’s medical inspection, CCWF had several significant infrastructure projects underway, which included building a new pharmacy, increasing clinic space for four yards, expanding medication distribution areas, remodeling the TTA, and creating a new space for an OB/GYN clinic. These projects started in summer 2015, and the institution estimated that these projects would be completed by the end of fall 2018 (MIT 5.999). Central California Women’s Facility, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical Case Review Rating: needs and continuity of patient care during the inter- and Inadequate intra-system transfer process. The patients reviewed for this Compliance Score: indicator include those received from, as well as those transferring Adequate (75.1%) out to, other CDCR institutions. The OIG review includes evaluation of the institution’s ability to provide and document Overall Rating: health screening assessments, initiation of relevant referrals based Inadequate on patient needs, and the continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the institution, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning an inadequate rating and the compliance review resulting in an adequate score. The OIG’s internal review process considered those factors that led to both scores. The deficient processes for patients transferring out of the institution and returning from a community hospital placed patients at increased risk of harm. For these reasons, the OIG rated this indicator inadequate. Case Review Results The OIG clinicians reviewed 22 cases that generated 47 inter- and intra-system transfer events, including information from both the sending and receiving institutions. These included 26 hospitalization and outside emergency room events that resulted in a transfer back to the institution. There were 15 deficiencies, 9 of which were significant. Transfers In CCWF properly screened patients who transferred into CCWF from other institutions. Receiving nurses reviewed medication administration summaries to verify all medications had arrived in the receiving envelopes. If the prior institution did not send the patient’s durable medical equipment, the receiving nurses ordered the items needed or ensured that a provider did so. The nurses notified the primary care team about new arrivals and communicated to the primary care provider information regarding pending specialty appointments. Designated primary care providers usually scheduled high-risk patients for evaluation within seven calendar days. While the process for Central California Women’s Facility, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California receiving patients from other CDCR institutions was satisfactory, there was one significant deficiency identified in the cases the OIG reviewed: • In case 10, the provider did not see the patient for her chronic lung condition until 55 days after her arrival. At that appointment, the provider failed to address the patient’s lung condition. Transfers Out At CCWF, the intended transfer-out process began one week in advance of the patient’s transfer date, when custody staff provided medical staff with the names of inmates leaving the institution. The health care team prepared the transfer envelopes with the patient’s health information summary sheet, a three-day supply of medications, disability and effective communication system report, and transfer checklist. The RN ensured that the patient had not developed any urgent/emergent illness condition that may have required medical evaluation. If necessary, the RN initiated a medical hold to prevent the transfer of a patient with an unstable condition. The RN then notified the appropriate provider and held the patient’s transfer until the provider medically cleared the patient for transfer. CCWF had considerable difficulty performing the final transfer step. In five of the six cases reviewed, an RN did not evaluate the patient prior to her transfer. • In cases 4, 6, 7, and 33, the patient transferred to another CDCR institution without an RN examination before departure. • In case 35, the RN also did not examine the patient before transfer. Instead, the LVN checked the patient’s vital signs, which showed an elevated heart rate. The LVN did not notify the RN and did not recheck the patient’s heart rate. The RN should have assessed the patient for possible contributing factors such missed medication doses or medication side effects. Fortunately, by the time the patient arrived at the receiving institution, her pulse was normal. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients usually require hospitalization for severe illness or injury. Second, they are at risk due to potential lapses in continuity of care that can occur during any transfer. The patients usually return through the TTA, and the RN is responsible for assessing the patients and ensuring timely initiation of the hospital discharge plan. Nurses usually communicated the hospital discharge recommendations for wound care, medications, treatments, and follow-up appointments to providers. Providers then ordered correct treatments for patients. However, this did not always occur: Central California Women’s Facility, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California • In case 2, the patient had successful surgery to remove rectal cancer. After the surgery, the patient developed severe abdominal pain and distention. CCWF staff sent the patient to the emergency department, and the patient returned with recommendations for medication to relieve severe constipation. The provider did not order the recommended medication. Subsequently, the patient continued to have severe abdominal pain and distention. CCWF staff repeatedly failed to properly evaluate or treat her continuing problems. These repeated failures may have ultimately contributed to her death. This case is also discussed in the Emergency Services indicator. • In case 8, the patient returned from the hospital with recommendations for a vacuum device to aid in the healing of a wound. Neither the TTA RN nor the utilization management RN communicated those recommendations to the provider on call. The patient did not receive the recommended treatment. Fortunately, the patient’s wound healed without the device. • In case 19, the patient returned from surgery with recommendations for antibiotics to prevent infection. The RN did not communicate those recommendations to the provider, and the patient never received the antibiotics. Fortunately, the patient did not develop an infection. • In case 25, the provider did properly review the hospital discharge paperwork. The patient required hospitalization for worsening liver failure. The hospital physician recommended a gastroenterology consultation and a reduction in the dose of a medication. The provider failed to order the recommended gastroenterology consultation and did not reduce the dose of the medication. Fortunately, these oversights did not appear to harm the patient. Clinician Onsite Inspection The transfer nurse was knowledgeable about the process for patients transferring into and out of CCWF. The space available for patient examination was limited. Transfer nurses could only partially assess patients in the small space. The nurses sent patients needing a more thorough physical examination to the TTA instead. The TTA nurses assessed patients returning from the hospital and off-site procedures. The Omnicell (automated medication storage unit) was in the TTA, which ensured that medications were readily available for TTA patients, new arrivals to CCWF, and patients newly admitted to the SNF. Case Review Conclusion CCWF had serious problems with the transfer process. While the process for patients transferring into CCWF was acceptable, there were significant problems for patients transferring out of the institution and for those returning from the hospital. For Inter- and Intra-System Transfers, the case review rating was inadequate. Central California Women’s Facility, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California Compliance Testing Results The institution obtained an adequate compliance score of 75.1 percent in the Inter- and Intra-System Transfers indicator. Two of the four applicable tests earned proficient scores, as follows: • The OIG inspected the transfer packages of eight patients who were transferred out of the facility to determine whether the packages included required medications and support documentation. All eight transfer packages were compliant (MIT 6.101). • For 23 of 25 sampled patients who transferred into CCWF (92 percent), nursing staff timely completed the assessment and disposition sections of the Initial Health Screening form (CDCR Form 7277) on the same day that they performed the patient’s initial health screening. Two exceptions occurred. In the first exception, the screening nurse identified that the patient had signs and symptoms of tuberculosis, but did not refer the patient to the triage and treatment area for a more thorough evaluation. In the second exception, the registered nurse did not complete the disposition section of the screening form (MIT 6.002). Two tests in this indicator received inadequate scores, as follows: • The OIG tested 25 patients who transferred into CCWF from another CDCR institution or county jail to determine whether they received a complete initial health screening assessment from nursing staff on their day of arrival. CCWF received a score of 40 percent for this test because nursing staff timely completed the assessment for only 10 of the sampled patients. For 15 patients, nurses neglected to answer one or more of the screening form questions (MIT 6.001). • Of 25 sampled patients who transferred into CCWF, 19 had an existing medication order upon arrival; 13 of the 19 patients (68 percent) received their medications without interruption. Six patients incurred medication interruptions of one or more dosing periods upon arrival (MIT 6.003). Central California Women’s Facility, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California PHARMACY AND MEDICATION MANAGEMENT This indicator consists of an evaluation of the institution’s ability to Case Review Rating: appropriately administer pharmaceuticals and manage Inadequate pharmaceutical security, encompassing the process from the written Compliance Score: prescription to the administration of the medication. By combining Inadequate (73.9%) both a quantitative compliance test with case review analysis, this assessment identifies issues in various stages of the medication Overall Rating: management process, including ordering and prescribing, Inadequate transcribing and verifying, dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. Case Review Results The OIG clinicians evaluated 40 events related to medications and found 21 deficiencies. Six of the deficiencies were significant. Medication Continuity The OIG clinicians identified a strong pattern of poor medication continuity, for existing patients as well as those who had just arrived at CCWF. Sometimes, patients who returned from the hospital also did not receive their medications correctly. Breaks in medication continuity occurred in cases 10, 12, 38, and the following: • In case 1, the patient was transferred from the SNF to the regular housing unit, and life-sustaining medications (KOP nitroglycerin and inhaler) were ordered and never given to the patient. • In case 4, staff did not give the pregnant patient her prenatal vitamins until eight days after her arrival at CCWF. • In case 6, (as in case 4), staff also did not give another pregnant patient her prenatal vitamins until eight days after her arrival at CCWF. • In case 8, CCWF staff sent the patient the hospital because of gastrointestinal bleeding. At the time of discharge, the hospital physician recommended an important medication to lower her risk of further bleeding. CCWF staff did not administer the medication until two days after the patient returned to the institution. • In case 23, on several occasions, nurses failed to administer the patient’s insulin. Central California Women’s Facility, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California • In case 25, the patient was transferred from the regular housing unit to the SNF, but did not receive her regularly scheduled chronic care medications. • In case 30, the patient transferred into CCWF, but CCWF staff did not continue her iron tablets. Medication Administration CCWF staff usually administered new medications correctly, but performance in this area was inconsistent. Several significant deficiencies occurred. • In case 12, the provider inappropriately ordered a second medication within the same class of blood pressure medications the patient was already on. The pharmacist did not realize the error until four weeks after the provider wrote the prescription. The provider waited an additional two weeks to respond to the pharmacist’s message, and by that time, the second medication was dispensed. The extra medication increased the patient’s risk of overdose, which could have caused excessively low blood pressure or kidney failure. • In case 43, the provider ordered an antibiotic medication for an infection, and the patient never received the KOP (keep