Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 1 of 33

1 Jorge
(No. 013834)
013834)
JorgeFranco,
Franco,Jr.
Jr. (No.

jf@jhc-law.com
E-Mail: jf(Qjhc-law.com
2
L.L.P.
2 JENNINGS,
JENNINGS, HAUG
HAUG&& CUNNINGHAM,
CUNNINGHAM,
L.L.P.

3

2800 North Central Avenue, Suite 1800

4
5

Facsimile: 602-277-5595

3 2800
NorthArizona
Central 85004-1049
Avenue, Suite 1800
Phoenix,
85004-1049
Phoenix,
Arizona
Telephone: 602-234-7800
602-234-7800
Telephone:
4 Facsimile: 602-277-5595

Attorneys for
for Defendants
Fulton Brock,
Brock, Don
Stapley,
Attorneys
Defendants Fulton
Don Stapley,
6
Andrew
Kunasek,
Max
Wilson
and
Mary
Rose
Wilcox
6 Andrew Kunasek, Max Wilson and Mary Rose Wílcox
7
88
9

UNITED STATES DISCTRICT COURT

10

DISTRICT OF ARIZONA

11

12
13

Fred Graves, Isaac Popoca, on their
and on
on behalf
behalf of
of aa class
class of
own behalf and
all pretrial detainees in the Maricopa
County
County Jails,
Plaintiffs,

14
15

16
17

Case No. CV-77-0479-PHX-NVW
CV-77-0479-PHX-NVW

NOTICE OF FILING SEVENTH
REPORT OF DR. KATHRYN A.
A.
BURNS

VS.
vs.

Joseph Arpaio, Sheriff of Maricopa
County;
et al.;
al.;
County; et
Defendants.

18

19
19

Pursuant
to thistoCourt's
OrderOrder
dateddated
January
28, 2009
(#1769),
Pursuant
this Court's
January
28, 2009
(#1769),defendants
defendants

20 Fulton
Don Stapley,
Andrew Kunasek, Max
Max Wilson
20
Fulton Brock,
Brock, Don
Stapley, Andrew
Wilson and
and Mary
Mary Rose
Rose Wilcox,
Wilcox,

21 through
21
throughundersigned
undersignedcounsel,
counsel, hereby
hereby give
give notice
notice of filng
filing the
the Seventh
Seventh Report
Report of
of
22 Kathryn
22
KathrynA.
A.Burns,
Burns,MD.,
M.D.,MPH
MPH dated
dated August
August 2011.
2011. The
Thereport
reportisis attached
attached hereto.
hereto.
23
24

25

26
27

28

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 2 of 33

1
this 9th
of August,
2011.
1 DATED
DATED
thisday
9th day
of August,
2011.
22
33

& CUNNINGHAM,
CUNNINGHAM, L.L.P.
L.L.P.
JENNINGS HAUG &

4
55
66
77
88

lorge Franco, Ir.
Ir.
lsi Jorge
Jorge Franco, Jr.
Jr.
2800
Central Avenue,
Avenue, Suite
1800
Suite 1800
2800 N.
N. Central
Phoenix,
AZ 85004-1049
85004-1049
Phoenix, AZ
Attorneys
Attorneys for
for Defendants
Defendants Fulton
Fulton Brock,
Brock, Don
Stapley, Andrew Kunasek,
Kunasek, Max Wilson and
Mary Rose Wilcox
Wilcox

9

10
11

12
13

14
15

16

17
18
19
20
21
22
23

24
25

26
27

28
2

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 3 of 33

CERTIFICATE OF
OF SERVICE
SERVICE
CERTIFICATE

11

22 I hereby
certify
that that
on August
9, 2011,
I electronically
transmittedNOTICE
NOTICE
I hereby
certify
on August
9, 2011,
I electronically transmitted

A. BURNS
BURNS to
to the
the Clerk's
Clerk's
SEVENTH REPORT
REPORT OF
OF FILING SEVENTH
OF DR.
DR. KATHRYN A.

33 Offce
Officeforforthe
theUnited
UnitedStates
StatesDistrict
DistrictCourt,
Court,District
DistrictofofArizona,
Arizona,using
usingthe
theCM/ECF
CM/ECF
System for filing and transmittal of a Notice of Electronic Filing to the following
44 System
for filng and transmittal of a Notice of Electronic Filng to the following
CM/ECF registrants:
55

6
6
7
8

9
9
10

Esq.
Larry A. Hammond,
Hammond, Esq.
SharadH.H.Desai,
Desai, Esq.
Esq.
Sharad
C. Rubalcava
Christina C.
OsbornMaledon,
Maledon,P.A.
P.A.
Osborn
2929 N. Central Avenue,
Avenue, Suite
Suite2100
2100
2929
Phoenix,
AZ 85012-2793
Phoenix, AZ
85012-2793
lhammond@omlaw.com
Ihammond(Qomlaw.com
dhil(Qomlaw.com
dhill@omlaw.com
sdesai@omlaw.com
sdesai(Qomlaw.com

11
11

Margaret Winter,
Winter,Esq.
Esq. (admitted
(admittedpro
prohac
hacvice)
vice)
Margaret
Gabriel
Eber,
Esq.
(admitted
pro
hac
vice)
Gabriel Eber, Esq. (admitted pro hac vice)
Eric Balaban,
Balaban, Esq.
Esq. (admitted
(admittedpro
prohac
hac vice)
vice)
Eric
13
ACLU
National
Prison
Project
13 ACLU National Prison Project
915 15th Street,
Street, N.W., 7th Floor
14
Washington, D.C.
D.C. 20005
20005
14 Washington,
mwinter@npp-aclu.org
mwinter(Qnpp-aclu.org
15 geber(Qnpp-aclu.org
15
geber@npp-aclu.org
ebalaban@npp-ac1u.org
12
12

16
16 ebalaban(Qnpp-aclu.org

17 Daniel
17
DanielJ.J.Pochoda,
Pochoda, Esq.
Esq.
ACLU
18 P.O. Box 17148
18

P.O. Box 17148
19
Phoenix, AZ
85011
19 Phoenix,
AZ 85011
dpochoda@ac1uaz.org
dpochoda(Qacluaz.org
20

21 Michele
21
MicheleM.
M.Iafrate,
Iafrate, Esq.
Esq.

Courtney Cloman, Esq.
Esq.

22 Iafrate
22
Iafrate&&Associates
Associates

649
649 N.
N. Second
Second Avenue
Avenue

23 Phoenix,
AZ 85003-0001
23
Phoenix, AZ
85003-0001
24 michele.iafrate@azbar.org

24 michele.iafrate(Qazbar.org

25
26
27
27

28
33

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 4 of 33

1
1 I further
I further
certify
certify
thatthat
on on
August
August
9, 9,
2011,
2011,a acopy
copyof
of the
the attached
attacheddocument
document was
was
22

delivered to:
to:
delivered

Neil V.
V. Wake
Wake
The Honorable Neil
33 United
UnitedStates
StatesDistrict
DistrictCourt,
Court, District
District of
of Arizona
Arizona
4 401 W. Washington Street, SPC 52
4 401
W. 524
Washington Street, SPC 52
Suite
Suite
524
AZ 85003-7640
85003-7640
5 Phoenix,
Phoenix, AZ
5
66
77
88

lsi Kim
Kim Cecil
Cecil
lsi
kc/4982-2

99

10

11
11
12

13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
44

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 5 of 33

UNITED STATES DISTRICT COURT
COURT
FOR THE DISTRICT OF
OF ARIZONA

Arpaio
Graves v.
v. Arpaio

NoCV
NoCV 77-0479-PHX-NVW
77-0479-PHX-NVW

SEVENTH REPORT OF
OF KATHRYN A. BURNS, MD, MPH
ON CORRECTIONAL HEALTH SERVICES COMPLIANCE
WITH SECOND
SECOND AMENDED JUDGMENT
AUGUST 2011
AUGUST

seventh report
report fied
This is the seventh
filed to
toupdate
updatethe
theCourt
Courton
on Correctional
Correctional Health
Health Services
Services

as itit pertains
pertains to
(CHS)
compliance
the terms of the Courts
Court's Second
Second Amended Judgment as
(CHS) compliance
with the termswith
of
pretrial detainees
the delivery
delivery of
of mental health care to pretrial
detainees confined in the Maricopa
Maricopa County
Jails. Dr. Lambert King,
King, medical
As in
Jails.
medical consultant,
consultant, and
and Ii visited
visited the jails June
June 27-29,2011.
27-29, 2011. As
prior visits, i[ met with CHS
CHS administrative
prior
administrative and
and supervisory
supervisory medical and mental health staff;

toured the
toured
theMental
MentalHealth
HealthUnit
Unit(MHU);
(MHU);visited
visitedLower
LowerBuckeye
BuckeyeJail
Jail(LBJ),
(LBn, 4th
4th Avenue Jail
Jail and

Estrella; and
and reviewed
reviewed aa number of documents
documents and
and medical
medical records.
records. In
Estrella;
In addition,
addition, II
il (SMI)
interviewed several inmates
inmates classified
classified as seriously mentally ill
(SMI) that are housed in
segregated housing
housing units, observed aa group
group session
session in
in the
the MHU
MHU and
and spoke
spokewith
with the inmates
segregated

after the group about the treatment
treatment they
they receive.
receive.
Dr. Dawn
Dawn Noggle,
Mental Health,
and II reviewed
reviewed the
the format
format and
and
Dr.
Noggle, CHS
CHSDirector
Director of
of Mental
Health, and

Health Report
Report that
that is
is compiled
compiled and
and sent to me
me monthly.
monthly. I have asked
contents of the Mental Health
for some revisions in terms of
of the types
being presented
presented and
and requested the
types of information
information being

types of
of data.
data. II reviewed
and Incident
inclusion of
of some
some other types
reviewed the
the Psychological
Psychological Autopsies and

Reviews pertaining
pertaining to
to the
the three
three inmate deaths by suicide
suicide that
that have
have occurred.
occurred. (I
Reviews
(I had
independently reviewed the medical
independently
medical records of these inmates prior
prior to the site
site visit and
discussed and
and compared
compared my
my findings
findings with
with those of
discussed
of CHS.)
CHS.) I reviewed the status of
of the
1
1

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 6 of 33

Continuous Quality Improvement
program, some
some recently completed studies, minutes
Improvement program,
minutes of
the Quality Improvement
Improvement Council
Council and clinic subcommittees. Dr.
Dr. King
King and iI reviewed some
some
anotheras
as well
well as
as with
withDr.
Dr. Noggle
Noggle and
and Dr.
Dr.
critical
incidentsand
and discussed
discussed them
them with
withone
one another
critical incidents
Jeffrey
CHS' review
Jeffrey Alvarez,
Alvarez, CHS
CHSMedical
MedicalDirector.
Director. We
We reviewed
reviewed the
the documentation
documentation from CHS'
review

the incidents,
incidents, the issues identified and plans of correction developed in response.
of the

I have
have organized
organized this
this report
report according to
to the format and recommendations made in
Fifth Report and Addendum.
my Fifth

Intake/Receiving
IntakejReceiving Screening
CHS
work on
Intake/Receiving Screening
Screening process:
process: The
The
CHS has
has done
done extensive
extensive work
on the
the Intake/Receiving

policy and procedures have been revised to include a triage determination of how soon a

policy and procedures have been revised to include a triage determination of

detainee who screens positive requires aa follow-up
follow-up mental health
health assessment and

psychiatric provider appointment. The
The triage
triage category
category and
and date(s)
date(s) for
for scheduled
scheduled follow-up
follow-up
screening form
form which becomes
part of
becomes part
appointments are documented on the mental health screening
the paper medical record.
Further, the number
theofnumber of intake/screening
intakelscreening questions
questions has been expanded substantially
Further,

medical and mental health items. Additional
for both medical
Additional items have been added, the
sequencing of items was improved and all portions of the screening are now electronic.
has permitted
permitted all of the mental health related questions to
Moving to an electronic process
process has

be extracted into a one-page
one-page report
report for
for each
each detainee
detainee (rather
(rather than the previous scattered
sample mental
mental health
health screening
screening report
report extracted
questions and a supplemental form.)
form.) A
A sample
end of this report
report as
Appendix A:
as Appendix
from the
the larger
larger screening
screening process
process is attached at the end

Report. The revised screening
screening instrument
instrument and
Mental Health Screen
Screen Report.
and electronic
electronic process
process

2

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 7 of 33

were
were implemented
implemented April
April 6,
6, 2011.
audit was
was completed at the
A Quality Improvement
Improvement audit
the end
end of
of April
April to determine

whether inmates with mental health needs received
timely assessment
assessment and
and treatment
treatment after
whether
received timely
booking. One hundred
booking.
hundred twenty-nine receiving screens
screens were
were reviewed;
reviewed; three
three inmates were
released at intake
a sample
of 126. a
Of sample of 126. Ofthem,
released
at leaving
intake
leaving
them, 123 (97.6%) were assigned a mental

number. (This
improvement of
health triage code
code number.
(This represents
represents and improvement
of more than 8% when

compared to a study conducted in March
March prior to the consolidated electronic process.)
process.)

next part
part of the
the audit
audit attempted
attempted to answer whether the appropriate
The next
appropriate triage
triage code
code was

based upon
upon the
the responses
responses to
to the
the screening
screening questions.
questions. Audit
Audit results
assigned at intake based
indicated that the appropriate
the cases.
cases. Follow-up
appropriate urgency
urgency code
code was assigned in 85% of the
Follow-up
appointments were scheduled
in thescheduled
Jail Management System
OMS) Jail
for 91Management
% of
appointments
were
in the
System OMS) for 91% of the cases

follow-up appointment
appointment was
requiring follow-up. Lastly, 64% of the inmates for whom a follow-up

requiring follow-up. Lastly, 64% of

made were actually seen
seen as
as scheduled.
scheduled. (Inmates released prior to the scheduled
appointment were
sample.) These results wil
appointment
were excluded
excluded from
from this sample.)
will be
be used
used to
to develop
develop a plan
of correction targeting
performance in ensuring patients
patients are
are seen
seen face-to-face
face-to-face within
targeting better
better performance
the targeted time
time frame.
frame. (Prior
(Priorto
to the
the advent
adventof
of the
the electronic
electronic process, an audit showed
only 45% 45%
of
appointments were kept.) One
of the scheduled
scheduled appointments
One step in the quest for
only

improvement
improvement starting
startingJuly
July 11 isis to
to expand
expand psychiatric
psychiatricprovider
providercoverage
coverageatatthe
the4tl1
4 th Avenue

clinicto
to midnight)
midnight) three
three nights per week.
week. (At
intake clinic
to include
include evening hours (coverage to
(At
evening hours.)
hours.) The process
process will
wil be
the time of
of the site visit, there were no evening
be audited
audited again
again

within six months.

