Pelican Bay State Prison Cycle 6 Medical Inspection Report

Amarik K. Singh, Inspector General OFFICE of the OIG INSPECTOR GENERAL Independent Prison Oversight March 2022 Cycle 6 Medical Inspection Report Pelican Bay State Prison Electronic copies of reports published by the Office of the Inspector General are available free in portable document format (PDF) on our website. We also offer an online subscription service. For information on how to subscribe, visit www.oig.ca.gov. For questions concerning the contents of this report, please contact Shaun Spillane, Public Information Officer, at 916-255-1131. Cycle 6, Pelican Bay State Prison | i Contents Introduction 1 Summary 3 Overall Rating: Adequate 3 Medical Inspection Results 7 Deficiencies Identified During Case Review 7 Case Review Results 7 Compliance Testing Results 8 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 14 Access to Care 14 Diagnostic Services 22 Emergency Services 26 Health Information Management 30 Health Care Environment 34 Transfers 42 Medication Management 47 Preventive Services 54 Nursing Performance 56 Provider Performance 63 Specialized Medical Housing 67 Specialty Services 72 Administrative Operations 77 Appendix A. Methodology 81 Case Reviews 82 Compliance Testing 85 Indicator Ratings and the Overall Medical Quality Rating 86 Appendix B. Case Review Data 87 Appendix C. Compliance Sampling Methodology 90 California Correctional Health Care Services’ Response 98 Cycle 6, Pelican Bay State Prison | ii Illustrations Tables 1. Pelican Bay State Prison Summary Table 3 2. Pelican Bay State Prison Policy Compliance Scores 4 3. Pelican Bay State Prison Master Registry Data as of January 2021 5 4. Pelican Bay State Prison Health Care Staffing Resources as of January 2021 6 5. Pelican Bay State Prison Results Compared with State HEDIS Scores 10 6. Access to Care 19 7. Other Tests Related to Access to Care 20 8. Diagnostic Services 24 9. Health Information Management 32 10. Other Tests Related to Health Information Management 33 11. Health Care Environment 40 12. Transfers 45 13. Other Tests Related to Transfers 46 14. Medication Management 52 15. Other Tests Related to Medication Management 53 16. Preventive Services 55 17. Specialized Medical Housing 70 18. Specialty Services 75 19. Other Tests Related to Specialty Services 76 20. Administrative Operations 79 A–1. Case Review Definitions 82 B–1. Case Review Sample Sets 87 B–2. Case Review Chronic Care Diagnoses 88 B–3. Case Review Events by Program 89 B–4. Case Review Sample Summary 89 Figures A–1. Inspection Indicator Review Distribution 82 A–2. Case Review Testing 84 A–3. Compliance Sampling Methodology 85 Photographs 1. Clinic outdoor waiting area 34 2. Clinic indoor waiting area 35 3. Torn examination room table cover 36 4. Torn pillow cover used for Physical Therapy services 36 5. Examination room configuration did not allow patients to lie fully extended without obstruction 37 6. Expired medical supply dated August 1, 2020 37 7. Unlabeled medical supplies 38 8. Exhaust under the clinic sink had accumulated dust 39 Cover: Rod of Asclepius courtesy of Thomas Shafee Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated persons1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 6, the OIG continues to apply the same assessment methodologies used in Cycle 5, including clinical case review and compliance testing. These methods provide an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk who tend to access services at the highest rate. This information helps to assess the performance of the institution in providing sustainable, adequate care.3 We continue to review institutional care using 15 indicators, as in prior cycles. Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT).4 We determine a total compliance score for each applicable indicator and consider the MIT scores in the overall conclusion of the institution’s performance. In addition, our clinicians complete document reviews of individual cases and perform on-site inspections, which include interviews with staff. In reviewing the cases, our clinicians examine whether providers used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient.5 At the same time, our clinicians examine whether the institution’s medical system mitigated the error. The OIG rates the indicators as proficient, adequate, or inadequate. 1 In this report, we use the terms patient and patients to refer to incarcerated persons. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. 4 The department regularly updates its policies. The OIG updates our policy-compliance testing to reflect the department’s updates and changes. 5 If we learn of a patient needing immediate care, we notify the institution’s chief executive officer. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 2 The OIG has adjusted Cycle 6 reporting in two ways. First, commencing with this reporting period, we interpret compliance and case review results together, providing a more holistic assessment of the care; and second, we consider whether institutional medical processes lead to identifying and correcting provider or system errors. The review assesses the institution’s medical care on both system and provider levels. As in Cycle 5, our office continues to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. At the time of the Cycle 6 inspection of Pelican Bay State Prison (PBSP), the receiver had delegated this institution back to the department. We completed our sixth inspection of PBSP, and this report presents our assessment of the health care provided at that institution during the inspection period between November 2020 and April 2021.6 The data obtained for PBSP and the on-site inspections occurred during the COVID-19 pandemic.7 PBSP is located in Crescent City in Del Norte County. PBSP has one Level I minimum-security yard, one facility housing Level II patients, and two Level IV yards housing maximum-security patients in a general population setting. In addition, PBSP has a security housing unit (SHU) facility, which was designed for individuals who present serious management concerns, including prison gang members and violent maximum-security patients. The institution operates multiple clinics where medical staff handle nonurgent requests for medical services. It also provides inpatient care at its correctional treatment center (CTC) and treats patients needing urgent or emergent care in its triage and treatment area (TTA). PBSP has been designated by CDCR as a basic care prison, secondary to its location in a rural area away from tertiary care centers and specialty care providers whose services would likely be frequently used by higher-risk patients. 6 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include cardiopulmonary resuscitation (CPR) reviews between August 2020 and February 2021, death reviews between January 2020 and March 2021, and RN sick call reviews between August 2020 and April 2020. 7As of October 5, 2021, the department reports on its public tracker that 78% of the incarcerated population at PBSP is fully vaccinated while 42% of PBSP staff are fully vaccinated: https://www.cdcr.ca.gov/covid19/population-status-tracking/ Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 3 Summary We completed the Cycle 6 inspection of PBSP in September 2021. OIG inspectors monitored the institution’s medical care that occurred between November 2020 and April 2021. The OIG rated the overall quality of health care at PBSP as adequate. We list the individual indicators and ratings applicable to this institution in the PBSP Executive Summary Table below. Table 1. PBSP Summary Table Cycle 6 Cycle 6 Cycle 6 Change Health Care Indicators Case Review Compliance Overall Since Rating Rating Rating Cycle 5 Access to Care Adequate Adequate Adequate Diagnostic Services Adequate Adequate Adequate Emergency Services Adequate N/A Adequate Health Information Management Adequate Inadequate Adequate Health Care Environment N/A Inadequate Inadequate Transfers Adequate Adequate Adequate Medication Management Proficient Inadequate Inadequate Prenatal and Postpartum Care N/A N/A N/A N/A Preventive Services N/A Adequate Adequate Nursing Performance Adequate N/A Adequate Provider Performance Adequate N/A Adequate Reception Center N/A N/A N/A N/A Specialized Medical Housing Adequate Proficient Adequate Specialty Services Adequate Inadequate Inadequate Administrative Operations† N/A Proficient Proficient * The symbols in this column correspond to changes that occurred in indicator ratings between the medical inspections conducted during Cycle 5 and Cycle 6. The equals sign means there was no change in the rating. The single arrow means the rating rose or fell one level, and the double arrow means the rating rose or fell two levels (green, from inadequate to proficient; pink, from proficient to inadequate). † Administrative Operations is a secondary indicator and is not considered when rating the institution’s overall medical quality. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 4 To test the institution’s policy compliance, our compliance inspectors, (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 315 patient records and 874 data points and used the data to answer 87 policy questions. In addition, we observed PBSP’s processes during an on-site inspection in June 2021. Table 2 below lists PBSP’s average scores from Cycles 4, 5, and 6. Table 2. PBSP Policy Compliance Scores Scoring Ranges 100%–85.0% 84.9%–75.0% 74.9%–0 Medical Cycle 4 Cycle 5 Cycle 6 Inspection Policy Compliance Category Average Average Average Tool (MIT) Score Score Score 1 Access to Care 89.4% 86.5% 79.7% 2 Diagnostic Services 89.8% 75.2% 82.2% 4 Health Information Management 44.3% 83.1% 64.2% 5 Health Care Environment 85.0% 71.5% 67.9% 6 Transfers 93.8% 56.0% 77.1% 7 Medication Management 87.7% 72.2% 64.4% 8 Prenatal and Postpartum Care N/A N/A N/A 9 Preventive Services 76.4% 95.5% 83.4% 12 Reception Center N/A N/A N/A 13 Specialized Medical Housing 98.0% 95.0% 85.0% 14 Specialty Services 83.3% 91.0% 54.2% 15 Administrative Operations 74.4%* 84.3% 86.5% * In Cycle 4, there were two secondary (administrative) indicators, and this score reflects the average of those two scores. In Cycle 5 and moving forward, the two indicators were merged into one, with only one score as the result. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 5 The OIG clinicians (a team of physicians and nurse consultants) reviewed 47 cases, which contained 950 patient-related events. After examining the medical records, our clinicians conducted a follow-up on-site inspection to verify their initial findings. The OIG physicians rated the quality of care for 20 comprehensive case reviews. Of these 20 cases, our physicians rated 18 adequate and 2 inadequate. Our physicians did not identify any adverse events during this inspection. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in the 13 health care indicators. Multiple OIG physicians and nurses performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our clinicians acknowledged institutional structures that catch and resolve mistakes that may occur throughout the delivery of care. As noted above, we listed the individual indicators and ratings applicable for this institution in Table 1, the PBSP Summary Table. In May 2021, the Health Care Services Master Registry showed that PBSP had a total population of 2,085. A breakdown of the medical risk level of the PBSP population as determined by the department is set forth in Table 3 below.8 Table 3. PBSP Master Registry Data as of May 14, 2021 Medical Risk Level Number of Patients Percentage High 1 17 0.8% High 2 93 4.5% Medium 489 23.5% Low 1,486 71.3% Total 2,085 100.0% Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 5-14-21. 8 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 6 Based on staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 4 below, Pelican Bay State Prison had zero vacant executive leadership positions, two vacant primary care provider positions, 1.7 vacant nursing supervisor positions, and 31.6 vacant nursing staff positions. Table 4. P BSP Health Care Staffing Resources as of May 2021 Executive Primary Care Nursing Nursing Positions Leadership* Providers Supervisors Staff† Total Authorized Positions 6.0 5.0 10.7 86.6 108.3 Filled by Civil Service 6.0 4.0 9.0 55.0 74.0 Vacant 0 2.0 1.7 31.6 35.3 Percentage Filled by Civil Service 100.0% 80.0% 84.1% 63.5% 68.3% Filled by Telemedicine 0 0 0 0 0 Percentage Filled by Telemedicine 0% 0% 0% 0% 0% Filled by Registry 0 1 0 20 21.0 Percentage Filled by Registry 0% 20.0% 0% 23.1% 19.4% Total Filled Positions 6.0 5.0 9.0 75.0 95.0 Total Percentage Filled 100.0% 100.0% 84.1% 86.6% 87.7% Appointments in Last 12 Months 0 2 1 17 20 Redirected Staff 0 0 0 0 0 Staff on Extended Leave‡ 0 0 0 6 6 Adjusted Total: Filled Positions 6 5 9 69 89 Adjusted Total: Percentage Filled 100% 100% 84.1% 79.7% 82.2% * Executive Leadership includes the Chief Physician and Surgeon. † Nursing Staff includes Senior Psychiatric Technician and Psychiatric Technician. ‡ In Authorized Positions. Notes: The OIG does not independently validate staffing data received from the department. Positions are based on fractional time-base equivalents. Source: Cycle 6 medical inspection preinspection questionnaire received May 2021, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 7 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. An adverse event occurs when the deficiency caused harm to the patient, highlighting the serious consequences, and providing an impetus for improvement.9 All major health care organizations identify and track adverse events. The OIG identifies deficiencies and adverse events for the benefit of the institution’s quality improvement program. The OIG did not find any adverse deficiencies at PBSP during the Cycle 6 inspection period. Case Review Results OIG case reviewers assessed 10 of the 13 indicators applicable to PBSP. Of these 10 indicators, OIG clinicians rated one proficient, nine adequate and zero inadequate. The OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, none were proficient, 18 were adequate, and two were inadequate. In the 950 events reviewed, there were 129 deficiencies, 30 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at PBSP: • Correctional treatment center staff provided good quality medical care. • Staff utilized built-in messaging to communicate patient care issues quickly and to ensure timely care. On several occasions specialty nurses messaged providers to ensure timely follow-up appointments and orders. • Providers made good decisions during emergent or urgent situations. Our clinicians found PBSP could improve in the following areas: • During the Covid-19 pandemic, providers should more carefully consider whether a patient encounter could be postponed safely. 9For a definition of an event, see Table A–1, page 73. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 8 Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to PBSP. Of these 10 indicators, our compliance inspectors rated two proficient, four adequate, and four inadequate. We tested policy compliance in the Health Care Environment, Preventative Services, and Administrative Operations indicators, as these indicators do not have a case review component. PBSP demonstrated a high rate of policy compliance in the following areas: • Providers performed well in completing history and physical examinations within the required time frames. • Because the institution’s specialized medical housing unit had working call buttons, medical staff were able to enter patient rooms in a timely manner during emergent events. • Providers performed exceptionally well in endorsing and communicating diagnostic services results according to CCHCS policy. • Nursing staff received and reviewed health care services request forms and conducted face-to-face encounters within policy time frames. PBSP demonstrated a low rate of policy compliance in the following areas: • The institution did not perform well in providing specialty services to patients with approved high-priority, medium- priority, and routine-priority orders. • Providers often did not review specialty services reports within the required time frames. • Patients did not timely receive their ordered chronic care medications and hospital discharge medications; patients with a temporary layover at PBSP also did not receive their medications timely. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 9 Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 6. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores. However, through the California Department of Health Care Services’ Medi-Cal Managed Care Technical Report, the OIG obtained Kaiser Medi-Cal HEDIS scores for three of five diabetic measures to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered PBSP’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. PBSP’s results compared favorably with those found in State health plans for diabetic care measures. We list the nine HEDIS measures in Table 5. Comprehensive Diabetes Care When compared with statewide Medi-Cal programs (California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal), PBSP performed better in all three diabetic measures that have statewide comparative data: HbA1c screening, Poor HbA1c control, and blood pressure control. Immunizations Statewide comparative data were not available for immunization measures; however, we include this data for informational purposes. PBSP had a 55 percent influenza immunization rate for adults 18 to 64 years old, and a 63 percent influenza immunization rate for adults 65 years of age and older.10 The pneumococcal vaccine rate was 70 percent.11 10 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. The sample for older adults did not include a full sample. 11 The pneumococcal vaccines administered are the 13 valent pneumococcal vaccine (PCV13) or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at a different institution other than the one in which the patient was housed during the inspection period. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 10 Colorectal Cancer Screening Statewide comparative data were not available for colorectal cancer screening; however, we include these data for informational purposes. PBSP had an 81 percent colorectal cancer screening rate. Table 5. PBSP Results Compared with State HEDIS Scores California California PBSP Kaiser Kaiser California NorCal SoCal Cycle 6 Medi-Cal Medi-Cal Medi-Cal HEDIS Measure Results* 2018† 2018† 2018† HbA1c Screening 100% 90% 94% 96% Poor HbA1c Control (> 9.0%) ‡, § 19% 34% 25% 18% HbA1c Control (< 8.0%) ‡ 69% – – – Blood Pressure Control (< 140/90) ‡ 86% 65% 78% 84% Eye Examinations 80% – – – Influenza – Adults (18–64) 55% – – – Influenza – Adults (65+) 63% – – – Pneumococcal – Adults (65+) 70% – – – Colorectal Cancer Screening 81% – – – Notes and Sources * Unless otherwise stated, data were collected in June 2021 by reviewing medical records from a sample of PBSP’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication titled, Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2019–June 30, 2020 (published April 2021). www.dhcs.ca.gov/documents/MCQMD/CA2019-20-EQR-Technical-Report-Vol3-F2.pdf ‡ For this indicator, the entire applicable PBSP population was tested. § For this measure only, a lower score is better. Source: Institution information provided by the California Department of Corrections and Rehabilitation. Health care plan data were obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 11 Recommendations As a result of our assessment of PBSP’s performance, we offer the following recommendations to the department: Access to Care • Medical leadership should determine the root cause(s) of challenges in the timely provision of chronic care follow-up appointments with providers, nurse-to-provider referrals and implement remedial measures as appropriate. • The department should provide clear policy guidance to institutions regarding how to manage care during the pandemic, including how to manage care for chronic care patients whose appointments might be cancelled or delayed, how to prioritize patient movement to ensure provider appointments occur, how to properly close an appointment for patients who only receive a medical chart review, and how to balance the workload to ensure equitable distribution of patient care among nursing and providers. Emergency Services • Nursing leadership should provide additional training to staff for complete documentation of emergency medical events to include all appropriate times, interventions provided, report to EMS personnel, patient reassessments, and communication with the providers. • The Emergency Medical Response Review Committee (EMRRC) should more thoroughly review emergency response events and accurately detail findings. Health Information Management • The department should consider adjusting the default drop- down menu on the results letter in the EHRS so that the menu defaults to patient letter instead of DDP-Scan; the department should train providers to generate the results letters appropriately. Health Care Environment • Nursing leadership should consider performing random spot checks to ensure staff follow medical supply management protocols. • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 12 and treatment cart logs to ensure the EMRBs and treatment carts are regularly inventoried, sealed, and meet the minimum par level. Transfers • Nursing leadership should develop and implement internal auditing of staff to ensure complete and thorough assessments for patients returning from hospitalizations. • Healthcare leadership should consider adjusting the initial health screening form to add the symptom of fatigue for tuberculosis (TB) symptom monitoring and screening. Medication Management • Medical and nursing leadership should ensure that chronic care, hospital discharge, and en route patients receive their medications timely and without interruption. Nursing Performance • Nursing leadership should determine the root cause of challenges that prevent outpatient nurses from performing complete assessments and implement remedial measures as appropriate, including training of staff. • Nursing leadership should determine the causes that prevent PBSP correctional treatment center (CTC) nurses from performing complete assessments and proper wound care, and implement remedial measures as appropriate, including training of staff. Provider Performance • Medical leadership should consider reminding providers to carefully review charts before rescheduling appointments due to COVID-19 Interim Guidelines.12 • Medical leadership should remind providers to document their rationale for not following specialists’ recommendations. Specialized Medical Housing • Nursing leadership should remind CTC nurses to ensure complete documentation of wound care assessments including clinical appearance of the wound, surrounding tissue and measurements. 12 https://cchcs.ca.gov/covid-19-interim-guidance/ Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 13 • Nursing leadership should provide additional training on complete assessments including CCHCS policy on abnormal vital signs. • PBSP leadership should formulate a plan to ensure handwritten documents are collected and scanned into the patient’s chart in a timely manner. • Nursing leadership should ensure that the initial assessments are completed within the required timeframe as stated in CCHCS policy. Specialty Services • Medical leadership should ensure that the institution timely receive and review the specialty reports. • Medical leadership should determine the root cause(s) of challenges in the timely provision of specialty appointments and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 14 Access to Care In this indicator, OIG inspectors evaluated the institution’s ability to provide patients with timely clinical appointments. Our inspectors Overall reviewed the scheduling and appointment timeliness for newly arrived Rating patients, sick calls, and nurse follow-up appointments. We examined Adequate referrals to primary care providers, provider follow-ups, and specialists. Case Review Furthermore, we evaluated the follow-up appointments for patients Rating who received specialty care or returned from an off-site hospitalization. Adequate Compliance Results Overview Score Adequate PBSP provided good access to care in the context of the COVID-19 (79.7%) pandemic. The comparison of PBSP’s performance in Cycle 6 with its performance during Cycle 5 presented a unique challenge with respect to the COVID-19 pandemic and its repercussions throughout the correctional health care system. We considered specific concerns affecting PBSP during the review period such as reducing unnecessary appointments to minimize spread. However, it is imperative not to reschedule or cancel appointments when patients clinically need to be seen. The OIG case reviewers evaluated each case with the understanding that these circumstances may have impacted patient care. We did not consider postponed appointments to be deficiencies insofar as the provider’s assessments met standards of care. However, in some instances, providers postponed or canceled appointments when patients should have been seen. This is discussed in the Provider Performance indicator. Access to providers was mixed in the outpatient setting and in specialty services. PBSP provided excellent access to follow-up care after hospitalizations and after TTA encounters, and provided excellent access to CTC providers. PBSP provided good access to nurses and acceptable access to care following specialty appointments. After reviewing the case review and compliance results, we considered the context of the pandemic, the ongoing outbreak during the review period, and the clinical background of the cases. Ultimately, we rated this indicator as adequate. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 15 Case Review and Compliance Testing Results We reviewed 140 provider, nursing, specialty, and hospital events that required the institution to generate appointments. We identified eight deficiencies relating to Access to Care, four of which were significant.13 Access to Clinic Providers PBSP had mixed performance providing access to provider-ordered follow-up appointments. Case review clinicians found no deficiencies in the scheduling of provider appointments, while compliance testing showed poor access to chronic care follow-up appointments (MIT 1.001, 58.3%) and nursing to primary care provider sick call referrals (MIT 1.005, 72.7%). The differing results found by case review compared to compliance testing is attributed to case review clinicians taking into account that appointments were rescheduled due to the interim COVID-19 guidelines.14 While in some instances the provider should have seen the patient, it was appropriate for other appointments to be rescheduled during the pandemic to minimize COVID-19 transmission. The instances in which we felt the patient should have been seen are discussed in the Provider Performance indicator, as it was the provider’s decision to reschedule the patient. Access to Specialized Medical Housing Providers PBSP provided excellent access to specialized medical housing providers. Providers performed admission histories and physicals timely (MIT 13.002 90.0%). Case review clinicians did not find any deficiencies in access to providers in the correctional treatment center (CTC). The providers saw patients according to policy guidelines. Access to Clinic Nurses PBSP provided good access to RN sick call most of the time. Both case review and compliance inspectors noted that nursing staff triaged sick call requests the same day they were received (MIT 1.003, 100%). Compliance inspectors identified that patients had a face-to-face assessment within one business day of the sick call triage most of the time (MIT 1.004, 93.3%). However, OIG clinicians reviewed several sick calls that were canceled or rescheduled due to COVID-19 guidelines and believe the patients should have been seen. Examples are described in the cases below: 13 Access to Care deficiencies were found in cases 1, 6, 11, 12, 18, and 20. Significant deficiencies occurred in cases 1, 18, and 20. 14 https://cchcs.ca.gov/covid-19-interim-guidance/ Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 16 • In case 18, a patient submitted a sick call request with complaints of severe skin pain, red bumps on his back, clear yellow drainage from under his arms, and creases on his arms and behind his legs for three days. Even though the patient documented he had yellow drainage, which could be a sign of infection, the nurse who reviewed the sick call determined a visit was not necessary. This was the third time within the past month an appointment was deferred. Appointments for this patient continued to be canceled and the patient was eventually hospitalized with sepsis, cellulitis, and dehydration. • In case 1, a patient without a history of migraines or headaches submitted a sick call request with a complaint of severe headaches due to sunlight and bright lights. The nurse reviewed the appointment, and deemed the request nonessential. Two and a half months later, the patient submitted another sick call request with complaint of numbness to the right arm and the nurse requested an appointment within one business day instead of the same day. Before the patient could appear for the face-to-face appointment, he was sent to the hospital with slurred speech, asymmetrical gait, drooping to right side of the face, and right extremity weakness. He was diagnosed with a hemorrhagic stroke. We reviewed events in which patients had provider-to-nurse referrals, care manager referrals, and care coordinator referrals. These appointments occurred as scheduled and we did not identify any delays or deficiencies. Access to Specialty Services PBSP had mixed performance with access to specialty services as case review clinicians did not assign deficiencies in cases where off-site specialists canceled appointments or appointments were canceled due to quarantine. Compliance testing revealed poor access to high-priority specialty consults (MIT 14.001, 25.0%), medium-priority consults (MIT 14.004, 20.0%), and routine-priority consults (MIT 14.007, 66.7%). Specialty follow-up appointment access after high-priority specialty visits was also poor (MIT 14.003, 50.0%); however, provider follow-up appointment access after medium and routine priority specialty visits was acceptable (MIT 14.006, 85.7% and MIT 14.009, 80.0%). Follow-Up After Specialty Services PBSP providers followed up with patients after specialty appointments (MIT 1.008, 87.5%). Case reviewers identified that in several cases, Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 17 specialty nurses appropriately messaged providers to ensure patients received follow-up that the specialists recommended. Follow-up After Hospitalization PBSP provided excellent provider follow-ups after hospitalization; neither case review nor compliance testing identified any deficiencies. (MIT 1.007, 100%). Communication between nurses and providers helped ensure that all recommendations regarding patient care were followed. Follow-Up After Urgent or Emergent Care (TTA) PBSP followed up with patients after urgent or emergent care in the TTA. Case review clinicians did not find any follow up access to care deficiencies for patients who were evaluated in the TTA. Follow-Up for Patients Transferring Into the Institution PBSP had mixed performance providing follow-up appointments for patients transferring into the institution. A fair percentage of newly arrived patients were seen timely (MIT 1.002, 76.0%). Clinician On-Site Inspection Most deficiencies identified by case review clinicians were due to face- to-face nursing appointments which were either rescheduled or did not occur, related to COVID-19 guidelines. PBSP managers explained that the deficiencies were due to interim COVID-19 guidelines to minimize movement and reserve face-to-face encounters for urgent and emergent care only. PBSP leadership assigned the supervising registered nurse (SRN) II the role of reviewing all nursing appointment orders and postponing any they deem nonessential. OIG clinicians evaluated deficiencies in light of the challenges imposed by the COVID-19 pandemic and considered the remaining deficiencies to be instances in which a patient with a postponed appointment needed to be seen much sooner. During our on-site visit, we were unable to tour facility A and B clinics, as all quarantine and isolation patients were housed in these areas, and facility B clinic was being utilized to monitor and treat COVID-19 positive patients. On the first day of the on-site visit, no clinic lines were being run because the entire institution was undergoing mass COVID testing. On the second day of the on-site visit, we were able to tour the facility C and D clinics where patients were being seen. One nurse advised they normally receive approximately nine sick call requests per day and perform an average of five to six face-to-face Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 18 assessments daily. Due to nursing staffing shortages, clinic RNs were redirected to assist in other areas of the institution. Staff reported that facility C clinic typically had no backlog of patient visits. However, on the day of our visit, they reported that they had backlog of patient visits, which they attributed to a COVID-19 outbreak in the community and in the institution. On both days of our on-site visit, OIG clinicians remotely attended the daily all-staff meetings, which were led by the CEO. After the roll call noting that all clinical areas were present, staff were advised of pertinent information such as areas in quarantine or isolation, any patients on hunger strike, suspension of patient lines due to mass testing, and suspension of the incoming transfer bus. The meetings were short but very informative. We were also able to attend the provider huddle led by the chief medical executive (CME). This meeting covered information concerning COVID-positive patients, treatment regimens, emergent transfers to a higher level of care, hospital returns, and specialty appointments. On the second day, we monitored the C yard huddle, which was extremely thorough and included information regarding all aspects of the huddle script. There appeared to be good communication from leadership and clinical staff concerning patient care. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 19 Compliance Testing Results Table 6. Access to Care Scored Answer Compliance Questions Yes No N/A Yes % Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum 14 10 1 58.3% allowable interval or within the ordered time frame, whichever is shorter? (1.001) * For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, 19 6 0 76.0% was the patient seen by the clinician within the required time frame? (1.002) * Clinical appointments: Did a registered nurse review the patient’s 30 0 0 100% request for service the same day it was received? (1.003) * Clinical appointments: Did the registered nurse complete a face-to- face visit within one business day after the CDCR Form 7362 was 28 2 0 93.3% reviewed? (1.004) * Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within the 8 3 19 72.7% maximum allowable time or the ordered time frame, whichever is the shorter? (1.005) * Sick call follow-up appointments: If the primary care provider ordered a follow-up sick call appointment, did it take place within the time 0 0 30 NA frame specified? (1.006) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment within the required time 2 0 0 100% frame? (1.007) * Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) * , † 7 1 26 87.5% Clinical appointments: Do patients have a standardized process to 3 3 0 50.0% obtain and submit health care services request forms? (1.101) Overall percentage (MIT 1): 79.7% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high- priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 20 Table 7. Other Tests Related to Access to Care Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the NA NA NA NA required time frame? (12.003) * For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar NA NA NA NA days? (12.004) * For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time 9 1 0 90.0% frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, 0 0 10 NA Assessment, and Plan notes on the patient at the minimum intervals required for the type of facility where the patient was treated? (13.003) * Did the patient receive the high-priority specialty service within? 14 calendar days of the primary care provider order or the Physician 1 3 0 25.0% Request for Service? (14.001) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 1 1 2 50.0% (14.003) * Did the patient receive the medium-priority specialty service within 15–45 calendar days of the primary care provider order or the Physician 3 12 0 20.0% Request for Service? (14.004) * Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care 6 1 8 85.7% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 10 5 0 66.7% Request for Service? (14.007) * Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 4 1 10 80.0% (14.009) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still had State-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 21 Recommendations • Medical leadership should determine the root cause(s) of challenges in the timely provision of chronic care follow-up appointments with providers, nurse-to-provider referrals and implement remedial measures as appropriate. • The department should provide clear policy guidance to institutions regarding how to manage care during the pandemic, including how to manage care for chronic care patients whose appointments might be cancelled or delayed, how to prioritize patient movement to ensure provider appointments occur, how to properly close an appointment for patients who only receive a medical chart review, and how to balance the workload to ensure equitable distribution of patient care among nursing and providers. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 22 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s ability to timely complete radiology, laboratory, and pathology tests. Our Overall inspectors determined whether the institution properly retrieved the Rating resultant reports and whether providers reviewed the results correctly. Adequate In addition, in Cycle 6, we examined the institution’s ability to timely Case Review complete and review immediate (stat) laboratory tests. Rating Adequate Results Overview Compliance Score During this review period, PBSP performed well in completing and Adequate retrieving diagnostic tests. Due to COVID-19 testing, PBSP conducted (82.2%) four times the number of diagnostic tests it conducted in Cycle 5. Case reviewers found good test completion and management of diagnostic reports. Compliance testing showed untimely management of pathology information and incomplete patient notification letters. After considering the various aspects of diagnostic services, the OIG rated this indicator adequate. Case Review and Compliance Testing Results We reviewed 391 diagnostic events and found six deficiencies, one of which was significant. Of those six deficiencies, we found four related to health information management and one pertained to the completion of diagnostic tests.15 For health information management, we consider test reports that were never retrieved or reviewed to be a problem as severe as tests that were never performed. Test Completion PBSP’s performance in completing diagnostic tests was mixed. Compliance testing found excellent radiology test completion (MIT 2.001, 100%) and poor laboratory test completion (MIT 2.004, 50.0%). Case review clinicians found only one deficiency related to delayed completion of a laboratory test. Health Information Management Management of diagnostic services is critical, as therapy and decision- making rely on accurate and timely information. PBSP providers had excellent performance reviewing radiology studies (MIT 2.002, 100%), laboratory studies (MIT 2.005, 100%), and pathology reports (MIT 2.011, 15 Diagnostic deficiencies were found in cases 16, 17, 22, 45, and 47. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 23 100%). However, the institution needed improvement with retrieval of pathology reports (MIT 2.010, 33.3%) and communication of pathology results with patients (MIT 2.012, 66.7%). Case review clinicians identified four deficiencies; two were related to delayed endorsements and the other two were due to the provider not sending notification letters to the patients. Clinician On-Site Inspection Case review clinicians interviewed leadership, supervisors, and providers about diagnostic workflows and deficiencies. Diagnostic supervisors indicated they have increased their oversight to ensure diagnostic results are sent to providers for their endorsements. The providers reported they had no issues with laboratory services or radiology services, as diagnostic tests occurred timely, and providers had access to the results. The providers were also aware they were required to send notification letters to patients to inform them of the diagnostic results. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 24 Compliance Testing Results Table 8. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 10 0 0 100% specified in the health care provider’s order? (2.001) * Radiology: Did the ordering health care provider review and endorse 10 0 0 100% the radiology report within specified time frames? (2.002) * Radiology: Did the ordering health care provider communicate the results of the radiology study to the patient within specified time 9 1 0 90.0% frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 5 5 0 50.0% specified in the health care provider’s order? (2.004) * Laboratory: Did the health care provider review and endorse the 10 0 0 100% laboratory report within specified time frames? (2.005) * Laboratory: Did the health care provider communicate the results of 10 0 0 100% the laboratory test to the patient within specified time frames? (2.006) Laboratory: Did the institution collect the STAT laboratory test and NA NA NA NA receive the results within the required time frames? (2.007) * Laboratory: Did the provider acknowledge the STAT results, OR did nursing staff notify the provider within the required time frames (2.008) NA NA NA NA * Laboratory: Did the health care provider endorse the STAT laboratory NA NA NA NA results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within 1 2 0 33.3% the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 3 0 0 100% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the pathology study to the patient within specified time frames? 2 1 0 66.7% (2.012) Overall percentage (MIT 2): 82.2% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 25 Recommendations The OIG does not have any specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 26 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency Overall medical care. Our clinicians reviewed emergency medical services by Rating examining the timeliness and appropriateness of clinical decisions Adequate made during medical emergencies. Our evaluation included examining the emergency medical response, cardiopulmonary resuscitation (CPR) Case Review quality, triage and treatment area (TTA) care, provider performance, Rating and nursing performance. Our clinicians also evaluated the Emergency Adequate Medical Response Review Committee’s (EMRRC) ability to identify Compliance problems with its emergency services. The OIG assessed the Score institution’s emergency services through case review only; we did not (N/A) perform compliance testing for this indicator. Results Overview PBSP generally delivered good emergency care. Compared to Cycle 5, OIG clinicians reviewed slightly fewer events but identified more deficiencies. The prior cycle identified five significant deficiencies while in Cycle 6, we only identified one significant deficiency. Providers performed very well in providing emergency care. Staff provided timely and appropriate care most of the time, but did not always document accordingly. One area of concern was review of the emergency medical response (EMR) audits when transferring patients to a higher level of care. While the audits were completed timely, they did not identify areas of performance improvement in approximately half of the cases. More thorough audits would assist management in identifying additional training opportunities for staff. Taking all aspects into account, the OIG rated this indicator as adequate. Case Review Results We reviewed 20 urgent or emergent events and identified 16 emergency care deficiencies, only one of which was considered significant.16 Emergency Medical Response PBSP staff responded promptly to emergencies throughout the institution. Medical and custody staff worked cohesively to initiate care, activate EMS, and transfer patients to a higher level of care when applicable. OIG clinicians did not identify any significant deficiencies in PBSP’s emergency response. 16 Deficiencies in emergency services were identified in cases 1, 2, 3, 6, 16, 17, 18, and 20. The only significant deficiency was identified in case 17. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 27 Cardiopulmonary Resuscitation Quality PBSP performed well in this subindicator. The OIG clinicians reviewed four cases that required cardiopulmonary resuscitation (CPR).17 Medical personnel initiated CPR in three of the cases. Custody staff initiated CPR when medical staff arrived on scene for the other case. The patients were assessed, and appropriate interventions were initiated. Staff utilized the automated external defibrillator (AED), assisted ventilations, provided narcotic reversal medications, checked blood sugar levels, and requested 9-1-1 without delay. The following case is an example of appropriate emergency response and interventions: • In case 3, a patient had a seizure, which was witnessed by staff, and fell to the ground. Five medical staff responded and provided care. When the patient became pulseless, CPR was initiated, and the AED was utilized. The patient received electrical shocks and four doses of narcotic reversal medication. Emergency medical services (EMS) arrived, received report, and continued care. The patient’s pulse returned and the patient ultimately survived a cardiac arrest. Provider Performance PBSP providers performed excellently in urgent, emergent, and after- hours care. In the cases we reviewed, providers considered diagnoses appropriately and sent patients to the hospital when necessary. They documented contact by the TTA nurses and urgent co-consults. We did not identify any provider deficiencies in emergent or urgent care. Nursing Performance PBSP nurses performed well most of the time for emergency events. Patients housed in COVID-19 quarantine were seen in the B yard clinic to prevent possible spread of the COVID-19 virus. Nursing staff evaluated patients and obtained initial vital signs, which were relayed to providers. Patients were usually monitored appropriately with the exception of the case described below: • In case 17, a medical alarm was activated for a patient complaining of abdominal pain with nausea and rectal bleeding. Nursing staff responded and transported the patient to the clinic. The patient presented with a rapid heart rate. A nurse did not obtain orthostatic vital signs, nor did the nurse recheck the vital signs during the entire two hours the patient was at the clinic. The patient was seen by a provider, who 17 CPR was performed on patients in cases 3, 4, 5, and 6. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 28 consulted with the chief physician and surgeon, and ordered that the patient transfer to a higher level of care. Nursing Documentation While nurses responded quickly and provided appropriate interventions most of the time, nursing documentation was an area in need of improvement. Frequently, PBSP nurses failed to document times for emergent transfers to a higher level of care as required by policy, did not document handoff reports to EMS or the off-site ER, and failed to document patients’ conditions prior to transfer. We identified a lack of documentation of medications provided during emergency events in the medication administration record (MAR). Although documentation deficiencies were the most commonly identified during urgent and emergent events, these documentation deficiencies are considered minor and did not significantly increase the risk of harm to patients. Emergency Medical Response Review Committee While the EMRRC met monthly and discussed pertinent findings obtained from the EMR audits, in seven of the 14 audits we reviewed, we identified missing or conflicting times and information, and poor identification of deficiencies by supervisory staff.18 The OIG compliance team found incomplete checklists, missing entries, and missing time documentation (MIT 15.003, 25.0%). Clinician On-Site Inspection OIG clinicians toured the triage and treatment area (TTA) during our on-site visit. The TTA has two bays. We were advised one bay is used for emergent or urgent patients and the other is shared by the off-site return nurse and specialty clinics. Staffing for the TTA includes an RN rover who responds to all emergencies on the yards and an additional TTA RN for all shifts. The nurses are notified via radio and respond to emergency situations with a van equipped with a Stryker stretcher and emergency response equipment. At PBSP, the pill line staff are first responders. When the institution has simultaneous calls, additional staff is pulled from the correctional treatment center (CTC) or specialty clinic. During normal business hours, PBSP has a designated provider for the TTA and the provider-on-call is utilized after hours, on weekends, and on holidays. TTA staff advised that there was never a problem reaching 18 Deficiencies in EMR audits were identified in cases 1, 2, 3, 6, 17, and 20. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 29 the CME or the CP&S. Nursing staff acknowledged that the director of nursing (DON) was a great resource. Recommendations • Nursing leadership should provide additional training to staff for complete documentation of emergency medical events to include all appropriate times, interventions provided, report to EMS personnel, patient reassessments, and communication with the providers. • The Emergency Medical Response Review Committee (EMRRC) should more thoroughly review emergency response events and accurately detail findings. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 30 Health Information Management In this indicator, OIG inspectors evaluated the flow of health information, a crucial link in high-quality medical care delivery. Our Overall inspectors examined whether the institution retrieved and scanned Rating Adequate critical health information (progress notes, diagnostic reports, specialist reports, and hospital discharge reports) into the medical Case Review record in a timely manner. Our inspectors also tested whether Rating clinicians adequately reviewed and endorsed those reports. In addition, Proficient our inspectors checked whether staff labeled and organized documents in the medical record correctly. Compliance Score Results Overview Inadequate (64.2%) PBSP had a mixed performance in this indicator. Case review clinicians identified excellent hospital discharge report performance and good diagnostic, emergency, and specialty report performance. However, compliance scores showed poor performance handling specialty reports and scanning. Factoring the proficient case review score and the poor compliance score, the OIG rated this indicator as adequate. Case Review and Compliance Testing Results Our case review team reviewed 950 events and found 9 deficiencies related to health information management. Of these 9 deficiencies, one was significant.19 Hospital Discharge Reports We reviewed 12 off-site emergency department and hospital visits. PBSP staff timely retrieved hospital records, scanned them into the medical record, and reviewed them properly. Case review clinicians did not identify any deficiencies related to hospital discharge reports. While compliance testing showed excellent performance with retrieval and scanning of hospital discharge reports (MIT 4.003, 100%), it also showed the institution did not include a discharge summary in one of the samples (MIT 4.005, 50.0%). Specialty Reports PBSP had poor compliance scores for handling specialty reports. PBSP did not always scan specialty reports timely (MIT 4.002, 70.8%), and had late retrieval of high-priority specialty reports (MIT 14.002, 50.0%), late retrieval of medium priority specialty reports (MIT 14.005, 46.7%), and 19 Health information management deficiencies were identified in cases 10, 16, 17, 18, 21, 22, 45, and 47. A significant deficiency was found in case 18. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 31 late retrieval and endorsement by the provider of routine-priority specialty reports (MIT 14.008, 26.7%). We also discuss these findings in the Specialty Services indicator. Case reviewers did not encounter many specialty consultations and there were only a few deficiencies. The following is an example: • In case 18, a dermatology report was not sent to the provider for review. As a result, the subsequent dermatology follow-up was beyond the time frame the specialist recommended. During our on-site inspection, health information management supervisors acknowledged that a staff member should have sent the report to the provider. Diagnostic Reports PBSP performed well in managing diagnostic reports. Compliance testing showed excellent performance in timely reviewing pathology reports (MIT 2.011, 100%), but poor communication of pathology results (MIT 2.012, 66.7%). Case review found that providers generally reviewed and endorsed diagnostic reports and sent notification letters to inform patients timely. However, of the 396 events, we identified three instances in which providers did not endorse the diagnostic results within policy time frames. Please refer to the Diagnostic Services indicator for further discussion. Urgent and Emergent Records OIG clinicians reviewed 43 emergency care events and found that PBSP nurses performed well in recording these events. Providers recorded their emergency care excellently in the TTA as well as during their role as the provider-on-call. We did not identify any deficiencies pertaining to urgent and emergent records. The Emergency Services indicator provides additional details. Scanning Performance PBSP had mixed performance in this subindicator. Case review clinicians found good scanning performance. However, compliance testing was poor due to the mislabeling of patient letters as DDP-Scan (MIT 4.004, zero); every sample was mislabeled.20 Clinician On-Site Inspection We discussed health information management processes with PBSP health information management supervisors, nurses, and providers. 20 DDP is Developmental Disability Program. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 32 Providers expressed that diagnostic and specialty reports were available timely. Nursing documentation issues were due to paper charting during EHRS downtime. Compliance Testing Results Table 9. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic health record within three calendar days of the encounter 20 0 10 100% date? (4.001) Are specialty documents scanned into the patient’s electronic health 17 7 10 70.8% record within five calendar days of the encounter date? (4.002) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of 1 0 1 100% hospital discharge? (4.003) * During the inspection, were medical records properly scanned, 0 24 0 0 labeled, and included in the correct patients’ files? (4.004) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements 1 1 0 50.0% and did a provider review the report within five calendar days of discharge? (4.005) * Overall percentage (MIT 4): 64.2% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 33 Table 10. Other Tests Related to Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Did the ordering health care provider review and 10 0 0 100% endorse the radiology report within specified time frames? (2.002) * Laboratory: Did the health care provider review and endorse the 10 0 0 100% laboratory report within specified time frames? (2.005) * Laboratory: Did the provider acknowledge the STAT results, OR did NA NA NA NA nursing staff notify the provider within the required time frames? (2.008) * Pathology: Did the institution receive the final pathology report 1 2 0 33.3% within the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 3 0 0 100% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of 2 1 0 66.7% the pathology study to the patient within specified time frames? (2.012) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the 2 2 0 50.0% required time frame? (14.002) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the 7 8 0 46.7% required time frame? (14.005) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the 4 11 0 26.7% required time frame? (14.008) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Recommendations • The department should consider adjusting the default drop- down menu on the results letter in the EHRS so that the menu defaults to patient letter instead of DDP-Scan; the department should train providers to generate the results letters appropriately. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 34 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, Overall equipment management, and examination rooms. Inspectors also tested Rating clinics’ ability to maintain auditory and visual privacy for clinical Inadequate encounters. Compliance inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its Case Review ability to support health care operations. The OIG rated this indicator Rating (N/A) solely on the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians Compliance do not rate this indicator. Score Inadequate Results Overview (67.9%) PBSP’s health care environment performance decreased when compared to its Cycle 5 inspection. Various PBSP aspects of the institution’s health care environment still needed improvement: multiple clinics contained expired medical supplies, inventories were not performed for emergency medical response bags (EMRBs), and EMRB logs were missing staff verification. These factors resulted in an inadequate rating for this indicator. Compliance Testing Results Outdoor Waiting Areas We examined outdoor patient waiting areas (see Photo 1). Health care and custody staff reported existing waiting areas had sufficient seating capacity. Staff reported the outdoor waiting area is only utilized when the indoor waiting area is at capacity. Staff also reported they only call patients close to their appointment time during inclement weather. Photo 1: B clinic outdoor waiting area (photographed June 8, 2021) Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 35 Indoor Waiting Areas We inspected indoor waiting areas (see Photo 2). Health care and custody staff reported existing waiting areas contained sufficient seating capacity. During our inspection, we did not observe overcrowding or noncompliance with social distancing requirements in any of the clinics’ indoor waiting areas. Photo 2: B Clinic indoor waiting area (photographed June 8, 2021) Clinic Environment All clinic environments were sufficiently conducive for medical care; they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Of the 10 clinics we observed, seven contained appropriate space, configuration, supplies, and equipment to allow their clinicians to perform proper clinical examinations (MIT 5.110, 70.0%). In two clinics, the examination room table had torn covers and one of the two clinics also had a torn pillow cover used for physical therapy services (see Photos 3 and 4). The remaining clinic did not allow patients to lie fully extended on the examination table without obstruction (see Photo 5). Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 36 Photo 3: Torn examination room table cover (photographed June 8, 2021) Photo 4: Torn pillow cover used for Physical Therapy services (photographed June 8, 2021) Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 37 Photo 5: Examination room configuration did not allow patients to lie fully extended without obstruction (photographed June 10, 2021) Clinic Supplies Five of the 10 clinics followed adequate medical supply storage and management protocols (MIT 5.107, 50.0%). We found one or more of the following deficiencies in five clinics: expired medical supplies (see Photo 6), unlabeled medical supplies (see Photo 7), staff members’ personal food stored with medical supplies, and compromised sterile medical supply packaging. Photo 6: Expired medical supply dated August 1, 2020 (photographed June 8, 2021) Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 38 Photo 7: Unlabeled medical supplies (photographed June 9, 2021) Nine of the eleven clinics met the requirements for essential core medical equipment and supplies (MIT 5.108, 81.8%). The correctional treatment center (CTC) lacked a Snellen chart. CTC staff reported patients are sent to the triage and treatment area (TTA) for eye examinations. In another clinic, we found a nonfunctional oto- opthalmoscope. We examined emergency medical response bags (EMRBs) to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. None of the nine EMRBs passed our test (MIT 5.111, zero). We found one or both of the following deficiencies with all EMRBs: staff failed to ensure EMRB compartments were sealed and intact, and staff had not inventoried the EMRBs when seal tags were replaced. In addition, the treatment carts in the TTA and CTC did not meet the minimum inventory level and lacked documentation indicating reasonable substitutions were made. Medical Supply Management All the medical supply storage areas located outside the medical clinics stored medical supplies adequately. However, we found staff’s personal food items stored in the pharmacy’s designated refrigerator and freezer located in the receiving warehouse. In addition, staff did not record the refrigerator and freezer temperatures. These deficiencies resulted in a score of zero for this test (MIT 5.106). Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 39 According to the chief executive officer, PBSP did not have any concern about the medical supplies process. Health care managers and medical warehouse managers expressed no concern about the medical supply chain or their communication process with the existing system in place. Infection Control and Sanitation Staff appropriately disinfected, cleaned, and sanitized eight of 11 clinics (MIT 5.101, 72.7%). In one clinic, cleaning logs were not maintained. In two clinics, we found that either the stretcher was unsanitary or the exhaust under the clinic sink had accumulated dust (see Photo 8). Photo 8: Exhaust under the clinic sink had accumulated dust (photographed June 8, 2021) Staff in nine of 10 clinics (MIT 5.102, 90.0%) properly sterilized or disinfected medical equipment. In one clinic, staff did not date stamp and initial the packaging of sterilized medical equipment. We found operating sinks and hand hygiene supplies in the examination rooms in nine of 11 clinics (MIT 5.103, 81.8%). The patient restrooms in two clinics lacked antiseptic soap, disposable hand towels, or both antiseptic soap and disposable hand towels. We observed patient encounters in five clinics. Health care staff in all clinics adhered to universal hand hygiene precautions (MIT 5.104, 100%). Health care staff in all clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure PBSP’s health care management and plant operations manager reported infrastructures in all clinical areas were in good working order and did not hinder health care services. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 40 At the time of our medical inspection, the institution reported the Health Care Facility Improvement Program (HCFIP) project was in progress and included the renovation of Facility C primary clinic that started April 26, 2021. The institution estimated the project would be completed by April 2022. In addition, the renovation of the Clinic D medication distribution room was still in the planning phase (MIT 5.999). Table 11. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately 8 3 0 72.7% disinfected, cleaned, and sanitary? (5.101) Infection control: Do clinical health care areas ensure that reusable invasive and noninvasive medical equipment is properly sterilized or 9 1 1 90.0% disinfected as warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks 9 2 0 81.8% and sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal 5 0 6 100% hand hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to 10 0 1 100% blood-borne pathogens and contaminated waste? (5.105) Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs 0 1 0 0 of the medical health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for 5 5 1 50.0% managing and storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have 9 2 0 81.8% essential core medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas 11 0 0 100% conducive to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms 7 3 1 70.0% conducive to providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, 0 9 2 0 and do they contain essential items? (5.111) Does the institution’s health care management believe that all clinical This is a nonscored test. Please areas have physical plant infrastructures that are sufficient to provide see the indicator for discussion adequate health care services? (5.999) of this test. Overall percentage (MIT 5): 67.9% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 41 Recommendations • Nursing leadership should consider performing random spot checks to ensure staff follow medical supply management protocols. • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) and treatment cart logs to ensure the EMRBs and treatment carts are regularly inventoried, sealed, and met the minimum par level. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 42 Transfers In this indicator, OIG inspectors examined the transfer process for Overall those patients who transferred into the institution, as well as for those Rating who transferred to other institutions. For newly arrived patients, our Adequate inspectors assessed the quality of health screenings and the continuity of provider appointments, specialist referrals, diagnostic tests, and Case Review medications. For patients who transferred out of the institution, Adequate inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed if staff transferred patients with their medical equipment and gave Compliance Score correct medications before patients left. In addition, our inspectors Adequate evaluated the ability of staff to communicate vital health transfer (77.1%) information, such as preexisting health conditions, pending appointments, tests, and specialty referrals; and inspectors confirmed if staff sent complete medication transfer packages to the receiving institution. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented the recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Results Overview PBSP performed well in this indicator. Compared to Cycle 5, OIG clinicians reviewed more events and identified almost twice as many deficiencies, although none were significant. While PBSP performed proficiently for the transfer-out process, there was room for improvement in the transfer-in and hospitalization-return processes. Both case review and compliance testing had similar results, and the overall rating was adequate. Case Review and Compliance Testing Results We reviewed 35 events in 13 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified seven deficiencies, none of which were significant.21 Transfers In PBSP’s transfer-in process had mixed performance. OIG clinicians reviewed nine events in four cases in which patients transferred into 21 Deficiencies were identified in cases 5, 17, 18, 20, 23, and 47. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 43 the facility from other institutions. We identified only two minor deficiencies:22 • In case 5, an R&R nurse did not recognize a patient was a diabetic and did not check the patient’s blood sugar. • In case 23, a patient arrived to PBSP with his medication but did not receive his evening dose. Our cases reviewers found nurses generally performed complete initial assessments. However, the case review findings differed from the compliance rating (MIT 6.001, 24.0%). The low compliance score was almost entirely due to staff’s failure to ask patients during tuberculosis screenings whether they experienced fatigue. Similarly, our case reviewers PBSP staff usually ensured medication continuity. This medication continuity findings were also reflected in compliance testing for patients who arrived at the institution (MIT 6.003, 84.2%). Case review did not identify problems with provider assess or access to high-priority specialty services ordered by the provider upon patients’ arrival to PBSP. In compliance findings, although patients were generally seen by the clinician within the required time frame (MIT 1.002, 76.0%), the patients often did not receive specialty services that were ordered by the provider within 14 days (MIT 14.001, 25.0%). Transfers Out R&R nurses performed very well in managing medications for patients who transferred out of the institution. There were no identifiable case review deficiencies, which mirrors the Cycle 5 findings. In the cases we reviewed, we found that proper screenings, which include vitals and COVID-19 testing, were conducted. Additionally, we found that patients were transferred out with all durable medical equipment and medications. This correlates with compliance testing in that all patients were transferred with their required medications and documents (MIT 6.101, 100%). Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high-risk for lapses in care quality. These patients typically experienced severe illness or injury. They require more care and place strain on the institution’s resources. Also, because these patients have 22 Transfer-in events occurred in cases 5, 18, 23, and 24. Deficiencies were identified in cases 5 and 23. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 44 complex medical issues, the successful transfer of health information is necessary for good quality care. Any lapses can result in serious consequences for these patients. OIG clinicians reviewed 24 events in nine cases in which patients returned from an off-site hospitalization or emergency room visit. We identified five deficiencies, none of which were significant.23 While PBSP provided good care, there is opportunity for improvement in this area. Most of the deficiencies we identified related to incomplete assessments and nurses’ failure to identify and recheck abnormal vital signs when patients returned to the institution. This can be problematic, as providers rely on information gleaned from nursing staff to make decisions regarding orders and housing. We did not identify any deficiencies with primary care provider follow-up appointments, a finding that coincided with compliance findings (MIT 1.007, 100%). Neither case review nor compliance testing revealed any deficiencies pertaining to the availability of hospital or emergency room summary reports (MIT 4.003, 100%). However, compliance testing noted providers did not always review reports within five calendar days of a patient’s discharge (MIT 4.005, 50.0%). Compliance testing also identified that the continuity of hospital recommended medications was inconsistent (MIT 7.003, 50.0%). Case reviewers, however, did not find any clinically relevant medication issues after a patient’s hospital discharge, or any issues in the timeliness of providers’ review of hospital records. Clinician On-Site Inspection During the on-site inspection, OIG clinicians toured the clean and well- organized receiving and release (R&R) area. There were three interview rooms; one of those rooms was equipped as an exam room, and patient scales were placed in the hallway outside the rooms. The RN assigned to the R&R advised us this area had recently been updated. Pertinent policy information, including abnormal vital signs, was displayed in plastic covers for reference. The R&R nurse advised us the facility had recently hired an RN for third watch. Before the addition to the third watch post, a nurse would arrive early to prepare patients for transferring out and would stay late to process patients transferring into the facility. OIG clinicians were advised that licensed correctional clinic (LCC) automated drug delivery system medications were recently made available in the R&R. Before implementation of the LCC medications, the rover RN was notified when patients needed medications and would obtain them from the pharmacy or Omnicell. 23 Hospitalization or emergency room returns were reviewed in cases 1, 2, 5, 16, 17, 18, 19, 20, and 47. Deficiencies were identified in cases 17, 18, 20, and 47. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 45 When patients arrived at the facility during regular weekday hours, a designated provider reconciled charts and placed orders, and after hours the RN utilized the provider-on-call (POC). The RN we interviewed appeared proficient in the transfer-in and transfer-out processes and was able to answer questions concerning policy and local operating procedures with ease. During the on-site visit, medical leadership reported that there was a COVID-19 outbreak in the community with a significant number of hospital admissions, and that the bus that was to arrive with patients transferring into the institution had been placed on hold. Compliance Testing Results Table 12. Transfers Scored Answers Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6 19 0 24.0% answer all screening questions within the required time frame? (6.001) * For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the initial health screening form; refer the 17 0 8 100% patient 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? (6.002) For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 16 3 6 84.2% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding 6 0 0 100% transfer packet required documents? (6.101) * Overall percentage (MIT 6): 77.1% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 46 Table 13. Other Tests Related to Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 19 6 0 76.0% patient seen by the clinician within the required time frame? (1.002) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment with a primary care provider 2 0 0 100% within the required time frame? (1.007) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital 1 0 1 100% discharge? (4.003) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a 1 1 0 50.0% provider review the report within five calendar days of discharge? (4.005) * Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the 1 1 0 50.0% patient within required time frames? (7.003) * Upon the patient’s transfer from one housing unit to another: Were 19 6 0 76.0% medications continued without interruption? (7.005) * For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications 1 3 0 25.0% administered or delivered without interruption? (7.006) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 2 0 0 100% sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Recommendations • Nursing leadership should develop and implement internal auditing of staff to ensure complete and thorough assessments for patients returning from hospitalizations. • Healthcare leadership should consider adjusting the initial health screening form to add the symptom of fatigue for TB symptom monitoring and screening. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 47 Medication Management In this indicator, OIG inspectors evaluated the institution’s ability to administer prescription medications on time and without interruption. Overall The inspectors examined this process from the time a provider Rating prescribed medication until the nurse administered the medication to Inadequate the patient. When rating this indicator, the OIG strongly considered the compliance test results, which tested medication processes to a Case Review Rating much greater degree than case review testing. In addition to examining Proficient medication administration, our compliance inspectors also tested many other processes, including medication handling, storage, error Compliance reporting, and other pharmacy processes. Score Inadequate Results Overview (64.4%) PBSP had mixed performance in this indicator. Although case review clinicians did not find many deficiencies in medication management, compliance testing showed PBSP had difficulty distributing chronic care medications, hospital discharge medications, and transfer medications timely. Most of the deficiencies were due to delays in medication administration. Factoring both case review and compliance results, we rated the Medication Management indicator inadequate. Case Review and Compliance Testing Results We reviewed 125 events in 26 cases related to medication management and found five deficiencies, none of which were significant.24 New Medication Prescriptions Both compliance and case review found PBSP performed well in delivering new medication prescriptions most of the time. This correlates with compliance testing (MIT 7.002, 92.0%). Case review identified a minor deficiency in the following case: • In case 18, a patient did not receive his ordered medication, prednisone timely. Prednisone was prescribed and filled on three separate occasions. However, the prednisone was administered one and two days late. Chronic Medication Continuity PBSP had mixed results in chronic medication continuity. Case review clinicians identified only two minor deficiencies in patients receiving their chronic care medications without interruption. Compliance testing, however, found that PBSP performed poorly and identified that 24 Deficiencies in medication management were identified in cases 8, 15, and 18. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 48 patients usually received their chronic care medications one to two days late (MIT 7.001, 5.9%). CCHCS policy states keep-on-person medications must be available to patients one business day prior to exhaustion. Hospital Discharge Medications Case review and compliance testing again showed different results. Case review did not identify any medication management deficiencies when patients returned from a hospitalization or emergency room visit. However, the compliance team identified that half of the patients who returned from a hospitalization did not receive their needed medications within the required time frames (MIT 7.003, 50.0%). While the institution performed better than in Cycle 5 for this test, the results were still poor and showed room for improvement. Specialized Medical Housing Medications Both case review and compliance testing found PBSP performed well most of the time in ensuring patients received their needed medications upon admission to the correctional treatment center. This correlates with compliance findings (MIT 13.004, 80.0%). OIG clinicians did not identify any deficiencies when reviewing cases in which patients were admitted to specialized medical housing. Transfer Medications PBSP performed well in ensuring patients who transferred into the institution (MIT 6.003, 84.2%) and those who transferred from yard to yard (MIT 7.005, 76.0%) received their medication timely.We found a documentation discrepancy in one compliance sample. Specifically, we found a nurse who documented medications that were not dispensed due to patients’ refusal; however, in the comments section of the medication administration record (MAR), this nurse documented there was no time to dispense medication to a patient. This incongruent documentation presents a serious question regarding medication continuity.25 PBSP had mixed performance managing medications for patients who were temporarily housed at the facility and had existing medication orders. Compliance testing found that most patients sampled did not receive their medications without interruption (MIT 7.006, 25.0%). However, case review clinicians identified only one deficiency: a patient 25 Sample number 25, MIT 7.005. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 49 transferred into the institution with his medications and did not receive his evening dose. Both case review and compliance testing found PBSP performed proficiently in ensuring all patients who transferred out of the institution received a five-day supply of medications (MIT 6.101, 100%). Additional information is discussed in the Transfers indicator. Medication Administration Case review and compliance evaluated the institution’s performance in administering medications and monitoring patients taking medications, specifically tuberculosis (TB) medications. In the 47 cases the clinicians reviewed, we did not identify any patient receiving TB medications. PBSP did not have testable compliance samples for MITs 9.001 and 9.002. Clinician On-Site Inspection During the on-site visit, OIG clinicians met with the pharmacist and toured the pill lines. The C yard pill line room was small, but clean and well-organized. There were no keep-on-person (KOP) medications pending delivery, and we were advised the pharmacy had yet to deliver the medications for the day. The pill line staff advised that because no patients housed in administrative segregation were classified with mental health status, all of those patients were allowed to have KOP medications in their cells. Staff reported that due to employee shortages, there were a lot of mandates for nursing overtime. We were also advised staff were redirected up to several times per shift. In the receiving and release area, we observed where the licensed correctional clinic (LCC) automated drug delivery system medications were placed. As discussed in the Transfers indicator, these medications had been made available the week before our visit and assisted the nursing staff in providing continuity of medication administration for patients who transferred in and out of the institution. The OIG team monitored several huddles during the on-site visit and identified there was good communication among each team regarding medication management. Some issues discussed were medication compliance, medications expiring within three days, parole medications, suboxone, specialty medication for COVID-19 patients, and upcoming expiring medication orders. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 50 Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in six of nine clinic and medication line locations (MIT 7.101, 66.7%). In three locations, nurses could not describe the narcotic medication discrepancy reporting process. In addition, in one of the three locations, we observed the medication nurse remove narcotic medication from the tackle box in a manner that does not allow spontaneous count. PBSP appropriately stored and secured nonnarcotic medications in all clinic and medication line locations (MIT 7.102, 100%). Staff kept medications protected from physical, chemical, and temperature contamination in seven of the 11 clinic and medication line locations (MIT 7.103, 63.6%). In three locations, staff did not separate the storage of oral and topical medications. In one location, nurses stored return-to-pharmacy medications directly on the floor. Staff successfully stored valid, unexpired medications in eight of the 11 applicable medication line locations (MIT 7.104, 72.7%). In three locations, nurses did not label the multi-use medication as required by CCHCS policy. Nurses exercised proper hand hygiene and contamination control protocols in four of seven locations (MIT 7.105, 57.1%). In three locations, nurses neglected to wash or sanitize their hands before each subsequent regloving. Staff in five of seven medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 71.4%). In two locations, nurses did not maintain unissued medication in its original, labeled packaging. Staff in one of seven medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 14.3%). In six clinics, medication nurses did not reliably observe patients while they swallowed direct observation therapy medications. In addition, in one of the six clinics, we observed a medication nurse did not follow the CCHCS care guide when administering Suboxone medication. Pharmacy Protocols PBSP followed general security, organization, and cleanliness management protocols for nonrefrigerated and refrigerated medications stored in its pharmacy (MIT 7.108, 7.109, and 7.110, 100%). Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 51 The pharmacist-in-charge (PIC) did not thoroughly review monthly inventories of controlled substances in the institution’s clinic and medication storage locations. Specifically, the nurses present at the time of the medication area inspection did not correctly complete several medication area inspection checklists (CDCR form 7477). These errors resulted in a score of zero for this test (MIT 7.111). We examined eight medication error reports. The pharmacist-in-charge timely and correctly processed all reports (MIT 7.112, 100%). Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors also followed up on any significant medication errors found during compliance testing. We did not score this test; we provide these results for informational purposes only. At PBSP, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in restricted housing units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. Fourteen of 16 applicable patients interviewed indicated they had access to their rescue medications. Two patients reported they did not have their prescribed rescue inhaler. One patient stated he does not need the inhaler, while the other patient stated the medication was taken away and placed in the patient’s property when he transferred to the restricted housing unit. We promptly notified the CEO of this concern, and health care management obtained new refusal documentation for one patient, and immediately issued a replacement rescue inhaler to the other patient (MIT 7.999). Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 52 Compliance Testing Results Table 14. Medication Management Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive all chronic care medications within the required time frames or did the institution follow departmental policy for refusals or 1 16 8 5.9% no-shows? (7.001) * Did health care staff administer, make available, or deliver new order prescription medications to the patient within the required time frames? (7.002) 23 2 0 92.0% Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 1 1 0 50.0% required time frames? (7.003) * For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or NA NA NA NA delivered to the patient within the required time frames? (7.004) * Upon the patient’s transfer from one housing unit to another: Were medications continued without interruption? (7.005) * 19 6 0 76.0% For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or 1 3 0 25.0% delivered without interruption? (7.006) * All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic 6 3 2 66.7% medications assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the 11 0 0 100% assigned storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of 7 4 0 63.6% contamination in the assigned storage areas? (7.103) All clinical and medication line storage areas for nonnarcotic medications: Does the institution safely store nonnarcotic medications that have yet to expire in 8 3 0 72.7% the assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 4 3 4 57.1% preparation and medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications 5 2 4 71.4% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 1 6 4 14.3% medications to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and cleanliness management protocols in its main and remote 1 0 0 100% pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated medications? (7.109) 1 0 0 100% Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen medications? (7.110) 1 0 0 100% Pharmacy: Does the institution’s pharmacy properly account for narcotic medications? (7.111) 0 1 0 0 Pharmacy: Does the institution follow key medication error reporting protocols? (7.112) 8 0 0 100% Pharmacy: For Information Purposes Only: During compliance testing, did the This is a nonscored test. Please OIG find that medication errors were properly identified and reported by the see the indicator for discussion of institution? (7.998) this test. Pharmacy: For Information Purposes Only: Do patients in restricted This is a nonscored test. Please housing units have immediate access to their KOP prescribed rescue see the indicator for discussion of inhalers and nitroglycerin medications? (7.999) this test. Overall percentage (MIT 7): 64.4% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 53 Table 15. Other Tests Related to Medication Management Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 16 3 6 84.2% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding 6 0 0 100% transfer-packet required documents? (6.101) * Patients prescribed TB medication: Did the institution administer the NA NA NA NA medication to the patient as prescribed? (9.001) * Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on NA NA NA NA the medication? (9.002) * Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 8 2 0 80.0% within required time frames? (13.004) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Recommendations • Medical and Nursing leadership should ensure that chronic care, hospital discharge, and en route patients receive their medications timely without interruption. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 54 Preventive Services In this indicator, OIG compliance inspectors tested whether the Overall institution offered or provided cancer screenings, tuberculosis (TB) Rating screenings, influenza vaccines, and other immunizations. If the Adequate department designated the institution as high risk for coccidioidomycosis (valley fever), we tested the institution’s ability to Case Review transfer patients out quickly. The OIG rated this indicator solely based Rating (N/A) on the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do Compliance not rate this indicator. Score Adequate Results Overview (83.4%) PBSP staff performed well in offering patients an influenza vaccine for the most recent influenza season, as it offered colorectal cancer screening for all patients ages 50 through 75, and required immunizations to chronic care patients. However, they faltered in screening patients annually for TB. These findings are set forth in the table on the next page. We rated this indicator Adequate. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 55 Compliance Testing Results Table 16. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the NA NA NA NA medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on NA NA NA NA the medication? (9.002) † Annual TB screening: Was the patient screened for TB within the last 12 13 0 48.0% year? (9.003) Were all patients offered an influenza vaccination for the most recent 25 0 0 100% influenza season? (9.004) All patients from the age of 50 through the age of 75: Was the 25 0 0 100% patient offered colorectal cancer screening? (9.005) Female patients from the age of 50 through the age of 74: Was the NA NA NA NA patient offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was NA NA NA NA patient offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? 12 2 11 85.7% (9.008) Are patients at the highest risk of coccidioidomycosis (valley fever) NA NA NA NA infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 83.4% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † In April 2020, after our review but before this report was published, CCHCS reported adding the symptom of fatigue into the EHRS PowerForm for tuberculosis symptom monitoring. Source: The Office of the Inspector General medical inspection results. Recommendations The OIG offers no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 56 Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care Overall delivered by the institution’s nurses, including registered nurses (RNs), Rating licensed vocational nurses (LVNs), psychiatric technicians (PTs), and Adequate certified nursing assistants (CNAs). Our clinicians evaluated nurses’ ability to make timely and appropriate assessments and interventions. Case Review We also evaluated the institution’s nurses’ documentation for accuracy Rating Adequate and thoroughness. Clinicians reviewed nursing performance in many clinical settings and processes, including sick call, outpatient care, care Compliance coordination and management, emergency services, specialized medical Score housing, hospitalizations, transfers, specialty services, and medication (N/A) management. The OIG assessed nursing care through case review only and performed no compliance testing for this indicator. When summarizing overall nursing performance, our clinicians understand that nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Results Overview PBSP generally delivered acceptable nursing care. Nursing staff performed well in care management, emergency services, transfer services, and specialty services. However, compared to Cycle 5, OIG clinicians identified significantly more deficiencies with a notable number related to COVID-19 nurse rounding and supervisory audits. We identified challenges with registry staff’s performance of quarantine and isolation rounds. Our clinicians identified opportunities for improvement in several areas including documentation and assessments. We rated PBSP Nursing Performance indicator as adequate. Case Review Results We reviewed 182 nursing encounters in 41 cases. Of the nursing encounters we reviewed, 102 were in the outpatient setting. We identified 83 nursing performance deficiencies, 11 of which were significant.26 26 Deficiencies in the quality of nursing care were identified in cases 1, 2, 3, 5, 6, 11, 12, 13, 15, 16, 17, 18, 19, 20, 23, 28, 29, 30, 31, 32, 35, 36, 37, 38, 39, 40, 41, 42, 45, 46, and 47. Significant deficiencies were identified in cases 1, 6, 16, 17, 18, 36, 38, 41, and 47. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 57 Nursing Assessment and Interventions Most deficiencies related to the quality of nursing care provided at PBSP were due to incomplete or inadequate nursing assessments. During case review, OIG clinicians identified several emergency response events in which nursing staff did not reassess or recheck vital signs for patients who were sent to a higher level of care. We also identified that nurses in both the inpatient and outpatient settings did not follow CCHCS protocol for abnormal vitals and did not recheck vital signs or notify the provider when patients had low heart rates, high heart rates, or elevated blood pressures.27 Clinic nurses often did not weigh patients during face-to-face assessments and, in several cases, they did not thoroughly document when performing focused assessments for specific complaints as described in the cases below. • In case 17, a patient submitted a sick call request stating he was recently diagnosed with colitis and that, while he had been taking antibiotics, the symptoms returned. He had abdominal pain with bloody, tarry stool, weakness, and chills. The patient was not evaluated the same day the sick call request was triaged. When the patient was seen, the nurse did not fully document an abdominal assessment. • In case 41, a patient submitted a sick call request with complaints of having fatigue, dizziness, and chest tightness for one week. The patient reported symptoms were intermittent and began three weeks prior. While he had no symptoms at the time of the evaluation, he was concerned about whether “his heart was okay.” The nurse did not subjectively assess the frequency, severity, and duration of the intermittent chest pain and whether it occurred when the patient was active or at rest. The nurse also did not subjectively assess the frequency and duration of the patient’s dizziness and did not consider the patient’s risk factors of high blood pressure, high cholesterol, obesity, and recent COVID-19 infection. While case review did not identify a pattern of deficiencies related to interventions, the deficiencies we did identify were significant in the following cases: • In case 1, a patient submitted a sick call request for a burning sensation in the left calf. A nurse performed a face-to-face evaluation and utilized nursing protocols to provide acetaminophen from the OTC stock medications, even though the patient’s electronic health record indicated the patient was 27 Abnormal vital signs were not rechecked and the provider was not notified in cases 6, 16, 17, 45, and 47. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 58 allergic to acetaminophen.28 Staff’s failure to review medication allergies placed the patient at risk of harm. • In case 17, a patient complained of abdominal pain, weight loss and bloody diarrhea. A clinic nurse evaluated the patient and noted the patient had a fast heart rate. The nurse did not weigh the patient or check the patient’s orthostatic vital signs. The next day an emergency response was activated for the patient due to abdominal pain and rectal bleeding. The first responder noted the patient had a rapid heart rate. Again, a nurse did not check orthostatic vital signs or weigh the patient. Nursing staff did not recheck vital signs for over two hours before the patient was sent to a higher level of care. Nursing Documentation In almost every area we reviewed, nursing documentation showed room for improvement. Nurses frequently failed to document all times during emergency responses, failed to document giving report to emergency medical staff or to the emergency room, and often did not document medication given in the medication administration record (MAR). We identified deficiencies in face-to-face assessments, including inconsistent documentation in the Infectious Disease section of the assessment form that did not correlate with patient’s complaints. We also found that the clinic nurses sometimes did not document exact area or location of pain or injury. When performing quarantine and isolation rounds, nursing staff often did not completely document vital signs, complaints, or both vital signs and complaints. In the inpatient correctional treatment center (CTC), nursing staff often failed to document peripherally inserted central catheters (PICC) or wound care, did not consistently document the percentage of meals patients consumed, and intermittently failed to document the effectiveness of PRN pain medication. While documentation deficiencies do not affect patient care and are considered minor, this is an area in which PBSP could improve. Nursing Sick Call Our clinicians reviewed 43 sick call requests and identified 24 deficiencies, seven of which were significant.29 Some of the significant deficiencies were related to inadequate assessments and failure to perform timely evaluations. Even when taking into consideration that, due to COVID-19 guidelines, only urgent and emergent complaints 28 OTC means over the counter. 29 Deficiencies in face-to-face assessments for sick call requests were identified in cases 1, 5, 6, 17, 18, 20, 28, 29, 30, 31, 32, 35, 36, 37, 39, 40, 41, and 42. Significant deficiencies were identified in cases 1, 6, 17, 18, 36, and 41. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 59 were scheduled to be evaluated in person, we identified several situations that warranted immediate attention. This is discussed further and examples are cited in the Access to Care indicator. Care Management OIG clinicians reviewed four cases in which patients were evaluated by a care manager.30 We were advised clinic RNs act as care managers and clinic LVNs perform care coordinator duties, which include monthly and yearly TB screenings, vital sign checks, and distribution of DME and diabetic supplies. Case review did not identify any deficiencies in scheduling or evaluating patients for care management appointments. Wound Care We reviewed two cases involving wound care orders. Both patients were housed in the CTC.31 During case review, OIG clinicians identified several days on which wound care was not provided or documented. We also identified lack of documentation of PICC line care and dressing changes.32 There are further discussed in the Specialized Medical Housing indicator. Emergency Services PBSP performed well when responding to urgent and emergent patients. While nurses initiated prompt and appropriate interventions, their documentation was often incomplete, lacking timelines and assessment information. Another area with room for improvement was the accuracy of emergency response reviews completed as part of the EMRRC audits. This is further discussed in the Emergency Services indicator. Hospital Returns We reviewed 24 events in nine cases in which patients returned from an off-site hospitalization or emergency room visit. We identified five deficiencies, all related to nursing performance. All deficiencies were due to either missing documentation or incomplete assessments; all deficiencies were deemed minor, as they did not significantly affect patient care. Please see the Transfers indicator for additional information. 30 Patients were evaluated by the care manager in cases 5, 16, 23, and 24. 31 Wound care was ordered for cases 46 and 47. 32 PICC is a peripherally inserted central catheter. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 60 Transfers Most of the time, PBSP performed well in transferring patients in and out of the institution. However, for patients who returned from hospitalizations or emergency room visits, assessments were often incomplete. We also identified that when patients presented with abnormal vital signs, nurses did not recheck vitals or notify the provider as CCHCS policy requires. Please refer to the Transfers indicator for additional information. Specialized Medical Housing OIG clinicians examined 95 events that occurred within nine cases in which patients were admitted to the correctional treatment center.33 Nurses provided adequate care, but we identified several incomplete assessments, missing documentation, and failure to perform wound care. This area offers opportunity for performance improvement and is discussed in more detail in the Specialized Medical Housing indicator. Specialty Services We reviewed 28 events in 13 cases in which patients received specialty services. In four cases, patients returned from a specialty procedure or consultation. Nursing staff performed complete assessments, reviewed discharge recommendations, and notified the provider. We only identified one minor deficiency related to nursing performance. Medication Management OIG clinicians examined 125 events involving medication management and identified five medication deficiencies, none of which were significant. Nursing staff generally administered medications appropriately, but we identified some instances in which nursing staff did not properly document patient care in the medication administration record (MAR). The Medication Management indicator provides further information. Clinician On-Site Inspection Just before the OIG on-site visit, we were advised there was a COVID- 19 outbreak in the community and at the institution. On the first day of our visit, during the all-staff meeting, we were advised all clinic lines were interrupted, and nursing staff were redirected to assist with testing the entire patient population for the virus. We were also advised that the housing units on A and B yards were utilized for quarantine 33 Due to frequency of nursing contacts in the specialized medical housing, we bundle up to two weeks of patient care into a single event. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 61 and isolation. This hampered the OIG’s ability to interview clinic staff. We were, however, able to interview nursing educators, the utilization manager, the employee health nurse, the public health nurse, and nursing staff in the TTA and CTC. On the second day of the on-site visit, we were able to tour two of the clinics. Staff informed us of multiple mandates and redirections due to nursing shortages. OIG staff were advised nursing morale was low and nursing staff were “tired.” During the compliance team’s on-site visit, we were advised PBSP had a nursing shortage of about 60 percent. During the case review on-site visit, we learned that about one and a half to two years prior, PBSP lost six registered nurses (RN) and had not recovered since. This was a drastic change from Cycle 5, when PBSP only had a 17 percent nursing shortage. At the time of the on-site visit, the institution had 14 positions filled with registry RNs and seven positions filled with contract and registry LVNs. On the first day of the visit, another experienced nurse was working a last shift before retiring. The on-site response to the low staffing levels included the use of registry staff to fill vacancies, and recruitments for civil service candidates were continuous. We were also advised that PBSP evaluates patient care activities daily and directs staffing resources to meet workload demands. The institution was also affected by the COVID-19 outbreak. During our interview with the employee health nurse, the OIG team was advised there were 57 active cases among staff and only 30 percent of staff were vaccinated. On the first day of the OIG on-site visit, the public health nurse advised the facility had 25 positive cases within the incarcerated population, with 1,800 test results pending. During the compliance visit, we were advised that 66 percent of the patient population was vaccinated. OIG clinicians were also able to meet with nursing instructors who advised training was continuous given staff turnover, new nursing registry, and mandatory trainings. The instructors reported difficulty scheduling staff for all the required trainings due to nursing shortages and the need to redirect staff. They also reported the annual skills training consisted of only one to two hours of training and some of the subjects covered included IVs, infectious disease, and hand hygiene. The annual CTC training covered information on chronic care conditions, IVs, chronic pain, and wound care. We were also advised that some area supervisors also provide specific on-the-job training to their staff, such as PICC line care for patients housed in the correctional treatment center. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 62 Recommendations • Nursing leadership should determine the root cause of challenges that prevent outpatient nurses from performing complete assessments and implement remedial measures as appropriate, including training of staff. • Nursing leadership should determine the causes that prevent PBSP CTC nurses from performing complete assessments and proper wound care, and implement remedial measures as appropriate, including training of staff. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 63 Provider Performance In this indicator, OIG case review clinicians evaluated the quality of Overall care delivered by the institution’s providers: physicians, physician Rating assistants, and nurse practitioners. Our clinicians assessed the Adequate institution’s providers’ ability to evaluate, diagnose, and manage their patients properly. We examined provider performance across several Case Review Rating clinical settings and programs, including sick call, emergency services, Adequate outpatient care, chronic care, specialty services, intake, transfers, hospitalizations, and specialized medical housing. We assessed Compliance provider care through case review only and performed no compliance Score (N/A) testing for this indicator. Results Overview PBSP providers delivered satisfactory care to patients. However, some providers rescheduled patients due to interim COVID-19 guidelines. In certain situations, this increased the risk of patient harm. There were also a few cases in which providers did not follow specialists’ recommendations and did not document the reasons. The COVID-19 pandemic provided context for our evaluation of providers’ care during the review period. After extensive deliberation, we rated this indicator as adequate. Case Review Results OIG clinicians reviewed 112 medical provider encounters and identified 21 deficiencies, 12 of which were significant.34 In addition, OIG clinicians examined the quality of care in 20 comprehensive case reviews. Of these 20 cases, 18 were rated adequate, and two were inadequate. Assessment and Decision-Making PBSP providers appropriately assessed patients’ conditions and made sound decisions. They generally asked concise questions and performed proper documentation of patient histories. Providers formulated reasonable differential diagnoses, ordered appropriate tests, and referred patients when necessary. We found 11 deficiencies related to providers’ decision-making.35 34 Provider performance deficiencies were found in cases 1, 7, 8, 9, 10, 11, 13, 16, 17, 18, 21, and 46. Significant deficiencies were identified in cases 8, 10, 16, 17, 18, 21, and 46. 35 Decision-making deficiencies were found in cases 1, 7, 8, 9, 10, 11, 16, 17, and 18. Significant deficiencies were found in cases 8, 16, 17, and 18. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 64 We identified that certain providers tended to reschedule patients due to COVID-19 interim guidelines. While this was acceptable for certain episodic or chronic conditions, it was detrimental for others. The following are examples: • In case 16, a provider canceled a chronic care appointment for a patient with a history of high blood pressure and protein in his urine. Protein in urine is an indication of kidney damage. It was important to follow the patient as the blood pressure can cause further kidney damage. The patient was eventually seen three months later by a different provider. • In case 18, a provider canceled appointments and cited COVID- 19 as the reason for the appointment cancellation even though a nurse repeatedly requested follow-up with the patient due to the patient’s weeping eczema. The nurses eventually consulted with another provider and the patient was admitted to the hospital. Review of Records Generally, PBSP providers reviewed medical records carefully. We found one deficiency in which a provider did not review the medication record to identify that a patient had not taken his asthma medication for months, and another deficiency in which a provider did not review vital signs in a patient with a history of elevated blood pressure. Emergency Care PBSP providers managed patients with urgent and emergent conditions exceptionally well in the TTA. On-site providers examined, diagnosed, and triaged patients appropriately. We did not identify any problems in providers’ communication with TTA RNs. Chronic Care During the review period, in most instances, PBSP providers appropriately managed patients’ chronic health conditions; however, we found two deficiencies related to blood pressure control and two related to diabetes control. Several patients began Hepatitis C treatment. We did not review any patients on anticoagulation. Specialty Services PBSP providers appropriately referred patients for specialty consultation when needed. However, when specialists made recommendations, providers did not always follow them and did not document any reasons why. We found this in three of the cases we Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 65 reviewed. We discuss providers’ specialty performance further in the Specialty Services indicator. • In case 46, a provider did not follow an infectious disease (ID) specialist’s recommendation to change antibiotics, order laboratory tests, and schedule further ID follow-up. The provider did not document any reason why the recommendations were not followed. • In case 16, a provider did not follow a cardiologist’s recommendations for a nephrology consultation, to keep the blood pressure below specific values, and to order a sleep study. Documentation Quality PBSP providers accurately documented encounters with patients and communication with nurses. The chief medical executive even documented when she had to contact a patient’s family for end-of-life discussions. However, there were a few instances in which providers did not accurately document information. In one case, a CTC discharge summary did not include complete information. Another instance is described below. • In case 11, a provider incorrectly documented that a patient, who had a high blood pressure, had normal blood pressure on the day of his visit. Provider Continuity Generally, PBSP offered good provider continuity. Providers were assigned to specified clinics. When patients were moved into isolation, placed in quarantine, or moved to the CTC, they were assigned a new provider. Clinician On-Site Inspection At the time of our inspection, PBSP had an active COVID-19 outbreak. In response, they conducted mass testing on the first day of our inspection. Medical leadership also discussed how to improve vaccination rates for their staff. We attended daily provider huddles as well as team-based huddles. The team huddles were well-run and included pertinent information and discussion. The providers we interviewed expressed they had full trust in the executive and medical leadership team. One provider stated patients at PBSP had better provider access than private sector patients. Medical Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 66 leadership was always available to listen and help with any concerns. The providers stated that, due to the remoteness of the institution, they sometimes approached care in a unique way. They had good working relationships with nursing as well as custody staff. Providers mentioned that nursing staff faced challenges due to staffing shortages. The providers noted that nurses whom they worked with were very diligent despite the staffing shortages. Medical leadership stated they had a great group of providers, including several advanced practitioners. They explained that a prior CEO was an advanced practitioner who helped spearhead the use of advanced practitioners in prison health care. Leadership utilized two telemedicine providers and planned on utilizing more. They had no problems with any of their providers. The CME helped contact families when necessary. The CP&S helped approve patients to transfer out of the isolation setting. Both the CME and CP&S were very involved with day-to-day operations. Recommendations • Medical leadership should consider reminding providers to carefully review charts before rescheduling appointments due to COVID-19 Interim Guidelines.36 • Medical leadership should remind providers to document their rationale for not following specialists’ recommendations. 