on person) medication. • In case 55, the provider prescribed a medication with instructions to limit the maximum dose to 10 tablets per month. Nonetheless, CCWF staff administered 50 tablets in the first month and 80 tablets in each of the following two months. In another month, CCWF staff administered 20 tablets. Medication Refusals CCWF nurses did not always properly document or intervene when patients refused their medications. • In case 23, the patient refused her insulin administration, and the nurse did not obtain a signed Refusal of Treatment form (CDCR Form 7225), as required by CCHCS policy. • In case 25, the patient refused a vital medication that her doctor prescribed to decrease the fluid buildup in her body. The patient refused these medications multiple times, but nursing staff did not notify the provider of her refusals. Medication Errors There were two medication errors, as follows: • In case 53, the nurse administered two doses of an antibiotic when the provider ordered only one dose. Central California Women’s Facility, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California • In case 55, the provider gave a telephone order to discontinue a blood pressure medication. The nurse failed to discontinue the medication in the EHRS, and the medication order continued for an additional five days. Clinician Onsite Inspection The OIG clinicians interviewed the pharmacist in charge and the medication nurses in various clinics. The medication staff in the clinics and the administrative segregation unit explained the safety practices for medication administration. They also explained some of the barriers that began with the implementation of the EHRS. For example, new orders for antibiotics automatically defaulted to a three-day delay. If there were missing medications, the nurse had to retrieve them from the TTA or send the patient to the TTA to receive them, which was a time-consuming process. Nurses had inconsistent practices for notifying providers regarding the refusal of medications. In one clinic, the nurses stated that they communicated the refusals to the provider during the morning huddle. In another clinic, the nurses stated they sent messages to the provider. The CNE, nursing supervisors, and medication nurses explained why patients missed doses of medications when they transferred between various housing units and the SNF, or vice versa. Nursing staff had to discharge the patient in the EHRS before the system would allow new orders, but this did not always occur. Case Review Conclusion CCWF had significant problems maintaining medication continuity for patients newly arriving at CCWF, for patients transferring between units at CCWF, and for patients returning to CCWF from the hospital. Medication administration was unreliable. The OIG clinicians rated the Pharmacy and Medication Management indicator inadequate. Compliance Testing Results The institution received an inadequate compliance score of 73.9 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. Medication Administration In this sub-indicator, the institution received an adequate score of 78.0 percent. Two tests scored in the proficient range: • When the OIG sampled nine patients who were in transit to another institution and were temporarily laid over at CCWF, eight (89 percent) received their medications without interruption. One patient received her medications one day late (MIT 7.006). Central California Women’s Facility, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California • CCWF timely provided new and previously prescribed medications to 22 of 25 sampled patients upon their return to the institution from a community hospital (88 percent). Two patients received their medications one and 21 days late; one final patient received her oral medication 25 days late and received her inhaler 55 days late (MIT 7.003). One test received an adequate score: • Inspectors found that 21 of 25 patients sampled (84 percent) received their newly ordered medication in a timely manner. One patient received a medication that the clinician ordered as “urgent” one day late; two patients received their keep-on-person (KOP) medications 23 and 27 days late; for one final patient, there was no evidence found that she received her ordered medication (MIT 7.002). Three tests revealed areas for improvement: • CCWF ensured that 16 of 25 patients sampled (64 percent) received their medications without interruption when they transferred from one housing unit to another; nine patients did not receive one or more doses of their medications at the next dosing interval after the transfer occurred (MIT 7.005). • Among 14 sampled patients, 10 (71 percent) timely received chronic care medications. Four patients missed multiple dosages of medication, and the nurses did not refer the patient to a clinician for counseling (MIT 7.001). • Inspectors reviewed files of 20 sampled patients who recently arrived at CCWF from a county jail and identified 14 patients who needed to be reissued non-PRN medications upon their arrival. Of the 14 applicable patients sampled, ten patients received their medications timely (71 percent). Three patients received one or more of their medications one day late; one final patient received three medications that were late by 22, 31, and 50 days (MIT 7.004). Observed Medication Practices and Storage Controls In this sub-indicator, the institution received an inadequate score of 48.1 percent. Four tests showed areas for improvement: • CCWF failed to store non-refrigerated, non-narcotic medications properly in any of the eight applicable clinic and medication line storage locations. In each location, one or more of the following deficiencies occurred: staff did not properly separate topical and oral medications when stored; and multi-use medication was not labeled with the date it was opened (MIT 7.102). • Inspectors observed the medication preparation and administration processes at six applicable medication line locations. Nursing staff was compliant regarding proper hand Central California Women’s Facility, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California hygiene and contamination control protocols at two locations (33 percent). At four locations, not all nursing staff washed or sanitized their hands when required, such as before putting on gloves, before re-gloving, or before physical contact with patients (MIT 7.104). • Only two of six inspected medication preparation and administration areas demonstrated appropriate administrative controls and protocols (33 percent). At four different locations, one or more deficiencies occurred: medication nurses did not always ensure that patients swallowed direct observation therapy medications, medication nurses did not appropriately administer medication as ordered by the provider, and medication nurses did not follow the standard practice of disinfecting multi-dose insulin vials prior to withdrawing medication (MIT 7.106). • The institution employed adequate security controls over narcotic medications in four of the eight applicable clinic and medication line locations where narcotics were stored (50 percent). In four clinics, one or more deficiencies occurred: the narcotics log book showed that on multiple dates, nurses did not properly perform a controlled substance inventory; the nurses did not counter-sign the log book to confirm that controlled substances were disposed of properly; and the supervising nurse did not describe the appropriate narcotics discrepancy reporting process to the CNE and PIC (MIT 7.101). One test earned an adequate score: • CCWF nursing staff at five of six sampled locations (80 percent) employed appropriate administrative controls and protocols when preparing patients’ medications. At one medication line location, loose medication was not stored in its original labeled packaging (MIT 7.105). The institution performed in the proficient range in one test in this sub-indicator: • Refrigerated, non-narcotic medications were properly stored in eight of nine clinics and medication line locations (89 percent). One medication line location lacked a designated area for return-to-pharmacy refrigerated medication (MIT 7.103). Pharmacy Protocols In this sub-indicator, the institution received a proficient score of 100 percent, comprised of scores received at the institution’s main pharmacy. • In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored and monitored non-narcotic medications that required refrigeration and those that did not; and maintained adequate controls over and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.109, 7.110). Central California Women’s Facility, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California • CCWF’s pharmacist in charge timely processed all 25 sampled medication error reports (MIT 7.111). Non-Scored Tests • In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during compliance testing to determine whether CCWF properly identified and reported the errors. The OIG provides those results for information purposes only; however, at CCWF, the OIG did not find any applicable medication errors (MIT 7.998). • The OIG tested patients in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. Inspectors interviewed all ten of CCWF’s applicable patients, and all of them indicated that they had their rescue medications (MIT 7.999). Central California Women’s Facility, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to Adequate pregnant patients. This includes the ordering and monitoring of Compliance Score: indicated screening tests, follow-up visits, referrals to higher levels Adequate (83.3%) of care, e.g., high-risk obstetrics clinic, when necessary, and postnatal follow-up. Overall Rating: Adequate Case Review Results The OIG clinicians reviewed four cases and 16 events related to prenatal or post-delivery care. Among the four cases, there were four deficiencies, none of which was significant. Prenatal Care CCHCS policy requires medical staff to conduct a health screening, including a pregnancy screening, for all women arriving at CCWF. The receiving nurse was responsible for reviewing all available medical transfer information and implementing orders to ensure continuity of medical care. Nurses usually referred pregnant women appropriately to the primary care team and obstetric services for coordinated care. Nurses often made minor errors when assessing pregnant women who arrived at CCWF from a county jail: • In case 4, the patient arrived at CCWF during the 27th week of her high-risk pregnancy. The patient was taking topical medications for a rash and antibiotics for a skin abscess, but the receiving nurse neglected to examine the patient’s rash. Fortunately, the abscess did not recur. • Also in case 4, the receiving nurse neglected to order the patient’s medications. The patient’s prenatal medications and antibiotics lapsed upon arrival to CCWF. • In case 6, the staff did not order medications for the pregnant patient upon her arrival at CCWF. This error resulted in an eight-day lapse in the patient’s prenatal medications. • In case 7, the pregnant patient arrived with a sexually transmitted disease for which she was taking antibiotics. The receiving nurse did not obtain important information regarding the patient’s infection. Despite the pattern of suboptimal nursing assessment and medication lapses, pregnant patients received adequate care because other CCWF clinicians corrected the errors within the first week of the patients’ arrival. There were no deficiencies identified in any subsequent obstetric care. The institution usually transferred pregnant patients to another CDCR facility within four weeks to continue their prenatal care. Central California Women’s Facility, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California Case Review Conclusion CCWF made prompt referrals to the primary care and the obstetric teams when a pregnant patient arrived at the institution. The receiving nurse demonstrated a pattern of errors in assessment and medication continuity. These errors did not cause significant harm because the patient also underwent an initial provider evaluation within seven days, at which time the provider corrected the nurses’ initial errors. Since CCWF was not the assigned institution for providing prenatal care and post-delivery services, CCWF transferred pregnant women timely to CIW, the institution that was designated to provide those services. The OIG clinicians rated the Prenatal and Post-Delivery Services indicator adequate. Compliance Testing Results CCWF received an adequate compliance score of 83.3 percent in the Prenatal and Post-Delivery indicator. Five of the six tests in this indicator scored 100 percent, as follows: • All five pregnant patients sampled saw an obstetrician or nurse practitioner within seven calendar days of arriving at the institution (MIT 8.001). • CCWF assigned all five sampled pregnant patients to a lower bunk and placed them in lower-tier housing (MIT 8.002). • All five pregnant patients sampled received all of their prenatal visits with a supervising obstetrician or obstetrics nurse practitioner at the required intervals (MIT 8.004). • Providers timely completed and reviewed all five sampled pregnant patients’ initial prenatal