Case Reviews)
Reviews) are
are consistent
consistent with
Findings in the records reviewed
reviewed (Appendix
(Appendix B:
B: Case
internal study: improvement
the findings of
of CHS
CHS internal
improvementisisneeded
needed in
inthe
theareas
areas of
of assigning
assigning the

3

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 8 of 33

appropriatetriage
triagecode
codeand
and ensuring
ensuringappointments
appointmentsactually
actuallyoccur
occur as
as scheduled.
scheduled.
appropriate

Health Needs
Needs Requests (Inmate Self-Referrals
Self-Referrals)Iand
andStaURJif..errals
StaffRJierrals
CHS revised
Needs Request
include aa
CHS
revised the
the Health Needs
Request (HNR)
(HNR) policy
policy and
and procedures to include
HNRs related
24-48 hours
hours and
and created
created
face-to-face triage of HNRs
related to
to mental
mental health needs
needs within
within 24-48
HNRs and
Data is
is available starting
in January
database to
to track
track all
all HNRs
a database
and triage
triage response
response times. Data
starting in
2011.
2011
HNRs were
In April,
April, 1223
1223 mental
mental health-related HNRs
were received and 91.1% were triaged
In May,
May, 1589 mental health-related
health-relatedHNRs
HNRs were received and
face-to-face within
within 48-hours. In
thatthe
thepolicy
policyrequires
requiresaaface-to-face
face-to-face triage
triage of
of all
all
triaged within
within 48-hours.
48-hours. (Note
(Notethat
90% were triaged
CHS is
is
health-related requests.)
requests.) This
Thisrepresents
representsoverall
overalldata
dataand
anddemonstrates
demonstratesCHS
mental health-related
exceeding
theuponagreed
exceeding the agreed
compliance upon
threshold compliance
of85% in terms of threshold of85% in terms of timeliness overall.
Durango
Durango clinic
clinicdid
didnot
not reach
reach the
the overall
overallperformance
performance threshold
threshold and the process and
challenges
reviewed. Subsequently,
Subsequently, Saturday hours were added to mental
challenges there were reviewed.
HNRs
health staff
coverage and
to 80.9%
80.9% (May)
(May) of
ofHNRs
staff coverage
andperformance
performanceimproved
improved from
from 75% (April)
(April) to
triaged face-to-face
face-to-face within
within48-hours.
48-hours. Other
Other procedural
procedural improvements
improvements are
are planned at
Durango.
(For example,
example, changing
Durango. (For
changing the
the procedure
procedure to
to shorten
shorten the time
time it takes for medical
do the
the initial
initial paper
paperreview
reviewof
ofall
all HNRs
HNRs and
nurses who do
and enter
enter day and time of receipt to
forward mental health-related requests to
to mental
mental health
health staff.)
staff.)
the database
only with
with whether
whether the triage
Note
Note thatthat
the database
and analysis of and analysis of results deal only
occurred within 48-hours of receipt and include a triage urgency code.
(The urgency code
code. (The
is
and a code of 4
is aa number
number between 1 and 4 with a code of 1 being the
the most urgent
urgent and
is no need for followfollowmeaning
meaning the
the follow-up
follow-up will
wil occur as previously scheduled or there
there is

44

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 9 of 33

up.) A
wil be
up.)
A quality improvement study will
be necessary
necessary to
to review
review the
the clinical
clinical judgment

rendered with
rendered
with respect
respectto
to appropriately
appropriatelyclassifying
classifying the urgency
urgency of the response, the
recommended follow-up (such
as referral
referral to aa psychiatric
psychiatric provider,
appropriateness of recommended
(such as

MHU or increased frequency of
of mental health
health contacts and counseling) and
admission to MHU

whether the
whether
the timeframes
timeframes for
for the
the planned
planned follow-up
follow-up were met. Now
Now that the basic elements
HNRs arein
oftracking
response timeframes
timeframes to
to HNRs
of tracking receipt and response
are in place, aa quality
quality improvement
improvement

audit is possible.
audit

Findings
in the
the records
records reviewed and summarized at the end of this
this report in
Findings in

Appendix B
Bdemonstrate
demonstrate the
the improvement in triage
triage response
response rate but
but there
there is
is aa need for aa.
Appendix
more clinically
oriented review
of
more
clinically
oriented
review of the triage decision and
and recommended
recommended follow-up,
follow-up,

particularly
issues related
particularly
as it relates to more timely referrals for
for psychiatric follow-up
follow-up on issues

simply telling
tellng the detainee to ask the psychiatric provider about their
to medications (not simply
concern at their next regularly scheduled appointment) and increasing the frequency

and/or type
and/or
typeof
of intervention
intervention in
in response
response to
to aa clinical
clinical need. Referrals
Referrals to mental health from
other jail
be tracked
tracked for timeliness
other
jail staff,
staff, including
including medical
medical and
and detention
detention staff
staff should
should also be

of triage response as well as clinical
response classification
classification
clinical appropriateness
appropriateness of triage response
decisions. Record
problems with
with mental health
decisions.
Record review findings demonstrated some
some problems

to referrals
referralsfrom
from other
otherjail
jail staff.
staff. (Appendix
(Appendix B:
B: Cases
Cases #3,
responses to
#3, #5
#5 and #9)
responses

M~ntq,lH~qlthJlJlit(MHJll
Mentql JJealth Unit (MJJJl1

CHSprogress
progress in
in addressing
addressing issues and concerns
mixed: many
CHS
concerns in
in the
the MHU
MHU isis mixed:

been made
made but
but serious problems persist. Advances
Advances are substantial and
advances have been
include:

5

Case 2:77-cv-00479-NVW Document 2001

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Revising the
the system
system for
for scheduling
schedulingthe
the follow-up
follow-upappointments
appointments at
at outpatient
outpatient
Revising

facilities when
when aa patient
patient is
is discharged
discharged from
from the
the MHD.
MHU. Prior to the procedural revision, the
facilities
receiving outpatient facilty
facility was responsible
responsible for
for scheduling mental health professional and

psychiatric provider follow-up
follow-upupon
uponthe
thepatient's
patients return. There
There were
were many
many problems with
continuity of care
care and
and patients
patients were not seen timely under this process. A
A procedural
change requiring
the MHU staffthe MHU staff to schedule
schedule outpatient
outpatient follow-up
follow-up through
through the
the Jail
Jail
change
requiring

Management System
System OMS)
OMS)has
hasbeen
beenmade.
made. This
Thisrequired
required additional staff training
training to show
to schedule
scheduleappointments
appointments at the
the other sites as
as well
well as
as ensuring
ensuring that
JMS to
them how
how to
to use
use JMS

follow-up interval
interval recommendations
recommendations were
were incorporated into the process. Training
follow-up
Training was
place. A Quality Assurance
Assurance audit
audit to
to determine the
completed and the new procedure is in place.

is planned for
for July.
July.
effectiveness of the new procedure is
There has been a near exponential increase in the number
number of
of group

treatment opportunities
treatment
opportunitiesoffered.
offered. Each
Each mental
mental health
health professional
professional conducted
conducted 24-31 groups
April; 105
105 groups
groups were
were held
held and
and there
there were 14 cancellations.
cancellations. (The reason for
during April;
tracked. In
the reasons for cancellation were staff absences and
In April,
April, the
cancellation is also tracked.
patient
size is
is 5.5
5.5inmates.
inmates. II had
had the
the opportunity
opportunity to sit
patient refusals.)
refusals.) The
The average
average group size
sit in
in on
on aa

group and speak with the participants during the site visit. (This
(This particular
particular group was
group treatment room
room on
on the MHU housing unit. Patients
Patients were
were seated
seated in
being held in a group

irons.) The
The facilitator
faciltator was very professional and managed
chairs without handcuffs or leg irons.)
engaged in engaged
meaningful discussion
about the topic. discussion
All of
to get all of the
theparticipants
participants
in meaningful
about the topic. All of the

to get all of

group treatment
treatment options in
men in the group were very enthusiastic about the addition of group
the MHU.
MHU.

criticism that
that has
has been
been leveled
leveledregarding
regarding group
group treatment
treatment has been that it has
A criticism

6

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 11 of 33

reserved as
as aa modality for only lower custody level
been reserved
level inmates (so that they could be out
of their cells and
inmates remained
and out
out of
of cuffs)
cuffs)while
while higher
higher custody
custody (or
(or more
more acutely
acutelyill)
il) inmates
in their
their cells
cells (meal slot in the solid cell door open
open to
to permit
permit some
some sound
soundpenetration)
penetration) with
with
attemptingto
to engage
engage them in
in some
some form of
of activity
activitysuch
such as
as
aa mental health professional attempting

music appreciation
appreciation while
while walking
walkingaround
around the
the dayroom.
dayroom. (Individual interactions
exercise or music
with higher custody inmates were
were also
also conducted
conducted almost
almost exclusively
exclusively at the cell front
without regard for
for confidentiality.)
confidentiality.) Another
Another improvement
improvement has
has been
been the
the creation
creation of
of secure,
confidential individual and group treatment
treatmentspace
spaceon
onall
all MHU
MHU housing
housing units.
units. The
installation of secure
secure therapeutic
therapeutic modules arranged in a group room to permit congregate
activity
of closed
closed custody inmates was
activity of
was completed
completed in
in late
late June.
June. Out-of-cell
Out-of-cell group
group treatment
treatment
for closed
closed custody inmates was scheduled to start
start the
the week
week of
ofJuly
July 11, 2011.
Other areas in which
which progress is underway:
Dr.
Dr. Noggle
Nogglehas
hasaameeting
meeting scheduled
scheduled for
for August
August 88 with
with the
the Presiding Judge over
Probate and Comprehensive Mental Health Court to
of being able
to work
work through the details of
to transfer
transfer inmates
inmates to
to Desert
Desert Vista inpatient psychiatric care when necessary for
immediate care (Le.,
(i.e., before
before decompensating
decompensating to
to the point of requiring Court Ordered
Treatment
(COT)
if COT
is denied.) This will likely require the court granting a
Treatment (COT) andj
or if COTand/or
is denied.) This
wil
"conditional
of the patient
patient from
from the
the jail
jail to
to the
the hospitaL.
hospital. The scheduled meeting is
"conditional release" release"
of
legal requirements to access acute
to work through the procedural and legal
acute inpatient
psychiatric care via the
agreement with
Maricopa County
County Health
the intergovernmental agreement
with Maricopa
System.
CHS
Restoration to
to Competency
Competency (RTC)
(RTC)
CHSisisworking
working on aa mechanism
mechanism to
to transfer
transfer Restoration
patients whose clinical
clinical need
need exceeds
exceeds that
can be
that which
which can
be provided
provided in the MHU to Arizona

7

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State
to the
the extent
extent that
that they
they can
can safely return to MHU
MHU or
State Hospital
Hospital until
until they are stabilized
stabilzed to
their
determined (Le.,
(Le., their competency has been
their criminal case disposition has been determined
restored or they have been
This mechanism
been declared
declared non-restorable.)
non-restorable.) This
mechanism will
wil require further
butCHS
CHS has
procedural development
development but
has identified
identifed a funding source to pay for
for the
the state
hospital care, which should increase the likelihood of procedural success.
In spite of
of the progress made,
made, serious
serious issues
issuespersist
persist in
in MHU.
MHU. Chart reviews

problemswith
with inadequate,
inadequate, incomplete
incomplete admission
admission assessments;
to illustrate
ilustrate problems
continued to
premature
release; unilateral
discharge decisions
decisions made by MHU
discussion,
premature release;
unilateral discharge
MHU without
without discussion,
about the frequency,
coordination or continuity of care with
with outpatient
outpatient providers; concerns about
intensity and quality of
of treatment
treatment interventions
interventions in
in the
the MHU.
MHU. There
There was aa critical
intensity
critical incident
involving dehydration
involving
dehydration and
and serious
serious adverse
adverse medication
medication reactions in
in the
the same
same patient
patient that
were not timely
timely addressed
addressed and required emergency transport
out for
for medical
medical care
care in the
transport out
community on two separate
separateoccasions.
occasions. (The
(Theincident
incidentisisdetailed
detailedininthe
theAppendix
AppendixBB-- Case
Case
CHS has
analysis Quality
Quality Assurance review
review in
in early
earlyJuly.)
July.)
#5 and CHS
has scheduled
scheduled a root cause analysis
This
This incident is
is particularly
particularly noteworthy because the patient was confined to the acute unit
of the MHU
MHU for
for three
three and
and aahalf
halfmonths
monthswhere
whereintervention
intervention and
and monitoring
monitoring are by

definition, most intense and frequent, and yet, his physical and psychiatric conditions
definition,
deteriorated
dramatically. (He
(Hewas
wasin
inhis
his cell
cell for weeks on end, refusing to eat and shower.
deteriorated dramatically.

taken out for
for emergency treatment,
treatment, his hair and feet were described as being matted
When taken
with
feces.) The
Thecase
case isis also
also complicated
complicated by
by the
the patient
patienthaving
havingbeen
been sent
sent to jail
jail for
forRTC
RTC
with feces.)
which actually
actually delayed
delayed his
his access
access to
care. Review
Review of
ofthis
this case
case
to acute
acuteinpatient
inpatient psychiatric
psychiatric care.
also
ofthe
also served
served to
to highlight
highlight the physical condition of
the cells in the MHU,
MHU, particularly
particularly those in
The dayroom
dayroom areas
areas were painted
painted more
more than
than aa year
year ago but the cell
the acute care
care units.
units. The

8

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 13 of 33

interiors were
werenot.
not. Custody
Custodyhas
haspolicies
policies with
with respect
respectto
tocleaning
cleaningand
and disinfecting
disinfecting the
the cells
cells
interiors
but in
in spite
spite of
of periodically disinfecting surfaces, the floors,
but
floors, walls
walls and
and windows
windows appear
appear
stained with
with what
what appears
appears to
to be
be dirt,
dirt, feces
feces andj
and/or
blood in some instances.
grimy and stained
or blood
Some of the Plexiglas
Plexiglas or
into the
the cells
cells
or lexan
lexan windows
windowsthat
that are
are supposed to permit visibility
visibilty into