36 https://cchcs.ca.gov/covid-19-interim-guidance/ Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 67 Specialized Medical Housing In this indicator, OIG inspectors evaluated the quality of care in the Overall specialized medical housing units. We evaluated the performance of the Rating medical staff in assessing, monitoring, and intervening for medically Adequate complex patients requiring close medical supervision. Our inspectors Case Review also evaluated the timeliness and quality of provider and nursing intake Rating assessments and care plans. We assessed staff members’ performance in Adequate responding promptly when patients’ conditions deteriorated and looked for good communication when staff consulted with one another while Compliance Score providing continuity of care. Our clinicians also interpreted relevant Proficient compliance results and incorporated them into this indicator. At the (85.0%) time of our inspection, PBSP’s specialized medical housing consisted of the correctional treatment center (CTC). Results Overview PBSP provided acceptable care for patients housed in the CTC. In Cycle 5, case review clinicians identified only two deficiencies, none of which were significant, which resulted in a proficient rating. However, in Cycle 6, OIG clinicians identified 25 deficiencies, three of which were significant. We discuss these significant deficiencies in the subindicators below. After considering case review results and compliance testing, we rated the Specialized Medical Housing indicator as adequate. Case Review and Compliance Testing Results We reviewed nine CTC cases that included 28 provider events and 38 nursing events. Due to the volume of care that occurs in specialized medical housing units, each provider and nursing event represents up to one month of provider care and one week of nursing care, respectively. We identified 25 deficiencies, three of which were significant.37 Provider Performance PBSP providers generally provided good care in the CTC. Case review clinicians found that providers always performed admission histories and physicals timely and rounded on patients in clinically appropriate intervals. Compliance testing also showed that providers performed admission histories and physicals timely (MIT 13.002, 90.0%). The 37 Specialized medical housing deficiencies were identified in cases 1, 17, 19, 45, 46, and 47. Significant deficiencies were identified in cases 46 and 47. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 68 compliance team did not test for clinically appropriate intervals, as MIT 13.003 was not applicable. In general, providers made sound decisions and documented communication with patients and other staff. However, the following are exceptions. • In case 46, a CTC provider saw a patient following an infectious disease specialist consultation. The provider did not follow through on the specialist’s recommendations to change antibiotics or order laboratory tests, nor did the provider order follow-up with the specialist. • In case 46, a CTC provider did not thoroughly document a discharge summary. The provider did not relay that a patient had a specialty consultation and was waiting for transesophageal echocardiogram (TEE) results. By happenstance, the patient did not have any adverse outcomes.38 Nursing Performance Both case review and compliance testing concluded that patients admitted to the CTC received timely initial health assessments most of the time (MIT 13.001, 70.0%). We noted patients were assessed by nursing staff every shift, but the assessments were often incomplete. OIG clinicians concluded that of the 25 deficiencies identified in the specialized medical housing cases, 21 were directly related to quality of nursing care. Prominent areas of concern were incomplete assessments, lack of documentation that wound care was provided, failure to recheck abnormal vital signs, missing data, and failure to provide pertinent interventions. An example is described below. • In case 47, a patient was admitted to the CTC for serratia bacteremia, presumed endocarditis, epidural abscess, and cervical disc fusion. Orders were written for IV antibiotics for six weeks, wound care, and as-needed pain medication. During our review of nursing care from December 11, 2020, through December 31, 2020, nurses did not document assessing or completing wound care from December 13, 2020, through December 23, 2020, and did not provide pain intervention or pain medication for moderate or severe pain for three different assessments. This falls below clinical nursing standards. However, the compliance team noted the CTC maintains an operational call system to ensure patients have access to care (MIT 13.101, 100%). 38 The transesophageal echocardiogram test uses soundwaves to image the heart lining, muscle, valves, and pumping function. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 69 Medication Administration Compliance testing found that patients admitted to the CTC received their medications timely most of the time (MIT 13.004, 80.0%). Case review did not find any issues in medication administration during our review period for Cycle 6. Clinician On-Site Inspection The CTC has 20 beds, 10 designated for medical patients and 10 designated for mental health patients; all 20 beds have functional call lights. They have two negative pressure rooms with ante rooms for respiratory isolation. At the time of our on-site inspection, we were advised only a few beds were available. The CTC was equipped with a standard scale to weigh patients upon admission and as ordered, but we were advised there was no wheelchair-accessible scale at the institution. During our on-site visit, we interviewed CTC nursing staff. Two registered nurses and a psychiatric technician were on duty. One of the RNs had been redirected to work in the CTC due to mass COVID-19 testing throughout the institution. The second RN was a registry RN who had been working at the institution for only a few months. We were advised there is usually a designated primary care provider for the CTC during weekdays, and that staff contact the physician-on-call after hours, on weekends, and on holidays. We met with the CTC provider, who expressed great working relationships with nursing staff and custody staff in the CTC. OIG clinicians remotely attended the well-organized CTC daily huddle. In attendance were medical providers such as the chief physician and surgeon, and mental health providers such as the psychiatrist, the psychologist, nursing staff, and the pharmacist. The director of nursing (DON) was also in attendance as the supervising registered nurse II was not on duty that day. Discussion included admissions, discharges, emergencies, medication renewals, specialty appointments, and treatments. The meeting started promptly and was both thorough and concise. When OIG clinicians met with nursing leadership to review on-site questions concerning documentation missing from CTC cases, we were advised the institution had no connectivity to the EHRS during a specific time frame and that documentation was handwritten and scanned into the chart. The missing documents were not provided to the OIG. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 70 Compliance Testing Results Table 17. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % 7 3 0 70.0% For OHU, CTC, and SNF: Prior to 4/2019: Did the registered nurse complete an initial assessment of the patient on the day of admission, or within eight hours of admission to CMF’s Hospice? Effective 4/2019: Did the registered nurse complete an initial assessment of the patient at the time of admission? (13.001) * 9 1 0 90.0% For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time frame? (13.002) * NA NA 10 NA For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, Assessment, and Plan notes on the patient at the minimum intervals required for the type of facility where the patient was treated? (13.003) *, † 8 2 0 80.0% Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient within required time frames? (13.004) * 1 0 0 100% For OHU and CTC only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? (13.101) * 0 0 1 NA For specialized health care housing (CTC, SNF, Hospice, OHU): Do health care staff perform patient safety checks according to institution’s local operating procedure or within the required time frames? (13.102) * Overall percentage (MIT 13): 85.0% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still have State-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 71 Recommendations • Nursing leadership should remind CTC nurses to ensure complete documentation of wound care assessments including clinical appearance of the wound, surrounding tissue and measurements. • Nursing leadership should provide additional training on complete assessments including CCHCS policy on abnormal vital signs. • Leadership should formulate a plan to ensure handwritten documents are collected and scanned into the patient’s chart in a timely manner. • Nursing leadership should ensure that the initial assessments are completed within the required timeframe as stated in CCHCS policy. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 72 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty Overall services. The OIG clinicians focused on the institution’s ability to Rating provide needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, and medical Inadequate staff’s retrieval, review, and implementation of any specialty Case Review recommendations. Rating Adequate Results Overview Compliance PBSP provided poor specialty services. Although providers and nursing Score Inadequate staff performed competently, compliance testing for specialty access (54.2%) scored low. Case reviewers found that some providers did not always follow specialists’ recommendations. Health information management in this indicator is another area where case review found good performance; however, compliance testing showed very poor retrieval of health information. Because compliance testing showed uniformly poor performance in specialty health information management, we rated PBSP as inadequate for this indicator. Case Review and Compliance Testing Results We reviewed 28 events related to specialty services; 24 were specialty consultations and procedures. We found seven deficiencies in this category, four of which were significant.39 Access to Specialty Services PBSP’s performance in this subindicator was mixed. Case review clinicians did not find any deficiencies related to access to specialty services. When providers requested specialty services, the appointments occurred within the requested time frames. When delays were due to cancellations by outside specialists, or when clinically stable patients were rescheduled due to COVID-19 interim guidelines, we did not assign deficiencies. However, compliance testing found untimely appointments and poor access to specialty services with routine priority (MIT 14.007, 66.7%) medium priority (MIT 14.004, 20.0%), and high priority (MIT 14.001, 25.0%) referrals. PBSP performed excellently in managing previously approved specialty appointments for newly transferred patients (MIT 14.010,100%). 39 Specialty services deficiencies occurred in cases 6, 16, 18, 21, and 46. Significant deficiencies were found in cases 16, 18, 21, and 46. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 73 Provider Performance PBSP providers requested specialty consults correctly when they were initially needed. However, providers did not always follow through with specialists’ recommendations even though they were aware of them, as evidenced by their endorsement of the reports. Compliance testing showed that the institution followed up with patients in a timely manner after specialty services (MIT 1.008, 87.5%). Nursing Performance Nurses at PBSP performed well in assessing patients who returned to the facility from off-site specialty appointments. While nursing staff appropriately obtained vital signs, assessed patients, and relayed off- site recommendations to providers, we identified one minor deficiency in which a patient had an abnormally low heart rate and a nurse did not recheck the patient’s pulse or document notification to the provider. Health Information Management PBSP’s performance in managing specialty services health information was mixed. Compliance testing showed poor retrieval and significant difficulty obtaining provider review of routine-priority (MIT 14.008, 26.7%) medium-priority (MIT 14.005, 46.7%) and high-priority specialty reports (MIT 14.002, 50.0%). Testing also showed untimely scanning of specialty reports into the EHRS (MIT 4.002, 70.8%). Although case review found fewer problems, there were still issues processing specialty reports. The following is an example. • In case 18, a dermatology consultation was not sent to a provider for review and, as a result, the subsequent dermatology follow-up was delayed. On-site, the health information management supervisor acknowledged the report was not sent to the provider and stated the staff member will be assigned training. Clinician On-Site Inspection We discussed specialty services with the specialty services supervisors. They explained that due to COVID-19, they had a policy in which providers or medical leadership would review pending appointments and determine whether patients needed to be seen by the specialist as originally ordered, or whether the appointment could be postponed. During the review period, PBSP also experienced issues with Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 74 specialists’ availability in the community. eConsult was available to the providers, and we observed one case in which it was utilized.40 OIG staff interviewed the utilization management (UM) RN who advised that PBSP generates approximately 20 to 30 medical referrals weekly. The UM RN reviews the chart and enters information into InterQual.41 If a referral does not meet criteria, the UM RN discusses it at the weekly provider meeting. The UM RN reiterated there was a backlog of some specialty appointments due to the lack of specialist appointment availability in the community. On-site specialty services included optometry and physical therapy that did not require approval. Orthotics and audiology, which do require referrals, were also available on-site. In addition, CT scans, MRIs, ultrasounds, and FibroScans were offered at the facility monthly, and appointments were scheduled by the radiology staff.42 Due to the location of the institution and lack of close off-site facilities for specialized procedures, the UM nurse advised there had been instances of delays in transportation. 40eConsult is a web-based application that allows providers to consult with specialists for advice and recommendations about patients’ medical conditions. 41 InterQual is an evidenced-based clinical support tool used to assist in determining whether proposed services are clinically indicated and provided in the appropriate level, or whether further evaluation is required. 42 A FibroScan is an imaging diagnostic test that evaluates for liver scarring and fatty changes from liver disease. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 75 Compliance Testing Results Table 18. Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % 1 3 0 25.0% Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for Service? (14.001) * 2 2 0 50.0% Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time frame? (14.002) * 1 1 2 50.0% Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? (14.003) * 3 12 0 20.0% Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or Physician Request for Service? (14.004) * 7 8 0 46.7% Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time frame? (14.005) * 6 1 8 85.7% Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care provider? (14.006) * 10 5 0 66.7% Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request for Service? (14.007) * 4 11 0 26.7% Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time frame? (14.008) * 4 1 10 80.0% Did the patient receive the subsequent follow-up to the routine- priority specialty service appointment as ordered by the primary care provider? (14.009) * 2 0 0 100% For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * 2 2 0 50.0% Did the institution deny the primary care provider’s request for specialty services within required time frames? (14.011) 2 2 0 50.0% Following the denial of a request for specialty services, was the patient informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 54.2% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 76 Table 19. Other Tests Related to Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Specialty service follow-up appointments: Did the clinician follow-up 7 1 26 87.5% visits occur within required time frames? (1.008) *, † Are specialty documents scanned into the patient’s electronic health 17 7 10 70.8% record within five calendar days of the encounter date? (4.002) * * The OIG clinicians considered these compliance tests along with their own case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following most specialty services. As a result, we test 1.008 only for high- priority specialty services or when the staff orders PCP or PC RN follow-ups. The OIG continues to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Recommendations • Medical leadership should ensure that the institution timely receive and review the specialty reports. • Medical leadership should determine the root cause(s) of challenges in the timely provision of specialty appointments and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 77 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the Overall Rating medical grievance process and checked whether the institution Proficient followed reporting requirements for adverse or sentinel events and patient deaths. Inspectors checked whether the Emergency Medical Case Review Response Review Committee (EMRRC) met and reviewed incident Rating packages. We reviewed and determined whether the institution (N/A) conducted the required emergency response drills. Inspectors also Compliance assessed whether the Quality Management Committee (QMC) met Score regularly and addressed program performance adequately. In addition, Proficient the inspectors examined if the institution provided training and job (86.5 %) performance reviews for its employees. They checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator affected clinical patient care directly (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Results Overview PBSP performed well in this indicator. It scored high in most applicable tests; however, a few areas had room for improvement. The EMMRC had incomplete checklists and forms. In addition, PBSP did not properly complete required forms during emergency medical response drills. These findings are set forth in the table below. We rated this indicator proficient. Nonscored Results We obtained CCHCS Death Review Committee (DRC) reporting data. Three unexpected (Level 1) deaths occurred during our review period. The DRC must complete its death review summary report within 60 calendar days of a death. When the DRC completes the death review summary report, it must submit the report to the institution’s CEO within seven calendar days of completion. In our inspection, we found the DRC timely completed one death summary report and submitted the report to the institution’s CEO timely. However, DRC did not complete two death review reports promptly; the DRC finished these Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 78 two reports 45 and 104 days late, respectively, and submitted them to the institution’s CEO 38 and 100 days after that (MIT 15.998). Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 79 Compliance Testing Results Table 20. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % NA NA NA NA For health care incidents requiring root cause analysis (RCA): Did the institution meet RCA reporting requirements? (15.001) 6 0 0 100% Did the institution’s Quality Management Committee (QMC) meet monthly? (15.002) 3 9 0 25.0% For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did the incident packages the committee reviewed include the required documents? (15.003) 4 0 0 100% For institutions with licensed care facilities: Did the Local Governing Body (LGB) or its equivalent meet quarterly and discuss local operating procedures and any applicable policies? (15.004) 0 3 0 0 Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and custody staff participate in those drills? (15.101) 10 0 0 100% Did the responses to medical grievances address all of the inmates’ appealed issues? (15.102) 3 0 0 100% Did the medical staff review and submit initial inmate death reports to the CCHCS Death Review Unit on time? (15.103) 10 0 0 100% Did nurse managers ensure the clinical competency of nurses who administer medications? (15.104) 4 0 5 100% Did physician managers complete provider clinical performance appraisals timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 10 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) 2 0 1 100% certifications? (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy 6 0 1 100% maintain a valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement 1 0 0 100% Agency (DEA) registration certificates? (15.109) Did nurse managers ensure their newly hired nurses received the 1 0 0 100% required onboarding and clinical competency training? (15.110) This is a nonscored test. Please Did the CCHCS Death Review Committee process death review refer to the discussion in this reports timely? (15.998) indicator. This is a nonscored test. Please What was the institution’s health care staffing at the time of the OIG refer to Table 4 for CCHCS- medical inspection? (15.999) provided staffing information. Overall percentage (MIT 15): 86.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 80 Recommendations The OIG offers no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 81 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the receiver’s office, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population- based metrics. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A–1. Inspection Indicator Review Distribution for PBSP Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 82 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 6 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Case, Sample, The medical care provided to one patient over a specific or Patient period, which can comprise detailed or focused case reviews. A review that includes all aspects of one patient’s medical care Comprehensive assessed over a six-month period. This review allows the OIG clinicians to examine many areas of health care delivery, such as Case Review access to care, diagnostic services, health information management, and specialty services. A review that focuses on one specific aspect of medical care. Focused This review tends to concentrate on a singular facet of patient Case Review care, such as the sick call process or the institution’s emergency medical response. A direct or indirect interaction between the patient and the health care system. Examples of direct interactions include Event provider encounters and nurse encounters. An example of an indirect interaction includes a provider reviewing a diagnostic test and placing additional orders. Case Review A medical error in procedure or in clinical judgment. Both procedural and clinical judgment errors can result in policy Deficiency noncompliance, elevated risk of patient harm, or both. Adverse Event An event that caused harm to the patient. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 83 The OIG eliminates case review selection bias by sampling using a rigid methodology. No case reviewer selects the samples he or she reviews. Because the case reviewers are excluded from sample selection, there is no possibility of selection bias. Instead, nonclinical analysts use a standardized sampling methodology to select most of the case review samples. A randomizer is used when applicable. For most basic institutions, the OIG samples 20 comprehensive physician review cases. For institutions with larger high-risk populations, 25 cases are sampled. For the California Health Care Facility, 30 cases are sampled. Case Review Sampling Methodology We obtain a substantial amount of health care data from the inspected institution and from CCHCS. Our analysts then apply filters to identify clinically complex patients with the highest need for medical services. These filters include patients classified by CCHCS with high medical risk, patients requiring hospitalization or emergency medical services, patients arriving from a county jail, patients transferring to and from other departmental institutions, patients with uncontrolled diabetes or uncontrolled anticoagulation levels, patients requiring specialty services or who died or experienced a sentinel event (unexpected occurrences resulting in high risk of, or actual, death or serious injury), patients requiring specialized medical housing placement, patients requesting medical care through the sick call process, and patients requiring prenatal or postpartum care. After applying filters, analysts follow a predetermined protocol and select samples for clinicians to review. Our physician and nurse reviewers test the samples by performing comprehensive or focused case reviews. Case Review Testing Methodology An OIG physician, a nurse consultant, or both review each case. As the clinicians review medical records, they record pertinent interactions between the patient and the health care system. We refer to these interactions as case review events. Our clinicians also record medical errors, which we refer to as case review deficiencies. Deficiencies can be minor or significant, depending on the severity of the deficiency. If a deficiency caused serious patient harm, we classify the error as an adverse event. On the next page, Figure A–2 depicts the possibilities that can lead to these different events. After the clinician inspectors review all the cases, they analyze the deficiencies, then summarize their findings in one or more of the health care indicators in this report. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 84 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 85 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and compliance inspectors. Analysts follow a detailed selection methodology. For most compliance questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the relationships and activities of this process. Figure A–3. Compliance Sampling Methodology Compliance Testing Methodology Our inspectors answer a set of predefined medical inspection tool (MIT) questions to determine the institution’s compliance with CCHCS policies and procedures. Our nurse inspectors assign a Yes or a No answer to each scored question. OIG headquarters nurse inspectors review medical records to obtain information, allowing them to answer most of the MIT questions. Our regional nurses visit and inspect each institution. They interview health care staff, observe medical processes, test the facilities and clinics, review employee records, logs, medical grievances, death reports, and other documents, and obtain information regarding plant infrastructure and local operating procedures. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 86 Scoring Methodology Our compliance team calculates the percentage of all Yes answers for each of the questions applicable to a particular indicator, then averages the scores. The OIG continues to rate these indicators based on the average compliance score using the following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent and 75.0 percent), or inadequate (less than 75.0 percent). Indicator Ratings and the Overall Medical Quality Rating To reach an overall quality rating, our inspectors collaborate and examine all the inspection findings. We consider the case review, and the compliance testing results for each indicator. After considering all the findings, our inspectors reach consensus on an overall rating for the institution. Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 87 Appendix B: Case Review Data Table B–1. PBSP Case Review Sample Sets Sample Set Total CTC/OHU 3 Death Review/Sentinel Events 2 Diabetes 4 Emergency Services – CPR 2 Emergency Services – Non-CPR 2 High Risk 5 Hospitalization 5 Intra-system Transfers In 2 Intra-system Transfers Out 2 RN Sick Call 18 Specialty Services 2 Total 47 Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 88 Table B–2. PBSP Case Review Chronic Care Diagnoses Diagnosis Total Anemia 3 Arthritis/Degenerative Joint Disease 2 Asthma 4 COPD 1 11 COVID-19 Cardiovascular Disease 1 Chronic Kidney Disease 2 Chronic Pain 7 Cirrhosis/End-Stage Liver Disease 1 Deep Venous Thrombosis/Pulmonary Embolism 1 Diabetes 7 Gastroesophageal Reflux Disease 3 Hepatitis C 9 Hyperlipidemia 9 Hypertension 15 Mental Health 4 Seizure Disorder 2 Sleep Apnea 9 Total 91 Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 89 Table B–3. PBSP Case Review Events by Program Diagnosis Total Diagnostic Services 392 Emergency Care 43 Hospitalization 24 Intra-system Transfers-In 9 Intra-system Transfers-Out 2 Outpatient Care 351 Specialized Medical Housing 95 Specialty Services 34 Total 950 Table B–4. PBSP Case Review Sample Summary MD Reviews Detailed 20 MD Reviews Focused 3 RN Reviews Detailed 15 RN Reviews Focused 24 Total Reviews 62 Total Unique Cases 47 Overlapping Reviews (MD & RN) 15 Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 90 Appendix C. Compliance Sampling Methodology Pelican Bay State Prison Quality No. of Indicator Sample Category Samples Data Source Filters Access to Care MIT 1.001 Chronic Care 25 Master Registry • Chronic care conditions (at least Patients one condition per patient—any risk level) • Randomize MIT 1.002 Nursing Referrals 25 OIG Q: 6.001 • See Transfers MITs 1.003–006 Nursing Sick Call 30 Clinic Appointment • Clinic (each clinic tested) (6 per clinic) List • Appointment date (2–9 months) • Randomize MIT 1.007 Returns From 2 OIG Q: 4.005 • See Health Information Community Management (Medical Records) Hospital (returns from community hospital) MIT 1.008 Specialty Services 34 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001–003 Radiology 10 Radiology Logs • Appointment date (90 days–9 months) • Randomize • Abnormal MITs 2.004–006 Laboratory 10 Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.007–009 Laboratory STAT 0 Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.010–012 Pathology 3 InterQual • Appt. date (90 days–9 months) • Service (pathology related) • Randomize Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 91 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 30 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 IPs for MIT 1.004 MIT 4.002 Specialty Documents 34 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 IPs for each question MIT 4.003 Hospital Discharge 2 OIG Q: 4.005 • Community hospital discharge Documents documents • First 20 IPs selected MIT 4.004 Scanning Accuracy 24 Documents for any • Any misfiled or mislabeled tested inmate document identified during OIG compliance review (24 or more = No) MIT 4.005 Returns From 2 CADDIS Off-site • Date (2–8 months) Community Hospital Admissions • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize Health Care Environment MITs 5.101–105 Clinical Areas 11 OIG inspector • Identify and inspect all on-site MITs 5.107–111 on-site review clinical areas. Transfers MITs 6.001–003 Intrasystem Transfers 25 SOMS • Arrival date (3–9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 6 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 92 Quality No. of Indicator Sample Category Samples Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care 25 OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize MIT 7.002 New Medication 25 Master Registry • Rx count Orders • Randomize • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns From 2 OIG Q: 4.005 • See Health Information Community Hospital Management (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals— N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 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) • Randomize MIT 7.006 En Route 4 SOMS • Date of transfer (2–8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101–103 Medication Storage Varies OIG inspector • Identify and inspect clinical Areas by test on-site review & med line areas that store medications MITs 7.104–107 Medication Varies OIG inspector • Identify and inspect on-site Preparation and by test on-site review clinical areas that prepare and Administration Areas administer medications MITs 7.108–111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 8 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) 16 MIT 7.999 Restricted Unit On-site active • KOP rescue inhalers & KOP Medications medication listing nitroglycerin medications for IPs housed in restricted units Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 93 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001–007 Recent Deliveries N/A at this OB Roster • Delivery date (2–12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2–12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001–002 TB Medications 0 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior Annual Screening to inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior Vaccinations to inspection) • Randomize • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior Screening to inspection) • Date of birth (51 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. prior institution to inspection) • Date of birth (age 52–74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. institution prior to inspection) • Date of birth (age 24–53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP—any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever 0 Cocci transfer • Reports from past 2–8 months status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 94 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001–008 RC N/A at this SOMS • Arrival date (2–8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001–004 Specialized Health 10 CADDIS • Admit date (2–8 months) Care Housing Unit • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101–102 Call Buttons All OIG inspector • Specialized Health Care Housing on-site review • Review by location Specialty Services MITs 14.001–003 High-Priority 4 Specialty Service • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize MITs 14.004–006 Medium-Priority 15 Specialty Service • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize MITs 14.007–009 Routine-Priority 15 Specialty Service • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 95 MIT 14.010 Specialty Services 2 Specialty Service • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3–9 months) • Randomize MITs 14.011–012 Denials 4 InterQual • Review date (3–9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 96 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.001 Adverse/sentinel 0 Adverse/sentinel • Adverse/Sentinel events events (ASE) events report (2–8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB 4 LGB meeting • Quarterly meeting minutes minutes (12 months) MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/closed (6 months) grievance files MIT 15.103 Death Reports 3 Institution-list of • Most recent 10 deaths deaths in prior • Initial death reports 12 months MIT 15.104 Nursing Staff 10 On-site nursing • On duty one or more years Validations education files • Nurse administers medications • Randomize MIT 15.105 Provider Annual 4 On-site • All required performance Evaluation Packets provider evaluation documents evaluation files MIT 15.106 Provider Licenses 10 Current provider • Review all listing (at start of inspection) MIT 15.107 Medical Emergency All On-site • All staff Response certification ◦ Providers (ACLS) Certifications tracking logs ◦ Nursing (BLS/CPR) • Custody (CPR/BLS) MIT 15.108 Nursing Staff and All On-site tracking • All required licenses and Pharmacist in Charge system, logs, or certifications Professional Licenses employee files and Certifications Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 97 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.109 Pharmacy and All On-site listing • All DEA registrations Providers’ Drug of provider DEA Enforcement Agency registration #s (DEA) Registrations & pharmacy registration document MIT 15.110 Nursing Staff New All Nursing staff • New employees (hired within last Employee training logs 12 months) Orientations MIT 15.998 Death Review 3 OIG summary log: • Between 35 business days & Committee deaths 12 months prior • California Correctional Health Care Services death reviews Office of the Inspector General, State of California Inspection Period: November 2020 – April 2021 Report Issued: March 2022 Cycle 6, Pelican Bay State Prison 98 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: June 2020 – November 2021 Report Issued: March 2022 Cycle 6 Medical Inspection Report for Pelican Bay State Prison OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General STATE of CALIFORNIA March 2022 OIG