screening tests (MIT 8.005). • Clinical staff documented the patient’s weight and blood pressure at every prenatal visit for all five samples tested (MIT 8.006). One test showed an area for CCWF to improve: • Five sampled patients who were pregnant did not receive their extra food and milk as CCHCS policy requires. One patient received her extra food and milk nine days late; for the other four patients, CCWF staff did not order extra food or milk. As a result, CCWF scored a zero on this test (MIT 8.003). Central California Women’s Facility, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether various preventive medical services Case Review Rating: are offered or provided to patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic care Compliance Score: immunizations. This indicator also assesses whether certain Proficient (85.2%) institutions take preventive actions to relocate patients identified as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Proficient The OIG rates this indicator entirely through the compliance testing component; this indicator does not include a separate qualitative case review. Compliance Testing Results With a compliance score of 85.2 percent, CCWF performed in the proficient range in this indicator. • The OIG found that all 30 patients sampled at CCWF received annual tuberculosis screenings (MIT 9.003). • CCWF timely gave or offered all 25 patients sampled influenza vaccinations during the most recent influenza season (MIT 9.004). • The OIG found that all 25 patients subject to the annual screening requirement received appropriate colorectal cancer screening. All patients either had a normal colonoscopy within the last ten years, or CCWF had offered them a screening test in the last year (MIT 9.005). • CCWF gave or offered a mammogram to all 30 patients sampled within CCHCS policy guidelines (MIT 9.006). • CCWF offered a pap smear to 25 of 27 patients (93 percent) aged 21 through 65 in compliance with CCHCS policy. Two patients’ pap smears were provided 42 and 62 days late (MIT 9.007). One test earned an adequate score, as follows: • The OIG tested whether CCWF offered vaccinations for influenza, pneumonia, and hepatitis to patients who suffered from a chronic care condition. Among the 20 sampled patients with applicable chronic care conditions, 15 patients (75 percent) were timely offered vaccinations. For four patients, there was no evidence found that they received or refused the pneumococcal immunization within the last five years; for one patient, there was no evidence found that Hepatitis A and B vaccinations were administered nor of documented immunity (MIT 9.008). Central California Women’s Facility, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California The following two tests revealed areas for improvement at CCWF: • CCWF scored poorly for the timely administration of tuberculosis (TB) medications. The OIG examined the health care records of all 14 patients who were on TB medications during the inspection period, and only seven patients received all of their required medications (50 percent). Seven patients missed one or more doses of their medications, and there was no evidence found that they received required counseling for those missed doses (MIT 9.001). • The OIG reviewed CCWF’s monitoring of 14 sampled patients who received TB medications and noted that the institution complied for only nine of them (64 percent). Five patients did not receive monitoring as required by CCHCS policy (MIT 9.002). Central California Women’s Facility, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Inadequate completed entirely by OIG nursing clinicians within the case Compliance Score: review process and does not have a score under the OIG Not Applicable compliance testing component. Case reviews include face-to-face Overall Rating: encounters and indirect activities performed by nursing staff on Inadequate behalf of the patient. Review of nursing performance includes all nursing services performed onsite, such as outpatient, inpatient, urgent/emergent, patient transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although nursing services provided in specialized medical housing units are reported in the Specialized Medical Housing indicator, and those provided in the TTA or related to emergency medical responses are reported in the Emergency Services indicator, all areas of nursing services are summarized in this Quality of Nursing Performance indicator. Case Review Results The quality of nursing performance at CCWF was inadequate. The OIG clinicians reviewed 385 nursing encounters, of which 160 were in the outpatient setting. Most outpatient nursing encounters were for sick call requests, walk-in visits, and RN follow-up visits. In all, there were 123 deficiencies identified in this Quality of Nursing Performance indicator, of which 28 were significant. Sixty-two of these deficiencies related to outpatient nursing services, 14 of which were significant. Nursing Assessment and Intervention In numerous cases, sick call nursing staff did not initiate urgent same-day or next-day patient referrals to providers when warranted. Some nursing decisions regarding assessment and intervention were ineffective or demonstrated the lack of basic nursing knowledge. Some cases had multiple significant deficiencies, such as cases 2, 8, and 51. The details of these cases are summarized under Nursing Sick Call and Care Management. Nursing Documentation There were 26 minor deficiencies related to missing or incomplete documentation of nursing assessments. Nurses did not always document their care, as illustrated in the following examples: • In case 2, the patient had undergone removal of a rectal mass and had painful swelling at the surgical site. The nurse did not assess the surgical area for signs of infection. Central California Women’s Facility, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California • In case 44, the nurses provided daily wound care to the patient’s toe for nine days. On the ninth day, the provider identified the development of a second wound on the foot, but nurses did not assess the new wound. Nursing Sick Call The OIG clinicians reviewed 160 nursing encounters, 132 of which were for sick call. Nurses reviewed sick call requests timely and usually assessed patients on the next business day as CCHCS policy requires. When a patient requests to be seen for a potentially urgent condition, the nurse should assess the patient the same day that he or she reviewed the request. In these situations, CCWF nurses often failed to see their patients the same day. Another problem was that nurses did not consult with the provider or refer the patient to the TTA when patients presented with conditions such as severe pain or continuing or worsening conditions. The following cases are examples of these deficiency patterns: • In case 2, the patient underwent surgical removal of a rectal cancer but was having ongoing abdominal pain. The sick call nurse assessed the patient but did not notify the provider about her ongoing stomach pain. The nurse released her back to the housing unit with a four-day follow-up appointment in the RN clinic. The nurse assessed the patient four days later and notified the provider about the patient’s severe abdominal pain. A multitude of errors occurred, which ultimately may have contributed to the patient’s death. This case is also discussed in the Emergency Services indicator. • In case 8, the primary care RN assessed the patient four different times. At each of these nursing sick call encounters, the patient complained of severe leg pain with numbness and difficulty walking. On numerous occasions, sick call nurses failed to recognize the severity of the patient’s symptoms or potential safety issues related to the risk of injury from falls and did not consult or refer the patient to the provider. For example, on the third sick call visit, the patient had stiffness and swelling and was dragging her feet when being pushed in the wheelchair. The patient required an immediate referral, but the nurse referred the patient to the provider for a routine evaluation within 14 days. On the fourth visit, the patient had numbness, continuing leg pain, and unsteadiness when walking. The nurse released the patient back to her housing unit and did not refer her to the provider. Six days later, the patient submitted the fifth sick call request for severe leg pain and the inability to walk. The nurse who reviewed the sick call request scheduled the patient for nursing assessment on the following day, but should have assessed the patient the very same day. When the nurse finally consulted with the provider, the provider emergently sent the patient out to a higher level of care, where she underwent extensive back surgery for the bulging discs in her spinal cord. • In case 18, the nurse assessed the diabetic patient for increased bed-wetting and elevated blood sugar levels. The nurse did not consult with, or initiate an urgent referral to, the Central California Women’s Facility, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California provider regarding the possible need for readjustment of the patient’s diabetic medication regimen. • In case 21, the patient presented at sick call with a swollen right leg. The nurse sent the patient back to her housing unit and did not assess her leg for tenderness, swelling, other indications of a possible blood clot or notify the provider. Four days later, a provider sent the patient to the community hospital to rule out a blood clot in her leg. • In case 27, the patient had a fast heartbeat, weak muscles, and tongue tingling after taking the newly prescribed high blood pressure medication. The nurse did not assess the patient’s vital signs or notify the provider about the possibility of a drug reaction. • In case 41, the patient had injured her ankle after a fall and could not bear weight on her foot. The patient requested a brace and an X-ray. The nurse did not assess the patient the very same day, instead scheduling the patient for assessment on the next day. The patient was at risk of potential injury from additional falls. • In case 48, the patient with asthma felt sick and had chest congestion, difficulty breathing, and a productive cough. The nurse referred the patient for a nursing assessment two days later, but should have assessed the patient’s breathing status the very same day. This error placed the patient at risk of worsening breathing problems due to exacerbation of asthma. • In case 51, the patient with a history of a chronic systemic autoimmune disease (body’s immune system attacks healthy cells) had pain in her leg, toes, and hands. The patient requested a diagnostic radiology scan and a prescription for the pain medication she had taken two years previously. The sick call nurse assessed the patient and referred her for a routine provider evaluation, but staff canceled the appointment. The patient submitted a second sick call request for continued leg pain. The nurse did not, as CCHCS policy requires, see the patient with physical complaints. Access to Care The case review process revealed no deficiencies in access to nursing sick call assessment appointments. However, one significant deficiency occurred: • In case 43, staff scheduled the patient for a seven-day follow-up with the RN for assessment of skin rash, but the appointment did not occur. Urgent/Emergent Care The emergency nursing care provided at CCWF was inadequate. The OIG clinicians identified 11 of the 32 deficiencies for urgent/emergent nursing care as significant. See the Emergency Services indicator summary for further information. Central California Women’s Facility, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California Care Management The role of the primary care manager includes assessing patients, initiating appropriate interventions to support goals in patients’ treatment plans, and monitoring patients with chronic health needs and those at increased risk for developing serious health complications. One case demonstrated the need for evaluation of the RN primary care manager’s responsibilities by nurse managers at CCWF, as well as the system and processes in place to support the care manager’s ability to appropriately assess, coordinate, and advocate for needed health care services. • The patient in case 8 had ongoing, progressively severe leg pain, numbness, and worsening difficulty walking, clearly demonstrating the need for consistent follow-up by nurse care management services. This patient’s care should have included frequent monitoring by RN care management with regular provider consultation. Hospital Returns The TTA nurses evaluated the patients returning from the hospital. Performance in this area was poor. Details of the post-hospital return case reviews are described in the Inter- and Intra-System Transfers indicator. Specialized Medical Housing CCWF has a licensed skilled nursing facility (SNF). The SNF nurses performed acceptably. The Specialized Medical Housing indicator summary describes the SNF cases reviewed. Inter- and Intra-System Transfers Nurses provided appropriate and timely care to patients leaving and arriving at CCWF. See the Inter- and Intra-System Transfers indicator summary