Some of

are so scratched that
that visibility is
These conditions
conditions are most prominent
prominent in
in the
is reduced.
reduced. These
acute and sub-acute housing
the MHU.
MHU.
housing units but
but also exist to a lesser extent
extent throughout
throughout the
recognize that this is a jail
jail environment
environment and
and that maintaining cleanliness
cleanliness presents
presents many
MHU isisintended
challenges. Nevertheless,
Nevertheless, the MHU
intendedto
to be
beaatherapeutic
therapeutic environment
environment but the
filthy in
in spite
spite of
of applying
applying surface disinfectant. Acutely
Acutely
conditions inside the cells appear fithy
inmates are
are confined
confined under these conditions for twenty-three
mentally ill
il inmates
twenty-three or more hours
day, sometimes for many days
per day,
days on
on end.
end. This
This environment
environment is
is not therapeutic for them

nor hygienic for
for other inmates and staff who work there.
Suicide Prevention Program
The Suicide
A stand-alone policy
Suicide Prevention
Prevention Policy and
and procedures
procedures were
were revised.
revised. A
on the use of therapeutic
restraintswas
was written.
written.The
Theuse
useof
ofseclusion
seclusion as
as aa step
step in
in suicide
therapeutic restraints

on the use of

there isis no
no stand-alone
stand-alone seclusion policy:
prevention
has been eliminated. (Also,
(Also, there
prevention has
therapeutic
seclusion as a separate
separate level
level of care
therapeutic seclusion
care or procedure no longer exists.)
exists.) The
policies
May 9, 2011. Staff training
on both policies occurred
training on
occurred April
April 25 - May
policies were were
effective effective
May 9,2011. Staff
20,2011. All
All three
three of
ofthe
suicides reviewed occurred
the suicides
occurred prior
prior to the adoption and training on
the suicide prevention program revisions. More
More comprehensive suicide risk assessments,
timely referrals to psychiatric care and improved coordination with medical providers
would have significantly
significantly impacted
impacted the
the mental
mental health management of those cases and may
have
The implementation
implementation of
of the policy
policy and procedural
have resulted
resulted in
in different
different outcomes.
outcomes. The
9

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 14 of 33

improvements and training wil
will be
be reviewed
reviewed during
during future
future site
site visits.
visits.
Outpatient
Outpatient Care
Care
Outpatient
care was not
not aa focus of this visit
visit as
as CHS
CHS acknowledged
has
Outpatient care
acknowledged that
that attention
attention has
not yet been focused
(Intake screening,
screening, HNR,
focused on
onthis
this level
level of
of care.
care. (Intake
HNR, quality
quality improvement,
work on electronic medication administration
records, suicide
suicide prevention
prevention policy
policy revision,
administration records,
staff training on
on new
new procedures
procedures and other initiatives were appropriately given priority
CHS' decision
over outpatient
care revisions.) Although
Althoughnot
notunexpected
unexpected given
given CHS'
outpatient care
decisionto
toprioritize
prioritize
other initiatives over outpatient
outpatient care, chart review findings
findings demonstrate
demonstrate that problems

identifed continue to exist.
exist. These
with outpatient care previously
preViously identified
These issues
issues are quite
quite serious
and
intervals,even
even when
when patients
patients are
are not doing well;
and include infrequent
infrequent contact/treatment
contact/treatment intervals,

over-reliance on psychotropic medication as
as essentially
essentially the
the sole
sole treatment
treatment intervention in
response to
to HNR
HNR rather
than pro-active,
pro-active, planned,
planned, clinically
clinically
contact in response
many instances; contact
rather than
interventions; poor
poor continuity
continuity of
of care upon discharge from
treatment interventions;
driven and focused
focused treatment
MHU;
refer aa patient
patient to
to aa higher
higher level
level of
of care
care is
MHU; and
and concerns
concernsthat
that the
the clinical
clinical threshold to refer

high. The latter includes decisions to refer patients for a psychiatric assessment,
assessment, refer
too high.
appointment previously scheduled when
to a psychiatric provider sooner than the appointment
MHU level
level of
of care
care or
or psychiatric
psychiatric hospitalization
hospitalization if appropriate.
appropriate.
necessary, and referring
referring to
to MilD

Coordination of
Medical and
and Mental Health Care
Coordination
o/Medical

This is
is an
an area
area to
to which
which CHS
eiis must devote substantial attention and scrutiny as
evidenced by these recent critical incidents: MHU
MHU patient
patienttransferred
transferred out to hospital for

medical care twice;
twice; pregnant
pregnant methamphetamine
methamphetamine intoxicated
intoxicated mentally ill
il woman gave birth
medical
at Estrella;
Estrella; suicide during alcohol
in bathroom at
alcohol withdrawal; and an instance of mental

10

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 15 of 33

staff failng
failing to
to assess
assess an
an inmate
inmatein
in response
responsetotoaamedical
medicalreferraL.
referral. (Cases
(Cases##5,5,4,
health staff
4, 22
8.)
Appendix 8.)
and 3 summarize these incidents in Appendix

Some initiatives
thatCHS
CHS has
of care
care
Some
initiatives that
has already
already implemented
implemented to address coordination
coordination of
A
joint psychiatric
psychiatric and medical provider meeting that occurs every other month. A
include: aa joint
LBJ infirmary
the LBJ
psychologist assigned to the
infirmary attends weekly staffing meetings held on
CHS medical
medical
infirmary patients
patients to
to ensure
ensuremental
mentalhealth
healthinvolvement
involvementinincare
careissues.
issues.The
TheCHS
planning to attend the morning
director, mental health director and nursing director are planning
MHU meeting together once
once weekly
rapid care
care
weekly in order to assure better and more rapid
MHU patient
coordination starting
startingin
in July
July as a response
to the
the MHU
coordination
response to
patient emergency medical
medical transfer
transfer

incident.
reviews of
of critical incidents have become much more
The quality assurance reviews
comprehensive, appropriately
self-critical, and
and focused
focused on
comprehensive,
appropriately self-critical,
on implementing
implementing improvements.
CHS
CHSunderstands
understands that
that proactive quality improvement studies in addition to reactive critical
order to
to better
better examine
examine medical
medical and mental health care
incident reviews are required in
in order
coordination. i Istrongly
stronglyrecommend
recommendstarting
startingwith
withaaquality
quality improvement
improvement study
study focused
focused on
the management
management of arriving inmates that are intoxicated or experiencing withdrawal from
and/or
their being
being in need of medical monitoring and at risk of
drugs andj
or alcohol based upon their
medical and psychological
have added this
psychological complications
complications including suicide. iIhave
Continuous Quality
recommendation to the section
section of
of this
this report dealing with
with Continuous
Improvement
as welL.
well.
Improvement as

11

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TreatmentJorI1lompetent
Incom12.etentCriminql
CriminQI Dlif..endants
Treatmentlor
Delendants

earlier in
in the
the section
sectionreviewing
reviewingMHU,
MHU, there
these
As noted earlier
there has been no change to these
or improved
improved access
access to
to inpatient
inpatient care
care since
since the
the last
last site
site visit
visit but
but aa funding stream
stream
processes or
processes
is
been identified to purchase
purchase state
state hospital
hospital care
care when
when necessary
necessary and
and aa meeting
meeting is
has been
the Mental
Mental Health
Health Court to work
work through
throughthe
thelegal
legal requirements
requirements necessary
necessary
scheduled with the
Tn the meantime,
meantime, detainees
detainees committed to the jail under this
for aa transfer to Desert Vista.
Vista. In

status continue
continue to
to be
be unable
unable to
to timely
timely access
access a higher level of care
status
care (inpatient) even when
MHU case
case discussed
discussedabove
aboveand
andininAppendix
AppendiXB,
B, Case
Case #5.)
their condition
conditionisiscriticaL.
critical. (See
(SeeMHU
their

Psychotropic Medications
policy, aa number
In addition to having revised the policy,
number of important
important initiatives are
underway with
regard to improvements in this area.
with regard
area. Firstly, monthly reports from the
Diamond, demonstrate
there have
have been
been no
no policy
policy violations with
vendor, Diamond,
demonstrate there
with respect to
polypharmacy (prescribing multiple similar medications
medications to
to the
the same
same person)
person) for
for the
the past

wil be
three
months.
Second,
system
in which jail staff will
be able
able to
to access
access electronic medical
three months.
Second, a system
in which a
jail
staff
records of patients receiving outpatient services
services through
Magellan isis underway.
through Magellan
underway. (The
the Magellan
Magellan
software is being loaded
loaded onto
onto computers
computers in
in July.)
July.) Thirdly, aa meeting with the
medical
July as
medical director
director has been scheduled for July
as well
wellininorder
order to
to begin
beginto
toaddress
address continuity
continuity
of care
care across
across systems
systems with
with respect
respect to
to medication
medication prescribing
prescribing patterns
patterns and formulary
considerations.
A database
COT has
database to
to accurately track COT
hasbeen
beendeveloped
developed and
and isis currently
currently functional
is not delayed when an order
so
so that
that treatment
treatment is
order already exists
exists and
and so
so that
that opportunities
opportunities for
seeking
seeking renewed
renewed orders
orders under
under clinically
clinically appropriate circumstances are not missed.
missed. A

12
12

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Filed 08/09/11 Page 17 of 33

quality improvement
audit concerning
concerning psychotropic
psychotropic medication
medication was
was completed
completed in
in May
May
improvement audit

2011 and compared to similar audits conducted quarterly. The
The medical
medical records
records of
of one
hundred
whopsychotropic
reported
taking
psychotropic
medications at the time of booking
hundred patientspatients
who reported taking
medications
at the
time of
March were
were reviewed.
reviewed. Audit findings demonstrated
demonstrated that 74% of
during the month of March

in the sample were seen
seen by
by a psychiatric provider and the average number
number of
of days
patients in

between a referral
referral and
and psychiatric
psychiatric provider
provider visit
visit was 5.5 days. (Previously,
(Previously, the average
was 7 days.) No psychotropic medication was ordered for 26 of the 100 patients but the

was 7 days.) No psychotropic medication was ordered for 26 of

that medication
medication was not necessary was not documented for
rationale for the determination
determination that

21 of the
the patients
patients - an
an area
area that continues to need improvement. The
The average length of
time for a patient to actually receive medication after an order for medication is written is
number of
of days
days from booking to actual medication
less than one day but the average number

administration continues
days. (This does represent
represent an
administration
continues to
to lag behind: it's 5.5
5.5 days.
an improvement
improvement
over the the
9-day 9-day
average in average
the November 2010
audit November 2010 audit and the 7-day average found during
over
in the

the February
February 2011
2011 audit.)
The number
medication has
has improved
improved as
the
audit.) The
numberofof missed
missed doses
doses of
of medication
as

38% of
of patients did
did not receive at least one dose (and sometimes more) of
well but still,
stil, 38%
medication. The most common reasons coded on the medication administration record for
the missed
missed dose(s)
dose(s) were:
were: "patient
"patient not in cell, no
no show"
show" 47%;
47%; "medication
"medication not available"
21%
21
%and
andno
nocode
codelisted
listed (blank
(blank space)
space) 18%.
18%. The audit also found
found that a psychiatric
provider conducted
a face-to-face assessment
for medication
renewal orders forfor
12 ofmedication renewal orders for 12 of the
provider
conducted
a face-to-face
assessment

at medication
medication renewal
renewal time.
time. In
In general,
general, findings
findings in the medical
13 patients stil
stillin
injail
jail at

looks at
at whether
whether
records reviewed are consistent
consistent with the
the audit
audit findings
findings but the audit only looks
a face-to-face
face-to-face appointment
appointment occurred
occurred for
for medication
medication renewal
renewal orders;
orders; there were many
instances of medication adjustments (dosage
(dosage changes, discontinuations, etc.)
etc.) without the

13

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 18 of 33

assessments in
in the records
records II reviewed
reviewed at
at Estrella.
Estrella.
face-to-face assessments
Unfortunately, the
the electronic medication administration
administrationrecord
record(EMAR)
(EMAR) project
projectwas
was
Unfortunately,
unable to be
be launched
launched as
as anticipated
anticipated in
in the
the interim
interim since
since the
the last
last site
site visit.
visit. Although
Although aa very
unable
of staff
staff time and training
was expended
expended for
initiative, ititbecame
became apparent
apparent
large amount of
training was
for this initiative,
when attempting
attemptingto
to "go
"go live"
live" that there were
were major
major incompatibilty
incompatibilityproblems
problemsbetween
betweenJMS
JMS
when
and EMAR software.
software. OMS
(JMSprovides
provides the
the names,
names,basic
basicdemographic
demographicinformation
information and inmate
location within
withinthe
the jail
jailsystem
system - jail,
jail, housing
housing unit,
unit, cell
cell number, etc.)
was anticipated that
etc.) ItIt was
EMAR would
EMAR
would assist in reducing missed doses
doses of
of medication
medication and
and improve
improve accuracy of
were missed
missed by
by eliminating
eliminating redundant,
redundant, overlapping,
overlapping, vague or
documentation when
when doses
doses were
documentation
nonsensical coding.
Further time
time and
and effort
effortto
tolaunch
launchEMAR
EMAR is
is required
required though
though CHS
CHS did
nonsensical
coding. Further
did not
However, it
have a new proposed schedule for
for implementation at the time of the
the site
site visit.
visit. However,
is imperative that
that this initiative becomes operational as soon as
as possible.
possible. All
All attention
attention will
wil
soon be focused on
on adoption
adoption and implementation of an electronic health record which
often takes years to fully
fully operationalize;
operationalize; having
having aa functional
functional medication
medication administration
administration and
accurate recording system will
ensure that
that this
this aspect
aspect of
of care is not disrupted
wil help ensure
throughout
that lengthy
lengthy process.
process.
throughout that
Staffing

Mental
Mental health
health staffing
staffng levels
levels and
and vacancies
vacancies are
are reported
reported to me in
in the
the monthly report.
Most
recent
(June
staffing
reports
indicate
very few mental health staff vacancies
Most recent
(June 2011)
staffng2011)
reports indicate
very few
mental health
staff
(less
overall in
in the
the field
field of
(less than
than 33 full-time
full-time equivalent
equivalent positions
positions overall
of psychologist
psychologist and
and mental
mental
health
health professional/associate; all
all current
current psychiatrist positions
positions are
are filled.)
filled.) The positions
created and posted from last year's mental health
health staffing
staffing plan analysis have been filed,
filled,
including
Currently, a review of nursing staffing
needs in
including the
the detention
detention escort
escort positions.
positions. Currently,
staffng needs
in
14
14

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MHU isisunderway
be available within the
the MHU
underwayand
andthe
theresults
results and
and recommendations
recommendations will
wil be
next month.