for more details. Offsite Specialty Services Returns The TTA nurse assessed the patients returning to CCWF from offsite specialty services appointments or procedures. There were no significant deficiencies identified in the nursing care provided to patients returning from specialty appointments or procedures. Clinician Onsite Inspection The OIG clinicians toured and interviewed the medical staff in all yard clinics, the administrative segregation unit, the receiving and release clinic (R&R), the TTA, and the SNF. Most of the staff stated the morale was good. CCWF staffed the clinics with two medical providers, two RNs, and one or two LVNs, depending on the number of providers in the clinic. The clinics held morning huddles and addressed new arrivals, patients returning from out-to-medical appointments, and patients who required multiple coordinated services. A nurse usually assessed sick call patients the next business day following the review of their health care requests, and there was no patient backlog for RN sick call appointments. Central California Women’s Facility, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California Although CCWF implemented the “Complete Care Model” as described in CCHCS policy, there were no nurse care coordinators in the clinics. The OIG clinicians did not observe any spontaneous consultation between nurses and providers regarding sick call patients who may have needed urgent provider evaluations. This lack of communication between nurses and providers was also evident in the case reviews. CCWF clinical administrators and staff could not explain reasons for communication issues. Case Review Conclusion The chief nurse executive at CCWF was aware of the nursing areas that needed improvement, and nursing managers were eager to implement process change strategies. Based on the patterns of significant deficiencies found in outpatient and urgent/emergent nursing services, the OIG clinicians rated the Quality of Nursing Performance indicator at CCWF inadequate. Central California Women’s Facility, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Inadequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, specialized medical housing, and Overall Rating: specialty services. The assessment of provider care is performed Inadequate entirely by OIG physicians. There is no compliance testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 306 medical provider encounters and identified 98 deficiencies related to provider performance, 22 of which were significant. Of the 23 cases reviewed, 16 cases were adequate and 7 cases were inadequate. Assessment and Decision-Making CCWF providers demonstrated a widespread pattern of deficient assessment, unsound medical decision-making or significantly delayed response to clinical issues. The OIG clinicians identified deficiencies of this type in nearly all of the reviewed cases, often multiple times in each case. Some examples include: • In case 12, the provider prescribed two blood pressure medications of the same type. The provider also prescribed two anti-inflammatory medications of the same type. These careless prescriptions increased the patient’s risk for medication overdose and adverse side effects. • In case 19, the patient had an abnormal urine test that showed a potential bacterial infection. Because the patient was about to undergo surgery, the provider should have treated the patient with antibiotics to eliminate the bacteria. The provider neglected to do so. • In case 23, the patient complained of severely low blood sugars, even after another provider had lowered her insulin dose. The provider ignored her claims, despite the patient having visited the TTA for low blood sugar symptoms twice in the past week. CCWF providers often failed to examine patients who required urgent evaluation. This finding was a repeated problem, identified in cases 1, 2, 4, 10, 14, 29, and 49. The following are just a few examples: • In case 1, the patient saw the nurse for abdominal pain and persistent vomiting. The nurse found evidence that the patient was dehydrated. The provider did not examine the patient. Central California Women’s Facility, Cycle 5 Medical Inspection Page 55 Office of the Inspector General State of California When the provider discharged the patient from the TTA, the provider did not order a provider follow-up. • In case 2, the patient had surgery to remove a rectal mass. After the surgery, the patient developed severe abdominal pain, abdominal swelling, and inability to pass gas. These symptoms were extremely worrisome for intestinal obstruction, a potentially life-threatening condition. The sick call RN referred the patient to the provider, but the provider failed to examine the patient. Instead, the provider ordered increased the opioid pain medication, which may have worsened the patient’s condition. The provider released the patient back to housing without provider follow-up. • Later in case 2, the patient continued to have severe abdominal pain. The nurse again referred the patient to the provider, who again failed to examine the patient and did not order a provider follow-up. Over the next three days, TTA nurses saw the patient two more times for her persistent severe abdominal pain, but a provider did not examine her. The patient then died suddenly, a potentially preventable death. This case is also discussed in the Emergency Services indicator. • In case 14, the diabetic patient developed an infected ingrown toenail. These are serious problems for diabetic patients because infections of these types can worsen and lead to amputation. The nurse referred the patient to a provider, but the provider did not examine the patient immediately. The provider made a risky decision to wait an additional five days before examining the patient. • In case 49, the patient was feeling dizzy and extremely fatigued due to her anemia. When a patient develops symptoms due to anemia, a provider should examine the patient urgently to determine if she needs a blood transfusion. The nurse called the provider, but the provider failed to examine the patient. CCWF providers repeatedly failed to order medically appropriate follow-ups. This type of deficiency was identified in cases 1, 2, 10, 12, 14, 22, 23, 24, and 25. Some examples are as follows: • In case 12, the patient had out-of-control diabetes. Nurses repeatedly notified the provider about the patient’s non-compliance with treatment. The provider consistently neglected to order follow-ups and failed to intervene appropriately. • In case 14, the patient also had poorly controlled diabetes. The patient needed close follow-up so that the provider could titrate her insulin and monitor the results. Instead, the provider ordered a lengthy 90-day follow-up, which unnecessarily lengthened the duration of the patient’s uncontrolled condition. Central California Women’s Facility, Cycle 5 Medical Inspection Page 56 Office of the Inspector General State of California • In case 22, the patient had liver cirrhosis and required regular monitoring and assessment. The provider failed to order a follow-up chronic care appointment. CCWF corrected the lapse in care only after the patient required hospitalization for gastrointestinal bleeding. CCWF providers had considerable difficulty in making appropriate referrals to specialists. The OIG identified this problem in cases 9, 12, 13, 14, 17, 25, and 28. • In case 9, the cardiologist recommended that the patient undergo further testing to rule out any coronary blockages. The provider neglected to order the test. • In case 12, the patient had significantly elevated pressure in her eye. The provider ordered only a routine, rather than expedited ophthalmology referral. The delay increased the patient’s risk of vision loss. • In case 13, the patient was seeing an endocrinology specialist for her uncontrolled diabetes. The provider neglected to order an endocrinology follow-up, resulting in a lapse in specialty care. • In case 17, the patient had only one remaining eye, which was diseased and under the care of an ophthalmologist. The provider neglected to order the follow-up ophthalmology consult, resulting in a lapse in care. Review of Records CCWF providers performed poorly with their review of medical records. Inattention to outside medical records was evident in nearly all cases reviewed. Some examples include: • In case 12, the nurse referred the patient to a provider because of a tongue mass. The provider failed to review the case and did not recognize or address the problem. • In case 25, the patient’s liver condition worsened, and she required hospitalization. When the patient returned, the provider did not review the hospital records. The provider did not recognize that the patient had developed a blood clot in her liver and did not recognize that the gastrointestinal specialist had recommended changes to the patient’s medications. • Also in case 25, the patient returned from the hospital with a new medication that promotes salt and water retention. This medication requires monitoring, as it can cause electrolyte abnormalities and other side effects. The provider did not review the records, failed to recognize that the patient was taking this medication, and did not order the necessary monitoring. • In case 28, the patient developed an ulcer in her eye. An ophthalmologist recommended that the patient begin taking steroid and antibiotic eye drops immediately. Even though the nurse sent the provider the message, the provider did not order the medication until Central California Women’s Facility, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California five days later. This delay could have resulted in delayed healing of the eye and may have led to scarring and vision impairment. Chronic Care While the OIG did not identify any problems with anticoagulation management, the CCWF providers performed poorly with diabetes management. • In case 12, the provider repeatedly failed to respond to notices that the patient was having problems taking her prescribed insulin. The provider also did not order an appropriate chronic care follow-up for the patient’s poorly controlled diabetes. • In case 14, the patient had poorly controlled diabetes. The provider should have ordered regular follow-up appointments to adjust the patient’s insulin rapidly. The provider ordered an inappropriately long follow-up. • In case 29, the patient’s diabetes was poorly controlled, but the patient also had intermittently low blood sugars. The provider should have recognized that the patient needed a different combination of long and short-acting insulin. Instead, the provider increased the long-acting insulin only, which erroneously increased the patient’s risk of developing dangerously low blood sugars. Emergency Care The providers usually made appropriate triage decisions when patients presented emergently to the TTA. The providers were typically available for consultation with the TTA nursing staff, with a few exceptions. Further discussion regarding emergency provider performance is found in the Emergency Services indicator. Specialized Medical Housing The provider in the specialized medical housing unit made regular rounds and was available for referrals from the nurses. Performance in this area is further discussed in the Specialized Medical Housing indicator. Clinician Onsite Inspection The medical providers discussed the events that occurred overnight or on the weekend during the morning report. The providers identified patients who need follow-up; the PCP would then ensure that an appointment was scheduled. Following the morning report, each yard clinic conducted its morning huddle for staff to identify significant events and patients who needed attention and follow-up. During the SNF “grand rounds,” medical staff discussed each patient and evaluated the need for their continued stay in the SNF. Central California Women’s Facility, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California The providers said that their morale has improved with the recent hiring of additional providers. The chief medical executive (CME) mentioned that even though all the provider vacancies were filled, there were still functional vacancies because two medical providers were on extended leave at the time of the onsite inspection. The CME and the chief physician monitored their medical providers’ performance by reviewing progress notes, submitted requests for services, compliance with Interqual® criteria, and on-call notes. Case Review Conclusion CCWF providers performed poorly in multiple aspects of patient care. Problems included assessment and decision-making, failure to examine patients, inappropriate specialty referrals, inappropriate follow-up orders, poor record review, and poor diabetic care. The OIG rated the Quality of Provider Performance indicator inadequate. Central California Women’s Facility, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Adequate system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, initial Inadequate (72.5%) health assessments, continuity of medications, and completion of required screening tests; address and provide significant Overall Rating: accommodations for disabilities and health care appliance needs; Inadequate and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance review resulting in an inadequate score. The compliance finding that newly arrived patients rarely received their intake examinations on time was a serious problem that increased the risk of harm, resulting in the inadequate indicator rating. Case Review Results The OIG clinicians reviewed nine cases where the patient arrived through the reception center, in which there were 27 related events. Four deficiencies were identified, two of which were significant. Access to Care Providers usually saw newly arrived patients from the county jail promptly. However, two cases demonstrated significant delays in provider appointments: • In case 2, the patient arrived from county jail with a fractured knee. The intake nurse made a referral for a provider appointment the next day. However, the provider did not evaluate the patient until 16 days later. • In case 36, the patient was a new arrival from the county jail. CCHCS requires CCWF to give the patient a history and physical evaluation by a provider within 7 days. Instead, the CCWF provider saw the patient in 24 days, or 17 days late. Nursing Performance The CCWF Reception Center nursing services were adequate with no significant deficiencies identified in the cases reviewed. Central California Women’s Facility, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California Onsite Inspection The receiving and release area (R&R) was used to process both intra-system and reception center arrivals. See the Inter- and Intra-System Transfers indicator summary for additional information about the onsite findings. Case Review Conclusion The R&R nurses demonstrated good ability to review the outside documents from the county jail and to determine their patient’s medical history and health issues. The nurses also properly entered the information into the patient’s electric medical record. The R&R nurse scheduled patients for their initial primary care provider appointment within seven days and made appropriate referrals to the primary care RN for assessment. CCWF then transferred the new patients to a designated yard, where the provider reviewed the patients’ information and reconciled their medications. There were some cases where CCWF significantly delayed the provider appointments, but overall, the reception center process was adequate. Compliance Testing Results With an average score of 72.5 percent, CCWF earned an inadequate compliance score in the Reception Center Arrivals indicator. Two tests showed areas for needed improvement: • Providers timely completed reception center history and physical examinations within seven calendar days of arrival for only three of 20 sampled patients (15 percent). For seven patients, the history and physical was completed 7 to 27 days late; for ten other patients, the history and physical was completed 32 to 62 days late (MIT 12.004). • After ordering intake tests for reception center arrivals, providers timely reviewed and communicated those test results to only 10 of 20 patients sampled (50 percent). For ten patients, providers either reviewed the test results late, communicated the patient’s results late, or both (MIT 12.006). One test scored in the adequate range: • Inspectors sampled 20 reception center patients to ensure that they received a timely health screening upon arrival at the institution. Nursing staff conducted timely and complete screenings for 16 of those patients sampled (80 percent). For four of the patients, nurses did not complete all of the required screening questions (MIT 12.001). Three tests earned scores in the proficient range: • All 20 sampled reception center patients had their required intake tests completed within specified timelines (MIT 12.005). Central California Women’s Facility, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California • The OIG sampled 20 reception center arrivals to verify that each patient had a timely completed and properly documented tuberculosis (TB) skin test. All 20 patients had their TB tests timely administered, read, and documented (MIT 12.007). • Reception center nursing staff timely completed, signed, and dated the assessment and disposition sections of patients’ initial health screening forms for 18 of the 20 samples tested (90 percent). On one patient’s form, nurses did not complete the disposition section. On another patient’s form, nurses did not complete the assessment section (MIT 12.002). Central California Women’s Facility, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Adequate facilities, including completion of timely nursing and provider Compliance Score: assessments. The case review assesses all aspects of medical care Proficient (95.0%) related to these housing units, including quality of provider and nursing care. CCWF’s only specialized medical housing unit was a Overall Rating: skilled nursing facility (SNF). Adequate For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance testing resulting in a proficient score. While each area’s results are discussed in detail below, the result variance is due to the testing approaches. Because the case review process contained a more detailed review, the OIG inspection team determined the final overall rating was adequate. Case Review Results The OIG clinicians reviewed 136 SNF events. These included 47 nursing encounters and 56 provider encounters. There were 21 deficiencies identified, one of which was significant. Provider Performance The OIG clinicians reviewed 54 provider encounters in the SNF and noted 8 deficiencies. The CCWF SNF provider promptly performed initial physical examinations on newly admitted patients. The provider saw the patients regularly, at least every 30 days for stable patients, but usually more frequently for newly admitted patients. The provider usually made accurate assessments and sound medical decisions. There were some provider areas where there was room for improvement. The provider sometimes neglected to review the medical records thoroughly or neglected to order appropriate interventions. These errors led to an occasional minor lapse in care. This type of deficiency occurred in case 1 and the following: • In case 8, the patient had a history of liver cirrhosis and fluid collection in her abdomen. The provider did not renew the water pill, spironolactone, which was necessary to prevent fluid accumulation in her abdomen. The provider also did not resume the blood pressure medication, propranolol, which was necessary to reduce the chance that her abnormally dilated esophageal blood vessels would rupture and bleed. • Also in case 8, the patient returned from a rehabilitation hospital with recommendations for a wound vacuum treatment. The provider neglected to review and address this recommendation. Central California Women’s Facility, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California • In case 10, CCWF staff admitted the patient to the SNF for breathing problems and pneumonia. The provider did not follow standard practice when the provider failed to order a follow-up X-ray to ensure that the pneumonia had resolved. Nursing Performance The nursing care services in the SNF were adequate. There were ten deficiencies identified, all of which were minor. The CCWF nurses generally conducted appropriate daily patient assessments that included physical examinations, observations regarding patients’ ability to perform activities of daily living, and re-assessments after providing treatment interventions, such as pain medication. Nursing documentation commonly included assessments from subjective patient interviews and objective physical examination, current patient status, and provider contacts. Pharmacy and Medication Management CCWF staff usually handled medication administration appropriately and timely. On rare occasions, there were minor deficiencies identified. • In case 1, CCWF staff admitted the patient to the SNF, and the patient missed one day of chronic care medications. The nurse should have retrieved the medications from the onsite medication cabinet but neglected to do so. • In case 25, the patient refused a vital medication to decrease the fluid buildup in her body. The patient refused these medications multiple times, but the nurses did not notify the provider. Specialty Services There was one case with a severe delay in access to physical therapy: • In case 8, the patient had back surgery and returned to CCWF from a rehabilitation hospital. The provider ordered the continuation of physical therapy, which the patient had received at the rehabilitation hospital and was extremely important for the patient to rehabilitate from the back surgery properly. The patient did not receive physical therapy. The patient had several falls while in the SNF, and fortunately did not suffer any injuries. However, the failure to provide physical therapy for this patient with weakness in her lower extremities and unstable balance placed her at risk for injury. The Specialty Services indicator also discusses this case. Clinical Onsite Inspection The CCWF SNF had 39 licensed beds. There were 26 medical beds and 13 mental health beds. There were two negative pressure rooms designed to prevent the spread of airborne infections. At the time of the onsite visit, there was only one vacant medical bed. Central California Women’s Facility, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California The SNF appeared neat, clean, and well organized. During the onsite visit, CCWF staffed the SNF adequately for their census of 25 medical patients. There were two RNs, three certified nursing assistants, and one licensed vocational nurse assigned to the second watch. Current admissions to the SNF included patients with dementia, spinal cord injury, shingles, paraplegia, and patients receiving intravenous antibiotic infusions. The nursing supervisor and staff easily explained work processes such as patient admissions, documentation of care, handling refusals of treatments and medications, and implementing emergency medical response procedures. Staff interviews indicated there was no physical therapist assigned to or contracted with CCWF. The institution often did not provide physical therapy services timely or at all. For example, in case 8, the patient did not receive the services because of this reason. Provision of physical therapy services is a requirement for skilled nursing facilities per the California Code of Regulations, Title 22, Article 3. Case Review Conclusion CCWF nurses and providers performed acceptably in the Specialized Medical Housing Unit. Providers saw the patients in the skilled nursing facility on time. CCWF met the patients’ nursing and specialty needs, with the exception of physical therapy. The Specialized Medical Housing indicator was rated adequate. Compliance Testing Results With an average of 95.0 percent, CCWF received a proficient compliance score in the Specialized Medical Housing indicator. Three tests earned a score of 100 percent, as follows: • For all ten patients sampled, nursing staff timely completed an initial health assessment on the same day that they admitted the patient to the SNF (MIT 13.001). • CCWF’s providers timely completed subjective, objective, assessment, plan, and education (SOAPE) notes at required intervals for all ten applicable SNF patients sampled (MIT 13.003). • When inspectors observed the working order of sampled call buttons in SNF patient rooms, inspectors found all working properly. In addition, according to staff members interviewed, custody officers and clinicians were able to access patients’ locked rooms expeditiously when emergent events occurred (MIT 13.101). One test received a score in the adequate range: • Providers completed a written history and physical examination within 24 hours of admission to the SNF for eight of ten patients sampled (80 percent). One patient’s examination exceeded compliance guidelines by over four hours; one other patient’s examination was over 24 hours late (MIT 13.002). Central California Women’s Facility, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a physician Case Review Rating: completes a request for services or physician’s order for specialist Inadequate care to the time of receipt of related recommendations from Compliance Score: specialists. This indicator also evaluates the providers’ timely Proficient (89.6%) review of specialist records and documentation reflecting the patients’ care plans, including when the providers’ courses of care Overall Rating: do not include the specialist recommendations, and whether they Inadequate communicate results of specialists’ reports to patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the provider updates the patient on the plan of care. For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning an inadequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores. Poor provider performance in making specialty referrals and reviewing specialists’ recommendations resulted in unreliable specialty services. The OIG ultimately rated this indicator inadequate. Case Review Results The OIG clinicians reviewed 298 events related to Specialty Services, which included 137 specialty consultations and procedures, and 48 nursing encounters. There were 50 deficiencies found in