Continuous Quality Improvement
(CQI]
Improvement (CQI)

The
The CQI CQI
system system
within the jails
within
has evolved
theconsiderably
jails hasoverevolved
the course of
considerably over the course of the past
year.
I included
findings
from some of the studies/audits
that have been undertaken
year. I included
findings from
some of
studies/audits that
addition to
to system-wide
system-wide audits/studies,
audits/studies, aa
recently in relevant sections
sections of
of this
this report.
report. In addition
CQI committee
joint medical-mental health
health local
local CQI
committee has
has been formed in each jail
jail where
process
issues unique
process and
and outcome
outcome studies
studies involving
involving issues
unique to the specific jail are being
peer review
review is
is now routine. Comprehensive
Comprehensive multidisciplinary
undertaken. Mental
Mental health peer
Dr.
reviews of adverse
adverse incidents occur
occur timely
timely and
and information
information isisshared
shared with
with all
allproviders.
providers. Dr.
King and
of the incident
incident reviews
reviews and
and found
and II had
hadthe
theopportunity
opportunity to review the findings of

generally well
well done.
done. Health
well represented
represented
them to be generally
Health and mental health care staff are well
staff are not
not yet routinely included in the process
on the incident reviews but detention staff
MHU reviews.)
The
(with
exception of
of involvement
involvement of
of detention
detention staff
staffin
in some
some of
of the
the MHU
(with the
the exception
reviews.) The
routine inclusion of custody staff in
in this
this process is encouraged so that
that any issues involving
the interaction
interaction between
between health
health care
care and
and custody staff or issues
issues involving
involving custody

procedures
procedures may
may also be identified and addressed as necessary.
Recommendation: A
Quality Improvement
Improvement study should be undertaken
undertaken focusing
Recommendation:
A Quality
focusing on
intoxication and withdrawal protocols and include medical and mental health care
ilustrate some
some issues/problems
issues/problems associated
associated
coordination. (Cases
(Cases #2 and #4 in Appendix B illustrate

with current
current practice.)
practice.)

15

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 20 of 33

SggrggationLDiscipline
5MliationlDigjplin
e

The policy has
has not yet
yet been revised to reflect the process through which mental
staff are notified and consulted regarding discipline of inmates
health staff
inmates with
with mental
mental illness.
ilness.
Consequently, there is nothing new to report
at this
this time.
time.
Consequently,
report at

Training
Dr. Noggle
"MCSO issued
additional training
trainingfor
forall
allMHU
MHU
Dr.
Noggle reported
reported "MCSO
issued aa request
request for additional
officers around the
the topics of
of trauma, stress and
and compassion
compassion fatigue/self
fatigue/self care.
care. All shifts

training
received the first 30-minutes of the
thetraining
training
June.
Another
in June.in
Another
30-minute
block of 30-minute block oftraining

received the first 30-minutes of

addition,as
aspreviously
previously noted,
noted, training on the
will be
be provided
provided in
in the coming quarter."
wil
quarter." InInaddition,
therapeutic restraint
restraintpolicy
policy revisions
revisions was also conducted
revised suicide prevention and therapeutic
during the interval between
between site
site visits.
visits.

Medical records review.
revie""
Synopses of
of each
each case
I reviewed eighteen medical
medical records
records during the site visit.
visit. Synopses
reviewed are attached to this
this report
report as Appendix B.
B. II have included more detail than in
reports particularly
particularlyin
inreviewing
reviewingfive
five cases that
that involved
involved critical incidents.
previous reports
Findings
Findings from
from the
the reviews
reviews have
havebeen
been referenced
referenced throughout
throughout this
this report and include serious
issues
care, coordination of
of medical
medical and mental
issues with
with respect to
to outpatient
outpatient mental health care,
health care
of alcohol and
MHU quality
quality of
of care
care
care induding
including treatment
treatment of
and other
other drug withdrawal,
withdrawal, MHU
and discharge planning and
and concern
concern about
about the
the thresholds
thresholds for
for referral/access
referral/access to higher
levels
levels of
of care.
care.

16

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 21 of 33

CONCLUSION
CONCLUSION
CHS has
CHS
hasmade
madesignificant
significantprogress
progress in
in aanumber
number of
ofareas
areas since
since the
the last
last site
site visit:
visit: the
substantially and made entirely
intake/receiving screening
screening process has been updated substantially
intake/receiving
HNR process is
electronic; the
the HNR
electronic;
is now documented, tracked and audited; the suicide
prevention policy and
prevention
and procedures have been updated and implemented; the number and
types of
of group
available in
in MHU
MHU have
have increased
on
types
group treatment
treatment available
increased dramatically;
dramatically; staff
staff training
training on
severalimportant
areas has
has occurred
occurred and
and perhaps
perhaps most
mostimportantly,
importantly, Quality
Quality Improvement
several
important areas
processes are
permitCHS
CHS to do meaningful selftools and processes
are now in place that permit
monitoring/analysis of
of issues,
issues, incidents and processes.
processes.
monitoring/analysis
CHS experienced
CHS
experienced some
some technological
technological glitches
glitchessince
sincethe
thelast
last visit
visit which
whichwill
wil impact
psychotropic medication
medication management.
management. After
After expending
expending much staff time
goal attainment in psychotropic
EMR project
incompatibility between
betweenJMS
JMS and
and effort, the EMR
project could
could not
not be launched due to incompatibility
EMR software.
decision was
was made
made for
for CHS
CHS to
the EMR
software. Additionally, a strategic decision
to use
use the county
of information technology for future project leadership including
including the plans for an
office
offce of
electronic health record. (Previously,
(Previously,CHS
CHS had
had their
their own staff person
person to
to lead
lead IT
IT initiatives
initiatives
not satisfied with his performance.) CHS
CHS does not believe
but were not
believe this
this change
change will
wil
negatively impact the time frame for
for review of vendor
vendor responses
responses to the Request for
Proposals for an electronic health record and may actually facilitate
facilitate implementation
implementation when
selected.
a product/vendor
product/vendor isis selected.
A number
number of
of critical
criticalareas
areas needing
needing focused
focusedattention
attention and
and improvement
improvement continue to
exist:
outpatientlevel
level of
of care expectations including
including setting
clinical thresholds
exist: outpatient
setting appropriate
appropriate clinical
thresholds
for referral
referral to
to higher
higher levels
levels of
of care; review of
of MHU
MHU quality of care
care including
including
comprehensiveness of assessment, monitoring and coordination of discharge planning and

17

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 22 of 33

follow-up; and
and coordination
coordination of medical
medical and
and mental
mental health
health care,
care, with
with particular
particular emphasis on
follow-up;
treatment of
intoxication and
treatment
of alcohol and other drug intoxication
and withdrawaL.
withdrawal. II included
included aa new
recommendation for a Quality Improvement
on current
current intoxication
intoxication and
and
Improvement study
study focused
focused on

withdrawal protocols
withdrawal
protocols in
in this report
reportbased
based upon
upon aa review
review of
of some recent
recent critical incidents in
alcohol and/or
and/or drug
care. In
which alcohol
drug use
use negatively
negatively impacted the delivery of care.
In addition,
although some progress has been made and there are
are plans
plans for
for continued development,
improved access to timely psychiatric hospitalization has not yet occurred.

Respectfully submitted,

~!)c~ ,tti-tf
Kathryn
A. Burns,
Burns, MD,
MD, MPH
MPH
Kathryn A.
August 8,2011
8,2011

18

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 23 of 33

Intake Mental
Health Screening
Intake
Mental Health

Booking#: P734098
P734098
Booking#:

DOB: 1/1/1976
Gender: M
DOB:
1/1/1976 Gender:
M

LName: Zphxtesta

FName: Adam

Facilty:
Facility: INTK
INTK
MName:
MName:

ACCEPTED:
7:54:00 AM
ACCEPTED: 212512011
212512011 7:54:00
AM

SFX:
SFX:
NO
NO

you presently taking prescription medications
medications or
or have
have any
any medication
medication with
with you?
you?
Are you
What medications?
Pharmacy!location:
Pharmacy~ocation:

NO
NO
N/R

ever served in the U.S.
U.S. Military?
Have you ever
been in
in or
or around
around combat
combat situations?
situations?
Have you been

Have you ever been victimized? NO

Comment:

Have you ever been victimized?

NO

Comment:

Have you ever been sexually assaulted? NO

NO

Have you ever been sexually assaulted?

Comment
Comment:
Do youyou
want want
to talk to to
someone
having been assaulted
victimized?been assaulted or victimized? NO
NO
Do
talkabout
to someone
aboutorhaving
Received help from
Department
Disabilities
(DOD)?
NO
Received
help
fromof Developmental
Department
of Developmental
Disabiliies (DOD)? NO
Difficulties learning or ever
in special education
classes? in special education classes? NO
NO
Difficulties
learning
or ever

Ever have or do you have a guardian now? NO

Have you ever attempted suicide? N/R
Ever have or do you have a guardian now?

NO

Have you ever attempted suicide?

N/R

When/how?

Are you thinking of hurting yourself/suicidal? N/R
Are you thinking of hurting yourself/suicidal?
Plan:

N/R

Has anyone
Has
anyone
in youor committed
familysuicide?
attempted or committed suicide? N/R
in you family attempted
N/R
as Seriously
Mentally III (SMI)?
N/R
Have you ever
beenever
designated
Have
you
been
designated
as Seriously Mentally II (SMI)? N/R

Do you currently believe that someone can control
N/R
control your mind
mind by putting
putting thoughts
thoughts into
into your
your head
head or
or taking
taking thoughts
thoughts out
out of
of your
your N/R
head?
Do
currently
feel that feel
other people
know your
thoughtsknow
and canyour
read your
mind?
Doyouyou
currently
that other
people
thoughts

N/R
and can read your mind? N/R

Have
lost or
gained
as much
two pounds
week for several
without weeks
even trying?
Haveyou
youcurrently
currently
lost
or gained
asasmuch
as twoa pounds
a weekweeks
for several
without

N/R
even trying? N/R

Have
your
family
or friends
noticednoticed
that you that
are currently
more active
you active
usually than
are? you usually are? N/R
N/R
Haveyou
youoror
your
family
or friends
you aremuch
currently
muchthan
more
N/R
like you have to talk or move more slowly than you usually do? N/R
N/R
were useless or sinful? N/R

Do
you
currently
Do you
currently
feel feel like you have to talk or move more slowly than you usually do?

Have
there
currently
been a few
weeksawhen
felt like when
you wereyou
useless
sinful?you
Have
there
currently
been
fewyou
weeks
feltor like

prescribed
for for
youyou
by a
for any
emotional
or mental
healthhealth
problems?
N/R
Are you
you currently
currentlytaking
takingany
anymedication
medication
prescribed
byphysician
a physician
for any
emotional
or mental
problems? N/R
Have you ever been in a hospital for emotional or mental health problems?
N/R
Have you been treated for mental illness?
N/R
When/what for?

Have you ever been in a hospital for emotional or mental health problems? N/R

Have you been treated for mental illness? N/R

Do you have a case manager? N/R

Do you have a case manager?

N/R

Case Manager's name and clinic:
Did the person refuse to answer all questions?

YES

Excessive emotional distress to incarceration?

NO

Did the person refuse to answer all questions? YES

Excessive emotional distress to incarceration? NO
Seen
Seenininintake:
intake:YY NN

By: MHP
By:
MHP Provider
Provider

SCHEDULE IN JMS:

ENTER INTO BEHAVIORAL HEALTH DATABASE
ENTER

Comments:
Date:
_ _ _ _ _-rD_a_t_e_:_
_ Complete ...;.U..;.;rg~e...;.n_c..t..Y_ _,...C_o_m_m_e_nt_s_:

MH CCC:
ENROLL MH

I_~_~__:__:';;":_:_S_S-f-I
MH F/U

PY EVAL
1M"
ASS''

I

I

~~

1

ITr 1"""""

ADDITIONAL
ADDITIONAL INFORMATION:

II

+1

1

I

STATUS:
I STATUS:
DX:
CONSENT FOR TX:

MH ASSESS:
MH
PYEVAL:
PY
EVAL:

SNTP:

ICOT/DATE:
I COT/DATE:

COMMENTS:
SIGNATURE/DATE:
CHS0527
0311
CHS0527 0311

SIGNATURE/DATE:

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 24 of 33

APPENDIX B
JUNE 2011 SITE
B -- CASE
CASE REVIEWS JUNE
SITE VISIT

#1

I DOB
03/27/73
I 03/27/73

I DOA

RS
IRS
10/06/10
110/06/10

I MHA
I Psychiatry
I Not completed I None

10/06/10
110/06/10
Death review (Suicide)
(Suicide)
old man
man booked
booked into the
the jail
jail 10/6/10.
10/6/10. He
He underwent
underwentreceiving
receiving screening
screening at
at the
the time
time of
of his
his booking
booking
37-year old
health referraL.
referral. No
No supplemental mental health
health screening
screening was
was in
in
and there were
were no
no indications
indications for a mental health
the file.
On 10/21/10,
inmate submitted
Needs Request
He was
was
On
10/21/10, the
the inmate
submitted aa Health
Health Needs
Request(HNR)
(HNR)requesting
requesting mental
mentalhealth
health services.
services. He
day who
who documented
documented that he was "to be
seen by a mental health staff person the
the following
following day
be scheduled"
scheduled" for aa
more comprehensive
However, the appointment for the assessment was not
comprehensive mental
mental health
health assessment.
assessment. However,
scheduled due to an error or oversight of the
the mental health staff
scheduled
staff person.
A month
month later,
later, 11/27/10,
11/27/10, detention staff referred the
A
the inmate
inmate to
to medical
medical as an emergency because the inmate's
inmate's
and threatening
threatening to kill
mother telephoned them
them and
and said that the inmate
inmate told
told her
her that
thathe
he was
was depressed
depressed and
himself. A medical
medical nurse
nurse saw
saw the
the inmate and called
to discuss
discuss the
the case.
case. An
An order for aa
himself.
called the physician
physician on call
call to
dose of
of medication, Vistaril, to address the inmate's anxiety was received
received and
and the
the patient received the
dose
medication. The
also completed
completed a referral
referral to mental health on behalf of the inmate, but
The medical
medical nurse also
but itit did
did
medication.
contain the information relayed
from detention
detention staff about the mother's
relayed from
mother'sphone
phonecall
call and
and the
the inmate's
inmate's
not contain
contemplating suicide.
suicide.