this category, of which 20 were significant. Access to Specialty Services Specialty appointments are integral aspects of patients gaining access to their needed specialty services. CCWF was typically able to provide the patient’s specialty services when ordered. Out of 137 specialty consultations, the OIG clinicians identified only eight lapses. The following are some examples: • In case 2, the patient had a rectal mass removed. She had a scheduled appointment with her surgeon, but the follow-up did not occur. • In case 25, the repeat esophagogastroduodenoscopy (EGD) to ensure the obliteration of the dilated veins in the lower esophagus did not happen within the recommended six-week period after the last EGD. Specialty services staff failed to schedule this patient with a gastroenterologist because of some difficulty with specialist contracts during that time. Central California Women’s Facility, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California However, concerning physical therapy, CCWF did not provide appropriate access. • In case 8, the patient had back surgery and needed continued physical therapy after the operation. The provider ordered physical therapy, but the patient did not receive the services. The patient had several falls while in the SNF, and fortunately did not suffer any injuries. However, the failure to provide physical therapy for the patient who had surgery, had weakness in the lower extremities, and had unstable balance placed her at risk for injury from falls. The Specialized Medical Housing indicator also discusses this case. • In case 20, the patient had back and hip pain, and developed the need to use a wheelchair. The provider ordered physical therapy, but the patient did not receive the services. Provider Performance CCWF providers often had problems making appropriate referrals to a specialist. When their patients returned from the specialist, the providers often delayed or overlooked the recommendations. The OIG discusses this performance further in the Quality of Provider Performance indicator. Nursing Performance There were not any significant nursing deficiencies identified in this category. The deficiencies that were identified related to either the occasional lapse in communication to the provider of the specialist recommendations of a medication or follow-up appointment. Overall, nursing performance was adequate. Health Information Management CCWF had problems with the retrieval of specialty reports. The deficiency was frequent and occurred in cases 1, 2, 9, 11, 17, 20, 26, 27, and 28. Missing specialty reports increased the risk of providers overlooking specialty recommendations and lapses in care. CCWF frequently misfiled specialty reports as well. This deficiency occurred in cases 1, 8, 11, 13, 17, 19, and 29. Case Review Conclusion CCWF providers did not consistently make appropriate specialty referrals. When the providers did make the referrals, the specialty department usually scheduled the appointment timely, except for physical therapy. When the specialty consultations were completed, CCWF often failed to retrieve the corresponding report, or the providers would not adequately review and implement those recommendations. Overall, CCWF could not sufficiently ensure that their patients receive needed specialty services or that the providers would act on the specialty recommendations. The OIG clinicians rated the Specialty Services indicator inadequate. Central California Women’s Facility, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California Compliance Testing Results The institution received a proficient compliance score of 89.6 percent in the Specialty Services indicator. Five tests earned scores in the proficient range, as follows: • For all 15 patients sampled, routine specialty service appointments occurred within 90 calendar days of the provider’s order (MIT 14.003). • For 14 of 15 patients sampled (93 percent), high priority specialty service appointments occurred within 14 calendar days of the provider’s order; one patient received her specialty service five days late (MIT 14.001). • Providers at CCWF timely received and reviewed high priority specialists’ reports for 14 of 15 patients sampled (93 percent); one patient’s report was reviewed four days late (MIT 14.002). • Providers timely received and reviewed the routine priority specialists’ reports for 14 of 15 patients sampled (93 percent); one patient’s report was reviewed 24 days late (MIT 14.004). • CCWF’s health care management timely denied providers’ specialty service requests for 18 of 20 sampled patients (90 percent). Management denied two specialty services requests four and eight days late (MIT 14.006). Two tests earned scores in the adequate range, as follows: • Among 20 patients sampled for whom CCWF’s health care management denied a specialty service, 16 (80 percent) received timely notification of the denied service, including a provider visit within 30 days to discuss alternate treatment strategies. For three patients, the provider visit occurred one, four, and 12 days late; one patient’s provider visit occurred 44 days late (MIT 14.007). • When an institution approves or schedules a patient for a specialty service appointment and then transfers that patient to another institution, policy requires that the receiving institution ensure the patient’s appointment occurs timely. At CCWF, 10 of the 13 sampled transfer-in patients received their specialty services appointment within the required time frame or had it canceled after the provider determined that it was no longer necessary (77 percent). Two patients received their appointments 58 and 104 days late, and for one patient, there was no evidence in the medical record that she received her appointment (MIT 14.005). Central California Women’s Facility, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Adequate (81.4%) reporting requirements for adverse/sentinel events and patient deaths. The OIG verifies that the Emergency Medical Response Overall Rating: Review Committee (EMRRC) performs required reviews and that Adequate staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. In addition, OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current medical emergency response certifications. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied on for the overall score for the institution. Compliance Testing Results The institution received an adequate compliance score of 81.4 percent in the Administrative Operations indicator, with 13 tests receiving scores of 100 percent, as follows: • The institution promptly processed all inmate medical appeals in the most recent 12 months (MIT 15.001). • The institution’s QMC met monthly, evaluated program performance, and acted when management identified opportunities for improvement (MIT 15.003). • CCWF took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004). • The OIG inspected incident package documentation for 12 emergency medical responses reviewed by CCWF’s Emergency Medical Response Review Committee (EMRRC) during the prior six-month period; all 12 sampled packages complied with policy (MIT 15.005). • Inspectors reviewed the last 12 months of CCWF’s local governing body (LGB) meeting minutes and determined that the LGB met at least quarterly and exercised responsibility for the quality management of patient health care each quarter, as documented in the meeting minutes. As a result, CCWF scored 100 percent on this test (MIT 15.006). Central California Women’s Facility, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California • Based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102). • Medical staff promptly submitted the initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit for all five applicable deaths that occurred at CCWF in the prior 12-month period (MIT 15.103). • The OIG’s inspectors examined the nursing reviews completed by five different nursing supervisors for their subordinate nurses; in all instances, the reviews were sufficiently completed (MIT 15.104). • All ten nurses sampled were current with their clinical competency validations (MIT 15.105). • All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 15.107, 15.109). • All active duty providers and nurses were current with their emergency response certifications (MIT 15.108). • All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 15.110). Four tests in this indicator received scores in the inadequate range: • CCWF reported the one adverse sentinel event (ASE) that occurred during the OIG’s testing period to the Adverse Sentinel Event Committee (ASEC) 16 days later than required by CCHCS policy. As a result, the institution received a score of zero on this test (MIT 15.002). • CCWF had five nurses that received their orientation 2 to 58 weeks late, and two nurses had still not received an orientation at the time of the inspection (one to six months late). The institution received a score of zero on this test (MIT 15.111). • The institution did not meet the emergency response drill requirements for the most recent quarter for two of its three watches, resulting in a score of 33 percent. More specifically, the institution’s first and second watch drill package did not have evidence of custody staff participation in the drill (MIT 15.101). • Five of ten CCWF providers had a proper clinical performance appraisal completed by their supervisor (50 percent). Five other providers did not have either timely or properly completed appraisals, including the following (15.106): Central California Women’s Facility, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California o All five providers’ most recently completed evaluations did not include the required PCP 360-degree evaluation or a core competency-based evaluation. o Two of these providers’ required Unit Health Clinical Appraisal were overdue by 19 and 45 days. Non-Scored Results • The OIG gathered non-scored data regarding the completion of death review reports by CCHCS’s Death Review Committee (DRC). Only five deaths occurred during the OIG’s review period, one unexpected (Level 1) death and two expected (Level 2) deaths. The DRC was required to complete its death review summary report within 60 calendar days from the date of death for Level 1 and within 30 days from the date of death for Level 2 deaths; the reports should then be submitted to the institution’s chief executive officer (CEO) within seven calendar days after that. One Level 1 death review summary was completed timely. However, for the two Level 2 deaths, the DRC completed its report six and 57 days late (36 and 87 days after the death) and submitted it to the CEO 22 and 2 days late. For the other two deaths that occurred, no final report had been issued at the time of the OIG inspection (MIT 15.998). • The OIG discusses the institution’s health care staffing resources in the About the Institution section of this report (MIT 15.999). Central California Women’s Facility, Cycle 5 Medical Inspection Page 71 Office of the Inspector General State of California R ECOMMENDATIONS • CCWF should implement strategies to evaluate, improve, and monitor the TTA nurses’ clinical performance during urgent/emergent encounters to ensure that they make appropriate and timely nursing assessments and interventions. • CCWF medical leadership, including the pharmacist in charge and staff, should implement a quality improvement process to ensure that staff properly closes encounters within the EHRS when patients transfer between CCWF units, and that staff administers medications ordered in the SNF timely. • CCWF medical leadership should arrange additional EHRS training for providers and nurses. The training should explain the barriers and challenges to the medication management process and should demonstrate the correct procedures to overcome those barriers within the EHRS. • Nursing and physician managers need to improve the consultation process between clinic nurses and providers; CCWF managers must ensure timely notification and communication processes are in place to handle patient situations requiring urgent medical consultation. • CCWF should provide certain specialty services, such as physical therapy. California regulations require SNFs, including CCWF to provide these services; if the service cannot be provided at the facility, then CCWF should arrange for transportation to and from the physical therapy service location. Central California Women’s Facility, Cycle 5 Medical Inspection Page 72 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the electronic medical record, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For Central California Women’s Facility, 13 HEDIS measures were selected for comparison, 12 of which were applicable, and are listed in the following CCWF Results Compared to State and National HEDIS Scores table. Multiple health plans publish their HEDIS performance measures at the state and national levels. The OIG has provided selected results for several health plans in both categories for comparative purposes. Central California Women’s Facility, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Results of Population-Based Metrics Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system to produce optimal results. CCWF performed very well with its management of diabetes. When compared statewide, CCWF’s scores significantly exceeded Medi-Cal’s in all five diabetic measures selected. When compared to Kaiser Permanente, Northern and Southern California, CCWF also prevailed in almost all diabetic measures, the only exception being Kaiser, Southern California, outscoring CCWF in diabetic eye exams. When compared nationally, CCWF outperformed Medicaid, Medicare, and commercial health plans in all five of the diabetic measures listed. CCWF also prevailed in comparison to the United States Department of Veterans Affairs (VA) for diabetic patients’ blood pressure control, diabetic monitoring, and number of patients under poor diabetic control. For eye exams, CCWF trailed the VA. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. For influenza shots for adults up to age 64, CCWF scored slightly higher than all other entities. With respect to influenza vaccinations for patients 65 and older, CCWF’s score matched the VA’s and was higher than Medicare’s by 4 percentage points. For pneumococcal vaccinations for older adults, CCWF scored higher than Medicare but 9 percentage points lower than the VA. Cancer Screening For colorectal cancer screening, CCWF performed extremely well, outscoring all entities that reported data (Kaiser, commercial plans, Medicare, and the VA). For cervical cancer screening, CCWF outscored Medi-Cal, Medicaid, and commercial entities, but trailed Kaiser and the VA. Similarly, CCWF’s scores for breast cancer screening were higher than those of Medicaid, Medicare, and commercial entities, but narrowly trailed the scores of Kaiser and the VA. Prenatal Care CCWF scored 100 percent for prenatal care, higher than all other reporting entities. Summary Overall, CCWF’s HEDIS performance reflected an adequately performing chronic care and preventive services program, with average to above-average comparative scores in nearly all measures. Central California Women’s Facility, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California CCWF Results Compared to State and National HEDIS Scores California National CCWF HEDIS HEDIS HEDIS HEDIS Kaiser Kaiser HEDIS HEDIS VA Clinical Measures Medi- Com- Cycle 5 (No. (So. Medicaid Medicare Average Cal mercial Results1 CA) CA) 20164 20164 20155 20152 20164 20163 20163 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 9% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 79% 49% 70% 63% 46% 55% 63% - Blood Pressure Control 94% 63% 83% 83% 59% 60% 62% 74% (<140/90) Eye Exams 77% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 58% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+) 76% - - - - - 72% 76% Immunizations: Pneumococcal 84% - - - - - 71% 93% Cancer Screening Breast Cancer Screening (50– 85% - 87% 87% 59% 73% 73% 86% 74)8 Cervical Cancer Screening 84% 59% 91% 85% 56% 75% - 93% Colorectal Cancer Screening 95% - 79% 82% - 63% 67% 82% Prenatal and Postpartum Care Prenatal Care 100% 82% 96% 97% 80% 84% - - Postpartum Care9 N/A 59% 96% 91% 61% 73% - - 1. Unless otherwise stated, data was collected in July 2017 by reviewing medical records from a sample of CCWF’s population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable CCWF population was tested. 7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the reported data for the <9.0% HbA1c control indicator. 8. The Kaiser HEDIS data age range is 52–74. 9. With regard to Postpartum Care, no patients applied to this test. Central California Women’s Facility, Cycle 5 Medical Inspection Page 75 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS CCWF Range of Summary Scores: 61.72% – 95.00% Indicator Compliance Score (Yes %) 1–Access to Care 83.2% 2–Diagnostic Services 76.7% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 93.0% 5–Health Care Environment 61.7% 6–Inter- and Intra-System Transfers 75.1% 7–Pharmacy and Medication Management 73.9% 8–Prenatal and Post-Delivery Services 83.3% 9–Preventive Services 85.2% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals 72.5% 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) 95.0% 14–Specialty Services 89.6% 15–Administrative Operations 81.4% Central California Women’s Facility, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California Scored Answers Yes Reference + 1–Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 17 8 25 68.0% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 13 12 25 52.0% 0 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 30 0 30 100.0% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a face- 1.004 to-face visit within one business day after the CDCR Form 7362 26 4 30 86.7% 0 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 5 2 7 71.4% 23 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 1 0 1 100.0% 29 the time frame specified? Upon the patient’s discharge from the community hospital: Did 1.007 the patient receive a follow-up appointment within the required 22 3 25 88.0% 0 time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 24 5 29 82.8% 1 frames? Clinical appointments: Do patients have a standardized process to 1.101 6 0 6 100.0% 0 obtain and submit health care services request forms? Overall percentage: 83.2% Central California Women’s Facility, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California Scored Answers Yes Reference + 2–Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 10 0 10 100.0% 0 frame specified in the provider’s order? Radiology: Did the primary care provider review and initial the 2.002 7 3 10 70.0% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 6 4 10 60.0% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 7 3 10 70.0% 0 frame specified in the provider’s order? Laboratory: Did the primary care provider review and initial the 2.005 6 4 10 60.0% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the 2.006 results of the diagnostic study to the patient within specified time 4 6 10 40.0% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 10 0 10 100.0% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 10 0 10 100.0% 0 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 9 1 10 90.0% 0 of the diagnostic study to the patient within specified time frames? Overall percentage: 76.7% 3–Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. Central California Women’s Facility, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California Scored Answers Yes Reference + 4–Health Information Management Number Yes No No Yes % N/A Are non-dictated healthcare documents (provider progress notes) 4.001 5 0 5 100.0% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter Not Applicable date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 18 2 20 90.0% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 19 1 20 95.0% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 Not Applicable patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 24 0 24 100.0% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and 4.007 20 5 25 80.0% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 93.0% Central California Women’s Facility, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Scored Answers Yes Reference + 5–Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned 5.101 9 1 10 90.0% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 9 1 10 90.0% 0 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 10 0 10 100.0% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 6 4 10 60.0% 0 precautions? Do clinical health care areas control exposure to blood-borne 5.105 10 0 10 100.0% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 0 1 1 0.0% 0 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 4 6 10 40.0% 0 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 2 8 10 20.0% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 4 5 9 44.4% 1 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 9 1 10 90.0% 0 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 4 5 9 44.4% 1 and do they contain essential items? Overall percentage: 61.7% Central California Women’s Facility, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California Scored Answers Yes Reference + 6–Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 10 15 25 40.0% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient 6.002 23 2 25 92.0% 0 to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon 6.003 13 6 19 68.4% 6 arrival, were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled 6.004 specialty service appointments identified on the patient’s health Not Applicable care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 8 0 8 100.0% 2 corresponding transfer packet required documents? Overall percentage: 75.1% Central California Women’s Facility, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 10 4 14 71.4% 11 policy for refusals or no-shows? Did health care staff administer, make available, or deliver new 7.002 order prescription medications to the patient within the required 21 4 25 84.0% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 22 3 25 88.0% 0 the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider 7.004 10 4 14 71.4% 6 administered, made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: 7.005 16 9 25 64.0% 0 Were medications continued without interruption? For patients en route who lay over at the institution: If the 7.006 temporarily housed patient had an existing medication order, were 8 1 9 88.8% 1 medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 4 4 8 50.0% 2 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 0 8 8 0.0% 2 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 8 1 9 88.9% 1 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 2 4 6 33.3% 4 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 5 1 6 83.3% 4 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 2 4 6 33.3% 4 protocols when distributing medications to patients? Pharmacy: Does the institution employ and follow general 7.107 security, organization, and cleanliness management protocols in 1 0 1 100.0% 0 its main and satellite pharmacies? Central California Women’s Facility, Cycle 5 Medical Inspection Page 82 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Pharmacy: Does the institution’s pharmacy properly store non- 7.108 1 0 1 100.0% 0 refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store 7.109 1 0 1 100.0% 0 refrigerated or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 1 0 1 100.0% 0 narcotic medications? Does the institution follow key medication error reporting 7.111 25 0 25 100.0% 0 protocols? Overall percentage: 73.9% Scored Answers Yes Reference + 8–Prenatal and Post-Delivery Services Number Yes No No Yes % N/A 8.001 For patients identified as pregnant, did the institution timely offer 5 0 5 100.0% 0 initial provider visits? 8.002 Was the pregnant patient timely issued a comprehensive accommodation chrono for a lower bunk and lower-tier housing 5 0 5 100.0% 0 and did the patient receive the correct housing placement? 8.003 Did medical staff promptly order recommended vitamins, extra 0 5 5 0.0% 5 daily nutritional supplements and food for the patient? 8.004 Did timely patient encounters occur with an OB physician or OB nurse practitioner in accordance with the pregnancy encounter 5 0 5 100.0% 0 guidelines? 8.005 Were the results of the patient’s initial prenatal screening tests 5 0 5 100.0% 0 timely completed and reviewed? 8.006 Was the patient’s weight and blood pressure documented at each 5 0 5 100.0% 0 clinic OB visit? 