and planned to
11/28/10, a mental health practitioner saw the patient
patient in
in response to the nursing
nursing referral and
follow-up with
with the
the patient
patient in four
four weeks.
weeks. No
follow-up
No referral to psychiatry
psychiatry was made in
in spite of the medication
evening. Two weeks later, 12/10/10,
12/10/10, patient
patientdied
diedas
as aa result of
of having
haVing hung himself
administered the previous evening.
in his cell,
cell.
Ii identified
following
problems
concerning
the
identified the the
following
problems concerning
the care
and management
of care and management of this patient:
Failure
fof/aw-up on original
original HNR
10/22/10 with
Failure to follow-up
HNR 10/22/10
with aa mental
mentalhealth
healthassessment
assessment
Inadequate
MHP 11/28/10
11/28/10
Inadequate evaluation by MHP
•. nonotreatment
treatmentrecords
records requested
requested
.
no
referral
to
psychiatry
• no referral to psychiatry
assessment
•. nonosuicide
suicide risk
risk assessment
planned
•. inappropriately
inappropriatelylong
long fallaw-up
follow-up interval
interval planned
No
psychiatric follow-up
fallaw-up scheduled
scheduledfollowing
following telephone
telephone order
order for
far medsl1/27/10
meds11/27/10
No psychiatric
CHS REVIEW:
CHS
Dr. Noggle
Noggle completed
completed a psychological
psychological autopsy
autopsy citing
citing a number
number of findings and noting
Dr.
noting the
the lack
lack of
of urgency
urgency code
code
on the medical referral;
referral; no
no mental
mental health assessment completed; and the
information about the
on
the lack
lack of information
health.
mother's phone call relayed
to mental health.
mother's
relayed to
The
case
was subsequently
also reviewed
through the CHS Critical Incident Review Committee on March 7,
7,
The case
was subsequently
also reviewed through
the CHS Critical
2011. The
2011.
The committee identified
identified the
the same
same issues
issues and
and developed
developed the
thefollowing
following corrective action
action
mendations/pla ns:
ns:
recom mendations/pla
Mental health assessments need to be
Mental
be consistently
consistently scheduled and documented.
Nurse referrals
referrals to
to mental health must indicate relevant information from
from detention or other
other sources
sources (e.g.,
(e.g.,
Nurse
to harm
harm himself)
himself)
patient threatening to
There must be a sick
sick call
callappointment
appointment the next
next day
day following
follOWing aa report
reportofofaapatient
patientbeing
beingsuicidaL.
suicidal.
There
used for
situations (emergencies.)
(emergencies.)
specific radio
radio channel
channel will be used
for man-down situations
A specific
CHS staff
will follow-up
follow-upwith
withdetention
detention staff
staff regarding
regarding use
use of
of radios
radios and
and operation
operation of elevators during
CHS
staff will
during aa
medical emergency.
1

Case 2:77-cv-00479-NVW Document 2001

#2

Filed 08/09/11 Page 25 of 33

DOB
DOB

DOA
DOA

RS
RS

MHA
MHA

01/14/73

02/22/11

02/22/11

None
None

Psychiatry
None
None

Review (Suicide)
(Suicide)
Death Review
booking for
for this
this38-year
38-yearold
oldman
manininthe
theMaricopa
MaricopaCounty
CountyJaiL.
Jail.
This was
was the
the 9th booking
day of his booking, he was seen
seen in
in ED
ED at
On the day
at Phoenix
Phoenix Baptist
Baptist Hospital
Hospital after
after his
his arrest
arrest for complaints of
like he
he was
was going
going to
to have
have aa seizure;
seizure; seen,
seen, released and
and booked
booked into
intojaiL.
jail.
weakness and feeling like
Receiving screening:
Receiving
screening:acknowledged
acknowledgedalcohol
alcoholand
andmental
mentalhealth
health history
history but
but denied
denied history of
of suicide
suicide attempts
attempts or
appeared intoxicated;
intoxicated; answered
answered all
all supplemental
supplemental screening
screening questions negative except
thoughts; appeared
except "under
the screening
screening form.
form.
influence" noted; no disposition is noted on the
precautions (periodic
(periodic monitoring
monitoringof
of vital
vital signs;
signs; no meds)
Physician orders
Physician
orders indicate he was put on withdrawal precautions
He refused
assessments. He
He was
for HTN
HTN as
as per the ED
ED recommendation.
He
refused the
the vital sign assessments.
was prescribed
prescribed metoprolol
metoprolol for
Problem list indicates
depression and
suicide attempt.
Problem
indicates history of depression
and mood
mood disorder;
disorder; history of suicide
He was
mental health
health or
orseen
seen in
in spite
spite of
of aa positive
positive intake
intake screening,
screening,
He
was not
not referred
referred to mental
2/26/11man-downwas
wascalled
called for
forassistance:
assistance: the
theinmate
inmatehad
hadhung
hunghimself
himselfininhis
hiscelL.
cell. He
He died.
2/26/11
- AAman-down
Review of other
Review
other jail stays:
11/7/10-12/8/10refused
medical
follow-up
and
chronic
carefor
forHTN,
HTN,physical
physical exam,
exam, PPD;
PPD; receiving
receiving
11/7/10-12/8/10
refused
medical
follow-up
and
chronic
care
screening was
screening
was positive
positive for
for alcohol
alcohol use
use and
andappeared
appearedunder
underthe
the influence;
influence; no
no mental
mental health referral generated;
form. Also
Also
all questions "No" and
supplemental screening answered all
and no disposition
disposition documented on the form.
refused withdrawal assessments.
11/19/10refused CHS
CHSBrief
Brief MH/Suicide
Health Assessment
by RN
RN but
but the
with
11/19/10- refused
MH/Suicide Health
Assessment by
the form
form was
was completed
completed with
"chart review"
review" and
and "Y"
"Y" marked
information obtained through "chart
marked for
for suffer
suffer depression
depression or
or under
under care, take meds or
ever prescribed
MH treatment
in community
(note that these
these options
options are
are not
nothelpful
helpful in
in
prescribed them, and MH
treatment in
community or
or jail
jaillnote
distinguishing current
distinguishing
current from
from past
past conditions);
conditions); inmate
inmate was
wasreferred
referred to
to mental
mental health
health but no assessment was

completed
5/19/10 (release
is some document
document dated
dated 5/25
5/25in
in the
thefile,
file, there's
there'sno
noelWA
CIWA assessment
assessment
S/19/1O
(release date
date unclear but there is
sheets)
Receiving
and history
history of
of withdrawal;
Withdrawal; "Y"
"Y" on
Receivingscreening
screening indicates
indicates hospitalized
hospitalized for detox in 2009; alcohol abuse and
"head
injury/facial laceration,
no indication
indication of
ofwhich
which ififany
any of
of these
these
"head injury/facial
laceration, bruising/bleeding,
bruising/bleeding, bloody
bloody clothes" - no
(no accompanying
accompanying note or progress
progress note
conditions existed at the time
time (no
note describing
describing his
his condition);
condition); "N" on all
supplemental mental health questions
1/5/1O-31)2./)Q
Receiving screening
screening indicates
1/5/10-3/13/10 Receiving
indicates positive
positive for
for alcohol
alcohol and
and history
historyof
oftreatment
treatment for "schyzo"
"schyzo" with
plans for a "MHP
"MHP evaluation
evaluation if staying."
Per
hewas
was enrolled
enrolledin
in MH
MH ece
CCCfor
forPsychotic
Psychotic Disorder
Disorder NOS
NOS on
had aa MH
MH Assessment
Per orders 1/26/10,
1/26/10, he
on that
that date, had
1/11/10,
Psychiatric Evaluation 1/22/10
1/22/10and
and aa Special
Special Needs
Plan 1/26/10
and there
there was
was aa plan
1/11/10, aa Psychiatric
Needs Treatment
Treatment Plan
1/26/10 and
for follow-up
follow-up in
in 60
60 days
days and
plan update in 6 months (intervals
that just
just arrived,
arrived,
and treatment
treatment plan
(Intervals too long
long for
for patient that

has been given a very serious diagnosis and no fal/ow-up
follow-up for
for two months!)
Mental Health
Health Assessment
referred to
to MD
MD and
and follow-up
follow-up with
with PhD
PhD
Assessment- referred
Psychiatrist
Risperdal and Benadryl
Benadryl started
Psychiatristappointment
appointment 1/22/10
1/22/10 - Risperdal
Risperdal and Benadryl
Benadryl discontinued,
Psychiatristappointment
appointment 2/22/10 - Risperdal
discontinued,thorazine
thorazine started
started per inmate
Psychiatrist
request/insistence
request/insistence (HNR)
(HNR)
File
DOC treatment.
File does
doescontain
contain records
records from
from DOC
treatment.
Special
counseling, cognitive
Q8
Special Needs
NeedsTreatment
Treatment Plan
Plan -- "supportive counseling,
cognitive restructuring"
restructuring" but planned sessions are Q8
weeks.
11/2/09-11/2/09
receiving screening
screening positive
positive for alcohol and withdrawal;
11/2/09-11/2/09 -- receiving
withdrawal; denied
denied any mental health
6/2/09-6/23/09
- receivingscreening
screeningpositive
positivefor
for alcohol,
alcohol, denied mental health, no referral generated;
6/2/09-6/23/09 receiving
supplemental
screening all
all "N";
"N"; DOC
DOC records
supplemental screening
records indicate
indicate diagnoses
diagnoses of Depression, Alcohol
Alcohol Dependence
Dependence and
Amphetamine
Amphetamine Dependence
6/25/07-8/30/07
-Receiving screening
screening indicated
indicated having
having taken thorazine
thorazil1e and Prozac
Prozac but last taken in
in 2/07 while
6/25/07-8/30/07 -Receiving

2

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 26 of 33

Healthappraisal
appraisal indicates
indicates suicide
suicide attempt
attemptinin'OS,
'05, history
history of
ofdepression.
depression.
in prison. Health
Selfreferral
referral 6/28/07;
6/28/07; MH
MHAssessment
Assessment 7/10/07
7/10/07 -- referred
referredfor
forpsychiatric
psychiatricevaluation;
evaluation;MAR
MAR from
from prison
prison for
forJuly
July
Self
for prescribed
prescribed thorazine.
thorazine.
indicates no
no show
show for
'06 indicates
an MD
MD note
note 12/15/05)
12/15/05)Used
Usedshoelaces
shoelaces to
to attempt
attempthanging
hanging in
in holding
holding tank
tank in
in Dysart
Dysart
11/20/05-? (There's
(There's an
11/20/05-7
th
before 4th
4 Avenue
before
Avenue receiving;
receiving;placed
placedon
onwatch
watchininrestraint
restraint chair
chair and
and admitted
admitted to P3 MHU
MHU11/23/05-11/29/05
11/23/05-11/29/05
th
inpatient care
care 11/21/05
11/21/05from
from4th
4 Ave
Ave but the petition
petition was
was denied.)
denied.)
and discharged
discharged to
to Towers.
Towers. (Petitioned for inpatient
3/9/05-3/9/05
identified the
the following
folloWingproblems
problemsconcerning
concerning the
the care
care and
and management
management of this patient:
iI identified
• NoNotreatment
treatmenttatop,event
preventar
or ameliorate
alcohol withdrawal.
.
ameliomte alcohol
withdmwal.
systemtoto
flagoror
otherwiseindicate
indicatehistory
historyofofsuicide
suicide attempt.
attempt. (This
(This inmote
inmate had
had aa history of
.• NoNo
system
flog
otherwise
attempted hanging
hanging when
when he
he was
was in
in aa correctional
correctional facility.)
facility.) Consider
Consideraa "flag"
"flag IIininJMS
JMS for
for situations
situationssuch
such
attempted
as these
mental health
health assessment
assessment with
as
these and
and an
an immediate
immediate referral
referral for mental
with this history and current risk
factors.
factors.
coordination
referral with
with mental
mentalhealth
health assessment
assessmentfor
forknown
knownhistory
historyof
of depression
depression and
andsuicide
suicide
• NoNo
.
coordination
or or
referral
attempt.
CHS REVIEW:
CHS
Dr. Noggle
Dr.
Noggle completed
completed aa psychological
psychologicalautopsy
autopsyand
andnoted
notedsimilar
similar potential
potential missed
missed opportunities
opportunities including
assessment and
assessment
andtreatment
treatment of
of withdrawal
withdrawal symptoms,
symptoms, record
record review
review would
would have
have identified
identified history of prior
suicide attempt,
no mental
mental health
health follow-up
follow-up appointment
appointment was
was scheduled.
scheduled.
suicide
attempt, no
The CHS
23, 2011.
2011.
The
CHSQuality
QualityAssurance
AssuranceIncident
IncidentReview
ReviewCommittee
Committeereviewed
reviewed the
the case
caseinin its
itsentirety
entirety on March 23,
The following
The
following action steps were
were identified:
Nurse
tocell
go side
cellifside if the withdrawal
withdrawal assessment
assessment is
Protocol changed
changed to
ratings
Nurse
to go
is refused.
refused. Protocol
to include
include withdrawal ratings
administration rather
rather than
than separate
separate process.
process. (In
(In general,
general, inmates do come
simultaneous to medication administration
come out
out for
medications even
medications
even when
whenthey
they decline
declineto
tocooperate/participate
cooperate/participate in
in withdrawal
withdrawal monitoring.)
nurse is
is
Nursing
Nursingpractice
practiceto
to require
require referral
referral to
to mental
mental health if
if withdrawal
withdrawal assessments
assessments are
are refused
refused and the nurse
concerned
the inmate.
inmate.
concerned about
aboutthe
A mental
must be
be scheduled
scheduled for
for aa positive
positive screen.
A
mental health
health appointment must
If a mental
mental health issue
issue isisidentified
identified during
during the
the inmate's health appraisal,
appraisal, an
an immediate
immediate referral
referral to
to mental
health should
should be generated.
generated.
Review
Reviewthe
the mental
mental health
health referral policy
policy and
and revise
reviseto
to incorporate
incorporate the
the above recommendations ifif necessary.
Mental health
health staff
staff should
should conduct
conduct rounds
rounds on
on all
all inmates
inmates in
in single
single cells
cells that are on extended lock-down status.
status.
Review
rding ea
rly treatment
rawal ifif the
the inmate
inmate has
has a known history
history of
of having
having
Review policy
policy rega
regarding
early
treatment of
of alcohol
alcohol withd
withdrawal
(complicated) withdrawaL.
withdrawal.
experienced
experienced aa difficult
diffcult (complicated)

3

Case 2:77-cv-00479-NVW Document 2001

#3

I DOB
DOB

I 05/15/59

I DOA
IDOA
I102/17/11
02/17/11

I

Filed 08/09/11 Page 27 of 33

I RS
RS

II 02/17/11

MHA
II MHA
II 02/21/11

Psych iatry
iatry
II Psych

None
II None
Death Review
Review (Suicide)
(Suicide)
History of HTN,
HTN, diabetes,
diabetes, stomach
stomach ulcer and
and asthma,
asthma, remote closed head
head injury; was sent out
outto
to Maricopa
Maricopa Co
Co
for influenza
Supplement 2/17/112/17/11 - no
influenza - seen
seen there and
and returned;
returned; MH
MH Screening
Screening Supplement
no disposition noted.
noted.
to mental
mental health
health--MH
MH Assessment 2/21/11
2/21/11Depression and
and anxiety
anxiety 9-10
9-10 on
on aa scale
scale
Medical referral
Medical
referral 2/21/11 to
- Depression
reported hallucinations;
hallucinations; no
no suicide
suicide risk
risk assessment;
assessment; follow-up
follow-up 2 weeks planned; no
no referral
referral
of 10, tearful and reported
to psych
psychiatry
iatry
to
Re-referred by
seen: "was
"was seen
seen on
by mental health
health staff
staff and
and follow-up
follow-up is
is
Re-referred
by medical
medical 2/23/11
2/23/11 but not seen:
on 2/21/11 by
scheduled."
Inmate
scheduled."
Inmate hung
himselfhung himself 02/27/11, died 03/02/11.
following issues:
I identified the following
.
forfor
referral
too high
high
• Threshold
Threshold
referraltoto psychiatry
psychiatry set
set too
• Failure
Failuretotoassess
assessthe
.
the inmate
inmateinin response
responseto
to aa second
secondmedical
medicalreferral
referral
.
assessment
• Lack
Lackofofcomprehensive
comprehensivesuicide
suicide risk
risk assessment
weekstoo
toolong
longgiven
givenhis
his condition
condition 2/21/11.
• Fallow-up
Follow-up
intervalofof22 weeks
.
interval
2/21/11.
CHS REVIEW
CHS
Dr. Noggle
in
Dr.
Noggle completed
completed a psychological
psychological autopsy
autopsy and
and identified
identified the same issue
issue of
of failing
failing to
to see
see the
the patient in
response to the
the medical
medical referraL.
referral. She did
did not identify
identify the
the planned
planned interval
interval for
for the
the next appointment
appointment as
as aa
problem. The
The mental health staff person
that an
an offer
offer for
problem.
person conducting
conducting the
the assessment
assessment 02/21/11 reported that
are
referral
referral
to to
a psychiatrist
a psychiatrist
was extended
was
butextended
the inmate refused.
but the
(Neither
inmate
the offer
refused.
nor
(Neither the offer nor the
the refusal
refusal are
nor is
is the recommendation
recommendation for
for psychiatric
psychiatric assessment.)
documented, nor
The CHS
March 23,
23, 2011.
2011.
The
CHSQuality
QualityAssurance
AssuranceIncident
IncidentReview
ReviewCommittee
Committeereviewed
reviewed the
the case
caseinin its
itsentirety
entirety on March
Committee identified
identified the
the following
following issues:
issues:
Training on suicide
suicide risk
risk assessment
assessmentfor
for mental
mental health
health staff
Mental health referrals
referrals are
are to
to be
be seen
seen within 24-hours of referral in
in aa private setting,
Providers document
Providers
document telephone referrals
referrals in
in aa progress
progress note.
for CHS
CHS staff is
More radio training
training for
is necessary.

The following
following recommendations/opportunities
recommendations/opportunities for
The
for improvement
improvementwere
wereidentified
identifiedand
anddistributed
distributedtotoall
allCHS
CHS
staff:
All
must be
All mental health referrals must
be seen
seen within 24-hours.
24-hours.
1. Providers
1.
Providersare
arerequired
requiredtotodocument
documentphone
phonecall
call referrals
referrals to
to mental
mental health
health in
in progress
progress note recording
recording
the name of the person
person spoken
spoken with.
2.
Providersdocument
documentother
otherreferrals
referrals(such
(such as
as to
topriest)
priest) in
in progress note.
2. Providers
3.
CHS staff
staffadopt
adoptlanguage
language "Man-down:
"Man-down:hanging"
hanging"when
when making
making radio
radio calls
calls in
in clinic.
3. CHS
4. If
CHS employee
only responder
responder to
to man-down
man-down (or
employee should
employeeisis only
(orrequire
require more
morestaff)
staff) employee
should ask
ask
4.
If CHS
detention
to request
medical staffto
man-down.
detention to request
all medicalall
staff
to attend man-down.

4

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 28 of 33

I
I
I
#4 DOB
DOA
RSII MHA II Psychiatry
I
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I
#4

DaB

DOA

RS

04/22/11

04/22/11

MHA

Psychiatry

This
patient delivered
delivered aa baby
baby in
in the
the
This case
case was
was reviewed
reviewed as
as aa result of concerns
concerns raised by plaintiffs'
plaintiffs' counsel:
counsel: the
the patient
bathroom of
of aa housing unit at Estrella.
Estrella. The
The inmate
inmate was
was booked
booked into
into the
the jail
jail on
on Friday
Friday night,
night, April
April 22,
22, 2011.
2011.
She
ofdrugs.
drugs. She
She refused
refused pregnancy
pregnancy testing,
testing, was
was placed
placed on
on CIWA
CIWA
She appeared
appeared pregnant
pregnant and
and under the influence of
checks for
for withdrawal
withdrawal and
and scheduled
scheduled for
forthe
the first
first available
availableobstetric
obstetricappointment
appointment on
on Monday.
Monday. She was sent
checks
from intake
intake to
to Estrella
Estrella on
on Saturday
Saturday morning and
and told the
the nurse
nurse there
there that
thatshe
she needed
needed to
to go
go to
tothe
thehospitaL.
hospital.
She
provide a urine
positive for pregnancy.
tests were
were positive
positive
She agreed
agreed to provide
urine sample
sample that
that tested positive
pregnancy. Other laboratory tests
for methamphetamine. The
unit. On
the inmate
inmate returned
returned to the
The inmate
inmate was
was sent
sent back
back to her
her housing unit.
On Sunday,
Sunday, the
clinic with multiple
multiple complaints.
complaints. Vital
Vital signs
signs normal
normal and
and fetal
fetal heart
heart rate
rate 135.
135. AAnursing
nursingnote
notedescribes
describes her
her as
as
dramatic;
hospital. A provider
provider is
is telephoned
telephoned and
and Tylenol
Tylenol is
is
dramatic, bizarre, screaming and
and demanding to go to the hospitaL.
ordered. The patient
is sent backistosent
her housing
the patient
patient is
ordered.
The patient
backunit.
to her housing unit. At 1:24 AM, a man-down is
is called because
because the
is
in labor.
labor. She
baby boy
boy at
at 1:33
1:33AM
AMininthe
the bathroom
bathroom of
of the
the housing
housing unit.
unit. Both
in
She delivered a baby
Both were taken by
and admitted for
for aa day.
day. The
The inmate
inmate returned
returnedtotojail
jailon
onTuesday,
Tuesday, Aprii
April 27
27 and
and is
is
ambulance
ambulance to
to the local hospital and
currently
housed in
in the
theMHU.
MHU. The
Thecase
case was
was reviewed
reviewed by
bythe
theCHS
CHS Quality Assurance
Assurance Review
currently housed
Review Committee
Committee who
identified the following
following "Lessons
"Lessons learned
Learned- - Recommendations/Opportunities
Recommendations/Opportunities for
for Improvement"
1.
Staff will
will review
records timely,
timely, including
for pertinent
1. Staff
review medical
medical records
including reading
reading previous
previous booking
booking for
pertinent information.
information.
2. If
applicable, OB
OB forms
forms from
incurrent
currentbooking
booking medical
medical
2.
If applicable,
from previous
previous booking
bookingwill
will be
be copied
copied and
and filed
filed in
record with updated
updated patient
patientlabeL.
label.
3.
Nursingstaff
staff will
will access
for pregnancy
history.
3. Nursing
accesscurrent
currentand
and archived
archived OB
OB log
tog in
in computer
computer for
pregnancy history.
4.
Nursingstaff
staff will
will obtain
use CHS
UDSkit.
kit.
4. Nursing
obtainUDS
UDS order
order for
for pregnant
pregnant females
females and
and use
CHS UDS
5. Provider
5.
Providerwill
willdocument
documentLMP
LMPand
andEDC
EDC on problem list.
6.
Nursingstaff
staffwill
willdocument
documentEDC
EDC on
on comment
commentline
linefor
for2319
2319 appointments
appointmentsininJMS.
JMS.
6. Nursing
7.
Nursingstaff
staffwill
willassesslevaluate
assess/evaluateeach
each situation
situation independent
independentof
ofperipheral
peripheralissues
issues (e.g.,
(e.g., history of
7. Nursing
inappropriate
behavior.)
inappropriate behavior.)
8. Key
8.
Keyfor
forOB
OBisisreadily
readily available
available on
on the
the board
board at
at Estrella.
Estrella.
9.
Man-downcart
cartatatEstrella
Estrellacontains
containsOB
OB pack.
pack.
9. Man-down

counsel received
received aaletter
letter from
from other inmate on
that the
the patient
Plaintiffs' counsel
on the housing
housing unit relaying concerns
concerns that
in labor
labor for
for several
several hours
hours but
but detention
detention staff attributed her
was in
her behavior
behavior to withdrawal and/or
and/or minimized
minimized her
pain
pain and
and discomfort
discomfort and
and did
did not
not call
callor
orsend
sendher
hertotomedical
medicalpromptly.
promptly.Another
Anotherinmate
inmatewrote
wrotethat
that the
the patient
was in
in extreme
extreme pain
pain and
and "howling"
"howling" in
in the
the bathroom but not
by detention
detention staff. Both
was
not checked
checked by
Both describe
describe
detention staff
staff as
as extremely callous,
callous, withholding
timely access
access to
In
withholding timely
to medical,
medical, verbally
verbally abusive
abusiveand
andprofane.
profane. In
addition to these concerns,
concerns, plaintiffs
plaintiffs raised
raised serious concerns regarding
regarding the
medical management
of this case
the medical
management of
and possible mental health concerns.
The
notc1earthat
clear thatCHS
CHS
The CHS
CHSreview
reviewand
andresulting
resulting recommendations
recommendations are
are focused
focused primarily on medical care. ItItisis not
Review Team
Team had
had access
access to
to information about
about security
Review
security staff
staff as
as that
thatrelayed
relayedby
byplaintiffs'
plaintiffs'counseL.
counsel. However,
However,
they are aware
aware now and
and itit should
should lead
lead to
to further
further investigation.
In addition,
addition, I believe
the following
following recommendations must be added
to the earlier list:
In
believe the
added to

•. The
The
CHSIncident
IncidentReview
ReviewCommittee
Committeeshould
should include
include at
at least
least ane
one representative from
CHS
from security staff
staff to
ensure
reviews are comprehensive and include
and custody
custody issues
issues that
ensure that the reviews
include medical,
medical, mental health and
that
can impact the delivery
delivery af
ofcare.
care.
issuesregarding
regardingthe
themanagement
management of
and withdrawal.
withdrawal.
Thiscase
caseraises
raises additianal
additional issues
ofintoxication
intoxication and
•. This
health
determine whether
shouldhave
havebeen
beenmade
made sooner
sooner than
than
case to
to determine
whether0a referral
referral should
•. Mental
Mental
healthreview
reviewofofcase
upon the patient's
patient's return
return from
from outside
outsidehospital
hospitalafter
afterdelivery.
delivery. (Nursing
(Nursing notes
notes describe
describe behavior
behavior as
as
bizarre.)
S
5

Case 2:77-cv-00479-NVW Document 2001

Filed 08/09/11 Page 29 of 33

I
I MHA I I Psychiatry
I
#5 I IIIDOB
I
DOA
RS
I
I
I
I
I 01/03/11 01/03/11 01/04/11 I Adm MHU

#5

DOB

DOA

RS

MHA

Psychiatry

01/03/11
01/03/11
01/04/11
Adm MHU
positive for
for mental health including
including psychotropic medications, history
history of
of psychiatric
psychiatric
Intake/receiving screening
screening positive
and sent
sent to
to MHU
hospitalization and current threats of
of self-harm.
self-harm. Seen
Seen for
for mental
mental health
healthassessment
assessment and
MHU for
admission. Patient
01/12/11 to
to Durango.
admission.
Patient also noted to be
be sent to jail for
for RTC.
RTC. Discharged
Discharged 01/12/11
Durango. Inmate
Inmate appeared
appeared to

psychoticand
anddescribed
describedasassame
samewhen
whenseen
seen by
bymental
mentalhealth
health 01(18(11,01(21(11
01/18/11, 01/21/11 and
become increasingly
increasingly psychotic
01/29/11 and
and again
again by
bydetention
detention staff
staff01/30/11
01/30/11 for
for irritable
01/26/11. Referred
Referred to
to mental
mental health
health by
by an
an LPN
LPN 01/29/11
behaviors. Seen
psychiatry 02/01/11
02/01/11 and oral
oral antipsychotic
antipsychotic medication
medication ordered.
ordered. (But patient
Seen by psychiatry
and bizarre behaviors.
consistently
patient moved
4 th Ave
closed custody
custodyafter
after allegedly
alleged Iy
consistently refusing
refusing oral
oralmedications.)
medications.) 02/07/11,
02/07/11, patient
moved toto4th
Ave closed
assaulting an
anofficer.
offcer. 02/11/11
assaulting
02/11/11seen
seen by
by mental
mental health
health and
and psychiatry
psychiatry and
and ordered to MHU.
MHU.
In MHU,
MHU, remained
remained noncompliant
noncompliant with
with medications and
and continued
continued to deteriorate
deteriorate psychiatrically.
psychiatrically. He
He refused
refused
In
food. He
emergency medication
medication 02/14/11
02/14/11 but
but otherwise,
otherwise, refused
refused treatment
treatment and stayed
food.
He received one dose of emergency
in his
his cell.
cell. He
Hewas
wasplaced
placedon
onlevel
level2 2suicide
suicideprecautions
precautions(seclusion)
(seclusion)
from
03/02/11 03/09/11.
03/09/11. He
from
03/02/11He was not
in
seen
seen regularly
regularly by
by psychiatry
psychiatryduring
during this
this time
time and
and all
all renewal
renewal orders
orders are
aretelephone
telephone orders
orders rather
rather than
than written
written
after a face-to-face
face-to-face assessment.
assessment. Food
Food and
andfluid
fluid intake
intake were
were not
not monitored.
03/15/11 the
due to
to dehydration.
dehydration. He
03/15/11
the patient
patient was
was taken to Maricopa
Maricopa Medical
Medical Center due
He was admitted overnight