8.007 Did the patient receive her six-week post-partum obstetric visit? Not Applicable Overall percentage: 83.3% Central California Women’s Facility, Cycle 5 Medical Inspection Page 83 Office of the Inspector General State of California Scored Answers Yes Reference + 9–Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 7 7 14 50.0% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 9 5 14 64.3% 0 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 30 0 30 100.0% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 25 0 25 100.0% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 25 0 25 100.0% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 30 0 30 100.0% 0 patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 25 2 27 92.6% 3 patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 15 5 20 75.0% 5 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 Not Applicable fever) infection transferred out of the facility in a timely manner? Overall percentage: 85.2% 10–Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 11–Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. Central California Women’s Facility, Cycle 5 Medical Inspection Page 84 Office of the Inspector General State of California Scored Answers Yes Reference + 12–Reception Center Arrivals Number Yes No No Yes % N/A For patients received from a county jail: Did nursing staff complete the initial health screening and answer all screening 12.001 16 4 20 80.0% 0 questions on the same day the patient arrived at the institution? For patients received from a county jail: When required, did the RN complete the assessment and disposition section of the health 12.002 18 2 20 90.0% 0 screening form, and sign and date the form on the same day staff completed the health screening? For patients received from a county jail: If, during the assessment, 12.003 the nurse referred the patient to a provider, was the patient seen Not Applicable within the required time frame? For patients received from a county jail: Did the patient receive a 12.004 history and physical by a primary care provider within seven 3 17 20 15.0% 0 calendar days? For patients received from a county jail: Were all required intake 12.005 20 0 20 100.0% 0 tests completed within specified timelines? For patients received from a county jail: Did the primary care 12.006 provider review and communicate the intake test results to the 10 10 20 50.0% 0 patient within specified timelines? For patients received from a county jail: Was a tuberculin test 12.007 20 0 20 100.0% 0 both administered and read timely? For patients received from a county jail: Was a 12.008 Coccidioidomycosis (Valley Fever) skin test offered, Not Applicable administered, read, or refused timely? Overall percentage: 72.5% Central California Women’s Facility, Cycle 5 Medical Inspection Page 85 Office of the Inspector General State of California Scored Answers Yes Reference + 13–Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 10 0 10 100.0% 0 eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 8 2 10 80.0% 0 examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 10 0 10 100.0% 0 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC Only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 1 0 1 100.0% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 95.0% Central California Women’s Facility, Cycle 5 Medical Inspection Page 86 Office of the Inspector General State of California Scored Answers Yes Reference + 14–Specialty Services Number Yes No No Yes % N/A Did the patient receive the high priority specialty service within 14.001 14 calendar days of the primary care provider order or the 14 1 15 93.3% 0 Physician Request for Service? Did the primary care provider review the high priority specialty 14.002 14 1 15 93.3% 0 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 15 0 15 100.0% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 14 1 15 93.3% 0 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 10 3 13 76.9% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 18 2 20 90.0% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 16 4 20 80.0% 0 patient informed of the denial within the required time frame? Overall percentage: 89.6% Central California Women’s Facility, Cycle 5 Medical Inspection Page 87 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 12 0 12 100.0% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 0 1 1 0.0% 0 requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 6 0 6 100.0% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100.0% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 12 0 12 100.0% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 4 0 4 100.0% 0 exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 1 2 3 33.3% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100.0% 0 all of the patient’s appealed issues? Did the institution’s medical staff review and submit the initial 15.103 5 0 5 100.0% 5 inmate death report to the Death Review Unit in a timely manner? Does the institution’s Supervising Registered Nurse conduct 15.104 5 0 5 100.0% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 10 0 10 100.0% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 6 0 6 100.0% 1 15.107 Do all providers maintain a current medical license? 12 0 12 100.0% 0 Are staff current with required medical emergency response 15.108 2 0 2 100.0% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy licensed as a correctional pharmacy by the California State Board 15.109 6 0 6 100.0% 1 of Pharmacy? Central California Women’s Facility, Cycle 5 Medical Inspection Page 88 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 1 0 1 100.0% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 0 1 1 0.0% 0 Overall percentage: 81.4% Central California Women’s Facility, Cycle 5 Medical Inspection Page 89 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Central California Women’s Facility Table B-1: Sample Sets Sample Set Total Anticoagulation 1 Death Review/Sentinel Events 3 Diabetes 3 Emergency Services — Non-CPR 3 High Risk 5 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 Perinatal Services 4 RN Sick Call 16 Reception Center Transfers 4 Specialty Services 4 53 Central California Women’s Facility, Cycle 5 Medical Inspection Page 90 Office of the Inspector General State of California Table B-2: Chronic Care Diagnoses Diagnosis Total Anemia 16 Anticoagulation 2 Arthritis/Degenerative Joint Disease 15 Asthma 21 COPD 10 Cancer 3 Cardiovascular Disease 12 Chronic Kidney Disease 7 Chronic Pain 23 Cirrhosis/End Stage Liver Disease 7 Deep Venous Thrombosis/Pulmonary Embolism 1 Diabetes 19 Gastroesophageal Reflux Disease 14 Gastrointestinal Bleed 4 HIV 4 Hepatitis C 13 Hyperlipidemia 18 Hypertension 31 Mental Health 14 Migraine Headaches 4 Rheumatological Disease 6 Seizure Disorder 8 Sleep Apnea 2 Thyroid Disease 11 265 Central California Women’s Facility, Cycle 5 Medical Inspection Page 91 Office of the Inspector General State of California Table B-3: Event — Program Program Total Diagnostic Services 208 Emergency Care 96 Hospitalization 45 Intra-system Transfers-In 6 Intra-system Transfers-Out 6 Outpatient Care 470 Prenatal & Postpartum Care 16 Reception Center Care 27 Specialized Medical Housing 136 Specialty Services 296 1,306 Central California Women’s Facility, Cycle 5 Medical Inspection Page 92 Office of the Inspector General State of California Table B-4: Review Sample Summary Total MD Reviews Detailed 23 MD Reviews Focused 4 RN Reviews Detailed 18 RN Reviews Focused 29 Total Reviews 74 Total Unique Cases 53 Overlapping Reviews (MD & RN) 21 Central California Women’s Facility, Cycle 5 Medical Inspection Page 93 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY Central California Women’s Facility (CCWF) Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry • Chronic care conditions (at least one condition per patient—any risk level) (25) • Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001 • See Intra-system Transfers (25) MITs 1.003-006 Nursing Sick Call MedSATS • Clinic (each clinic tested) (6 per clinic) • Appointment date (2–9 months) 30 • Randomize MIT 1.007 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 1.008 Specialty Services OIG Q: 14.001 & • See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite • Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs • Appointment date (90 days–9 months) • Randomize (10) • Abnormal MITs 2.004–006 Laboratory Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize (10) • Abnormal MITs 2.007–009 Pathology InterQual • Appt. date (90 days–9 months) • Service (pathology related) (10) • Randomize Central California Women’s Facility, Cycle 5 Medical Inspection Page 94 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001, • Non-dictated documents (5) 1.002, & 1.004 • 1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001 • Dictated documents (0) • First 20 IPs selected MIT 4.003 OIG Qs: 14.002 • Specialty documents (20) & 14.004 • First 10 IPs for each question MIT 4.004 OIG Q: 4.007 • Community hospital discharge documents (20) • First 20 IPs selected MIT 4.005 OIG Q: 7.001 • MARs (0) • First 20 IPs selected MIT 4.006 Documents for • Any misfiled or mislabeled document identified (0) any tested inmate during OIG compliance review (24 or more = No) MIT 4.007 Returns From Inpatient claims • Date (2–8 months) Community Hospital data • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize (each month individually) • First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (25) Health Care Environment MIT 5.10–1105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas. MIT 5.107–111 (10) onsite review Inter- and Intra-System Transfers MIT 6.001-003 Intra-System SOMS • Arrival date (3–9 months) Transfers • Arrived from (another CDCR facility) • Rx count • Randomize (25) MIT 6.004 Specialty Services MedSATS • Date of transfer (3–9 months) Send-Outs • Randomize (0) MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication (8) onsite review Central California Women’s Facility, Cycle 5 Medical Inspection Page 95 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize (25) MIT 7.002 New Medication Master Registry • Rx count Orders • Randomize (25) • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders (20) MIT 7.005 Intra-Facility Moves MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) (25) • Randomize MIT 7.006 En Route SOMS • Date of transfer (2–8 months) • Sending institution (another CDCR facility) • Randomize (9) • NA/DOT meds MITs 7.101-103 Medication Storage OIG inspector • Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector • Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107-110 Pharmacy OIG inspector • Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly • All monthly statistic reports with Level 4 or higher Reporting medication error • Select a total of 5 months (25) reports MIT 7.999 Isolation Unit KOP Onsite active • KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (10) listing Prenatal and Post-Delivery Services MIT 8.001-007 Recent Deliveries OB Roster • Delivery date (2–12 months) (0) • Most recent deliveries (within date range) Pregnant Arrivals OB Roster • Arrival date (2–12 months) (5) • Earliest arrivals (within date range) Central California Women’s Facility, Cycle 5 Medical Inspection Page 96 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) (14) • Randomize MIT 9.003 TB Codes, Annual SOMS • Arrival date (at least 1 year prior to inspection) Screening • TB Codes (30) • Randomize MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (25) • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection) Screening • Date of birth (51 or older) (25) • Randomize MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs prior to inspection) • Date of birth (age 52–74) (30) • Randomize MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs prior to inspection) • Date of birth (age 24–53) (30) • Randomize MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level) • Randomize (25) • Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months (number will vary) status report • Institution • Ineligibility date (60 days prior to inspection date) N/A at this institution • All Central California Women’s Facility, Cycle 5 Medical Inspection Page 97 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS • Arrival date (2–8 months) • Arrived from (county jail, return from parole, etc.) (20) • Randomize Specialized Medical Housing MITs 13.001–003 SNF CADDIS • Admit date (1–6 months) • Type of stay (no MH beds) • Length of stay (minimum of 5 days) (10) • Randomize MIT 13.101 Call Buttons OIG inspector • Review by location SNF (all) onsite review Specialty Services MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months) (15) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) (15) • Remove optometry, physical therapy or podiatry • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (13) • Randomize MIT 14.006-007 Denials InterQual • Review date (3–9 months) (19) • Randomize IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld (1) • Randomize Central California Women’s Facility, Cycle 5 Medical Inspection Page 98 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical • Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel • Adverse/sentinel events (2–8 months) Events events report (1) MITs 15.003–004 QMC Meetings Quality • Meeting minutes (6 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting • Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting • Quarterly meeting minutes (12 months) (4) minutes MIT 15.101 Medical Emergency Onsite summary • Most recent full quarter Response Drills reports & • Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of • Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of • Most recent 10 deaths deaths in prior 12 • Initial death reports (5) months MIT 15.104 RN Review Onsite supervisor • RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews • Randomize (5) MIT 15.105 Nursing Staff Onsite nursing • On duty one or more years Validations education files • Nurse administers medications (10) • Randomize MIT 15.106 Provider Annual • All required performance evaluation documents Evaluation Packets (10) MIT 15.107 Provider licenses Current provider • Review all listing (at start of (12) inspection) MIT 15.108 Medical Emergency Onsite • All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) • Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking • All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) Central California Women’s Facility, Cycle 5 Medical Inspection Page 99 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff • New employees (hired within last 12 months) Employee training logs • Orientations (all) MIT 15.998 Death Review OIG summary log • Between 35 business days & 12 months prior Committee - deaths • CCHCS death reviews (5) Central California Women’s Facility, Cycle 5 Medical Inspection Page 100 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE Central California Women’s Facility, Cycle 5 Medical Inspection Page 101 Office of the Inspector General State of California