for intravenous rehydration and sent
continued to refuse medications,
for
sent back
back to
to jail,
jail, returning to MHU.
MHU. He
He continued
medications, food,
liquids and
and nutritional
nutritional supplements.
not tracked.
tracked.
liqUids
supplements. Intake
Intake and output not
03/23/11 sent
03/23/11
sent out
out to
to Desert
Desert Vista
Vista for
for evaluation
evaluation of
of Court
Court Ordered
Ordered Treatment
Treatment (COT).
(COT). Nursing
Nursing noted that he
he
was weak
weak and
and shaky
shaky but
but was
was coaxed
coaxed into
into eating
eating and
and drinking once out of
was
of his
his cell.
03/29/11
returned from
from Desert
DesertVista
Vista and COT
COT order
to longlong03/29/11 returned
order signed
signedon
on04/01/11.
04/01/11. The patient was transitioned to
refuse to eat and drink and
and refused
acting antipsychotic
antipsychotic medication but he continued to refuse
refused blood
blood work to
monitor his condition.
05/12/11-05/17111
complicationslside effects of
05/12/11
-05/17/11 transferred
transferredto
toMaricopa
MaricopaMedical
MedicalCenter
Center again
again with severe
severe complications(side
antipsychotic
medication with
with inadequate
inadequate hydration
hydration and
and nutrition.
nutrition. Discharge
diagnoses: hypothermia,
antipsychotic medication
Discharge diagnoses:
rhabdomyolysis, leukopenia,
leukopenia, extrapyramidal symptoms, prolonged Q-T
interval and
and altered mental state.
rhabdomyolysis,
Q-T interval
state.
Discharged to
to Desert
Desert Vista
Vista as
as persistently
persistently and acutely disabled on May
Discharged
May 19,
19, 2011.
2011.
There are
are multiple
multiple serious
serious problems
problems with
with the management
There
management of
ofthis
this case:
case:
•. Discha,ge
Dischargefrom
fromMHU
MHUtotooutpatient
outpatientwith
withpoor
poor follow-up
follow-up
intervention
intervals
presentation
•. Outpatient
Outpatient
intervention
intervalstaatoolong
longfar
foracuity
acuityafofclinical
clinical presentation
from LPN
LPN and
•. Failure
Failuretotorespond
respondtimely
timelytoto referrals
referrals from
and custody
custody staff
staff
forMHU
MHU re-admission
considerationfrom
from Durango
Durango
•. Inappropriately
Inappropriatelyhigh
high threshold
threshold for
re-admission consideration
careissues
issues in
in MHU
(infrequentpsychiatric
psychiatric assessments,
assessments,no
noattention
attention to
to basic
basic hygiene,
•. Quolity
Qualityofofcare
MHU (infrequent
hygiene,
to encourage
encourage inmate to come out of
his cell,
effort to
of his
ceil, lack
lackof
ofmonitoring
monitoring fluid
fluid and
and nutrition
nutrition
insufficient effort
intake, etc.)
condition timely
timelyinin
MHU -- clearly,
clearly,
medicol
needexceeded
exceededMHU
MHU capacity
tendto
to physical
physical condition
MHU
medical
need
capacity to
to
•. Failure
Failuretoto tend
address.
address. Patient should
should have
havereturned
returnedto
toinfirmary
infirmary rather
rather than
than MHU
MHU for
for medical
medical monitoring
monitoring follOWing
following
his
his first
first and second emergency medical hospitalizations.
accessinginpatient
inpatientpsychiatric
psychiatric care
care and
andCOT
COTpartially
partially attributed
attributed to
in inaccessing
to RTC
RTC status
status
•. Delays
Delays
This case
case isis slated
slated for
for a root cause
Quality Assurance
Assurance Committee
Committee in
This
cause analysis by the CHS
CHS Quality
in July.
July.
In advance
of
In
advance
of this detailed analysis,
analysis, Mental
Mental Health, Medical and Nursing Directors have
have planned
planned to
to attend the
review of
of all
all MHU
MHU patients
patients together
together at least one
one day
day per
per week
week to
to identify
identify potential
morning case
case review
potential care
care
coordination issues sooner and assist in
in management
management of the case.

66

Case 2:77-cv-00479-NVW Document 2001

#6
#6

I DOB

I 02/02/84

I DOA

I 04/28/11

Filed 08/09/11 Page 30 of 33

I RS
I 04/28/11

I MHA
I 06/10/11

I Psychiatry
I 05/04/11

Picked up
up at
at time
time of receiving screening
screening but
but missed
scheduled for
for 04/30/11.
04/30/11.
Picked
missed mental health assessment
assessment scheduled
was seen
seen by
by psychiatry
psychiatry within
within six
However, she
she was
six days
days of arrival so the "missed"
"missed" assessment
assessment not
not critical/cruciaL.
critical/crucial.
She
in the community,
community, but aa private doctor
doctor provides
provides her medication
medication
She does not receive mental health care when in
prescriptions, that
that include
benzodiazepine. The
psychiatrist ordered
ordered the same antidepressant
include aa benzodiazepine.
The psychiatrist
antidepressant she
she receives
receives in
in
prescriptions,
with Buspar
clinical alternative in the jail
the community
community and
and replaced
replaced the
the benzodiazepine
benzodiazepine with
Buspar - aa very reasonable clinical
On 05/13/11,
05/13/11, the
the patient
patientreported
reportedshe
shewas
was greatly
greatly improved
improved but
but in
in mid-June
mid-June (06/14/11)
(06/14/11) began
began to
setting. On
complain
doesn'tlike
like the
the Buspar.
Buspar. The
TheMHA
MHA was
Seenby
bypsychiatry
psychiatry
complain that
that she doesn't
was eventually
eventually completed
completed 06/10/11.
06/10/11. Seen
and Buspar
Buspar discontinued
discontinued but although patient
patient appeared
appeared manic,
manic, no
no mood
mood stabilizer
stabilizer was
was prescribed
prescribed nor
nor was
was
and
Zoloft reduced or discontinued.

•.
•.
•.

Appropriately assessed
after intake
intake
assessed by
by psychiatry
psychiatry timely
timely (in
(in spite of
of by-passing MHA)
MHA) after
Failure to treat
treat assessment
of
manic
condition
assessment
Outpatient
care issues
issues (frequency,
Outpatient care
(frequency,intensity,
intensity, types
typesof
of treatment
treatment provided inadequate)

#7
#7

DOB
I DaB

DOA
I DaA

II RS
RS

II MHA
MHA

II Psychiatry

I 11/10/79
I 5/24/11
II 5/24/11
II 06/03/11
I106/15/11
06/15/11
Intake/receiving screen
screen OS/24/11
05/24111 at
at which
which time
time she
she reported
reported taking Buspar "now
"now and
and then"
then" but stopping
Intake/receiving
lithium altogether.
altogether. (She
lithium
(She isis not
not considered
considered SMI
SMI in the community but received
received treatment
treatmentfor
forpanic
panicand
andPTSD
PTSD
the last time she
she was incarcerated
Estrella in
She was
as a result of
incarcerated at Estrella
in fall
fall of
of 2010.)
2010.) She
was referred
referred to mental health as
the
intake screen.
screen. MHA
MHA was
OS/27/11 but
completed that
The inmate
HNR to
the intake
was scheduled
scheduledfor
for OS/27/11
but not
not completed
that date.
date. The
inmate sent
sent a HNR
to
be seen by
by mental
mental health
health on
on 05/30/11
05/30/11 but was out to court when mental health staff went to triage the
request. The
The inmate
inmate sent
sent another
another HNR
HNR 06/02/11
06/02/11 to
to be
be seen
seen to
to get
get back
back on medications.
medications. The
The MHA
MHA was
was
completed 06/03/11.
06/03/11. The
The inmate
inmatewas
wasseen
seenagain
again in
in response
response to
to another
anotherHNR
HNR 06/08/11 though the
the psychiatric
psychiatric
appointment
did
not
occur
until
06/15/11.
Depakote,
Vistaril
and
Thorazine
were
prescribed.
(When
the
appointment did not occur
Depakote, Vistaril and Thorazine were prescribed.
the use
ofthorazine was
temporary prescription
ofthorazine
was questioned,
questioned, ititwas
was verbally
verbally relayed
relayed to
to be
be a temporary
prescription to
to assist
assist with sleep
sleep due to
agitated, manic
manic state.
state. However,
her agitated,
However, this condition and
and plan is
is not documented in the file.)
.
•.
•.
•.

Problem with
with timely
timely follow-up of positive screen necessitating
necessitatingmultiple
multipleHNRs
HNRs
Prablem
Untimely psychiatric
psychiatric assessment
assessment
Inadequate
dacumentation of
Inadequate documentation
of condition and
and plan
Inadequate follow-up
manic" state
Inadequate
follow-up with medication
medication initiation
initiation and "agitated, manic"

#8
#8

DOB
I DaB
I 03/23/85

DOA
I DaA
I 04/17/11

I RS

I MHA

I Psychiatry

04/17/11
04/17/11
04/18/11
104/17/11
104/17/11
104/18/11
Intake screen
screen positive
positive as
asreported
reported treatment
treatment for
treated with Depakote
Intake
for bipolar
bipolar disorder,
disorder, depression
depression and
and ADHD
ADHD treated
Depakote
SMI. MHA completed
completed 4/17/11 with
with aa follow-up
follow-up 04/20/11;
04/20/11;also
also progress
progress notes
in community; reports Magellan
Magellan SMJ.
indicate contacts
contacts 05/04/11,06/02/11
05/04/11,06/02111 and 06/17111.
indicate
06/17/11. Psychiatrist
Psychiatrist assessment 04/18/11 and again 04/28/11.
Depakote
Depakote was
wasordered
ordered04/26/11
04/26/11 but
but changed
changedtotolithium
lithiumand
andCelexa
(elexa04/28/11.
04/28/11. Lithium level ordered for
05/07/11 and
nurse practitioner 06/17/11
06/17/11 and
05/07/11
and result
result was
was 0.3
0.3 (low).
(low). Seen
Seen by
by psychiatric
psychiatric nurse
and lithium
lithium dosage
increased
The next
next scheduled
scheduled psychiatric provider
increased with
with another level ordered to be drawn in a week's time. The
appointment isis 4 weeks.
appointment
•.

.

Problem
with documentation
documentation regarding delay in
in resuming
resuming depokote
depakote
Problem with
Infrequent follow-up
follow-up for
for lithium
lithium initiation
initiation and
and dose
dose titration
titration

7

Case 2:77-cv-00479-NVW Document 2001

#9

DOB
1 DaB
12/31/74
112/31/74

I DOA
I 05/10/11

Filed 08/09/11 Page 31 of 33

I RS
I 05/10/11

I MHA
I 05/16/11

I Psychiatry
I 05/16/11

Denied
However, computer check
check the
Denied mental
mental health
health problems
problems or
or treatment
treatment history during intake.
intake. However,
the following
foilowing
documents she
she isis Magellan
MageilanSMI.
SMI. Refused
RefusedMHA
MHA05/15/11
05/15/11 but seen
seen in
in medical
medical clinic
clinic 05/16/11
05/16/11 by supervisor
day documents
and
and MHA subsequently completed same day. Patient
Patientisis described
described as
as guarded and suspicious.
suspicious. Psychiatric
Psychiatric
and Vistaril
Vistarilwere
wereordered,
ordered, but
but not
not an
an antipsychotic
antipsychotic medication.
medication. Detention
assessment same
same day
day and Paxil
Paxil and
staff make referrals OS/25/11 and OS/26/11
of hearing voices and although
although seen
seen in
in
OS/26/11 for
for inmate's complaints of
she isisnot
not seen
seen by
by psychiatric
psychiatricprovider
provideruntil
until06/14/11.
06/14/11. (Medications were discontinued
response by MHP,
MHP, she
05/31/11 for
for inmate
inmate refusal,
refusal, but
but the
the inmate
inmate was
was not evaluated on
By 06/19/11,
06/19/11, her
her condition
condition has
has
on that date.) By
continued to
to deteriorate
deteriorateand
andshe
she isis sent
sent to
to MHtJ.
MHLJ. She
Shewas
was discharged
discharged back
back to Estrella 06/20/11;
seen by
by MHP
MHP
06/20/11; seen
in follow-up
foilow-up 06/21/11
06/21/11 and
and by
by the
the Estreila
Estrella psychiatrist 06/27/11
06/27/11 (but
(but the
the psychiatrist
psychiatrist noted
noted she
she did not
not have
have the
patient's chart at the time of
of the visit.)
response to
to acuity of patient's
patient's condition
•. Inadequate response
condition(psychIatric
(psychiatric assessment
assessment not timely
timely in
in response
response to

•.
•.
•.
•.

detention referrals)
Adequacy of MHP
MHP response
responseinin terms
terms of
of not
not relaying
relaying for psychiçtric
psychiatric assessment
assessment urgently
Faiiure to prescribe
prescribe antipsychotic
ontipsychotic medication for psychotic
Failure
psychotic symptoms .

Discontinuotion of
of medication
medication without
without face-to-face
face-to-face psychiatric
psychiatric assessment
assessment
Discontinuation
Inadequate assessment
in
MHU
with
prematufe
reiease
and
poor
continuity of
avaiiable
assessment in MHU with premature release and poor continuity
of care
core (no
(no chart available
for psychiatrist appointment)

#10
#10

DOB
I DaB

06/26168
I 06/26/68

DOA
I DaA
I 01/31/11

I RS
I 01/31/11

I MHA
I 02/11/11

I Psychiatry
I 03/02/11

of bipolar
bipolar disorder
disorderand
anddepression
depression but
but no
no treatment
treatment with
September 2010
Reported history of
with medications
medications since September
screening 01/31/11.
01/31/11. MHA
completed02/11/11.
02/11/11. Medication
ordered 03/02/11.
03/02/11. She
at the time of intake
intake screening
MHA completed
Medication ordered
She was
prescribed
Thorazine for
for auditory
auditory hallucinations.
hallucinations. (Dosage
is consistent
of psychosis.)
prescribed Thorazine
(Dosage is
consistent with
with treatment
treatment of
psychosis.) Patient
Patient
was sent
sent to
to MHU
MHtJ 04/12/11
04/12/11 for
to Estrella
Estreila 04/14/11.
04/14/11. She
was
for banging
banging her
her head;
head; discharged back
back to
She refused
refused MHP
MHP
follow-up 04/15/11
04/15/11 but was seen by
follow-up
by psychiatry 04/19/11. No
No further
furtherfoilow-up
follow-up until
until OS/27/11
OS/27/11 when seen in
in
Thorazinediscontinued
discontinuedatatthe
the patient's
patient's request (05/27/11)
response to HNR.
HNR. Thorazine
(05/27/11) but
but without
without being
being seen
seen by
by
psychiatric provider;
provider;appointment
appointment was
wasscheduled
scheduledfor
for06/03/11
06/03/11 but
but she
she wasn't
wasn't seen then either. There
psychiatric
There was
was an
an
MHP appointment
appointment 06/22/11
06/22/11 and
psychiatrist appointment
appointment 06/27/11.
MHP
and psychiatrist
•.
•.

Inadequate outpatient
without face-to-face
inadequate
outpatient management (infrequent intervals, medication
medicotion adjustment without
appointment)
Question
Question adequacy
adequacy of
of MHU
MHU assessment,
assessment,treatment
treatment planning
planning and
and discharge
dischargeto
tooutpatient
outpatient

#11
#11

II DOB
DaB
II 02/19/77

II DOA
DOA
II OS/28/11

II RS
RS
II OS/28/11

II MHA
II OS/28/11

I Psychiatry
MHtJ
I MHU

Sent
MHU (P5)
when she
she was
was discharged
discharged to
Sent to
to MHtJ
(P5) on
on day
dayof
of arrival:
arrival: OS/28/11
OS/28/11and
andremained
remainedthere
there until
until 06/22/11
06/22/11 when
Estrella. There is no evidence
evidence of discharge
discharge planning
planning between MHtJ
and Estrella
Estreila in
in preparing
preparing for
far discharge
Estrella.
MHU and
discharge after
does the
the MHU
MHU documentation
documentation support
improved at
a relatively lengthy MHtJ
MHU stay, nor does
supportthat
thatshe
she was
was c1inicaily
clinically improved
on the
the very
very next
next day
day 06/23/11
06/23/11 after
the time of discharge. Patient was subsequently readmitted to
to MHtJ
MHU on
wrapping things around her neck.
neck. Currently, in
in MHtJ
MHU only interventions
interventions appear
appear to be
be very brief
brief psychiatric
appointments
and weekly
weekly appointments with a counselor; goals
appointments and
goals for
for treatment,
treatment, progress or problems
addressed are not
not clear
clear from documentation.

Problems with
with MHU
MHU treatment including adequacy of
of treatment
treatment interventions
Problems
interventions (infrequent
(infrequent contact,
contact, no
no progress
progress
documented),
planning, poor
poor discharge
discharge planning
documented), treatment
treatment planning,

8

Case 2:77-cv-00479-NVW Document 2001

II Psychiatry
MHA
Psychiatry
II MHA
II 04/03/11
II 04/09/11
04/03111
04/09/11
II 04/03/11
Case
Case selected
selected for
for review because
because inmate
inmate is housed in 4th Ave
Ave SMU
SMU & identified
identified as
as SMI
SMI in
in JMSJMS-

#12

I DOB
DOB
02/18/61
I 02/18/61

I DOA
DOA
04/03/11
I

Filed 08/09/11 Page 32 of 33

I

RS
I RS

suicide by
by overdose
overdose in
in past,
positive for
Chart volume
volume 6 of
of 66 reviewed:
reviewed: Intake screening positive
for reports
reports of attempted
attempted suicide
of taking
taking psychotropic
psychotropic medications
medications but
butno
nocurrent
currentsuicidal
suicidalthoughts;
thoughts;supplemental
supplementalscreen
screenindicates
indicatesSMI
SMI
history of
history
with MHP
MHP
designation and
and history
history of
of psychiatric
psychiatric hospitalization.
hospitalization. MHA completed
completed 04/03/11
04/03/11 and follow-up with
referral was
was made for a psychiatric
psychiatric assessment
planned though unclear whether aa referral
assessment from
from the
the documentation.
Psychiatric
Patient seen
on rounds
rounds weekly
weekly in
in SMU
SMUininaddition
addition to
to individual
individual sessions
sessions04/06/11
04/06/11 and
and04/07/11.
04/07/11. Psychiatric
seen on
assessment completed
inmate anticipated
anticipatedhe
he would
would be
be released
released 04/11/011,
04/11/011, but
but he
he was
was not.
not.
assessment
completed04/09/1104/09/11- inmate
(Baseline
metabolic
laboratory
studies
ordered
by
psychiatrist
anyway.)
Subsequent
psychiatric
fol/ow-up
(Baseline metabolic laboratory studies ordered by psychiatrist anyway.) Subsequent psychiatric follow-up

04/22/11,05/05/11,06/11/11
04/22/11,05/05/11,06/11/11and
and06/20/11.
06/20/11.Prozac
Prozacstarted
startedfor
fordepression
depression05/05/11
05/05/11and
and dosage
dosage increased
increased at
appointment. (Special
(SpecialNeeds
Needs Treatment
TreatmentPlan
Plan dated
dated 04/17/11
04/17/11isisgeneric
genericand
andlists
listsdiagnoses
diagnoses only
only as
as
the June appointment.
and "Cluster
"Cluster B (personality
Polysubstance Dependence and
(personality disorder)
disorder) traits";
traits"; goals
goals and
and objectives
objectives do
do not address
diagnoses and
and "medication
"medication if indicated"
these diagnoses
indicated" isisthe
the intervention.
intervention. The plan
plan has
has not
not been updated.)
.• Psychiatric
Psychiatric care
(He was
was interviewed
interviewed in the medical
care and
and follow-up
fol/ow-upappropriate
appropriate and
and inmate
inmate stable. (He
clinic.)
.• Outpatient
Outpatient level of care
documentation, frequency
frequency and
and type
type of
ofnonnoncare issues
issues (treatment
(treatment planning dowmentotion,
medication interventions)

#13

I DOB

I 07/01/42

I DOA
I 01/02/11

RS
II RS

II 01/02/11

I MHA

I
I

I Psychiatry

I
I

Case
Caseselected
selectedfor
for review
review because
because inmate
inmate is
is housed
housed in
in 4th
4th Ave
Ave SMU
SMU && identified
identified as SMI
5MI in JMS
JMS-Intake
referral. Health
Intake screening
screening was
was negative
negative -- no indications for
for mental
mental health referraL.
Health assessment
assessment conducted

01/13111
included supplemental
supplemental mental
mental health
healthquestions
questions and
and still
still no
no indication
indication for
forreferraL.
referral. Staff assigned to
01/13/11 included
SMU
health issues/problems.
issues/problems.
SMU see
see inmate
inmate when
when rounding - there
there are no mental health
Incorrectly labeled
labeledas
as SMI
SMI in
in JMS
JMS
Incorrectly

#14
#14

I DOB
I 09/06/80

DDA
I DOA
I 04/16/09

I RS
I 04/16/09

I MHA
I

I Psychiatry
I

Case
as SMI
SMI in JMSCaseselected
selectedfor
for review
review because
because inmate
inmate is
is housed
housed in
in 4th
4th Ave
Ave SMU
5MU &
& identified
identified as
Very
clinical case
case
Very comprehensive
comprehensiveclinical
clinicalsummary
summaryininfile
filedated
dated02/22/10
02/22/10 but
but needs
needsto
to be
be updated.
updated. Difficult
Diffcult clinical
with organicity
organicity secondary
secondary to history
history of
ofinhalants,
inhalants, polysubstance
polysubstance abuse,
abuse, gang
gang involvement
involvement and
and impulsivity;
any. He
He is
is described
described as
as highly
highly profane and
better with
with medications
medications but he refuses to take any.
manages impulsivity
impulsivity better
irritable, assaultive
assaultive towards
The rationale regarding
regarding whether
towardsdetention
detention staff
staff from
from time
time to
to time. The
whether or not to
pursue COT
COT medications
and explanation
explanation for
for frequency (or
medicationsneeds
needstotobe
bedocumented,
documented, treatment
treatment plan updated and
of
interventions
clearly
spelled
out.
Attempts
to
see
him
are
made
at
intervals
of
45-90 days and
infrequency)
infrequency) of interventions clearly spelled out.
see him
made at intervals of 45-90
he
MHP.
he is
is seen
seen by
by psychiatry
psychiatry and MHP.

Outpatient level of care
care issues
issues (treatment
(treatment planning, rationale for frequency
frequency and types of interventions
interventions needs
needs to
ta
be
documented)
be dacumented)

9

Case 2:77-cv-00479-NVW Document 2001

#15

DaB
I DOB
05/74/84
I OS/2.4/84

I DOA
01/07/11
101/07/11

Filed 08/09/11 Page 33 of 33

I RS

I 01/07/11

I MHA

I 01/11/11

I Psychiatry

I 01/15/11

Caseselected
selected for
for review
review because
because inmate
inmate is
is housed
housed in
in 4th Ave SMU
SMU &
& identified
identified as
Case
as SMI in JMSIntake screening
screening on
on day
day of
of booking was
was positive for SMI; physician assistant
assistant did
did an
an assessment
assessmentat
atthe
the time
time of
01/11/11 and referred to
intake. MHA
MHA 01/11/11
to psychiatry.
psychiatry. Prescribed
PrescribedEffexor
Effexor and
and Zyprexa.
Zyprexa. Seen
Seen monthly
monthly for
provider. MHP
sees at
at intervals
intervals of
of 4-6
4-6weeks
weeks though
though notes
notes to
to not
medication management
management by
by psychiatric provider.
MHP sees
reflect goals,
interval.) Treatment
Treatment plan
plan lists
lists cannabis and
goals, objectives
objectives or
or changes
changes inintreatment
treatment (intervention or interval.)
amphetamine abuse but
but there
there is
is no intervention to address these
these issues.
issues.
Patient interviewed in
in medical
medical clinic
clinic and
clinically; would
and appears
appears stable clinically;
would benefit
benefit from
from supportive counseling at
and frequent
frequent intervals in
in addition to medication.
regular and

care issues
issues (treatment
(treatment planning,
planning, interventions,
interventions, treatment more than medication)
Outpatient level of care

,#16
#16

DaB
I DOB
03/14/77
I 03/14/72

I DOA
I 03/31/11

I RS
I 03/31/11

I MHA
I after 4/12/11

I Psychiatry
04/07/11
I 04/07/11'

'
Intake screen positive
for reports of bipolar disorder but said last follow-up
with three
three years previously.
Intake
positive for
follow-up with
previously. Seen
by
nurse
practitioner
04/07/11
based
upon
positive
screening
report
of
having
taken
lithium,
Paxil and
and Zyprexa
Zyprexa
by nurse practitioner 04/07/11 based upon positive screening report of having taken lithium, Paxil
and medications
medications were
wereordered.
ordered. Underwent health appraisal
appraisal04/12/11.
04/12/11. MHA
in community and
MHA not done until
rather than scheduled
scheduled at
later. Seen
Seen by
by mental
mental health
health on
on several
several occasions
occasions but
but mainly
mainly in response to HNR
HNR ratherthan
based upon
psychiatric provider timely
timely to
to address
address
appropriate intervals based
upon clinical
clinical condition;
condition; not referred to psychiatric
obvious medication
medication concerns and prominent side effects.
by psychiatry
psychiatry timely
timely after
after booking
•. Appropriately
Appropriately assessed
assessed by
booking (in
(in spite
spite of
ofby-passing
by-passing MHA)
MHA)

•.
•.

.

Lacking lab
Lacking
lab studies
studies and follow-up
& type of interventions)
Outpatient
level of care issues (frequency, intensity &
Outpatient level

I
I I MHA
I I Psychiatry
I
#17 III DaB I DOA
I RS
I
I
I

#17

DOB

DOA

RS

MHA

Psychiatry

07/17/79
103/05/10
03/05/10
107/17/79
103/05/10
103/05/10 I I

SMI,bipolar,
bipolar,depression
depression and
and PTSD
PTSDdiagnoses.
diagnoses. Sent
Sent to
to MHU
MHU11/11/10-01/11/11.
11/11/10-01/11/11.
Intake screening positive for SMI,
No MHP
MHPfollow-up
follow-up until
until 01/24/11
01/24/11 and
and no
no psychiatric
psychiatricprovider
provideruntil
until02/03/11.
02/03/11. On
No
On 02/07/11, mental
mental health
health
received
detention intelligence
intelligence that
that the
the patient
patientsaid
said she
she was
was going to kill herself on a monitored
received reports
reports from detention
not appear
appear that
that the
the patient
patientwas
was seen
seen by mental health in
in response
response to
telephone conversation; initially, does
does not
stopped back
back to
to assess.
assess. In
this information, but the documentation
documentation is
is not
not clear
clear whether
whetherthe
theMH
MH P stopped
In any event,
follow-up was
was not
not until 02/24/11 and then 03/15/11.
next follow-up
•.
•.
•.

Inadequate
risk
fallaw-up
Inadequate
riskassessment
assessmentand
andsuicide
suicide prevention
prevention follow-up

Inadequate
followingMHU
MHU discharge
of care
core following
discharge
Inadequatecontinuity
continuityof

contact,interventions,
interventions, etc.)
etc.)
Outpatient
care
issues
(frequency
ofof
contact,
Outpatient
care
issues
(frequency

#18

DaB
I DOB
01/27/88
I

I DOA
I 11/17/10

I RS
11/17110
I 11/17/10

I MHA
I

I Psychiatry
I

02/19/11-02/23/11 and returned
03/03/11Admitted MHU
MHU 02/19/11-02/23/11
returned to
toEstrella;
Estrella; no
no follow-up.
follow-up. Readmission
Readmission MHU
MHU 03/03/1103/09/11
and returned
returned to
to Estrella;
Estrella; no MHP
MHP follow-up,
seen by
Readmitted to MHU
MHU
03/09/11 and
follow-up, seen
by psychiatrist
psychiatrist03/16/11.
03/16/11. Readmitted
03/17/11.
•.
•.
•.

Problems
with MHU
MHU treatment
treatment inciuding
treatment and
Problems with
including adequacy of treatment
and discharge
discharge planning;
Poor continuity
continuity of
of care
care upon
upon return to Estrella and readmission
Outpatient care issues

10